EHR Adoption: What's Happening? Part 1
Part 1: Nazareth Hospital's progress toward the EHR.
Thank you to Advance Magazine for permission to use this article

Leslie: We recently read our country's first formal report, a comprehensive study funded by the Robert Wood Johnson Foundation, on the progress toward the EHR. Theresearchwas conducted by George Washington University Medical Center and the Institute for Health Policy at Massachusetts General Hospital and Partners Health System. The report is called "Health Information Technology in the United States: The Information Base for Progress." The results have been appearing in articles across the country related to EHR adoption.

Patty: Interesting report. The report findings include estimates that 17 percent to 24 percent of physicians in ambulatory settings use EHRs. On the inpatient side, the report uses the adoption of computerized physician order entry (CPOE) as a proxy for the use of EHRs in hospitals. The adoption of fully functioning CPOEs is approximately 5 percent. Researchers admit that there are some technical issues with the data, but this is the best data we have so far and serves as a baseline. I am still poring through the report. Thanks for bringing it to our attention. Let's talk about this more next month.

Leslie: Moving on to this month's interview, we promised our readers that we would go back into the trenches for the next few columns and talk to readers about their progress toward the EHR.

Patty: This month we visit with Maria Barbetta, the director of medical records at Nazareth Hospital, one of five member hospitals in the Mercy Health System located in Southeastern Pennsylvania. Nazareth has approximately 160,000 outpatient visits per year and 10,000 inpatient visits. It has a staff of 1,200 employees and 350+ physicians and specialists. Nazareth has earned national and regional praise for its intensive and coronary care units and its stroke treatment program and has been recognized by Pennsylvania Health Care Cost Containment Council as one of the hospitals in Southeastern Pennsylvania with significantly better outcomes.

Leslie: Hi Maria. Let's start our discussion identifying where your organization is on the road to the EHR. What components of the EHR are in place?

Maria: While we have some best of breed components in place, such as our cardiac information system, our EHR is built generally on a single-source philosophy. In most cases, we implement the components of our single-source vendor. When that's not possible, we then select best of breed components and integrate them as seamlessly as possible. We have the typical clinical EHR components in place as it relates to major ancillary systems and are currently migrating our lab and pharmacy systems to our single-source solution.

Patty: The debate about whether to go single-source or best of breed has been going on for such a long time.

Maria: It has. Organizations need to do what is right for them and their communities. Given how rapidly technology progresses, I think that integration is becoming easier, which makes best of breed more possible than in the past. So even when one has a primary vendor like we do, some level of interfacing is common. For example, our radiology system includes a picture archiving and communication system (PACS). It is not part of our single-source solution, but we are currently working on integrating the two systems.

Patty: So it sounds like your organization is working on the foundation of the EHR, migrating systems to your single-source. Is your record paper-based or hybrid?

Maria: We have not made the leap yet to a hybrid record but upcoming projects will force us in that direction. The transition from paper to electronic will depend on how long data can be stored in our single-source system. Until data can be retained long term we will be required to print documents that are created in electronic formats. Thus, we are paper-based at the moment. The migratory path need not be painful as I have learned from my prior experiences and we are planning for this transition.

Patty: Given that you are migrating your lab system, this might be a great time to explore eliminating the printing of results and accessing them and storing within your EHR.

Maria: This is a good place to start and will happen over time. For now, physicians access data electronically from their private offices but infrequently while they are in the hospital.

Leslie: Is there anything on the horizon that might help nudge the transition toward accessing data electronically while in the hospital, thereby eliminating the need to print lab results and filing them as a paper record?

Maria: We are gearing up for the implementation of CPOE, which is a key strategic 2008 initiative. Our hospital is part of Catholic Healthcare East, and CPOE is a key strategy for the whole system. I believe once caregivers begin using our EHR system more often in real-time, such as with CPOE, then we will be able to begin the migration toward less printing and more online access.

Patty: How is the organization preparing for the CPOE initiative and what is your role?

Maria: A steering committee is in place that meets regularly and includes corporate-level leadership, such as information technology, various key department heads such as pharmacy, and physicians in leadership. My boss, the chief medical officer, is the CPOE champion and a great advocate for medical record issues. I am kept abreast of the status of the project and provide input from the HIM perspective. We also discuss CPOE and other issues from an HIM perspective in the medical record committee.

Leslie: Was there a selection process?

Maria: The CPOE component is part of our single-source solution and thus understanding functionality and planning the roll-out has been the focus.

Patty: What HIM issues are on your radar regarding the implementation of CPOE?

Maria: There are a few but probably the most important issue relates to verbal and telephone order workflowin particular the e-signature process, so we ensure we remain compliant related to maintaining complete records.

Patty: That's such an important one. Things are smooth when ordering is done real-time but record completion backlogs and Joint Commission non-compliance issues have been incurred when processes aren't in place to handle verbal and telephone orders.

Leslie: Anything else?

Maria: We will need to determine if orders will be printed and stored as paper or not printed and stored electronically, thereby beginning the move toward a hybrid medical record. We also need to review how the orders print for release of information purposes. And from a legal record perspective, we will need to determine what aspects of CPOE are included in the legal record. For example, are alerts included? And finally, understanding the authentication process will be important.

Patty: You and I have a lot of history, Maria, as we, together with several HIM colleagues, developed one of the first document imaging solutions back in the late '80s and early '90s. So I can't help but ask you, is there a plan for document imaging in your organization?

Maria: I am currently researching the role document imaging could play as a component of the EHR. I have been tasked with this research and am compiling a business case and researching vendors. Senior leadership understands how critical this component is and has expressed interest in figuring out how it best fits. In addition, HIM directors within the Mercy Health System have gotten together to discuss best practices and share insights on system requirements.

Patty: Having been a pioneer in this area, this is very familiar territory for you.

Maria: I have seen a lot of changes and understand the functionality very well. I am bringing that expertise to this decision-making process. As an aside, remember when we thought 12-inch platters would be the standard in the future? That seems very funny to me now.

Patty: Electronic document management systems have come a long way. You are right about the platters! Magnetic storage was so expensive 20 years ago we thought platters would be here to stay.

Maria: Ironically, the issues that drive us toward document imaging are the same as they were two decades ago. For example, a big issue I have is that the size of our record continues to increase. This is as much a result of printing electronic documents as it is meeting the different regulatory requirements we have in Pennsylvania. Every clinical area it seems needs a form or an enhancement to a form to collect required regulatory data. While these regulatory data are best captured electronically through a clinical documentation system, we aren't there yet and need to deal with just the sheer volume of paper being generated.

Patty: What are some of the key lessons learned related to EHR planning?

Maria: An EHR isn't something you can pull off the shelf. It's important that people understand that decisions around single-source, best of breed or some combination take consensus and lots of discussion. There are several pathways to the EHR. It doesn't have to be overwhelming. It can be step by step, component by component.

Patty: There is a lot about to happen in your organization. How are you able to stay involved and keep abreast of projects?

Maria: I participate in a number of traditional committees such as revenue cycle, patient care, regulatory issues and medical record committee. The EHR impacts each of these areas so the topic is often present in our discussion. I am also on the Privacy Practices Committee at the corporate level, which deals with HIPAA concerns. I take every chance I get to talk about the EHR from the HIM perspective. One of my biggest challenges is leading and managing. I am down a supervisor, which requires me to tend to day-to-day management.

Patty: Work force shortages are a big challenge. I am sure our readers can empathize. And juggling leadership and management has become a way of life for many HIM leaders.

Maria: This is very true. I do try to spend more time leading and building key relationships as we work to define the EHR, and I work to prepare my department and the services we provide for an electronic environment.

Leslie: What would you say are your current leadership challenges?

Maria: Building relationships with people who are extraordinarily busy. To move the EHR forward, there needs to be time to dialogue. It's important that I engage key leaders in topics related to the legal EHR, data quality, public reporting, release of information, personal health records, etc. I am excited to be part of an organization that is moving toward the EHR and to have the opportunity to contribute to the transition. My experience from the vendor side, in which I developed EHR applications, as well as my experience in implementing document imaging enables me to provide guidance on critical HIM issues that impact the return on investment for the EHR.

Patty: Thank you Maria for sharing your challenges and your current journey with us and our readers. We wish you all the best and look forward to checking back with you in the future.

Leslie: Next month we check in on the EHR progress with an HIM colleague we interviewed in 2005. Until then, good luck with your implementations!

Leslie Ann Fox is chief executive officer and Patty Thierry Sheridan is president of Care Communications Inc., a national HIM consulting and staffing company headquartered in Chicago. They invite readers to send their thoughts and opinions on this column to lfox@care-communications.com or pthierry@care-communications.com .