EHR Adoption: What's Happening? Part 2
Northwest Community Hospital's progress toward the EHR.
Thank you to Advance Magazine for permission to use this article

Leslie: This month we visit with Debbie Sarantopoulos, RHIA, director, HIM-medical library, and privacy officer of Northwest Community Hospital (NCH) in Arlington Heights, IL. We last visited with Debbie in 2005 and discussed the EHR adoption within her organization.

Patty: The original article, "From the Trenches: EHR Strategies and the Role of Health Information Management" described NCH's Phase I EHR roll out. This included document imaging, a physician portal and a new deficiency management system with electronic signature functionality. Because you will be on vacation and will miss this month's interview with Debbie, I have asked Perla Leyva, a soon-to-be graduate of the Chicago DeVry's HIT program, to partner with me on this month's article. Perla is completing her professional practice experience at CARE Communications this month.

Leslie: Sounds good. I look forward to reading the article upon my return.

Patty: Perla, before we call Debbie, let's talk briefly about EHR adoption in general.

Perla: Sure Patty, let's get started. EHR adoption is an ongoing process. Implementing an EHR requires providers to literally "renovate" practice operations. It requires analyzing existing processes, carefully planning operational changes and diligent effort to bring about those changes. I loved the comparison listed on the American College of Physician Web site as "adding a room to your house: once the construction is completed you still must decorate, furnish and equip the room."

Patty: That is a great comparison; to leverage the value of an EHR requires customizing it to the needs of the health care organization to the extent possible, adjusting practice workflow to make effective use of its tools and continuously looking for new ways to leverage its value in the future.

Perla: An EHR is not itself the end objective but rather it is a means to improving practice efficiency and clinical quality over time.

Patty: Exactly Perla.

Perla: Based on existing high quality data on EHR adoption, it is estimated that 17 percent to 24 percent of physicians in ambulatory settings use EHRs to some extent. Also, 4 percent to 24 percent of hospitals have adopted computerized physician order entry (CPOE).

Patty: I also read that as of 2005, the proportion of hospitals with functioning CPOE systems was possibly as low as 5 percent. What challenges do you think have been encountered?

Perla: Deployment of EHR systems has not occurred rapidly, due in part to the high costs for providers of care, including the upfront capital investment, ongoing maintenance and short-term, productivity loss. However, many organizations have successfully implemented components of the EHR. For an example, we have the opportunity to talk with the HIM leadership at NCH.

Patty: Let's give Debbie a call and check in with NCH's progress toward the EHR.

Perla: Hi Debbie. Thank you for talking with us today. Looking back over the past 2 years, is there anything you would have done differently?

Debbie: There is nothing that stands out that I would have done differently. We made a decision early in the document-imaging roll out that we would use the resources of an HIM consulting organization in combination with the resources of our EHR vendor and the HIM department. The roll out was challenging, but having dedicated HIM and vendor resources to support aspects of planning was critical to our overall success. There is so much to consider with a change project of this scope that it's difficult to do it all. I think it also helped to outsource quality validation for 30-45 days post implementation. This provided objectivity about our quality and also real-time feedback to our scanning and indexing staff.

Patty: What new skills has your staff learned?

Debbie: During the initial transition from paper to document imaging, staff needed to learn how to use a PC and how to perform HIM functions using only a computer. HIM record processing roles have always been very detail oriented, but the indexing component added an extra layer of detail as well as increased stress. The entire organization relies on our staff to perform their work with great accuracy and to make scanned records available to caregivers within 24 hours of receipt in the HIM department.

Perla: It sounds like a big responsibility. The HIM role has taken on a brand new importance: to maintain a vigilant focus on the detail required to accurately and rapidly access documents, while meeting the necessary turnaround times.

Debbie: That's right. We also brought our release of information (ROI) function back in-house. We developed an ROI module and trained our own staff how to use the module to handle all requests for information in accordance with HIPAA regulations.

Perla: How is it going?

Debbie: It's going very well. Each month we bring in more revenue and have improved the overall customer service components of releasing medical records.

Perla: I understand you recently completed Phase II of NCH's EHR implementation. What was included in this phase and how did it go?

Debbie: Phase II was completed in May and included nursing and ancillary documentation, as well as nursing orders. It was a very smooth implementation. We now have additional "cold" fed documents coming into our imaging system and have reduced paper as a result of that change. We also went live with a new scheduling system in early January.

Patty: What was the preparation like for the implementation of nursing and ancillary documentation?

Debbie: Nursing leadership played a key role in preparing for the implementation. The Steering Committee evolved into a Clinical Advisory Council, which helped to ensure that lessons learned during Phase I were included in this phase. The Physician Advisory Council continued to play an important role in reviewing and approving the system build, while teams of multidisciplinary clinicians were formed. The Documentation, Orders, Continuum and Knowledge Teams were responsible for planning and implementation. Another key element was the addition of informatics clinicians, who played a very active role as the liaisons between the working teams and the system build. Most important, the resources and education needed to support the implementation became part of the planning components.

Perla: What was your role in the implementation?

Debbie: I participated in most of the work group meetings. As HIM-related issues were raised, I played a consultative role. I really enjoyed being involved with the project and how the HIM perspective was valued. The nursing and ancillary leaders took on the leadership role and looked to HIM for guidance.

Patty: I have always been impressed with NCH's no print edict. How is that going 2 years later?

Debbie: We continue to hold firm on our original stance with regard to printing, which is "not to print." I am so proud of our organization with regard to how they value not printing. We understand the implications behind this and have become accustomed to working toward a paperless environment.

Perla: What were the HIM challenges in Phase II?

Debbie: From the HIM perspective, the challenges were minimal. Communication was excellent during this phase. My presence during this phase ensured that HIM issues were addressed throughout the planning. It also allowed me to keep my staff informed by sharing progress reports from the meetings I attended. At this point, we are in monitoring mode, which means we are watching out for problems and keeping an eye on interfaces.

Perla: What was the greatest challenge to the organization?

Debbie: The organization had a huge change management challenge because a vast number of nurses and physicians needed to learn a completely new way of using medical records in their work. However, I am pleased to report that I think we did exceptionally well. We trained hundreds of nurses over the last few months. They reached a point that more than 90 percent were educated before Phase II went live. Physicians also went through training, and physicians on the advisory council provided input on design issues. They looked at tabs, content, screen displays and how to access data through the portal. I think ongoing communication and getting all the people who are part of the system actively involved really works to your benefit in the end. It helps avoid major problems.

Patty: Did you bring up all of the patient units at the same time?

Debbie: Yes. It was a big bang roll out. Initially, we thought that we would implement the new systems incrementally, but given our discussions and the ramifications of what is known as "rolling thunder" we decided to go with the big bang approach each time we roll out an EHR component. We see it as a decision between prolonging the pain, or dealing with the pain immediately, putting it behind you and moving on. NCH has become very adaptable with each system go-live and strengthens its capacity for change with each implementation.

Patty: How long was each phase?

Debbie: It took 2 years to prepare for Phase 1 and another 2 years for Phase II.

Perla: What is the next project?

Debbie: Once we are past the first few months of Phase II, we will start to work on planning for Phase III, which includes CPOE.

Patty: What might your role be with CPOE?

Debbie: I anticipate that my role will continue to be consultative, as it has been in the past phases. I believe I have a lot to offer from the HIM perspective, especially as it relates to setting up documentation systems, implementing record management principles, ensuring a legal EHR and working with physicians.

Patty: What has been the impact of Phase I and Phase II on the HIM department?

Debbie: The department has been evolving throughout this initiative—from the physical layout to the staffing organization. This year we will see the most significant changes as a result of EHR adoption throughout NCH, when we begin to roll out a remote coding program.

We will also renovate the department a bit. We are currently on two floors. We will take advantage of some of the real estate upstairs that has been freed up over time to move staff from downstairs to upstairs, giving real estate back to the organization. And most exciting of all, we are eliminating the last of the onsite paper storage. We will no longer have a file room and will officially have no more paper records stored in HIM by the end of the year.

Patty: Now that's cause for celebration!

Perla: From a change management perspective, how is the organization doing in terms of adopting the EHR?

Debbie: Adoption is coming along nicely. We deliberately began the EHR rollout with document imaging. This enabled providers to slowly get their feet wet and begin the transition to a paperless medical record. Over the course of the last 2 years, providers have been getting accustomed to working in a paperless environment; physicians have been using the system to access census, and concurrent and retrospective clinical information and to complete deficiencies. I think all future phases will benefit from what worked well in earlier phases.

Patty: Thank you Debbie for sharing your experience with us and our readers. We look forward to checking in 2 years from now!

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 .