Five Most Improved hospitals take separate routes to automation

Implementing an electronic medical record is a common objective among hospitals, but the paths to full adoption are as unique as the organizations themselves. Each of the 2007 Most Improved hospitals profiled here had to reach specific technology milestones before they could achieve the larger EMR goal.

Executives at Children’s Hospital in Denver, working against the hard deadline of a relocation, reached out to physicians who felt neglected during a previous IT effort. San Luis Valley Regional Medical Center resuscitated a failing vendor relationship, while Providence Alaska Medical Center worked to identify technology solutions that would improve care in far-flung service areas. At Eastern Maine Medical Center in Bangor, executives focused on developing an EMR that would lead to broader adoption of evidence-based medicine. For Pomona Valley Medical Center in Southern California, competing in a tight labor market made working closely with physicians an imperative.

All five hospitals have similar visions of a paperless future and integrated clinical decision support. But the leaders charged with bringing about those visions carefully tailored their approaches to deliver meaningful IT progress.

CHILDREN’S HOSPITAL, DENVER

Four years ago, when executives at Children’s Hospital, a 253-bed independently owned hospital in downtown Denver, began planning a new, $585 million campus that opened in late September, a wireless environment and fully integrated EMR for the new campus were the top priorities. Hospital executives chose a mobility-distributed wireless network, or a network without fixed infrastructure, that was developed by Cisco and not only serves clinical needs, but also accommodates patients and their guests. The system also will also boast 750 wireless phones that will allow nurses to receive patient alerts from anywhere in the building.

“The goal was to move into a new hospital with a minimal paper environment,” says Jack Storey, interim chief information officer. The design of the new campus reflects that desire—there are no storage areas for paper records, and nurses’ stations have no room for charts.

But instead of waiting until the new building was complete, Children’s spent the final year at the old facility implementing the record system ahead of the move. Launching the system and opening the new facility at the same time would have been too complicated, hospital leaders reasoned. “We had to get this implemented,” says Chief Operating Officer Mike Farrell.

But that meant getting buy-in from the hospital’s physicians. David Kaplan, M.D., the hospital’s chief medical information officer, recalls that when the hospital unveiled a prior documentation system eight years ago, it did so from the top down and neglected to work with physicians first. A day after the old system was implemented, it had to be taken down for two weeks to incorporate feedback from concerned physicians, Kaplan remembers.

To avoid those mistakes this time, the hospital formed an advisory committee consisting of physicians from a variety of disciplines. Dena Somers, director of clinical information systems, says the group helped craft procedures for when clinical decision support would require a hard stop to complete a task or when an alert would suffice. In some instances, “the physician group met and said, ‘That’s not going to facilitate good patient care to stop,’ ” Somers says.

Even after the initial implementation, physicians retained a level of ownership in the process, Kaplan says. For example, order entry templates developed by physicians had to be altered or shortened after some complained that they didn’t work well in practice.

“You think you’re doing it the right way and have good buy-in, but until you’ve tested your decisions with real-live situations you don’t know,” he says.

In March, the hospital went fully live with the EMR, the first stand-alone pediatric hospital in the country to do so. The next challenge was making sure the EMR was ready to run at the new building before the move was complete. That meant successfully moving the 600-server data center nine miles in seven elaborately planned stages—each taking place in one day, with teams working through the night each time. The last move was in August; after that, the old hospital’s IT system was operating from the new location.

“We were planning for one year before they moved anything,” Storey says.

SAN LUIS VALLEY REGIONAL MEDICAL CENTER, ALAMOSA, COLO.

Roughly 240 miles southwest of Denver, San Luis Valley Regional Medical Center is located in a vast alpine valley the size of New Jersey, but with a population of only 50,000. For a long time, the 50-bed hospital reflected that isolation. When Russell Johnson assumed the title of chief executive officer in 2001, “the IT was pretty modest,” he recalls. But Johnson was determined to bring San Luis Valley, which provides the second most charity care in Colorado, a fully functioning IT department and an electronic medical record.

So Johnson reworked the governance structure to create a board of directors to oversee operations and a foundation to promote the hospital’s long-term mission of adopting an EMR, which he acknowledges “is not as sexy” as other fund-raising efforts, but may be the most critical component of improving care. “It may be harder to relate to the giving public, but there’s nothing that we think is more important,” he says.

That effort, according to Chief Information Officer Spencer Hamons, will likely begin in the next 12 to 18 months.

In the short term, though, the Alamosa, Colo.-hospital had more basic IT hurdles to overcome. When Hamons was hired in 2004, he inherited a network operating at a paltry 60 percent uptime. With the exception of three servers, the hospital’s computer network consisted solely of desktop computers loaded with Windows 2000. “There was no redundant power supply, and no safety net whatsoever,” he says.

And then there was the hospital’s tenuous relationship with McKesson, its chief IT vendor. In 2004, the hospital was seven revisions behind on the McKesson Paragon system, which handles both revenue cycle and clinical support capabilities.

“The relationship between the hospital and McKesson had been abandoned,” Hamons recalls. “The hospital was not living up to its responsibility, and neither was McKesson. They’d stopped engaging the hospital.”

After an initial year spent identifying IT priorities, Hamons called McKesson and asked for a face-to-face meeting to rebuild the foundering relationship. Mike Youmans, McKesson’s division vice president for community customer operations, flew to Alamosa and both sides made promises to improve.

McKesson agreed to honor old contract agreements and also promised to train hospital employees with some of the new software at no charge. Last November, McKesson gave the hospital the software for a new pharmacy information system, replacing an antiquated DOS-based system that did not meet Joint Commission patient safety standards, Hamons says. In turn, Hamons agreed to buy a new radiology information system from McKesson. He also now serves on McKesson’s Paragon advisory board.

“They worked with us on the pharmacy system, so it was our turn to step up,” Hamons says.

PROVIDENCE ALASKA MEDICAL CENTER, ANCHORAGE

Providence Alaska Medical Center is the only tertiary care center in the entire state, so its IT leaders, while chasing best-of-class performance for the 364-bed Anchorage facility, have to be constantly mindful of good connections with other entities. The medical center is linked with three critical access Providence hospitals, 100 offices of Providence-affiliated physicians (98 percent of whom are independent), and nonaffiliated clinics it partners with through the Alaska Rural Telehealth Network.

To bring physicians on board with Providence’s plans to implement an EMR, the hospital developed a physician advisory committee to come up with new ideas. That led to a remote portal developed by Citrix that has been critical in connecting with physicians at far-flung locations, says Chief Information Officer Stephanie Morton, who adds that the advisory board “is very active in helping us be successful.” In particular, the advisory committee helped reorganize the way live nurse charting, a recent addition, could be accessed remotely. “The way the information was organized in the portal was not very helpful” initially, she says.

The new system, Morton says, responded to physician criticism to develop a more accessible charting system, which went live in 2006. Next, Providence implemented a PACS and a laboratory information system through which physician practices can order tests and automatically receive results.

The physician committee also championed the use of MercuryMD handheld mobile devices that allow physicians on rounds to look at patient data and update information as they walk, Morton says. The advisory committee is also taking a major role in developing computerized provider order entry, the next major project.

But the hospital also needed to advance IT capability in the system’s other three main critical access facilities in Seward, Valdez and remote Kodiak Island. Before January 2007, there was no fiberoptic link between the Alaskan mainland and Kodiak Island, and Providence Kodiak Island Medical Center had been running on a satellite system with routine 500 millisecond delays.

“They were generally having a difficult time communicating outside the island,” says Bill Yockell, Providence’s director of information technology.

In advance of the switch to fiberoptic cable, Providence Kodiak Island completely rewired its hospital. And Yockell waited until the city of Kodiak, the first adopter of the new fiberoptic system, was done installing its infrastructure and ironing out initial glitches before signing on the hospital as the second adopter.

“The staff there is ecstatic with its performance,” Yockell says.

The hospital has also stepped up efforts to help the state as a whole, working with the Alaska Rural Telehealth Network to create videoconferencing for remote hospitals.

POMONA (CALIF.) VALLEY MEDICAL CENTER

Urban areas can pose a unique set of IT challenges, too. Pomona Valley Medical Center, a 446-bed community hospital in Southern California, competes in the tight greater Los Angeles market for physicians. Complicating matters are state statutes that prohibit hospitals from directly employing physicians.

So when hospital leaders met two years ago at a retreat near the Pacific Ocean to plan for the adoption of an EMR, Chief Information Officer Kent Hoyos believed it was critical to bring physicians on board early. The hospital had already signed an agreement with Siemens to eventually develop a complete EMR, but Pomona Valley still needed to work with 600 physicians with admitting privileges in a competitive area, not all of whom were interested in an EMR’s capabilities, Hoyos says. “It’s a culture change,” he says. “Many of these guys don’t want the image, they want the [radiologist’s] report.”

That’s where gastroenterologist Gerald Goldman, M.D., entered the picture. Goldman doesn’t have a formal background in information technology, but he attended the retreat and was motivated to join the effort.

“When you left that meeting, you had the idea this was something we’re doing as a hospital,” says Goldman. “I was so taken, I wrote a job description and gave it to the CEO.” Goldman now serves as the staff clinical liaison for IT. And despite some physician grumblings, Goldman says the changes were critical to keeping Pomona Valley in a competitive recruiting position. “Our younger physicians expect this,” he says.

But the hospital didn’t focus solely on the EMR, which Hoyos hopes will be in place by the end of 2008. The meeting also led to the development of a physician portal, which now boasts access to charting from the emergency department and remote electronic signature capabilities, so physicians can check nurse charting from home. In the last two years, the hospital also has installed Siemens’ PACS for the hospital’s radiology department and a built new laboratory.

Hoyos enlisted Goldman’s help to ensure that the new PACS software and other programs critical for physicians were user-friendly. And Goldman and Hoyos began holding weekly meetings with physicians to discuss changes and solicit feedback. The meetings led to some interesting revelations; some radiologists wanted more detail in their reports, while others wanted to turn off voice recognition functions.

The next big project, Hoyos says, is making it possible for every physician to easily access digital images over the Soarian Web portal.

“It’s something every physician’s office needs to get to,” Hoyos says.

EASTERN MAINE MEDICAL CENTER, BANGOR

Physician involvement also has helped drive change at Eastern Maine Medical Center, which has 411 beds at its main location in Bangor and is part of a seven-hospital system. The hospital has had some form of an EMR since 1995, so when its leaders met in September 2006 to adopt a strategic plan for information systems, promoting clinical decision support was the top priority, says Catherine Bruno, CIO.

Following that meeting, the hospital entered into an agreement with Cerner for its Lighthouse application, which brings together the laboratory, pharmacy and order entry system, as well as patients’ admission and clinical data. The system has a maximum unplanned downtime of only four hours. “It’s fully integrated,” says Eric Hartz, M.D., chief medical information officer. “There aren’t many stand-alone niches.”

Today, medications are ordered electronically, and use of computerized provider order entry is written into the hospital’s bylaws, following a unanimous vote by the hospital’s medical staff. “It was kind of amazing,” Hartz says of the vote.

There were other challenges ahead, though, in terms of working with physicians. For Hartz, the EMR represents an opportunity for the hospital to promote evidence-based medicine by easily integrating clinical data and standard procedures into each physician’s pathway. The effort started in July with elective hip and knee surgery. “All the clinical data is expressed in the chart,” he says. “This is based on the care process, not just converting paper.”

Hartz acknowledges a few complaints from physicians but is aggressively pushing the system, which he hopes is the first of a broader effort to standardize care. In advance of the changes, the hospital began retraining orthopedic surgeons this summer.

“There’s variation amongst our providers,” Hartz says. “We have to retrain them all.… So far, there’s been lots of hesitation and frustration.”

The EMR’s clinical decision component will eventually include obstetrics and a coronary artery bypass graft surgery program, which the hospital will partner with Cerner on as the first adopter.

This article first appeared in the Fall issue of HHN's Most Wired Magazine.

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