By: Jack Holt, Vice President, Client Services
The initial requirements for Meaningful Use Stage 2 include a provision for 80 percent of patients to have access to critical information about their care via a web-enabled portal within 36 hours after their inpatient discharge. While this requirement has gotten a fair amount of scrutiny from providers, I am thrilled to see this step towards enabling patients to participate in their care more actively. The technology to do this is not new. Community hospitals can feel confident that their vendor will provide the necessary software capabilities to meet this requirement in their MU Stage 2 product releases. It’s the adoption of the technology that will be the important next step. I have been fortunate to work in communities where patient portals and Health Information Exchanges (HIEs) have really connected the patients and providers. Though adoption is sometimes slow, once patients start to understand the power of having a portable and accessible personal health record, the momentum slowly builds.
So what’s in it for the community hospital? There are two distinct wins for hospitals that successfully enable patient portals. The first is a reduced administrative burden to provide patient records. Directing patients to a portal is an excellent way to provide a very quick snapshot of the record without the administrative cost and burden of copying and mailing paper charts. Many hospitals prominently display the portal as a part of their internet home page so patients see the accessibility option right away. The second win is patient satisfaction. Hospitals who have successfully launched this functionality often report that their patients are much more plugged into the hospital and report higher satisfaction. Watch for more information in coming months on the portal solution from HMS as part of our MU Stage 2 release. Communicating directly and electronically with patients is clearly a step forward in meaningfully using an EHR.
In the age of meaningful use and clinical automation, the original pioneers of healthcare IT – the financial users --- are all too often forgotten in the implementation of a new HIS system. I have been in healthcare IT for almost 25 years and have seen a tremendous shift in the attention that is placed on the physicians and nurses during system implementation. Rightly so! However, the lifeblood of any business is the revenue cycle, and I always encourage hospital leaders to pay equal attention to the changes in finance, patient access and patient financial services.
Often, there is a feeling that replacing the financial applications is easy. “We’ve been billing for years!” is a common response. That is precisely why it’s important to focus on the financial implementation. Many hospitals have been using their current financial systems for many years---sometimes decades. The end users are extremely comfortable with the current system. The expertise is deep. The processes have been refined over long periods. It’s also no secret that the folks in these areas are often resistant to change. Again, rightly so! They make sure that the claims go out, the cash comes in and the board and CEO have the financial reports needed. A new system introduces tremendous change to an otherwise stable environment. Meanwhile, the hospital executive team almost exclusively focuses on the clinical implementation. The perception is that all the change and resistance will happen with clinicians.
Hospital leadership should assume that the financial implementation will be an equal challenge to the clinical implementation, but it will be challenging for very different reasons. The clinical implementation will introduce technology that has never been used. The financial implementation will take away technology that is comfortable and rote. Neither change is easy. The key element is to focus on the impending change and address those changes actively with the users in finance, patient access and patient financial services. The pioneers will experience great change. A strong focus on their needs will ensure a more smooth transition and a continued healthy revenue cycle for the hospital.
The need for interfacing and interoperability between systems has exploded in the last five years. Hospitals and vendors have struggled to keep pace with the demand to make disparate systems “talk” to each other. We have moved from simple admit, discharge and transfer interfaces to complex sharing of clinical documentation and discreet clinical data. Although HL7 is a common language that all vendors use to transmit data between systems, each system stores information differently. Interfacing systems can be very challenging.
If you are a hospital looking to automate and streamline the sharing of data across multiple systems, there are several important things to know. First, the vendors must negotiate and agree that they can send and receive each other’s data. If two vendors have successfully interfaced their systems in the past, chances are very high that those negotiations have already occurred, and the implementation of your interface will be relatively smooth. If the vendors have not interfaced previously, the process will be more challenging. The evaluation process should occur up-front, so the hospital is assured that the interfaces can be successfully implemented. Many vendors like HMS have interface-mapping technology (ours is called HMS Connex) that vastly improves the ability to work with other vendors. These vendor-to-vendor discussions are crucial.
Secondly, it’s important to understand that both vendors must perform some level of work to make the systems “talk” to each other. Each vendor has a schedule and available dates, and those dates must sync up, so the interfaces can be built and tested. You will want to work with both vendors early to get into their queues.
Finally, it’s important to allocate time for your resources to test. The vendors can often trigger transactions (patient updates, orders and results, for example), but the hospital needs to evaluate the accuracy of the data that is flowing between systems. Clinicians are making crucial decisions based on the data, so it must be tested and approved by the hospital.
Interfaces can really streamline hospital workflows and improve the information available to provide good patient care. Hospitals leaders must be aware, proactive and involved with their vendors to make the process effective.
One of the most significant challenges for EHR newbies is navigating the bedside experience with a computer in the mix. If you have never documented at the point of care, it can be a stressful experience in the beginning.
In general we focus on how workflow changes will affect the physician, clinician or nurse. We don't focus enough on how to incorporate this change into the patient experience. Often, new users are so focused on using the system, their well-honed listening and empathy skills take a back seat.
New-user anxiety generally falls into two categories: a) I'm going to do something wrong and b) I will not be as good as everyone else. Both of these feelings can be very distracting for new users and can ultimately affect the patient. The documentation can be perfect, but the patient can feel neglected. It does not have to be this way!
Preparing for an EHR seems like an exercise in learning software, and it is. However, it is also an exercise in how to incorporate technology into a very personal and often profound relationship. Senior leadership at the hospital needs to talk openly about these changes and how to navigate them. I have seen roundtables and focus groups used as effective communication mechanisms during implementation. Most hospitals now have nurses and physicians who have used an EHR in the past. Their lessons learned are invaluable.
Technology enables better patient care, and that is an undisputed fact. Balancing the human factors is a key element to success for both the patient and the provider.
I like to say that adopting an EHR is a journey and not a destination. While vendors like HMS focus on a specific go-live event to signify that our products are in use at a hospital, it’s just the beginning of the journey toward improving patient care and safety. Having a committee of clinical experts to govern and advise on standards and a roadmap is an essential part of EHR adoption. Products like HMS Patient Care Documentation are feature-rich and have tremendous flexibility and capabilities. Gaining the most benefit from an EHR takes strong leadership, collaboration and a focus on improving outcomes. While the IT team plays a critical role in implementing the technology, a committee of physicians, nurses and other clinicians can help to make key decisions and continue to evolve and optimize the use of an EHR. Some hospitals call this committee the EHR Advisory Committee. Others may call it the Clinical Governance Committee. Whatever the name, the concept is one that works very well.
Initial implementation of an EHR creates a great foundation from which to grow. However, almost immediately there will be requests for tweaks, changes and new content. The Clinical Governance Committee ensures that these requests are evaluated as a part of the overall vision of the EHR. Having documentation standards and following those standards will ensure that the appropriate content is developed and that it follows specific guidelines, not user preference. When conflicting opinions arise within the user community, it is helpful to know that an appointed group of peers will evaluate and decide how to proceed, not just a single IT informatics person.
Beyond the first few months of tweaking content, having an EHR opens up a world of opportunity to capture and measure data to improve outcomes. The Clinical Governance Committee should lead the evolution of the EHR, so it continues to have more meaningful data. As new product releases roll out, the Clinical Governance Committee should ensure that the hospital takes advantage of new capabilities, not only to meet future stages of meaningful use, but also to continue the evolution of the EHR’s capabilities.
I find that the most successful and satisfied users of an EHR have invested in clinical governance. I love to see our customers embrace the journey and take advantage of the powerful clinical tools that HMS has to offer.
Even though electronic health record (EHR) systems have been around in some form for almost 40 years, it still feels somewhat “new” to see clinicians and physicians interacting with computers at the point of care. Learning to use an EHR system is a challenge in itself, but dealing with computers can present an entirely separate challenge. Unfortunately, it is often hard for new users to make that distinction between hardware or network issues and the actual learning curve with the software itself. If the hardware doesn’t work, then the perception is “this new software doesn’t work.”
It is imperative that hardware and network struggles are conquered well before the EHR is launched so that the challenge for the users becomes patiently learning the new way of documenting—not struggling to find a working PC, having constant wireless drops or other myriad problems that can occur. These issues are completely preventable with good planning and testing. Unfortunately, all too often I have seen hospitals still un-boxing computers and setting up printers the day before the go live.
A thorough hardware assessment and walk-through are essential at the very beginning of the implementation process. (HMS offers this service.) Unless major renovations are in progress, it’s fairly straightforward to assess the hospital floor plan and make decisions about the quantity and placement of computers. Choosing the type of devices is more difficult. Options include wired PCs in the patient rooms, laptops attached to rolling carts (also known as workstations on wheels or WOWs) and wireless tablet computers. Each of these devices has a raving fan base and comes with pros and cons.
PC workstations in the patient rooms have the advantage of being wired directly to the hospital network. However, space, privacy and the feeling of being “tethered” to one location are typical concerns. WOWs and tablets offer a great deal of mobility but are very dependent on a highly reliable wireless connection that provides the appropriate speed to make the performance of the EHR software similar to performance on a wired PC. Often the users get busy and forget to charge the battery-powered WOWs or tablets, and a sea of dead devices leads to extreme frustration. It’s important to consider these factors early and make a decision within the first 60 days of the implementation. Then, get the hardware ordered, in place and tested well before the go live.
Removing all roadblocks to adoption of an EHR should be the mission of any hospital that is taking on a clinical implementation. Hardware and connectivity should be the last things to worry about on go-live day.
Having spent 22 years implementing and supporting healthcare IT solutions, I am very confident about one thing! Talking about change is infinitely more important than talking about the software itself. Having joined HMS less than a year ago to manage the HMS implementation team, I was thrilled to be coming to such a great company with a strong product that performs day in and day out. Having spoken to many of our customers, I realize how strongly they depend on the HMS software to run their hospitals and provide the backbone of their information. I also realize that their biggest challenge is the same as with any IT project: getting people to change.
Many of our customers are focused on automating the patient-care process for the first time ever. It can be a daunting challenge and requires a lot of change. Communicating about that change early and often is critical. Over the years, I have roamed the hallways of many a hospital and talked to hundreds of people who are curious about what is going on down there in the IT department. “I know they are working on the new system, and I’m going to get trained someday,” they all say. For most of the hospital, the new system can feel like a black box.
I’ve seen some great strategies to communicate and celebrate the change that’s coming and include the entire hospital in on the progress. HMS eLearning is a great example. By having users register and take self-paced, online courses, the hospital gets them to see and understand the system before they ever sit in a classroom. This really makes the users feel engaged and a part of the change. They start to learn the new lingo and understand how their world will change on Go Live day.
Other strategies are all about communicating and celebrating along the way. Many of our hospitals publish a periodic newsletter to keep the whole hospital informed of the progress during the implementation. Some hospitals use their super users (the hospital staff who are trained by HMS as the “go-to” experts) to do lunch and learns or present during medical staff meetings. Another great idea is to have small celebrations at each milestone along the way. Have an ice-cream social when the system build is completed, and training is ready to start. I recently visited a customer who put PCs in the physician lounge with instructions on how to log in and look at the Clinical View physician portal in the test system. It was great for the physicians to be able to “play” with the system hands on. Finally, I rely on my team of seasoned experts to mentor the users during training and Go Live and help them get through that learning curve and on their way to being HMS power users.
Implementations are always hard work. Bringing the whole hospital together can make it less scary and, dare I say ... even a lot of fun.
Frank Newlands, M.D.