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The "Big Bang" EMR Implementation

February 14, 2014
by Gabriel Perna
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Staten Island University Hospital

When Albert Villarin, M.D., FACEP arrived at North Shore-LIJ Staten Island University Hospital, everything was in silos.

As the current CMIO of the 721-bed, multi-site facility, puts it, "Leadership was siloed, the workflow was independent of each other. There was very little patient-centered methodology around the way decisions were made at the bedside level on up. When I got there, the words 'old culture' were repeated at the meetings I created. They were saying, 'We have an old culture. We don't do it that way.' Well, you have to change to evolve."

Changing that line of thinking, Dr. Villarin says, was essential to being able to successfully implement a nearly complete electronic medical record (EMR) system across the entire inpatient side, which Staten Island University Hospital was able to do. This means computerized physician order entry (CPOE), nursing documentation, bedside medication administration and barcoding, and medication reconciliation capabilities were all fully installed, 100 percent.

The bedside medication administration and barcoding integrates directly into the pharmacy, Villarin says, reducing delays and improving patient safety. The hospital also integrated automated calculations and alerts for sepsis and modified early warning scores (MEWS) into the nursing workflow   All in all, he says it was one of the largest complete go-lives for a McKesson (San Francisco) customer in the country and got them in compliance with Stage 1 of meaningful use, and nearly there for Stage 2 (they're just missing the patient portal).

Albert Villarin, M.D.

Creating a Patient-Centered Culture

To get to that point, Villarin spearheaded an initiative to create a patient-centered philosophy and move Staten Island University Hospital away from that "old culture." He brought together leaders across various clinical and administrative areas of the hospital and created workflow analytics groups. Those groups were put together to "change the modality of thinking," and create a unified patient-centered approach to various processes such as ordering, documentation, automated alerting, and medication management.  They met (and continue to meet) twice a month to discuss the advancement of technology and workflow integration.

Bringing together all of the areas of the hospital together in this manner allowed the hospital to create a system of transparency and accountability. In turn, this has ensured that everyone is doing what they are supposed, when they are supposed to. "They are afraid of being called out. It's the accountability and movement of the executive leadership," Villarin says.

In Villarin's own right, getting to this philosophy to touch all areas of the hospital took a while. He was a guy from the outside and knew it wouldn't be easy to gain trust and build successful relationships.

"The first six months I was here, I met with every single chairperson, nurse leader, manager, and department person, not only at the leadership level, but the clinical administrative unit level," Villarin says. He also ensured that the various stakeholders involved with the project would contact him directly via text message and not just set up a meeting through an administrator. "I've been texting for two years. I don't hold many meetings to solve small problems, they are a waste of time," he adds emphatically.

No Need for Piece-Meal

Thanks to these to these team-building and integrity-building efforts, by the time Staten Island University Hospital went live in April of last year, everything was in place for a complete rollout. There was no need for a piece-meal approach and processes were determined every department. To Villarin, doing anything than a complete, "big bang" implementation, with basically all of the pieces in place, was not an option.

"If you have a new car, you don’t buy pieces of the car and put together it together in your garage. You go out and buy a new car, and everything is in place in one piece," Villarin says.

Along the way, Staten Island University Hospital encountered challenges with certain workflow elements.  Various areas of the hospital, such as the emergency department, radiology, endoscopy, and chemotherapy, weren't involved with the in-patient go-live, but were on the "fringe," Villarin says. They had to be trained on both their system and the McKesson inpatient system.

The workflow, though, has ultimately been the greatest indicator of the project's success, he says, as end-users are happy with the paths and logic in which they use the EMR.

Moving forward, Villarin says Staten Island University Hospital plans on improving how order sets are entered. It will allow for the aggregation of multiple order sets to be deployed. Also, the hospital plans on adding voice-based documentation software (from the Burlington, Mass.-based Nuance) to the EMR. He also says he hopes to add a clinical analytics/population health element, and eventually connect it across the North Shore LIJ heath system. The success, will likely, hinge on those critical elements that have already got them to go basically overnight from a HIMSS Analytics Stage 1.5 hospital to a Stage 5 hospital.

"You must have transparency and accountability for everyone to understand how important this project is. You must have multiple layers of leadership involved. We mandated a new culture of clinician, administrative, and IS involvement in every meeting and every project. And informatics leadership and vision working with the IS, clinical and administrative team as the hub to bring it all together," Villarin says.