Four years ago, Davies Award-winning Citizens Memorial Healthcare overhauled its IT structure to operate more efficiently, improve patient care and manage rising costs. Today, a fully integrated, 100 percent paperless healthcare information system connects the 74-bed hospital with five long-term care facilities, 16 physician clinics and home care services across southwest Missouri. Recently, HCI Editor-in-Chief Anthony Guerra had a chance to talk with CIO Denni McColm about how such a small hospital accomplished such great things.
AG: The first thing that I noticed about your organization is that you have 74 beds, correct?
DM: It’s 76 technically, I believe, but I think we just added a couple of beds.
AG: So you’re a fairly small hospital, but it sounds like you’ve got a lot of electronic connections with the outside world. You’ve got 16 physician clinics, home care services, five long-term care facilities. So, while you’re a small hospital, you have a lot of entities you need to interact with. Does that sound correct?
DM: Yes, that is correct.
AG: So, that’s interesting. Tell me a little bit about being in that position. Again, not a big, big hospital, not 500/600 beds, but still a lot of pipes going in and out. Lay the groundwork for me.
DM: There used to be a lot of paper with all the pipes going in and out, just because of the complexity of the environment. We employ about 1,560 people, so it’s a pretty big network, plus some of the connected entities are not even employed; even the providers are independent. And that was the whole reason for the project when we started back in ’99-2000.
We decided that we wanted to provide seamless care across the continuum. We have all these services, and they really constitute a little integrated delivery network, and yet it didn’t seem very seamless for the patient that moved throughout system. Worse yet, it wasn’t seamless from the point of view of a provider who didn’t have access to the information about their patient; they had demographics and they had billing information, but they didn’t have lab results and radiology reports and those sorts of things. I think we counted at the time that there were 33 different medical records of patients when we had a paper chart. So that started us on the path of wanting to have one EMR for the whole continuum of care, and that’s been our central focus.
AG: So ’99, that’s a while ago. Sounds like you were a little ahead of your time, especially for a small facility.
DM: Yes. The hospital has been open since 1982, and since that time, we really had not made any significant investment in IT at all. It just seemed like it was time to do something in 1999 and the board was supportive of it. Today, people are saying the same thing — one record available, anywhere, anytime, just like our vision statement. So it’s kind of funny.
AG: The long-term care facilities in your network are not technically part of the same organization or they are?
DM: Technically, we’re two corporations. One is a public hospital, the hospital piece, and some of the physician offices are actually a public hospital district with elected board. Then, the long-term care facilities, some of them are outside of that public district domain, so they are a nonprofit, like a 509(c)(3). You know a lot of hospitals have a fundraising foundation. This is really an operating foundation. The community does not know the difference, and we are registered — both entities go by Citizens Memorial Healthcare. So they’re in the family, and we share some administrative services like a management service between the two corporations. Long-term care is one those community aspects of the whole project.
AG: How many physicians that practice in the hospital are employees of the hospital?
DM: We have about 100 physicians that are on staff. We have about 50 of them that admit or consult our inpatients and outpatients, and about half of those are employed and half are not. So, it’s not like they’re all employed if that’s the question.
AG: Yes, that’s the question.
DM: We get that a lot. We couldn’t make them do it.
AG: It’s a lot easier to get adoption when they’re employees, isn’t it?
DM: You know what, for us, because we have a mix, the project team working on it didn’t know the difference, but it certainly would make a difference if they were all non-employed or all employed.
AG: Do you have a CPOE in place, physician documentation, or not quite yet?
DM: Yes. Actually, we’ve had it since 2003. We did CPOE in the hospital in 2003. We don’t have paper charts at all.
AG: Well, what’s your CPOE percentage?
DM: 100 percent of the physicians use CPOE. We do allow community physicians if they are off the network to phone orders, but there are no paper charts. There’s no order sheet.
AG: When did you go through that process? Was it 2003? Was it a few years?
How long did it take to get 100% CPOE with the employed physicians and the admitting physicians?
DM: We did all that planning in 1999-2000, and we did a vendor selection in 2001, and we started going live in 2002. We were live with the clinical in December 2002, and then, over the course of December 2002 to December 2003, we brought up all of nursing and eliminated the paper charts and brought the physicians on completely. So, we really didn’t start working with the physicians intensively until about June 2003, and then we went completely paperless on Dec. 1, 2003.
AG: Was it harder to get the non-employed docs to use the system because you had less leverage over them?
DM: Perhaps it’s a unique aspect of our organization, but the people implementing it didn’t know the difference. We had one physician champion who is not employed with us and one that is (at the time), and we really were perceived as a partnership, there really wasn’t a distinction in the way we dealt with either ground of doctors.
I think that probably isn't true at other hospitals, but we really have a good relationship with our physicians. But that’s not to say that it wasn’t hard. We say it’s like they had grief at the loss of the paper — first they’re in denial, then anger, then bargaining, then depression, and finally acceptance. The hard part is when the physician, who may or may not be employed but still has a lot of importance to the organization, gets to the part where they’re angry and they’re bargaining. That’s when it’s hard to see it through, but we did see it through, and they’re happy too that they have access to all the information, and they know that entering the orders is safer.
AG: That’s one of the most interesting parts of all this to me. Do you think you have developed any best practices for getting that buy-in with the few physicians that really, really did not want to be bothered with this?
DM: It’s not unique, I don’t think, but we were very proactive and we used a whole lot of different avenues to keep dragging out of them, ‘Ok, what’s wrong? What can we do to make it better? What will make it work for you?’ The CEO was always saying, ‘We’re going to keep moving forward. We’re not stopping.’
This was quite painful, but some of most vocal physicians really wanted an audience to voice their concerns to, so we had meetings where they could do that. Some didn’t want to say it out loud at all, they wanted to write it on a piece of paper, so we had to wait for them to leave us notes, we had to wait for them to go public. We reached out to them in the office and reached out to them when they were doing rounds. We just did a whole lot of proactive work instead of just crossing our fingers and hoping that it worked, and that did pay off. It did pay off because one by one we could knock down all the reasons they thought they couldn’t do it.