Richard Eshbach is vice president and CIO of Mountain States Health Alliance, Johnson City, Tenn. Mountain States Health Alliance is a multi-hospital, integrated system, with 15 hospitals in northeast Tennessee and southwest Virginia.
Eshbach spoke recently with Healthcare Informatics Senior Contributing Editor Mark Hagland about the challenges and opportunities inherent in clinical information system implementation across a large multi-hospital system, and in particular, about some of the issues around nurses, physicians, and informatics.
MH: When did you begin the rollout of your EMR system-wide?
RE: We officially kicked off in early 2004, though the story had begun two years earlier as far as collaboration with clinical leadership, because the first thing we wanted to do was to identify our requirements with clinicians. So we formed a team of chief nursing officers and the corporate CNO and myself, and went through the education of the leaders and what we wanted to do, and myself.
MH: Do you have a chief nursing informatics officer?
RE: We did not at that time. We do have a corporate-level director of clinical informatics, and that person was already there, and is the lead of the project. Since then, we’ve also created a clinical informatics group of four professionals under our corporate CNO. There are some nurses in that group who help with the ongoing integration and use of technology in nursing and in the clinical areas. And I have analysts and nurse analysts under my team who support them. But the challenge you have with nursing or patient care across all clinical disciplines, is that you don’t have a clear clinical business owner. Is it just nursing? No, it’s also pharmacy, respiratory therapy, etc. So this team helps facilitate that.
MH: When did you go live?
RE: It’s been a multi-year, multi-phase project. We started at the foundation and built on a new platform. We started with a new clinical repository, and went live with that repository in 2005; then we went live with the clinician portal, then medication administration, then pharmacy.
MH: All you live in all of your hospitals?
RE: Not yet, no. The scope of our original project was our Tennessee hospitals, but we’ve gone from the 11 hospitals to the additional acquired ones.
MH: What are you live with right now?
RE: We rolled out the clinical repository across all our facilities, then the portal across all the facilities, then PACS, and now we’re putting in the new documentation system for nursing and physical therapy. And medication administration is live across all the facilities, including the use of barcoded armbands and medications.
MH: What kinds of things do CIOs need to do in order to build the kinds of relationships with CNOs and other clinician leaders that will facilitate the success of these complex clinical IS implementations?
RE: The CIO needs to recognize that what we’re talking about here is implementing clinical systems, not IT projects. One of the things that we did at MSHA was to bring a lot of front-line, very well-respected nurses onto our project team. And they spent a lot of time on the front end, mapping out what the current-state clinical processes were, and what the future-state processes would be. And this was nurses talking with nurses. So nurses were doing the change management aspect of the process, as well as mapping out the future state; in other words, they were doing the ‘what.’ And on the other side, we had the nurse analysts and other clinicians in IS, and they were the builders, so they were doing the ‘how.’ In short, having that working relationship, with a lot of clinicians on the team doing this, was key. Fortunately, we had nurses in clinical informatics; and those clinical informaticists could translate clinical terms into IT tactics well. Now, you can certainly do that with more typical IT people, but they’re going to have to listen a lot harder. So that process builds a lot of trust, and a lot of validity. And a lot of change management.
One other element here was educating senior executives the tools of change management, even to the extent of giving them talking points, so that if an irate physician comes at them, they’d know what was going on and know what the potential push-back was, and so that they’d be able to know how to respond to the push-back from physicians. Because if the senior executives fold when confronted by physicians, you’re dead in the water, and you’ll never get a system implemented.
MH: With regard to the physician side of implementation, do you have a CMIO?
RE: We do, though not formally with that title. But early on, we identified a physician who had always been a champion in that he had gotten involved. He was neither a yes-man nor a geek, but it so happened that he was going into retirement from active practice, and he was able to take on a role in what we were doing. And he had the respect of physicians. So, with his facilitation, we created a physician advisory group. And even in the early, early stages, we would take a group of about 40 physicians off for a weekend retreat, and we spent that weekend educating them for what was coming and what an electronic medical record was, and how that would impact them.
We’ve done that for five years in a row now, around the same time each year. And that really changed physicians’ attitudes about implementing CPOE. It took time. In the first year, the physicians were saying, essentially, with regard to CPOE, ‘Hell no, we won’t go, you’re trying to make us your clerical people.’ And in year two, they were reading articles and saying, ‘OK, maybe evidence-based medicine and pay for performance are really happening, so this is inevitable.’ And in year three, it was, ‘Let me figure out how I can work this in, in order to benefit myself, since I need to get involved.’ In other words, over time, as we educated them on what was happening in the industry and in the press, we were able to give them information that was validating information that we were telling them ourselves. And it helped that we brought in physician executives from our vendor company to converse with them on a peer-to-peer level as well.
MH: Are you live on CPOE now?
RE: No, not yet, our first facility is scheduled for the spring of 2010; so we’re finishing documentation this year, and laying on top of that plans of care, and then doing CPOE.
MH: What have been the biggest lessons learned in all this?
RE: There have been so many. Be prepared to make some modifications and changes. And with regard to the nursing side of an implementation specifically, expect that you’ll need to communicate with those front-line nurse leaders, because information doesn’t trickle down, and everyone’s so busy, so you really need to make the effort through several different channels, to reach them. And, go-live is not the end; you need to spend a lot of time on-site, and to continually train. The training you do in the classroom before go-live just introduces the concept. So we have weekly meetings, and we also have nursing informaticists at their shoulders on the floors, so they don’t get frustrated. But one of the biggest light bulbs that’s gone on and that we initially missed, in all our good intentions, and that is that we taught them how to use the system, but we didn’t teach them how to do their jobs.