William (Bill) Phillips is CIO of University Health System, San Antonio, Texas, which recently attained Stage 6 designation in the HIMSS Analytics EMR Adoption Model.
Q: How involved were the physicians in the IT process, especially CPOE?
A: That was a difficult task. We took many approaches to training, we had classrooms, we had online CBTs and we also created our own training where we made PowerPoint’s on disk and started handing them out to physicians with basic instructions how to get in, how to do orders, things like that. The training was very difficult so what we did when we went live in these units, I went to the CNO and said as we begin this roll out “I need help at the bedside and at point of care.” So I asked the CNO for 16 nurses to be dedicated to me for a period of seven months. In a time of nursing shortage I got that. Our organization knew the importance of getting to the EMR. So we trained those 16 nurses to be power super users. So when we went to a floor I carved this off into many multidisciplinary teams and I had teams that would evaluate the security aspects, hardware, workflow. We would actually evaluate the workflow of every clinic, whether it was on paper and then what it would be like in the electronic. As you know, you never, ever take what you’re doing on paper and copy that into the electronic. It will not work. So we’d roll a unit and have 24/7 support of these nurses in the unit for two weeks and they’d be helping the physicians and the nurses. We’d go to the next unit and teams would move. And we kept this going and so from the physician training… you know trying to get a physician to sit still in a room for four hours just wasn’t going to work. We had shortened classes, we had online CBTs and we had disks that we gave them and the bedside point of care instructions.
Q: These are voluntary physicians?
A: We own our own medical practice group that supports our ambulatory clinics and then we contract with the University of Texas for all our inpatient physicians and our specialty physicians. So we are truly a closed medical staff.
Q: So you CAN tell them they have to do this or else.
A: And we DID tell them (laughs) And we found the younger physicians, they grew up with mouse in hand instead of bottle in hand and they adapted right away. We did have some physicians that couldn’t type and we had to work with them and use a little bit of transcription here and there. And we interfaced transcription services right into the EMR. So the physician buy in was very interesting in that it ranked by areas of service. We found surgeons were a little harder than OB. Then we started seeing the outcomes and benefits in the continuum of care, because our patient populations move between our clinics and our inpatient setting on a regular basis.
Q: Do they go to other hospitals or outpatient facilities?
A: They pretty much stay here. Our patients are normally repeats. We also get a lot of one-timers because of our geographical location and we are supporting 22 counties, so we get a lot of one-timers as well. Our patients move between our facilities. And you used to have to wait for the medical record to come to you. I use the emergency center as a prime example where we have 70,000 visits a year, patients would show up not knowing what medications they’re on, saying “all I can tell you is I take a blue pill or a green pill.” And you know they would never really know what they’re on. Now our ED physicians see what the patient was being treated for in the ambulatory setting, what the meds are so they know, even if the patient is comatose, they know the medical history instantly. And we really utilize alerts and prompts. On our specialty services, we even have diagrams of the heart so what happens is when you have a cath, as an example, you go back to your PCP and your PCP was never really knowing how long to leave the Plavix and where your stent is placed. So now they draw on the actual image of the heart where they put the stent in and we have an order set that says, 'leave on Plavix for three months or six months.' And even out of the ED from an alert standpoint, we page out of range alerts. So a prime example is traponin -- you come in for a heart attack, you used to get an EKG and a blood draw and someone would have to go and find your results so if they were out of range, guess where you’re going? Time is muscle, you’re going to the cath lab.
Q: What is it that gets you that last HIMSS Analytics stage? What is 4 to 5 and 5 to 6? And what’s the cost to benefit ration at the upper levels—does it cost a lot more to get to Stage 6?
A: I’m asked a lot of times, “Hey Bill what do you think the hard savings are when you look at an EMR?” And you have to look at hard dollars and you have to look at soft dollars. And honestly hard dollars you get from outcomes and a good example of that is every healthcare organization in the country has to support core indicators. We’re already submitting voluntary numbers and getting the additional 1.5 percent bonus. So you start looking at that. That’s a hard dollar, that’s a hard number savings. We see hard number saving for results in duplicate tests or pneumonia vaccines. We have those hard dollars. But you also have soft dollars in the patient’s lives. What’s the value in that patient’s life when you can save them because of a drug interaction alert that fired off?
Q: Are the hard dollars greater earlier or later in a Stage 6 hospital?
A: Later. I feel that's becuase as you continue to use an EMR and you continue to adopt that methodology in your daily mining, your inefficiencies continue to come to light. One thing the EMR will do is point out any flaw in the workflow process you have, and it will shine a bright light on that flaw. A primary example is restraints. We didn’t build anything around reassessing restraint offers and we start mining data and we found out that 50 percent of reassessments were being done and then we put in a soft alert to see how the organization would adopt. Well we moved that up to 72 percent, stayed idle for a while. We had the data mining ability, we had the knowledge, we put a hard alert in and put it up over 90 percent instantly. The further along in those stages and you understand your data and you understand what you’re doing, the cost savings continue, and continue to come. And that’s what we’re seeing. Right now we’re doing things with pneumovax and we’re saving money. As physicians continue to buy in, and they start getting creative with their ideas, ‘Hey I think we’re wasting money over here, can you pull data and see what we’re doing here?'
Q: And you listen to them.
A: You bet. Because they’re the ones in the trenches. I have a couple of physicians that are very big on quality and just because of that they started looking at pneumovax and said “Hey if you can write this we can change this flow sheet.” And things like that start coming out. Then once you get the physicians to understand this is coming everywhere in the country eventually. We had the normal pushback from physicians “Hey you’re turning me into a clerical person” and I heard that over and over and we as an organization said “This is a computerized physician order entry system. That means you the physician will enter the order and not the nurse.” And we stood very strong on that and had a lot of resistance up front and got through it and we’re here today.
Q: What about the final pieces to get to Stage 6. Are those last miles harder and more expensive?
A: Yes, and they get more difficult. What I mean by that, one of the last items that pushed us over to Stage 6 was the integration with smart pumps and that gives you your medication management and bar-coding at the pump level as you're getting an order directly out of the system. And so you look at that investment in Alerus smart pumps and that’s a sizeable dollar amount. And if you bought them and didn’t plan to integrate them you really didn’t do a whole lot of good for the organization.
Q: Did you have that in mind even before Eclipsys?
A: Yes. The plan was from the get go we wanted to integrate everything that we physically possibly could. Integration is our roadmap. I share integration diagrams and it is unbelievable when you look at it. Without it you really haven’t accomplished anything and a lot of people don’t understand that. Until you make your systems all talk together and pass data between it you’re not accomplishing a lot.
Q: What kind of advice would you give other CIOs?