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?