Oroville Hospital Implements VistA, part 2

by guest author Matthew N. Fine, MD

This is the second in Dr Fine’s two-part series describing Oroville Hospital‘s implementation of VistAthe open-source EHR developed by the Veterans’ Administration. In his first post, he discussed their strategic approach and initial experiences with electronic documentation. Here, he picks up with Oroville Hospital’s CPOE go-live. – RC

Guest blogger Dr Matthew Fine, Chief Medical Officer and Director of Patient Safety, Oroville Hospital

Guest blogger Dr Matthew Fine, Chief Medical Officer and Director of Patient Safety, Oroville Hospital

After a whole year of hybrid charts the staff was chomping at the bit to go live and the anticipation outweighed the fear. Turning on CPOE was almost a welcomed event – watch out what you wish for. I think the (unintentional) strategy of having hybrid charts may be a good way to make full conversion to EHR more palatable.  CPOE was turned on October 15, and by the end of the first week nearly 70% of the orders were electronic and it’s now about 80%. There are holdouts among some of the physicians, notably surgeons and OB/Gynes.  Does anyone else have this problem? The hospitalists have a co-management arrangement with the surgeons, so most of their patients’ orders are electronic. This situation has actually give the EHR staff a little breather, enabling them to clean up many of the minor problems, including building a number of new orders sets – everything on VistA is easier with an order set.  We expect that CPOE will be mandatory within two months.  The pharmacy has created weight-based medication orders for pediatrics.  We don’t have a neonatal ICU, but it’s felt that the CP Flowsheet module could be adapted for this function. We are still working on a better medication reconciliation system.

Now, three weeks after the “go live” it’s still somewhat hectic and there are numerous minor and a number of major refinements required.  Dr. Singh our CMIO wondered when he would be able to go back to doing more clinical work – never!  Most of the problems have been delay in care, but a lot of the orders are carried out more quickly since they are sent directly to the appropriate department. There was a wrong medication entered by a pharmacist due to our still partly paper medication reconciliation system. Despite the challenges, some of our nurses and physicians, who also work in other area hospitals with proprietary systems, already prefer VistA.

Stage I meaningful use was achieved in 2011 and 2012 for the hospital and some of the clinics.  We are working on Stage II.

The EHR staff has participated extensively in the WorldVistA and, recently, OSEHRA, VistA’s non-governmental arm.   Oroville Hospital’s efforts are well known to the VistA community.  More than 100 patches to FOIA version of VistA have been created and some are being used by the VA in general.  The hospital is continuing to build additional enhancements and modules with the open source community.  Oroville Hospital made the necessary modifications and financed some other products through WorldVistA to get VistA certified by CCHIT. These upgrades include the ePrescribe system, which allows prescriptions to be sent to retail pharmacies through a clearing house, and has just been released to open source by WorldVistA.

Web based products were developed with collaborators in London. Enterprise Web Developer (EWD) was used as a framework to rapidly build rich web applications over a MUMPS database.  It allows us to deliver content to any device regardless of operating system, including iOS, Mac, Linux, Android and Windows based clients, eliminating device constraints. A number of our providers use an iPad to access information, but prefer mouse based computers for entering orders and writing notes. Also using EWD, Oroville has developed a real-time dashboard to monitor orders and other patient activity.  A patient portal for access to records from home will be rolled out next month.

For the last two years a number of clinics have been sharing health information. Last week Narinder and Denise participated in a regional HIE meeting in Sacramento that will allow for the trading of records with our SacValley MedShare HIE, of which Oroville Hospital is one of four core members.

Being from the clinical (the light) side of the project, I know I’ve given short shrift to the technological accomplishment of the team.  The usual progression of my requests for a new function is “the system can’t do that” to “it’s hard and will take a long time” to “I’ve got something to show you.” I also want to acknowledge the hard work done by many members of our staff.  Our HIT department is relatively small, so each department played a large part in developing their specific components.  Pharmacy, nursing and nutrition deserve special mention.

The total cost of the system, from soup to nuts, has been about $14 million.  Compared to proprietary systems, this amount contains a significantly higher proportion of hardware expenditures, including servers to support VMware.  This decision allowed the hospital to provide enough devices for all users, including dummy devices, and to let them use their preferred device.  Even though the system is open source, there will probably be some return on investment such as fees for use of the clearing house function for ePrescribe, consultation charges, and licensing for the order sets.  A detailed breakdown of the costs is covered in an upcoming article in the Open Health News.  If another non-VA hospital choses to use the use the system, it is felt their costs would be considerably less since they would not have the development expenses.

Bob Wentz said that he has been asked a number of times how a small hospital ended up developing an e-prescription system; he tells them – and I think his answer applies to the system as a whole – “Because we needed to.”

UCSF Launches Electronic Exchange of Health Information

On September 1st UCSF Medical Center turned on electronic health information exchange with our Epic electronic health record. It’s an important step forward and one of the features of electronic health records I’m most enthusiastic about. It has the power to improve health not just at our own institution but wherever our patients go. We had hoped to enable this as part of our June 2nd inpatient big-bang go-live, but decided to wait 90 days to make sure some final details were fully hammered out.

Epic has two levels of electronic health information exchange, “CareEverywhere” for exchanging information between Epic customers, and “CareElsewhere” for more limited exchange with a non-Epic EHR. For now we’ve turned on CareEverywhere, connecting us with participating northern California providers like UC DavisStanford, and Palo Alto Medical Foundation, although there’s no geographic limit within the United States for where records can be shared. (With their particular sense of humor, Epic presented this week at their annual meeting on the future “Intergalactic” sharing of health records, emphasizing the point with photos of the Curiosity Rover and The Netherlands)  Our first exchange was at 10am on the 1st when we electronically received records for an ill youth hospitalized at UCSF who had previously received care at Stanford, and we had a dozen exchanges in the first 7 days.

Like always, we only share health information between institutions after getting written permission from our patient.  The large majority of patients want their health information shared electronically with other physicians and hospitals when we need it to provide safe and appropriate care, as long as we are sharing securely. In my experience, my patients are surprised to learn even major hospitals have largely remained isolated islands of information. When I collect permission from a patient to obtain their records from a hospital across town, patients are usually surprised and discomforted to learn I didn’t have access to it already.  Health care is far behind other industries in this kind of information integration, and fixing this in a hurry is a centerpiece of the federal government’s standards for health IT implementation.

For the last few decades health records have been shared primarily by telephone and fax. We call the primary physician’s office (for example) and if we actually reach the physician immediately, we usually get their best recollection of the patient off the top of their head, followed by more complete information by fax hours or days later if at all. If the patient was recently hospitalized, getting that hospital record requires work from that hospital’s medical records department, seldom a 24/7 operation, and it arrives as a thick, grainy, often disordered, fax-of-a-copy-of-a-scan of the original record. This helps, but the information has to be manually transcribed in to our own record, which is only as accurate and complete as any 10-fingered process.

With electronic health information exchange, sharing patient records is more secure and more accurate. The electronic point-to-point connection between institutions is encrypted and the identity of the patient is confirmed electronically between the EHRs. The patient’s health information arrives immediately in our EHR instead of on the tray of a fax machine some unknown number of hours later.  A physician on our receiving end reads and validates the electronically exchanged information before incorporating it in to our own record. The exchange is at the level of data instead of pieces of paper, and so discrete information like medication lists, drug allergies, problem lists, and other pieces of history can be synchronized between the institutions.

Unfortunately we’re still not able to exchange information with San Francisco General Hospital or Kaiser Northern California, two providers with whom we share many patients.  Kaiser Northern California has been on Epic for years, but does not to participate in electronic health information exchange. San Francisco General is moving fast on implementing its own electronic health record, and we look forward to connecting with them when the capability on both sides is ready.

Epic Go-Live at 1 Month

We’ve been live on Epic now for a little over 1 month. Our newly-minted interns started work on June 21st and a flock of new upper-year resident physicians and fellows began July 1st.  One of the most enjoyable aspects of practice at UCSF is the phenomenal quality of students and trainees we attract, and as hoped, our new trainees have taken to the EHR and computerized provider order entry especially smoothly. In some respects they are more comfortable with the workflows than the senior trainees who directly supervise them because the new arrivals have no prior expectations from how things at UCSF used to work. We also have the advantage that something like one-third of our new trainees come from a hospital system that was itself an Epic customer.

Total call volume to our “provider” (physician, NP, and PA) and general help desks, starting with the go-live date.

The interaction between Epic CPOE and our lab and radiology systems continue to have some challenging wrinkles. Epic offers an integrated laboratory system called “Beaker” and a radiology system called “Radiant”. (Epic likes to give cute names to its software components) For reasons of project scope among others, we chose to stay with Sunquest and IDX/Rad for lab and radiology (respectively) for the time being. Although these are each leading systems and widely used elsewhere, the workflow integration between Epic and these ‘outside’ systems remains a work in progress in edge-case scenarios.

The only workflow to date we’ve backed out of is using Epic to satisfy the CMS requirement for an attending physician to document their face-to-face evaluation of an inpatient to qualify them for home care. We built this in Epic as an ‘order’ with all the required elements, and the Case Manager could tee this up (‘pend’ it in Epic jargon) for the attending’s review and signature. For reasons of workflow and the competition for attention, we’ve backed off on having this be electronic for now and reverted to the paper form.

The next piece of functionality we aim to turn on is health information exchange. Epic calls this “CareEverywere” for data-level exchange between Epic customers and “CareElsewhere” for the exchange of CCD documents with non-Epic EHRs.  Once we throw the switch on CareEverywhere we’ll be able to exchange data with other Epic customers, including our fellow University of California Medical Centers in Sacramento (UC Davis), Los Angeles, and San Diego, and with our respected colleague-competitors at Stanford. Health information exchange will be a signature advance in our service to the community, but at first the clinical impact will be modest because we share relatively few patients with these sites.  Of the main regional health care systems, we share the most patients with Kaiser-Permanente, San Francisco General Hospital, and the City-operated Department of Public Health clinics. However, although Kaiser-Permanente is also an Epic customer and participated in health information exchange in Colorado, their northern California region opts against health information exchange outside the Kaiser system. San Francisco General Hospital and the DPH clinics are underway with their own (non-Epic) EHR projects, and I hope to see us sharing CCD documents with them once the technical ability on both sides is in place.