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.”

Oroville Hospital Implements VistA

by guest author Matthew N. Fine, MD

Several years ago I had the pleasure of meeting Dr Matthew Fine, Chief Medical Officer and Director of Patient Safety at Oroville Hospital, at UCSF’s annual CME course Management of the Hospitalized Patient.  When Dr Fine attended the course again this year, he told me Oroville Hospital had recently gone live with CPOE on VistA, the EHR developed by the Veterans’ Administration. I’ve invited Dr Fine to post a two-part series here on Oroville Hospital’s experience. In this first part, he discusses their strategic approach and their initial experiences with electronic documentation, and in the second, their 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

On October 16, 2012, Oroville Hospital turned on the CPOE component of its EHR, becoming the first individual US hospital to successfully adapt the Veterans’ Administration’s highly regarded electronic medical records system. How did a small, 153 bed semirural California hospital serving a mostly Medicare and MediCal population arrive at this place?

Almost exactly six years before, in October 2006, I attended the EMR and CPOE workshop with Drs. Russ Cucina and Michael Blum at the UCSF Hospital Medicine conference chaired by Dr. Bob Wachter.  The last thing Dr Cucina mentioned was the VistA system, which he said had barriers to its use at a non-VA hospital. At Oroville Hospital we had been discussing what do about EHR. We found that the proprietary systems were expensive, less than functionally ideal, and we didn’t want the tail wagging the dog. At one of our meetings in early 2007 I remembered I’d heard about the VA system and that “it’s free.” That night our CEO, Bob Wentz, downloaded the program.

We explored working with private companies that were marketing VistA with some embellishments and impressive consulting fees. They also retained proprietary rights to the system, restricting or charging for modification and thereby closing the open source. The hospital leadership decided to see if we could do it ourselves. The CIO retired and moved to Mexico.

We visited several VA hospitals to see the system in operation.  Whenever we spoke with residents, who also work at their university hospital, we found they preferred the VA system.  A team was assembled including Dr. Narinder Singh, a techy internist who had helped implement an outpatient system, Denise LeFevre, the new CIO who had started working at Oroville Hospital about 25 years ago while still in high school, the CEO Robert (we can do this) Wentz, CEO and Zach (the ex-pizza guy) Gonzales, now Director of VistA Development.

Initially, they chose Linux over Windows and a non-proprietary data base GT.M was used instead of Cache to complete the open-source stack. The EHR team took classes from consultants to learn the functionality of the system. They learned what they could do on their own and for what they needed VistA clinical application coordinators from various disciplines. They traded ideas with the country of Jordan, which is also implementing VistA. Some of the consultants worked in both places.

In April of 2009 I started using the system in my office practice.  I insisted on a small mobile cart with a small device – I got a notebook, so I could look at the patient no matter where they were in the room.  At first we had “flat templates” which were soon replaced with ones that were more flexible and interactive. The mental work of learning a new system while taking care of patients was a real challenge, which I’m sure is the case for many physicians “of a certain age.” After about six months, I felt comfortable with the system and after about a year and half you couldn’t take it away from me.  Having known that the system would be trialed in my office, I did a time utilization study before and after EHR.  Before EHR, a routine follow-up encounter took about 10 minutes of which total clinical time (including multitasking) was 8:57 and undivided clinical time was 6:22.  Six weeks into EHR a visit took about 16 minutes and total clinical time was almost the same at 8:12, but undivided clinical time had fallen to 3:02. Follow-up visits are now taking about 12 minutes, but I feel the clinical only time has gone up considerably.  My long time patients often say something like “Wow, your typing has improved.”  While the EHR team was working on the inpatient side, over the next two years we added about twenty other clinics including pediatrics.

Slowly our homegrown and consulting geeks, many of whom had vast VistA experience began designing, building and arranging for the necessary components of the system. An interface was constructed for our Sunquest lab system which serves the hospital and many affiliated and independent clinics.  A McKesson PACS system for imaging was installed and integrated with VistA using HL7.  An electronic prescription system was developed from scratch.

Billing was a major issue. The hospital had a well-functioning financial management system and we did not want to interrupt the cash flow, so it was decided it should not be disturbed. Instead, an interface with the billing system was created that sends the needed pieces for billing to a proprietary system.

Even before the EHR was contemplated, the medical staff had been developing paper order sets. By 2011 there were almost 100. They had been designed using a systematic format, so they could be converted with few changes to CPOE. Since the providers were very familiar with them and had participated in their creation, acceptance has not been a significant problem.

Gradually the medical information was linked to VistA so the system would be “VistA-centric”. By the summer of this year the process was almost complete including lab, imaging, and dictated reports. Most recently ECGs, echocardiograms, and ABGs were added. All the nursing notes and most of the progress notes were being documented on the computer. The ICU flow sheet was created using the VA’s CP Flowsheet module and implemented at the same time as CPOE.  It’s complex and slow, but is being improved almost daily and will be used as the basis for anesthesia, obstetrical, and infusion center flow sheets.

Seven tips to prevent medical technology from ruining the doctor-patient relationship

Does this sound like something that has happened to you?  You are driving, you stop at a red light, and all of a sudden you find that your iPhone has migrated its way from your pocket or the passenger seat of the car into your hands.  You push an elevator button and pull the phone out of your pocket to glance at it in that split second while waiting for the door to open.  You eat dinner with a group of six friends and everyone is buried in Facebook rather than making eye contact.  In all facets of life, we are quickly becoming more entangled with our machines, allowing them to become extensions of ourselves.  The hallowed walls of the doctor’s office have not shielded out this rising tide.  This “Piece of my Mind” by Elizabeth Toll in the June 20th JAMA eloquently captures what so many of us have been feeling and seeing over the last few months and years.  Here is an excerpt of her opening paragraph and the drawing she discusses:

Dr. Toll goes on to discuss how this particular physician is someone overflowing with empathy for patients and enthusiasm for medicine.  Unfortunately, the computer has now demanded his attention, which he can no longer fully devote to his patient.  I agree wholeheartedly with Dr. Toll and I hope that her article will spark a dialogue about this issue in the medical community.

Part of the problem is the current generation of electronic health record (EHR) systems.  They demand too much cognitive effort to use.  In fact, Horsky et al showed that users of a CPOE system used twice as much cognitive effort on system operation as on patient-centered clinical reasoning.  This balance has to shift.  Nobody wants her physician wasting his energy and focus like this.

This improvement in EHRs will happen.  As was pointed out on Twitter this morning by @ReasObBob: “#EHRs will get better. Poor EHRs are not the problem but the symptom. New approach needed. We’re working on it.”  Bob is right.  The current generation of EHRs has been built to meet the demands of a healthcare system that is focused on compliance and billing.  We got what we asked for.  This time around, let’s ask for what we really want.  Let’s ask for EHRs that are sleek and streamlined, easy to use, and that augment the high-quality and high-empathy medical care we want to provide.

What are physicians to do in the meantime?  I have spent some time in the last few years thinking and reading about this.  How can we best maintain the doctor-patient relationship in the age of the EHR?  I offer you seven tips:

1) Set-up your office properly, with placement of the chairs, monitor, and keyboard to best support good eye contact between you and the patient.  Don’t allow your office to become like this drawing, where your chair could put your back to the patient.  This is common sense, not Feng Shui.  (I will post some photos of exam rooms at the bottom of this blog piece to allow you to start to think about what works and what does not work)

2) Get a quiet keyboard.  If you think this sounds trivial, try this: Spend one day in your clinic using a loud keyboard and then switch to a quiet one.  You’ll see.

3) If you can, spend thirty seconds preparing the electronic visit before you walk in to see the patient so that you are ready to hit the ground running.  You want to be immediately ready to let a patient start talking to you without interruption to start the visit.  Visits get off to a bad start when they go like this: “So, what brought you in here?”  “Well, my thyroid…” “Hold on a minute, I have to log-on and get a new progress note open so I can write down what you say.”

4) Let the patient see your screen.  Hopefully you are not reading ESPN.com when you are talking to your patient.  Let them share the experience with you, and share the fact that you are populating their medical record.  I have on many occasions had this lead to bonding moments with my patients when we are both hunting through the CPOE (computerized provider order entry) system for a particular type of glucose test strip prescription or some other seemingly hidden or obscure task.

5) For part of your visit with the patient, stop typing, take your hands away from the mouse and keyboard, and use the body language we learned how to use as first year medical students in Introduction to Clinical Medicine.  Every visit has at least one natural moment when the patient has to be certain that one-hundred percent of your attention is focused on her.

6) Practice.  Seeing patients while using an EHR is a learned skill.  None of us were able to handwrite a perfect note while talking to a patient the first day of medical school.  The new generation of medical students will learn how to talk to patients while typing from day one.  At UCSF, the new Kanbar Teaching and Learning Center has simulated exam rooms to help medical students learn this (although, embarrassingly, you’ll notice in the photos on their website that the computer monitors are buried in the corner of each exam room, assuring the “back-to-patient” syndrome).

7) Remember that this is our chance to take back the medical record.  Let us not forget that, even with paper charts, the medical chart has increasingly become about legal protection, billing, and reimbursement.  The EHR gives us a clean slate, a new opportunity that brings us legible notes and notes that are immediately visible to colleagues.  Take advantage of this.  Write good narratives.  Tell your patients’ stories.  Make the medical record useful again.

Sample photos of exam rooms

                     

Go-live Week 2 – good numbers, and the triple intersection of complexity

We’ve been live on Epic in inpatient now for two weeks and we’re cautiously very happy with our results. Direct entry of orders by physicians is stable at just over 90%, with the balance being orders written on paper in settings we planned for (chemotherapy and pediatric TPN) and verbal or telephone orders.  We’re digging in to our live data on verbal and telephone orders to see how they cluster and how we can continue to reduce them. Revenues remain within the margin of variation, and our near-term clinical metrics (door-to-floor, average length of stay, etc) are unchanged to slightly improved. The very interesting clinical outcomes, like rates of medication error or risk-adjusted mortality, await more data.

Our knottiest workflows in the system are what Epic calls (a little strangely) “Hospital Outpatient Departments”. These are facilities that serve both inpatients and outpatients, like interventional radiology and the endoscopy suite, and so require a mix of inpatient and outpatient workflow and software. If the patient needs full anesthesia for the procedure, as is often the case with child patients, you have a triple-intersection of complexity. In our paper-based prior existence this was all smoothed over by smart people with lots of institutional knowledge and the right relationships. They knew how to get anything done. In preparing for an integrated EHR we put a great deal of effort in to analyzing this work prospectively, but the magnitude of change brought by automation has had unintended effects. No surprise, and we’re crunching through all those processes again with the benefit of experiencing the system in real life, and the problems continue to look solvable.

Meanwhile our clinicians continue to ask deeper and more interesting questions about the system, moving from “How do I get my job done?”, to “How do I manage this complex discharge?”, and on to “Our Division wants to start publishing custom packages of SmartLinks and we want to send people to Wisconsin. Whom do we talk to?”

[ Special welcome to the Twitter followers of UCSF Division of Hospital Medicine chief Bob Wachter, physician-leader extraordinaire and blogger at Wachter’s World. ]

Go-Live Day 5 – the Complexity of Security and the Madness of Printers

We’re five days in to our go-live and continuing to maintain all our expected workflows on the system. Our CPOE rate hit 90% today, the balance being orders written on paper for expected reasons (Pediatric TPN and Chemotherapy) and telephone or verbal orders. Our ED door-to-floor time is about expected, neither better (yet) nor measurably worse. Revenues are within the margin of variation.

Below are the trouble tickets called in to our service desk broken out by category.  As anticipated the large majority of issues are users whose security is not set up perfectly for their role.  Security settings in Epic are very customizable and, it has to be said, enormously complicated. When I took the Epic security class in Madison it reminded me of the nephron.

Next in the stack is “optimization” which for now doesn’t count as trouble, and third on the list is printing.  With the incredibly powerful things we can do with technology, like order and document extracorporal membrane oxygenation on a premature infant clinging to life, I find it remarkable that printers everywhere continue to be such a pain. No amount of rigor and testing (and we did a lot of testing) here or elsewhere can seem to entirely decomplexify them.

Graph of the Trouble Ticket categories for UCSF's Epic go-live

Trouble Tickets by Category

The Go-Live Progression

The go-live progression:

Day 1: “What’s NoteWriter?  I want UCare back.”

Day 2: “Do I have to use NoteWriter?  I want UCare back.”

Day 3: “Which NoteWriter templates do you think are the best?”

Day 4: “I think I can do this NoteWriter thing.”

Day 5: “Let me show you this cool NoteWriter macro I made!”

Housestaff learn quickly.

Go-Live Day 4

Picture of a temporary power panel installed in the Apex (Epic) Command Center at UCSF.

More power than the early 20th century had planned for.

We’re now 96 hours live on the system with two weekend days and two weekdays under our belt.

From the beginning we made CPOE mandatory with the exception of chemotherapy protocols and pediatric TPN. We had 1669 calls to the support line on the first weekday (Monday) and 677 Tuesday. We’ve had 4,167 concurrent staff members in the system at its peak to date, including clinical and non-clinical users, and 16,446 orders entered electronically in Apex (Epic) in the last 24 hours.

We took over two large office suites on the campus for the support effort. One houses the service desk that receives calls, the other is the “Command Center” for the applications team. Both these groups are in UC Hall, built in 1917 and the oldest building on UCSF’s Parnassus Campus. Our facilities department had to wire in an auxiliary power distribution panel to accommodate the electrical load.  We also have two support resource rooms for drop-in help and training, one inside the cafeteria and once just adjacent to it.

The endless creativity of the user

Before flipping the switch and releasing a live system into the wild, you build and rebuild, meet and discuss, plan and prepare, train and cajole.  You think you have a good idea of how your end users will interact with the system.  Then you go live.  And thousands of people start using the system.  Those people provide more eyes, ears, and brains in front of the system, trying to get their daily jobs done.  Just as water cuts its own path through sand and stone, cleverly, but purposefully meandering towards a final destination, so do the users.  They are endlessly creative, figuring out ways to use the system that often could not have been anticipated and that are often ingenious.  In a system that is both as deep and broad as Epic, there truly are many ways to do any one thing.  So, it is often worth sitting back and watching what people figure out for themselves before jumping in to try to teach them “the right way” to do something, because hey, we might learn a better way.

Go-Live Day 3 – The Home Opener

An aerial photo of AT&T Park with downtown San Francisco in the backgroundOur medical informatics group likes baseball metaphors, and we’ve described the Monday just past as the home opener. Our ambulatory practices were in full swing using Apex (Epic) for registration and billing for the first time. With a large influx of new administrative users to the system we’ve had an uptick in users needing changes to their security setup, but worked through that volume during the day and evening. The spike in call volume around mid-morning briefly stressed parts of our voice telecom system (of all things). On the clinical side, the first full day using Apex for anesthesia and OR operations went remarkably smoothly; more later on the extraordinary efforts of Dr David Robinowitz and many others to implement this newer module of Epic at UCSF.

On the inpatient side, we’re refining aspects of the discharge process and the collaboration between physicians and case managers. Fewer than half the patients hospitalized at UCSF receive their primary care here, so we work hard to bridge the gap between our inpatient and specialty services and the care patients receive in their own communities. We plan to implement CareEverywhere, Epic’s health information exchange, which will go part of the way toward tightening those connections electronically.

T plus 2 days – First Monday on Inpatient Epic EHR

We’ve been live on inpatient CPOE for 48 hours and our first Monday morning is about to begin. We have 72 cases scheduled in the operating room and 4000+ scheduled ambulatory visits in addition to the ED traffic and inpatient census over the weekend. It’ll be a significant step-up in users to support, in the pace of events, and in process complexity. We have 12 telephone support staff on the MD hotline, and the command center is filling up with the full crew of build analysts and leads.