by guest author Matthew N. Fine, MD
This is the second in Dr Fine’s two-part series describing Oroville Hospital‘s implementation of VistA, the 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
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.”