Every EHR go-live marks their support staff in some colorful way so they’re easily identified. At UCSF we had our support team in green polo shirts. At UCLA we’re in spiff red fleece vests. As a Cal graduate, wearing Stanford colors on a UC campus will always disorient me, but it works.
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.”
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
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.
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.
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?”
Its our 7th day live on Epic in our inpatient areas, and at 1522 we lost commercial power. The rumor so far is that PG&E has had a substation go down and power is out for several blocks at least. Our clinical areas are equipped with multiple layers of emergency power and are fine, as is our phone bank for supporting clinicians, but here at the Command Center in UC Hall we’re in the dark for now.
Update – the word on Twitter is that power is out all the way to 19th Avenue (we are at 3rd Avenue) with 11,000 customers blacked out.
Update #2 – San Francisco Chronicle confirming.
Update #3 – power is back on after 55 minutes.
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.
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.
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.
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.