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
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.