Go Bruins – UCLA Goes Live Tonight with its “CareConnect” Epic Electronic Health Record

Big BruinAt midnight tonight UCLA Medical Center will go live with CareConnect, their name for their implementation of the Epic electronic health record. With this, four of the five University of California Medical Centers (Davis, San Diego, San Francisco, and Los Angeles) will have the same EHR infrastructure.
A handful of us from San Francisco, including my colleagues Carolyn Jasik, Ellen Weber, David Robinowitz, and I, are spending four days here helping support their clinicians and their go-live team. The two institutions have a lot in common, and several physicians from UCLA visited UCSF during our go-live to provide support and meet with our leadership team. It will be fascinating to see the similarities and differences in our respective builds and in how the clinicians work through their first days with the system.

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.

Slides from Grand Rounds at Seton Hospital

Thank you to everyone who joined me for grand rounds at Seton Hospital this morning.  Posted here are the slides from my talk, “Social Media and Your Practice, Ready or Not”.  Happy socializing —

 

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.

Slides for “Social Media and Your Practice – Ready or Not”

A special welcome to the attendees of Advances in Internal Medicine 2012, the annual continuing medical education conference chaired by Prof. Quinny Cheng at the University of California, San Francisco.

Below are the slides and resources from my keynote, “Social Media and Your Practice – Ready or Not.”  Thanks to all who attended,  I enjoyed the discussion.

 

EHR Go-Live Footwork

I wear a Fitbit digital pedometer, a gadget my colleague Dr Aaron Neinstein wrote about recently. Below is what our EHR go-live night looked like in terms of footwork, with the “T minus 2 hour” midnight mark at far left, and “T plus 22 hours” at far right. Fitbit’s online graph insists on displaying calendar days so the afternoon and evening run-up to the go-live does not show here. The stretch of inactivity at midday is me getting some sleep. Graph of pedometer readings for UCSF Epic EHR go-live

Social Media and Your Practice, Ready or Not [Presentation]

A special welcome to the attendees of Advances in Internal Medicine 2012, the annual continuing medical education conference chaired by Prof. Quinny Cheng at the University of California, San Francisco.

Below are the slides and resources from my keynote, “Social Media and Your Practice – Ready or Not.” Thanks to all attendees.  I enjoyed the discussion!