One of the biggest challenges in medicine is that people start forgetting the instant they leave medical school and the residency.
Best way it to get more information to the doctor doing the examination and getting it to them sooner. Doctors can make the right decision if they get the right information right when they see a patient.
Information is scattered. Time constraints mean that information needs to be at one spot. Possibility of allowing multiple doctors to look at records at the same time.
Impetus for the EMR is also due to government regulations. Ability to enforce compliance by electronic reminders.
Carle used Epic as a provider. About 1.5 years in evaluating systems. Traveled to different hospitals to inspect systems and components. Narrowed it down to three different systems. Vendor choice #2 didn't have a pharmacy module. Epic was weak in its nursing documentation. But as time went on, Epic gained better nursing documentation.
Nurses do the majority of performing the care of actual patients.
What documentation has to be done in certain circumstances? EMR helps enforce this. Dr. William Schuh asked to install the system, despite the fact that he's not grounded in high technology.
Now when hiring physicians – recruiters ask “what kind of EMR system are you experienced with?”
If you look at the EMR project as an IT project, it will fail. The approach is to look at it as a clinical tool. A lot of people spent a lot of time asking physicians “what do you need in order to do your practice?”
Overcame resistance by asking what their needs are and building implementations that are tailored to doctor's complaints and quibbles. Installed over 1.5 years and rolled out gradually.
A lot of what they had was already electronic: lab results, doctors notes, etc. First step was the pharmacy module. Second, electronic signing of notes. Third, make the bedside charts electronic. They'd be looking at info electronically but still writing it down. Then take the final step and make record keeping.
Ask for volunteers in the pilot. Rolled it out very quickly. (Half of the physicians volunteered.) Everyone else soon followed.
EMR helped solve problems of unclear handwriting and abbreviations.
Built as a clinical tool to make things easier for the physicians.
Five of us at the core, 20-30 physicians serving as advisors helping select the software vendor. Included nurses and IT people.
It was two years before Carle started turning anything on.
Headaches
- Training physicians and nurses. Have to give up own time in order to train people. Trained everyone the same – that was a mistake. Surgeons do things differently than a pediatric doctor; Carle should have tailored their training to the very specific tasks that each individual group. Training for the clinic will take this lesson to heart and it will be very specialized.
- Doctors were resistant in putting orders themselves into the EMR. This is due to government regulations; a departure from the old ways doctors operated (they are used to verbal orders).
- Somebody from each subspecialty is needed in order to implement a system well.
Steering committee to a signed contract => 1.5 years. Epic at the time had a process that was more “build it yourself.” Had to change Carle's workflow (via workflow analysis) in order to adapt to an EMR. 2 years to build the workflows in the EMR before turning on the system.
Epics now has a model system instead of building from scratch.
Getting doctors up to speed with inputting info electronically took longer than expected. May 2008 was finally done (getting the physicians on board). Originally was supposed to be January 2008. Project was on budget.
Two upgrades since then. First upgrade, no major changes (just minor changes.) Second change was also minor. Third upgrade was a huge change – there were changes to the interfaces – so more training.
EMR is on Carle's own servers. “Quite a few” people work on both IT and other projects. (16-20 dedicated people.)
Epic is not web-based. Only accessed from Carle. There are ways to access it from home. Schuh can access it from home using VPN.
Mechanisms in place to prevent unauthorized access. System can alert to who is looking at whose chart and why. “If I were to be snooping in a neighbor's chart, that would be caught.”
Everything must be encrypted or destroyed at the end of use.
Compliance department works to make sure that there is no unauthorized access.
Congress mandates that patients have the ability to see records within a certain amount of time. Looking to make a web portal for patients. Download some pieces of information to the web portal. (Sensitive information is not put online.) Planning on putting out the patient portals on about a year.
Future trends:
All hospitals will need an EMR.
Smaller practices will need to link up with other hospitals and practices; if they don't, they will not likely survive.
Mobile application connecting people with the EMR may be popular in the future. (Big things in portable devices.)
More advances in technology. More access to up-to-date research information.
Other hospitals:
Caved in when the physicians pushed back really hard.
Carle: BOD on down said that “this is what we are going to do.” It is a top-down instruction.
Fear from people; calm the fears with facts. “Why don't we fix that for you.”
It was all on at once.
Going to go live with our big system in August in the clinic. Going up with Epic's version of the outpatient.
Had a UI MBA grad in charge. Find out what your customers need and supply them, then you will be successful. “What does it have to do from your clinical perspective?”
The clinic is on a different EMR. So they want to be on one system. Physicians in the office were familiar to the EMR. Rollout was slow from paper to digital.
Originally, EMR was pitched as something that saved a lot of money. But the promised money savings is not really materializing; the main benefits are in the ease of access that doctors have to information. Having an EMR is just “one of those costs” of doing healthcare. Convenience factors.
Things looking down the road: electronic visits.