By 2005, CMH had won a Davies Award from the Healthcare Information and Management Systems Society for effective use of information technology-the only one awarded that year, and the first one ever for a rural hospital. By 2008, it had become a HIMSS Analytics Stage 6 hospital, one of only nine at the time, with electronic provider order entry and documentation, clinical decision support and a digital system for images. And in January, CMH became one of 39 HIMSS Analytics Stage 7 hospitals-a select group that has entirely electronic medical records and is using them in advanced ways to improve communication and patient care.
The rest are either high-powered academic medical centers or members of large systems. Kaiser Permanente Health Foundation alone accounts for 24. How did tiny rural CMH end up here, leapfrogging over places like Boston's Brigham and Women's Hospital or the Mayo Clinic (both currently Stage 6), who've been chasing the same clinical automation goals since the 1980s?
The way CIO Denni McColm tells it, Citizens Memorial didn't realize at the time that it was doing anything unusual. "We thought we were catching up with other hospitals."
CMH CEO Donald Babb credits McColm. "When you give Denni a challenge, she'll do anything to make it happen the right way." And former HIMSS Analytics executive vice president Mike Davis credits Babb. "These organizations don't get to this point because of their CIOs," he says. "They get there because of their CEOs." (See related story, p. 42, on the HIMSS Analytics staging process.)
In fact, it took that strong executive leadership plus a certain esprit de corps on the part of the organization's board, management, employees and affiliated physicians. Small hospitals have one huge advantage over larger ones: their teams are smaller and easier to manage.
"The biggest step was to make everyone understand that this was what we were going to do and there were no other options," Babb says. "The doctors and the employees and the board all had to be a part of it. On the physician side, probably 75 percent bought in to start with. A few dragged their feet, but I kept saying, 'We're not giving up-let's just do it together and make it work.'"
Unique Organization
Its I.T. sophistication isn't only thing that sets Citizens Memorial apart. Opened in 1982, it still has its original CEO and most of its founding board. McColm has been there since 1988, originally working in human resources and then as director of finance. She's health system's first CIO, since it didn't need one before.
The hospital is run under a district hospital authority that can levy taxes, but it stopped doing so in 1984, two years after opening, because it had become self-sustaining. Because of Missouri laws governing how hospital authorities may operate, CMH spun off a separate foundation in 1986 that runs its long-term care facilities and other allied health services. The foundation is also self-sustaining and its annual operating margins range from 3.8 percent to 4.5 percent.
The hospital currently has an operating margin of about 3.8 percent, Babb says, and a solid credit rating that allowed it to issue bonds to cover the $6 million initial cost of the clinical computing effort. Babb estimates CMH has spent an additional $3 million in the past few years, mostly financed through grants from the Agency for Health Research and Quality and other organizations.
Starting from Scratch
When CMH started looking at computerizing its clinical information, in the late 1990s, it was at HIMSS Analytics Stage 0, with nary an ancillary system on site. The only automation in the hospital was a financial system running on an elderly IBM AS/400 minicomputer, and that system had been modified so many times that it was unrecognizable and becoming impossible to maintain.
Everything else was on paper. Because the care network covered nine counties and more than a dozen clinics (now up to more than 30), paper charts were being shipped continually between locations, and patients had little faith that they'd end up in the right place. Some of the chronically ill wanted to keep their charts with them, but Babb says that allowing them to do so led to care coordination issues and incomplete records. Clearly, something had to be done.
Babb put McColm in charge of figuring out exactly what, and they dubbed the effort "Project Infocare." She put together a steering committee with a dozen members representing all CMH interest groups. It took the better part of two years to figure out the organization's needs, generate a request for proposals, and select a vendor.
To hold down the cost and simplify installation and maintenance, the steering committee decided to look for a single vendor for as many applications as possible, including both clinicals and a financial system. A deal was sealed in December 2001 with Meditech, Westwood, Mass., which is the EHR vendor for about one of every four U.S. hospitals, according to HIMSS Analytics.
The Case for a Single Vendor
McColm says Meditech won primarily because it had modules to handle the entire continuum of care that CMH was providing. "They were by far the strongest contender," she says. "Vital signs collected from home care automatically come into to the EHR. Someone from our long-term care facility can go visit a physician in one of our clinics and have a stay in the hospital, and the details from all those places automatically go into the EHR."
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