The hospital-one of the largest pediatric centers in the nation-deployed its first electronic systems back in the early 1980s, explains Harper, who has worked with the information systems department since the mid-1990s, the last two years as chief medical information officer. And even though additional, almost equally challenging I.T.-enabled projects await Children's, executives there can bask in the knowledge that their accomplishment of hitting Stage 7 on the HIMSS scale late last year puts them in rare company.
By the end of 2010, only 1 percent of hospitals had hit the top rung (with just over 3 percent at Stage 6). "Our culture adopts to change very well," Harper says. "Physicians know [the EHR] is the right thing to do. That made it easier. Instead of trying to convince them, we focused on how to do it best."
The governance structure that underlies Children's EHR accomplishment is a cornerstone of the effort. The management structure helped the organization surpass many hurdles, not the least of which was bringing nursing and physician documentation into the mix. Closed loop medication administration was among the last pieces to fall into place.
CPOE ... a cake walk?
Ironically, one key step in the process, computerized physician order entry, was not particularly difficult to accomplish. And while providers may not have squawked about electronic documentation, they did clamor for faster system access in the early days of the project, an issue that was resolved by revamping workstation architecture. The organization also sports an interactive patient portal, along with personal health record software that Children's quietly commercialized several years ago. "Once you have enough systems electronic, then all the people who aren't electronic want to be," Harper says. "You hit a tipping point."
The march to digitalization began in earnest in 2001, with the formation of an executive steering team that's still in place today. Members include both Harper and Dan Nigrin, M.D., the CIO, with other senior level staff from nursing, pharmacy, lab, patient care, and I.T.. The group has had little turnover during the past decade, a continuity which boosted the enterprise effort, says Nigrin. In addition to monitoring the overall progress of the effort, the executive group settled high-level decisions that affected users across the board, such as the design and content of the banner bar which presents key patient information at the top of the screen. "We knew it is an important segment of the chart to design well, and since everybody who uses the system needs to see it, it became a strategic design decision," Nigrin says.
The frequency of meetings of the executive team abated as the hospital progressed, but the steering committee still meets bi-weekly, Nigrin says. "We recognize that so much of the clinical operation depends on the system running well," he says.
The steering committee assembled a request for proposals and conducted the vendor selection, settling on a core clinical system from Cerner Corp. in 2002. Children's also uses Epic for its admission/discharge/transfer, scheduling and financial functions, with a handful of other vendors and some homegrown systems in play. Children's did take one unusual step as part of its clinical deployment. From the get-go, it opted to use its own staff for the implementation-and not hire a third-part consultancy to help with the design, build and deployment. "Many organizations hire a third party to implement, but we chose not to," Nigrin says. "That made it clear where the responsibilities lie. It was either us or Cerner. If three organizations are involved, sometimes you get into a finger-pointing exercise."
Consultant-free zone
What made the consultant-free approach work, Nigrin emphasizes, was adequate budgeting for staff time. "We are the ones who know the organization best," he explains. "We felt that if we staffed the project appropriately, and not ask people to do two jobs at a time, and if we accounted for that time and paid for it, we would do a better job than a third party." That's why personnel costs became the biggest chunk of the project budget, which stood at $40 million for the initial phase from 2003 to 2007, Nigrin says. Since then, Children's has spent nearly $10 million on the effort, bringing the total outlay to upwards of $50 million, Nigrin estimates.
In the long run, the money invested on clinician time led to a far more user friendly EHR, according to Nigrin and Harper. The I.T. department already had a strong clinician representation, with some two dozen staff people coming from clinical backgrounds, including medicine, nursing and pharmacy. Additional nursing and medical staff filled part-time roles during the project, serving as specialized "subject matter experts," or SMEs. "You definitely need clinicians on the team," Nigrin says. "Of all the things we did right, that was one of the most important."
The SMEs were crucial in facilitating adoption of both nursing and physician documentation modules, which Harper and Nigrin say were the most challenging aspects of the projects. "Bedside nursing documentation is the toughest part simply because nurses do so much," Harper says. "They are constantly in and out." Adds Nigrin: "Physician documentation and nursing documentation are done many times each day by the busiest people in the hospital. Unless the workflows are designed well, you end up with frustrated users."
Children's leaned on dozens of nurses to serve as SMEs and help design various aspects of the system. Representatives from such areas as ICU, newborn, med-surg and cardiac contributed specialized knowledge.
These drill-down groups tackled issues such as how particular questions should be phrased on the documentation screens, the layout of the forms nurses fill out, and the screen sequence.
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