Second Time's the Charm

Health Data Management Magazine, December 1, 2009

A rural Maine hospital, burned by a bad experience with its first attempt at rolling out electronic health records at the 10 physician practices it owns, took a radically different approach the second time around in hopes of a better result.

Back in 2004, the CIO at the time made a unilateral system selection without consulting the physicians, and the two practices that served as EHR guinea pigs are still suffering the after-effects.

This time the hospital, 48-bed Franklin Memorial in Farmington, made sure representatives from each practice participated in the software selection. "Whatever system they wanted was the one we were going to implement," says current CIO Ralph Johnson, who signed on in 2006 and found "physician EHR system" at the top of his to-do list. Although last year's economic downturn created a glitch in his schedule, he's now on track to get all of his practices up and running on the new EHR by Christmas.

Round One

For Franklin Memorial's first foray into ambulatory EHRs, the earlier CIO chose a system from Meditech's LSS Data Systems. The main criterion was the ability to integrate with the hospital's inpatient system from Meditech, Westwood, Mass.

Usability for physicians wasn't given a lot of weight, and the lack of it doomed the project, says Jay Naliboff, M.D. an obstetrician/gynecologist who is also medical director for primary care.

At least part of the problem, he acknowledges, was in the implementation, which involved adapting the system to the practices' workflows. A physician in one of the two pilot practices took on the task of figuring it out.

"He went to the wilderness, wandered around for 40 years, and came back with a hideously complicated set of screens and templates," Naliboff says. "It was how he thought about things, but it wasn't good. The physicians in the practices have used it for many years, and it's been a huge impediment to them. They can't get their charts done, and they end up dictating."

As a result, physicians at the two practices were stuck with an EHR they didn't like, and the rest didn't want to be in their shoes, Johnson says. "It left a bad taste in everyone's mouth."

Round Two

Despite the bad initial EHR experience, the hospital was determined to equip its physician practices with an EHR as a logical next step in its practice automation efforts.

For example, the hospital already had instigated a county-wide e-prescribing system. The system provides physicians, both those employed by the hospital and those in independent practices, with complete medication lists on their patients. And Franklin Memorial is the only rural hospital in the pilot group for Maine's statewide health information exchange, HealthInfoNet.

After briefly investigating whether there was something he could do to fix the unsatisfactory EHR and extend it to the rest of the practices, Johnson decided it was best to start from scratch. "There was just too much resistance to that product among the physicians," he said.

Franklin Memorial began its new vendor search in June 2008, seeking both an EHR and a new practice management system. It also wanted to establish a single database for the 10 practices (known collectively as Franklin Health) that used the same master patient index as the hospital's system.

The request for information from vendors specified that the product had to have a track record of successful integration with Meditech's inpatient system, which quickly narrowed the field. The committee ended up pursuing three vendors: LSS; NextGen Healthcare Information Systems Inc., Horsham, Pa.; and eClinicalWorks, Westborough, Mass.

LSS's current product was quickly eliminated because it didn't enable physicians to look at a comprehensive record on a single screen, Johnson says. "Our physicians wanted all the meds on the same screen as the problem list, and LSS could only do five meds at a time," he says. "If a patient was on 15, the physicians were afraid they wouldn't see them all and it would be a patient safety issue."

So the committee proceeded with product demonstrations and user site visits for the other two finalists. Although NextGen had the better demo by far, handled by a clinician, the committee put more stock in what current users had to say, and eClinicalWorks scored higher there, Naliboff says.

The Winner

The eventual winner was eClinicalWorks. Johnson says the two finalists were so close on functionality that the physicians said either would do, so the decision was made based partly on cost, and partly on user reviews about vendor support.

The vendor's ability to install on schedule was also important because the organization wanted to avoid the rush resulting from the EHR incentives built into the American Recovery and Reinvestment Act.

"We had a project that was shovel-ready, and we knew the queue was going to build quickly," he says. eClinicalWorks received high marks from existing customers for sticking to schedule, he says.

Although many eClinicalWorks clients access the software remotely via the Internet, Johnson is running it on a server at Franklin Memorial to make his Meditech integration tasks simpler.

Johnson figures Franklin Memorial will invest about $1 million to get the new systems up and running - a significant chunk of the organization's capital budget. Operating costs will be about $24,000 annually for licensing fees, which Johnson says won't be much more than the hospital paid just for the old physician billing system. The physicians will access the EHR mostly through tablet computers from Hewlett-Packard Co., Palo Alto, Calif., that they keep with them, although each office also will have at least one workstation with a scanner. Half the practices are housed in a new medical office building adjacent to the hospital that shares its wireless network. Johnson says outlying practices also are fully wireless.

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