The judges of this year's program included Chuck McDevitt and Vince Ciotti. McDevitt is the vice-president and CIO for Self Regional Healthcare, a 414-bed teaching hospital serving 300,000 residents of the seven-county, predominantly rural Lakeland's region of western South Carolina. McDevitt is in charge of all aspects of information technology as well as telecommunications, bio-medical services, and health information management at Self Regional Healthcare. Ciotti has over 40 years experience in the HIS industry: 15 years working for vendors in sales and implementations, as well as 25 years consulting for hospitals in I.T. assessments, system selections, and contract negotiations. He is principal at HIS Professionals LLC. Greg Gillespie, Joe Goedert, and Gary Baldwin from the HDM staff also judged entries.
Thinking big
When it comes to EHR deployments, Catholic Health Partners defines big. Spanning 24 hospitals in Ohio and neighboring states, the Cincinnati-based health system began an enterprise rollout in early 2010 with the ambitious goal of a five-year completion. A key player in the effort is Stephen Beck, M.D., charged with not only promoting adoption of the EHR among physicians and other providers, but guiding the overall strategy for improved clinical outcomes. He leads a team of nine clinical staff who participate in the design, build and deployment of clinical I.T. Currently, half the hospitals in the health system have gone live with the EHR, from Epic, on the inpatient side, while all 1,000 physicians employed by the health system have adopted the technology on the ambulatory side.
The Epic EHR replaces a mix of paper-based and electronic systems. When complete, Catholic Health Partners will have a common patient record across all its sites, drawing from a single database and built around common workflows, Beck says. He points to the emerging era of accountable care as underscoring the need for a common system. "It's important to have a common record as patients go from site to site," he says.
Catholic Health Partners has established some ambitious goals for its clinical staff. "We expect 85 percent of all orders to be entered electronically by physicians," Beck says. And most hospitals on the inpatient system have hit that mark, he says, with the others close to it. The key, Beck says, is ongoing training and promotion of the ideal of physician-driven quality. "We want physicians to understand that when they're in control and entering orders, it eliminates the risk of inappropriately translated written orders from paper or confusing about orders given over the phone," he says.
Two big factors have helped drive physician adoption of CPOE, he says: standardized order sets and embedded clinical decision support tools Beck's team has added to the system.
The presence of standardized order sets has enabled the health system to dial down its usage of order alerts, or messages firing off to clinicians about to request lab work, radiology exams, and other procedures. "We want to be cautious about firing off too many alerts," Beck says. "We don't want to overwhelm physicians. We are trying to minimize alert fatigue and yet maximize the gains of using a standardized system."
Clinical decision supports have encouraged physician adoption as well. Catholic Health Partners has embedded a search engine, from Wolters Kluwer Health, that physicians can access from the EHR. Although physicians are free to use their own data resources, having a common clinical search engine is another piece of standardization important to improved outcomes via less variation in practice, Beck says.
Beck acknowledges that an EHR deployment is never finished. But he's optimistic. "In five years, we will have better outcomes, safer cost and improved cost control. We will eliminate redundant and unnecessary tests. When patients realize they are getting the best technology there is to offer, they are happier with their health care."
Love and marriage
Some people are married to their jobs, but you could say that Brad Jannenga married into his. A veteran of the 1990s' dot-com boom, Jannenga designed and wrote successful platforms for a number of e-commerce companies. After moving to Arizona, he met his future wife, Heidi, who managed a large physical therapy clinic in Phoenix, whose clients included spring training baseball teams. Heidi asked Brad to help locate an EHR vendor to help reduce dictation costs and capture documentation electronically. Discouraged by the high price-and limited utility-of commercial products, the two hit on an idea that not only transformed the clinic but sent Brad down an unexpected career path. Brad would write the code for the EHR.
"I figured I could develop the software over the weekend and help Heidi automate a little of her workflow," he recalls. "We realized this might be a bigger opportunity than just a small app for the clinic. I had never done anything medical and my previous software experience was b-to-b. I figured medical is just another problem to solve."
For three months, Jannenga shadowed Heidi and the other physical therapy assistants and billing staff to learn the workflows and communications needs of the clinic. After that, he started writing the software package. By day, Jannenga would write code and by night, share it with Heidi. "She was like the product manager," he says. "It was a lot of late nights."
After nearly two years of development work, Jannenga launched WebPT in February 2008. Initially the software provided clinical documentation capabilities, and later expanded to include scheduling, billing, and external communication features which enable users to auto-fax or distribute patient summaries to referring physicians electronically.
WebPT now has a customer base of 3,800 clinics encompassing some 16,000 therapists, assistants and billing crew who use the software. The company has grown to 110 employees. The software is sold on a subscription basis and is hosted remotely for clinics at a data center in Phoenix. WebPT is a certified registry for CMS and clinics can use the software to capture PQRS (Physician Quality and Reporting System) data. Jannenga says that most EHR vendors catering to physical therapy clinics require client-server installations. He kept his own development costs down by writing the underlying program using open source software including the "LAMP" stack-Linux, Apache, MySQL, and PHP. Using the open source tools enabled him to keep the development costs down, he says.
Next up is an e-commerce platform. WebPT is negotiating with some medical equipment suppliers. Clinics could order supplies directly through the EHR and get better prices due to the ever-growing number of therapists on the system. "We are signing up about 150 clinics a month," Jannenga says.
Wake-up call
For Kevin Meldrum, the career wake-up call was the pounding on the door. The VA-a nationwide group of 152 hospitals serving veterans-had launched an early iteration of computerized physician order entry, and the keyboard-driven system flopped. "We wanted physicians to use the orders," he recalls. The door pounding came from a group of residents who demanded to know if he were the one responsible for the program. "They wanted to know who wrote the software that they didn't want to use. It was a profound experience."
That was in the early '90s. Ever since then, Meldrum has led the charge to try to make the VA's EHR system more user-friendly. The EHR is commonly known as VistA (for Veterans Health Information Systems Technology and Architecture). It now has 150,000 clinical and administrative users across the VA. And beyond that, the system-available for free in the public domain-has been adopted by many international hospitals.
Meldrum has been a steady presence in the EHR's long history. He led the design and development of "CPRS," the computerized patient record system. That's the VA's shorthand for the clinical portion of its VistA system, which Meldrum describes as the underlying architecture and original platform for lab and pharmacy data. Under Meldrum's leadership, the EHR has grown into a Windows-based application that is far easier to use than its keyboard-driven ancestor.
Meldrum developed the first prototypes of the Windows-based system beginning in 1993. By 1996, the system encompassed progress notes and was on its way. That year, Meldrum led the charge to rewrite the software of a 32-bit Windows environment. From 1997-2000, the VA undertook what he calls "rapid revisions," incorporating system changes based on recommendations from some 50 hospital beta sites. During this period, Meldrum's team released 48 updates of the graphical user interface.
Meldrum describes I.T. as a type of living organism that affects the environment around it. And the key to a successful program is being able to intuit what users really need and how they work. "A computer system is like a stimulus to the organization," he says. "The organization will either adapt to it or the system will die."
The VA is not done with the EHR design however. Next up says Meldrum is an upgrade which will enable better care coordination among teams of caregivers by clearly presenting care plans; offer patients better communications tools with their physicians, such as enabling data collection via mobile devices; and enhanced data analytics capabilities. "Working at the VA is amazing," Meldrum says. "There's a sense of camaraderie that is facilitated by the common mission of serving vets."
EHR education
When the topic turns to health I.T. education and training, the conversation invariably turns to William Hersh, M.D. Hersh conceptualized and implemented the first offering of the American Medical Informatics Association 10x10 education program, which has been completed by over 1,000 health care professionals and others in biomedical informatics. Supported by grant funding from the Office of the National Coordinator, he currently directs several education and research programs at OHSU. HDM interviewed Hersh via e-mail.
Q. What sparked your interest in medical informatics?
I was first exposed to computers in high school and started college in pursuit of a computer science degree in 1976. However, I lost interest in punch cards and the primitive systems of those days, so ended up going up to medical school. But in medical school in the 1980s, my interests in computers re-emerged, which led me to pursue a fellowship in medical informatics after completing my medical training in internal medicine. I never did envision developing a career focus on education while in my medical training or my informatics training. Yet once I started developing educational programs, I knew that education was my passion in life.
Q.What do you think are your biggest accomplishments to date?
Probably my biggest accomplishment has been to serve as the inaugural chair of one of the top academic departments in the field. Our department at OHSU has been able to sit at the cutting edge in research. Like many in higher education, I started my career as a researcher, and still do some research in secondary use of EHR data, but my primary passion is education. I have particularly enjoyed being able to combine my love for education with the use of technology, which has vastly expanded its reach.
Q. What will your ONC grants enable you to do?
I was delighted when the HITECH legislation in the American Recovery and Reinvestment Act (ARRA) included funding for workforce development. This validated my previous advocacy that successful use of health I.T. requires a competent workforce. Section 3016 of ARRA led the ONC to develop programs at both the community college and university levels. Because few community colleges had curricula in health I.T., ONC also created a program to develop curricular materials for those programs. OHSU was well positioned, since we already had an online graduate program in biomedical informatics that provided the kind of short-term (certificate and master's level) training needed to expand the workforce quickly. We also had online materials that could be adapted for community college programs.
