By Red Hutchinson, CIO, LRGHealthcare; Henry Lipman, CFO, LRGHealthcare; Peter Walkley, MD, CMO, LRGHealthcare; Ellen Wolff, VP, Patient Care and Surgical Services, LRGHealthcare
This is the first in a three-part series chronicling the implementation of an electronic health record in a small community hospital system in rural New Hampshire, as told by the hospital executives leading it.
LRGHealthcare, based in Laconia, N.H., comprises two community hospitals, 137-bed Lakes Region General Hospital and Franklin Regional Hospital, a 25-bed critical access hospital located 13 miles away. LRGH serves as a Level III Trauma Center and has been designated a Rural Referral Center and Sole Community Hospital under Medicare. After discussions and negotiations over a two-year period, on July 1, 2009, LRG signed an agreement to purchase a Web-based EHR from Virginia Beach, Va.-based IntraNexus. The SAPPHIRE product incorporates a suite of clinical applications ranging from CPOE to clinical documentation and lab and radiology.
LRG agreed to provide Health Data Management with an ongoing, three-part narrative as the implementation rolls out. The following is the first part of the story of how LRG got there, from the decision to move toward an EHR through the initial implementation stage.
Henry Lipman, CFO: LRG has a 30-year experience with IT going back to Shared Medical Systems (SMS) and Siemens. Our CFO at the time, Tom Clairmont (now CEO), implemented the first SMS system in the early 1980s and later we installed a system from Gerber Alley which was purchased by HBOC. We then switched back to SMS and installed their Allegra financial software which was later sold to IntraNexus. We already had a long consulting relationship with IntraNexus who had helped us install and support Allegra. We had bought the product in 2001 and were happy with it. When we merged with Franklin Regional in 2002 the product was flexible enough to expand to the new facility. We had two choices: work off Franklin’s existing HBOC platform or extend the one at Lakes. In 2006 we implemented all of the same systems at Franklin that were already in use at Lakes. We finished in 2007 after smoothly porting over 85 applications.
LRG is now on IntraNexus SAPPHIRE financials, which was previously known as Allegra. Basically, I think the company’s ability to meet our business objectives and the close consultation relationship led us to continue with the SAPPHIRE suite.
Peter Walkley, CMO: I think the decision process to move to an EHR started long ago. Nine years ago we identified that handwriting for physician orders was a significant problem. My colleagues in pharmacy and in QA and I came up with the idea of a PowerPoint presentation showing scanned-in real examples of physician handwritten orders. When we asked our audience, including doctors, nurses and pharmacists, “What do you think this shows?” we got four different interpretations.
Examples of medication-error “near misses” which did not harm any patients but pointed to the need for reform included a doctor who ordered “TID,” meaning three times a day, but everybody thought it read “BID” or twice a day. That was an example where poor handwriting can hurt patient care. Another common problem in medication safety is misreading “1.0” for the patient dose. Especially in the bottom carbon copy of the order it often appears to be 10 units instead of the correct 1.0.
In response, every one of our service areas said physicians needed to write neater. But recognizing how difficult that task was, the physicians universally said getting an EHR would solve the problem. This led to the net result of virtual universal recognition that we needed to move to an EHR.
I had attended a Boston conference at Partners Healthcare, which was building a homegrown EHR and came away impressed by their ability to direct care though the EHR, to improve quality and decrease the cost of care.
The Partners’ conference highlighted an example of a massive organization that spent hundreds of millions of dollars on a home-grown EHR. I think that’s what helped start our conversations here. For example, we conducted our own IT inventory and determined that in using Cerner for lab and radiology it was time to upgrade to Cerner Millennium, which seemed timely because of our need for an EHR. Cerner’s approach also seemed logical with its base of Millennium upon which you could add documentation and other clinical applications.
The problem was that it was cost-prohibitive, which caused us to hold back funding. There’s institutional will and there’s physician will, but it seemed that every year some new priority would push the EHR down the list. However, by then our entire leadership including trustees and management was primed for the EHR. About that time, Tom Clairmont saw a “60 Minutes” piece on the VA’s VistA EHR, which was theoretically available free of charge, and so we did a site visit at the Manchester VA with the idea that maybe VistA would be an affordable EHR for us.
We looked at VistA and SAPPHIRE. When given our EHR requirements IntraNexus CEO, Rick O’Pry responded, “Oh, sure we can do this.” That got the ball rolling. Henry’s favorite phrase is “due diligence,” and he was having discussions with IntraNexus as early as 2006 concerning the costs of all SAPPHIRE modules compared to the Cerner applications. In parallel we were thinking about clinical IT. Our senior team met in late 2007 and I attended HIMSS in 2008 and several classes on EHR implementation.
Despite the fact we had a laboratory order results system, few physicians actually used it. Physicians will often do the easiest thing, and it’s a whole lot easier to pick up a printed-out lab report.
Ellen Wolff, VP, Patient Care and Surgical Services: The only other online system installed was a surgical information system that was freestanding and not integrated. OR staff would end up making copies of 40 sheets of paper to document a procedure and for manual entry into the HIS. We have a younger population of nurses with some experience with an EHR and they’re looking forward to using a true EHR.
Red Hutchinson, CIO: SAPPHIRE was an EHR we could afford and because it is a Web-based system; it’s an IT solution that could that be supported and maintained by our current IT department.
Lipman: When we were undergoing the merger and looking at software applications, we found we could meet our business objectives with a single system. Also, we’d been able to run our Cerner and PACS applications through the SAPPHIRE system. When we considered ripping out an entire system and building from scratch we realized we’d lose a lot of IT momentum, add cost and delay our clinical initiatives. We’d be spending years and lose the incentives of a timely CPOE project.
Also, our I.T. staff is small. We thought it would be quicker to go through IntraNexus. The business lesson is look at who you’re starting with and determine if they would be a good partner long term.
Walkley: ARRA didn’t enter into our decision to implement an EHR. We had started these discussions long before ARRA had been conceived. We announced our decision to go ahead with the EHR a week before the final vote on ARRA, and we have been committed all along to the principal that it’s more important to get this right because of the implications for patients. The fact that we may also qualify for federal incentive funding from ARRA is a nice incentive but ultimately coincidental to our long term EHR plans.
Lipman: The board became involved in this process through its executive committee, which among its other roles acts as the IT steering committee. We’d been updating them regularly and as a consequence the board was pushing the organization toward an EHR. When Red Hutchinson arrived in 2006 he brought a lot of IT experience that helped validate the effort. The writing was on the wall. We were able to convey the idea that the IT infrastructure had to be sound.
Walkley: We had a lot of discussion about the OpenVistA product from Medsphere. Red did several very detailed analyses on what other commercial options were available.
Hutchinson: It amounted to a cost-benefit analysis and whether it was a good product that does what we needed it to do. My concern was the underlying infrastructure. The VistA product it turns out is built on an old Alpha platform, using MUMPS programming and proprietary databases. An issue for the VA was getting developers to keep it going and we felt that could also be an issue for hospital systems like LRG.
Lipman: We realized that if we wanted to focus on implementing clinicals it greatly helped to have the financial platform already in place. IntraNexus financials were already installed and working well.
Walkley: We summarized it in a slide: it was a product we thought could deliver and be affordable. It helped that IntraNexus was a small company that would always be on hand. The web-based capability—the ease of access—greatly appealed to us. Another thing was that they advertised we could change things ourselves without the vendor having to do it for us.
Lipman: The main concern I had with SAPPHIRE was the lack of implementation experience. On the other hand, I think a unique feature in our business relationship was that we required IntraNexus to bring in an independent, third-party to do a clinical review before any of the system was actually installed. This involved a detailed documentation of our current clinical work flow processes--our current state. This was followed by a second phase (future state) in which clinicians and administrators identified how they wanted to change the current work flow to improve clinical processes and become more efficient and streamlined supported by the EHR. It wasn’t just a matter of installing the system but ensuring that we could leverage IT for clinical benefits.
It’s a matter of being brave enough to do this kind of review. Otherwise you spend three times the effort after you install an EHR fixing things if you don’t do it right up front. Even with a clinical review process our experience is that in all IT implementations there’s a learning curve; it’s still a work in progress, with a lot of trial and error; in part because you are asking clinicians to change in some ways how they practice medicine.
At the end of the day ARRA incentives are not enough. Not only will ARRA not cover the total costs of an EHR implementation, if you rush to implement a system to demonstrate meaningful use requirements and qualify for ARRA payments, you may be faced with major issues ranging from clinician dissatisfaction to the need for costly system redesigns.
Wolff: We realized early on the need to keep nurses informed about the EHR project and how it would affect them. To do this we met as a management team. The 30-year nurses, me being one, were used to paper. This generation often tends to gravitate toward paper. Still, we started to meet to document current workflow and future workflow and momentum among nurses grew for accepting the new system.
Walkley: One of the concerns that developed quite early was the overwhelming magnitude of the effort. We’re a small organization with limited number of staff. It’s really a daunting task. Many of the larger healthcare organizations presenting at HIMSS have a 30- or 40-person teams to lead EHR implementations. That was a big concern. I recall going to our Senior Team and saying we have to remember who we are. We didn’t want to bite off more than we could chew by emulating a powerful academic medical center like Partners.
Wolff: My concern echoes Peter’s. The prospect of implementing an EHR heightened our awareness of being a community hospital. We’re cautious about affecting patient care. We’re not a factory or retail outlet buying an electronic tracking system. Our EHR needed to work and could not compromise the quality of patient care we had achieved for our community.
Lipman: And we had to remember that IT implementations even at small facilities are demanding. In the early 1980s we installed Gerber Alley, but the implementation went badly. IT implementations are a daunting amount of work.
Hutchinson: From an IT perspective our major concerns were do we have proper resources and is the vendor flexible enough to work with us? The EHR is the biggest thing we’ve ever done. We want to match the effort and task to the right people with the right skills. Also, this is a co-development effort with the vendor.
Lipman: One of the key planning considerations in this project was to map out the total cost of ownership (TCO), projecting costs over a several year period both during and after implementation. This process was led primarily by Red Hutchinson, our CIO. You can’t just look at initial acquisition costs. You have to look at the long term TCO. For example, you can get cheap software but it may have high maintenance costs. TCO allowed us to compare scenarios. Red deserves a lot of credit for helping map out the options and costing out a lot of moving parts in this equation.
Hutchinson: We had a lot of help from our vendor. We projected what support costs for software and hardware were going to be six or seven years out. It was painful. I came from banking, which uses TCO modeling extensively, and I know that this is a painful but necessary process. All of us on the senior team wanted to define the scope of this initiative so we could ensure patient safety, improve patient care and ease of use—and we have to be able to validate it! In five years we want to show we’ve reduced medication errors and improved patient care.
Lipman: I didn’t focus on this from an ROI perspective. Healthcare has moved from IT being a complement to care to IT being the platform on which care is delivered. If you’re a bank that doesn’t have ATMs you’ll probably be out of business. Quality of care and reduction in errors goes with it. There are a lot of parallels with other industries. If you’re not on an IT platform you’re a dinosaur.
One of the lessons learned was that the process took longer than expected. Determining total cost of ownership was a challenge. But one of the biggest challenges turned out to be financial-market turmoil, which forced us to change our original source of funding. At the end of September 2008 we had closed a bond issue (which included funding for the EHR) and then things started to go south. It wasn’t until a year ago in June, 2009 that confidence returned. We ended up signing the contract with IntraNexus July 1, 2009, had a kickoff meeting in August, launched the clinical review process in October and started implementation in December 2009 and January 2010.
Walkley: We had some issues in our contract negotiation. We’d all agree around the kitchen table on the concept and then the lawyer would come back with some densely worded description. We thought what we agreed to could be summarized in 10 sentences. We also needed to make sure the product was certified. When we did a hospital site visit the system was slow, prompting us to put in the contract that our system would be “lightning fast.” It proved to be difficult to define “lightning fast”.
Wolff: I don’t view contract signing as the end. In many ways it is just the beginning.. It’s like you’re a dog chasing a car. Now you’ve caught the car. What do you do with it? We found that more hard work remained.
Walkley: And, of course, physician support was essential form the beginning. A few physicians asked, "Why did you pick that product?” We said, “We told everybody what we were doing and you didn’t bring up any objections.” Those people were in the minority, however. We have an outpatient EHR, Centricity, that is our primary care system. But some specialists had problems with it and would translate that concern to the inpatient product they had never seen.
Wolff: With nurses it’s really more of a knowledge deficit regarding the new system. We’ve made a point of educating them on new workflows and how patient care will benefit.
Walkley: We have a nine-doctor hospitalist group that covers more than half of inpatients. Their mean age is mid-to-late 30’s and all of them have medical school EHR training and were clamoring for us to move forward.
Lipman: When we started this program we didn’t have a single hospitalist. It makes it easier to implement a clinical IS when you have a large concentration of users.
Wolff: In terms of governance on the ground, both the hospital and IntraNexus provide project managers who oversee day-to-day operations.
Hutchinson: Ellen and I are co-sponsors at the hospital and meet weekly with our counterpart at IntraNexus. As co-sponsors we report internally to the senior team, which includes VPs, Henry, the CFO and executive VP. Nine of us meet weekly. We also have an IT steering committee on the board of trustees with whom I meet.
Wolff: The project governance structure is based on a single charter which LRG and IntraNexus, designed that spells out the stakeholders, their responsibilities, processes for problem resolution, benchmarks and timelines.
Scope creep is a concern for all of us. Because some of the steps in the implementation have taken longer than anticipated and the contract calls for a fixed fee for a particular step, we continually are revisiting this with the vendor to make sure that everyone stays whole in this process. Both partners work off the same document. Some companies choose to do two charters, but we view that as a big mistake because it can result in differing expectations.
Walkley: We declared from the start that this could not be an IT project; it has to be a clinical project. Having Ellen, a clinical person, as a co-sponsor helps ensure that.
Wolff: The nurses really enjoyed the clinical review process. A lot of them feel that they spend way too much time meeting documentation requirements and doing it long-hand. What they’re hoping for is to spend more time at the bedside as a result of the new EHR.
Walkley: That “Aha” moment occurred with one pharmacist who was thinking about the future state. She said, “Oh, I know how we can do that.” There was an excitement associated with hearing someone ask you about what the future state could look like.
Wolffe: With the vendor we put together a comprehensive training program that targeted nurses first and physicians second. We have a dedicated training center here that’s busy even on weekends. Training sessions take three-and-a-half to five hours and typically involve step-by-step guidance of a professional trainer. Now we’re offering refresher training because “cold storage” training doesn’t take well. We’ll also have champions help new users when we go live. The education department is responsible for much of the training.
Hutchinson: The selection of hardware to be used to drive our EHR turned out to be an important way to save money. Three years ago we started looking seriously at virtual machines (VMs) as both a cost and time saving strategy. VMs allow us to partition separate parts of a computer to run a particular application without having to purchase a separate server for each application. So we’re virtualizing everything we possibly can. We’re now about to complete final testing and software validation for order entry and results reporting. At Go Live we’re going to bring one unit up at a time beginning with med/surge at Franklin. I expect in the next two to three weeks (by mid-September) we’ll have the first users on the system.
Walkley: We learned several lessons along the way, including a lot around communication. One reason we picked IntraNexus was because it was a small firm that we had known for a long time and we could all get along and communicate easily. It hasn’t always been as easy as I’d expected. There have been a few miscommunications and misinterpretations that have slowed things down. We made a big deal that this was not just another vendor/client relationship but was a partnership.
Lipman: The lesson is don’t underestimate management’s need for communication when implementing applications in a clinical setting, even when you believe you’re in synch and aligned.
Wolff: We worked really hard on communication. I’d venture to say we’re in a much better place today than three months ago.
Hutchinson: My main lesson learned in this process is communicate, communicate, communicate!
Lipman: Another key lesson is that an EHR implementation is not an IT project. It’s an organizational transformation issue.
Hutchinson: Without top-down support from the board and all of executive management this would be an impossible dream. Today LRG is in process of implementing order entry and results viewing. This implementation should be completed in the next few months. In future installments we will be following this implementation along with the implementation of pharmacy and then CPOM with workflow changes occurring at each stage for physicians, nurses, and other clinicians. Then we will cover the implementation of lab, radiology and scheduling.
The authors can be reached at:
Red Hutchinson, firstname.lastname@example.org;
Henry Lipman, email@example.com
Dr. Peter Walkley, firstname.lastname@example.org;
Ellen Wolff, email@example.com
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