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For other articles and previous issues click here. February 11, 2002 ALL
THE RIGHT MOVES Any healthcare organization that’s designed, built, and moved into a new facility knows it to be a huge and challenging undertaking. And any healthcare organization that’s transitioned, or even contemplated transitioning, to an electronic medical record (EMR) understands the risks and complexity of the project. Now imagine doing both at the same time. The leaders at Anne Arundel Medical Center (AAMC) in Annapolis, Md., not only imagined such a scenario, but they also proceeded to realize their vision for a new state-of-the-art, high-tech medical hospital with the electronic infrastructure to support a paperless environment, including a fully electronic medical record. On December 2, 2001, the new Acute Care Pavilion debuted with exactly this infrastructure and capability. Combining both initiatives resulted from a convergence of needs. AAMC’s movement toward an EMR began in 1990 when it gradually started to bring various patient care areas online. The existing network in the old facility, however, limited what the medical center could do. The age of the building presented another limiting factor. “It would have been difficult to rewire,” explains Chuck Shafer, AAMC’s CIO, referring to the type of cabling necessary to support the transmission of large amounts of data that comprise patient medical records. “It also would have been more expensive and taken longer.” The old building limited more than technological growth. By the mid-1990s, AAMC had expanded the special medical services it offered, nearly doubled its medical staff, and increased its service area to encompass 650,000 residents. With existing space maxed out, no room to grow, and the need for expanded medical and information technology (IT) exerting increasing pressure, AAMC’s leadership decided it was time to move. The decision to erect a new hospital then provided the opportunity and the means for the EMR effort to take off. Implementation became an organizational priority, a move that accelerated the remaining work for the EMR to be fully realized. Designed for
Present and Future Needs In addition to identifying many “do’s,” the group identified some important “don’ts.” “The new buildings we saw were beautiful, but many were designed around old processes,” remarks Core. “We wanted to implement process changes,” she continues, “and we knew the infrastructure [in particular] needed to be as robust as we could afford to support change now and in the future.” And robust it is. AAMC’s information systems (IS) link its new high-tech medical devices in a secure and efficient manner. The network infrastructure consists of a gigabit speed Ethernet wide-area network operating more than 20,000 feet of fiber optic cable and 1.2 million feet of Category 6 cable, which carry data to more than 1,200 workstations and 400 printers. Technologies, such as PACS and a fully electronic medical record, place a premium on network capabilities. The network is designed with redundant paths and processing functionality to ensure uninterrupted availability and heightened security. It connects to the Internet through two diversified 1.54 megabits per second T1 lines, which supply high capacity and redundant access. Combining all these features will enable AAMC to handle growth for a number of years. AAMC also incorporated wireless networking technology for bedside access to the patient’s EMR, making more than 100 wireless devices available to caregivers. “One of our chief objectives [in implementing an EMR] was to provide real-time, secure access to clinical information to support the provision of quality care,” says Shafer. In addition to wireless devices, there is one designated PC for every two patient rooms. AAMC took another positive step when it hired an IT planning consultant to assist staff in identifying future needs, a move too many other organizations stop short of making. As a result, Shafer believes AAMC has built a flexible system that will be easy to grow as the medical center’s needs change over time. Phased Implementation
“As more is automated, it’s less of a burden to scan and index,” states Gregrich. With less to scan, scanning can now take place on discharge rather than on record completion. “Our goal is to make everything available in the system within 48 hours of discharge,” she says. The 75% goal was reached last summer, and in August, AAMC transitioned to an electronic document. Until then, the complete medical record was the paper record, which was always printed out and available along with the electronic record. “We had to take the plunge to make a culture change,” maintains Gregrich. “It’s an exception now to get things on paper,” she says, noting that when requests are made for paper, it’s usually for a copy of an advance directive. AAMC expects the remaining pieces of paper documentation to go online for real-time access this year. Some areas, such as bringing progress notes and pharmacy medication records online, have been more challenging than others. Implementing a system for physician orders is also slated for this year. The transition to an EMR also included mandating electronic authentication (e-signature), functionality that the medical center first pilot-tested and made available to physicians on a voluntary basis in 1992. Prior to August 2001, optional use of e-signature had grown steadily to approximately 300 physicians. Now all 650 AAMC physicians use it. Another significant aspect of the EMR rollout has involved integrating PACS, which replaces conventional film with digital images. For AAMC, PACS encompasses images other than radiology, such as patient ID pictures. Here, too, implementation has been stepped, with project staff identifying three graduated phases. Phase I saw installation of a new data center with the capability to support PACS as well as all the other information and medical technology planned for the new hospital. Outpatient systems were also brought online during Phase I. Radiology and oncology were brought online in the new hospital during Phase II. Cardiology, the operating rooms, labs, and miscellaneous images will be brought into PACS during Phase III, scheduled for completion in early 2003. Designed for Ease of Use, Secure Access, and User Acceptance Bringing clinical documentation online and implementing e-signature were no small tasks. Formats had to be made consistent, and standards for such factors as system use, the documentation itself, corrections, and amendments needed to be identified and met. Processes had to be put in place for storing and retrieving data, and a system for secure access needed to be devised. Gradual implementation has given staff experience signing on to the system with a user ID and password. Job need was used to determine who was given access to what information and audit trails were established to track access and changes to data. Project staff also paid attention to details they believed would ultimately help staff accept and make an easy transition to the new system. For example, as paper forms needed to be revised, they were designed to be computer ready, incorporating lists and check-off formats and used in hard copy before being put online. Gathering input from staff was a big part of the planning, design, and implementation processes. Approximately 220 physicians, nurses, other clinicians, and administrative and management staff from across the organization became stakeholders in the wide array of changes being made. They participated in 12 to 15 process-change groups as well as user groups that provided input in critical areas such as applications and interface design, training, and documentation. A Commitment to Training, Documentation, and Continuing Education The latest hardware, software, and telecommunications equipment is only as effective as user comfort, familiarity, and proficiency. AAMC staff received extensive training before implementation, as well as just-in-time training. “Superusers” in each unit helped with training and became advocates for the new system and processes. They also assisted systems analysts—staff with both clinical and IS backgrounds—in preparing documentation, which was written in clear, accessible language geared toward users. Staff received this documentation with training and can access additional documentation online. AAMC also designated a learning center and training room dedicated to assisting staff in coming up to speed on the new systems and remaining current. “We’re constantly developing staff so they’re keeping up with the technology,” stresses Shafer. “The hospital is committed to continuing education,” he adds. This level of training and documentation would not have been possible without an explicit commitment from AAMC’s senior administration and department leadership. “It wasn’t a hard sell,” says Shafer. “Our leadership was behind it from the beginning.” Core echoes this, underscoring one of the organization’s strongest values: “We’re a learning organization,” she says, noting that the organization’s leadership thinking and style have been influenced by quality/performance improvement gurus Leland Kaiser and Peter Senge. And, as the saying goes, the proof is in the pudding. Shafer believes all the training has made a significant difference in terms of staff comfort with, acceptance of, and trust in the system. He reports that not only are the systems working as expected, but also everyone is using the system, including the EMR portions, as expected. Gregrich also points to the decrease in requests for hard copy medical records. “There’s been a dramatic drop,” she maintains, “from approximately 30 per day to approximately three per shift.” Lessons Learned
It’s true that AAMC’s experience has been extremely positive, but that outcome didn’t happen by luck or magic. It resulted from realistic and thorough planning, including benchmarking, that involved the people doing the work. Also, it anticipated potential problems and matched patient, staff, and organizational needs to the latest technology rather than retrofitting them. It resulted, too, from aggressive project management that relied on organization-wide involvement and accountability and kept the entire organization and project goals in mind throughout. AAMC also decided up front that it would not purchase any system or component that could not be interfaced with Meditech, its overarching hospital information system. Similarly, it decided that it would not buy any system or component that could not be rolled out throughout the entire organization. Then, once product purchase decisions were made, the project leaders sat down with all the vendors—even those that might be competitors—and identified the standards they would use to measure progress and success going forward. Most importantly, they all made a commitment to work together to attain project goals. Although there were no major quakes, there were some glitches, such as delays in bringing up some of the new applications or having to do more rewiring of the old building than expected to allow for pilot testing. In any project of this magnitude, however, there will inevitably be a few snags. But the difference at AAMC was in the way they were managed. AAMC’s positive experience is also the outgrowth of its leadership’s vision and support. Core maintains that getting leadership support and buy-in was the easy part of the project. “Our CEO is interested in innovation and encourages progressive thinking. He challenges staff to be visionary,” says Core. “Many of our board members are involved in IT in their professions.” This progressive thinking and action on the part of AAMC’s leadership has set the tone for the organization’s culture. Buy-in and participation from the medical, nursing, and other clinical staffs was another critical success factor. “Our clinical staff was always interested,” says Core. “We had a small but impressive group of ‘early adopters,’ and a supportive vice president of medical staff affairs who is computer literate and on the [project’s] steering committee.” She also notes that IT was represented in every constituency across the organization throughout the project, enabling communication and understanding of the needs of all parties. If they had to do it all over again, would AAMC have done anything differently? Three months prior to the move, the project leaders and vendors sat down to assess where they were with respect to “going live.” Core says she would have scheduled this meeting earlier and also planned for more frequent vendor meetings throughout the project. Gregrich adds that she would have postponed scanning medical record documents until 80% of the documentation came up online rather than the 75% target they met. All in all, AAMC’s implementation is the result of an impressive team effort. “AAMC staff members are wonderful,” stresses Core. “Their work ethic is second to none.” — Aggie Stewart is a freelance writer and editor based in Rhode Island. She also provides writing consultation services and can be reached at aggie@stewartpublicationservices.com. |
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