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August 30, 2010

All in the Family
By Elizabeth S. Roop
For The Record
Vol. 22 No. 16 P. 14

In its approach to HIT implementation, a large New Jersey medical center bypassed hiring new staff or calling on consultants, opting instead for in-house help.

When Hackensack University Medical Center (HUMC) made the decision to perform a facilitywide “big-bang” switchover to Epic Inpatient Clinical System, executive leadership knew success would require three things: a well-designed project plan, engagement of and buy-in from all departments, and dedicated long-term clinical and IT support for end users.

That understanding led to a unique approach to system implementation, one that cultivated a sense of shared clinical and IT ownership from the outset and relied on internal resources to manage the heavy lifting involved in the project. In fact, rather than bring in outside consultants or hire additional employees to manage system design, HUMC recruited a cross-section of clinical, administrative, and operational personnel to bring its unique perspectives to IT.

“We used a small model in the past where nurses helped design systems and worked closely with IT, so we already recognized that the clinical expertise was important to the success of an implementation,” says Terry Moore, DNP, RN BC, NE-BC, HUMC’s director of Epic Clinical Systems. “That led us to look at clinicians in different areas and understand that they have valuable knowledge about the workflow of departments and how things work for the patient, to bring that [knowledge] to IT and enhance it with the computer skills they would need ... to design the project.”

Moore says the first step was to evaluate informatics groups already in place across HUMC and determine who from them would be able to make the transition to IT. In addition to nurse informaticists, individuals were culled from all clinical divisions, including radiology, surgery, respiratory therapy, and pharmacy, as well as nonclinical divisions such as nutrition and food management, admissions, finance, and HIM.

The 24 new clinical systems analysts spent about three months earning their Epic certifications, which provided them with the technical skills necessary to transfer their clinical and workflow expertise to the new system’s design. They will remain permanent members of the IT department, playing critical roles as the facility continues its transition to Epic.

With the inpatient system in place across most of the hospital, the clinical systems analysts will apply their expertise to coordinating the deployment of advanced features, such as alerts and reminders within the computerized physician order entry (CPOE) system. They will also be finalizing the implementation of Epic systems within ambulatory practices affiliated with HUMC.

For the individuals, Moore notes that making the transition from clinical to IT wasn’t always smooth, but it has been a largely satisfying experience for those involved.

“When you are a clinician, it is a very different approach; learning the whole IT side and [way of] thinking can be a bit of a struggle,” she says. “The fact they were able to change what they do, learn new skills, and stay with the institution was a real plus for the individual.”

It was also a boon for the IT department, which, according to Chief Technology Officer Benjamin Bordonaro, gained credibility from having clinicians as key team members. It also resulted in significant savings, even with an extensive training investment.

“But the real long-term payback is the in-house retention of knowledge. We do use consultants for other projects, but since this was such a critical part of the institution, we wanted to retain that knowledge,” Bordonaro says. “Knowledge transfer doesn’t replace being fully involved in the project. There is that sense of involvement and accountability. You felt engaged in the project. People feel left out when a consulting team swoops in and performs the work. But with this approach, they knew their colleagues were implementing” the system.

Owned by All
While the use of clinical systems analysts was a significant contributor, it was not the only strategy that led to successful deployment. Perhaps the most critical component was HUMC’s determination to brand the implementation not as an IT project but as a hospital project—including securing input and participation from across the hospital—from initial vendor evaluation through go-live.

In fact, “The decision to go with Epic was not IT’s decision. We left that to a diverse group. The CMO [chief medical officer] recommended bringing in Epic for a look, and the CEO, CMO, CFO [chief financial officer], managers, and directors decided upon Epic,” says Bordonaro. “From a leadership standpoint, those same people who originally made that decision are still engaged in the project today. From the top down, we still have full support … because once everyone is invested, it’s an all-in and you can’t turn back. That has helped.”

It also helped that the entire project took place under the watchful eyes of a steering committee charged with maintaining momentum. A significant part of that was to ensure any disputes or issues that could not be resolved at the director level were quickly settled.

Having a strong and proactive steering committee in place and dedicated to resolving issues quickly was a methodology recommended by Epic and quickly adopted at the behest of the HUMC chief information officer (CIO) Lex Ferrauiola.

“Bringing the people on board was one piece of the puzzle, but that project structure was critical,” says Bordonaro. “The CIO was relentless at making sure that the project structure would always stay in place. Without that, the project wouldn’t have been so successful. When you can break through the chaos and the pending decisions and keep that structure, that’s what keeps it together. [Moore] also followed that straight through to go-live.”

To keep chaos to a minimum during and after the big-bang switchover, Moore made sure there were ample specially trained superusers on each nursing unit and in each department. The clinical staff, who wrote the selection criteria to ensure that the individuals identified to provide critical on-site assistance would have not only the skills and training but also the attitude necessary to maintain calm and foster a sense of excitement and enthusiasm, designed the role of these superusers.

Supporting these unit-based superusers was a larger network of even more experienced superusers who floated among units to handle more advanced troubleshooting. Also lending support were physician and nurse champions as well as staff from across the facility who had volunteered to undergo additional training. At the heart of it all was a command center where problems and issues that could not be resolved on the units were handled as expediently as possible.

“We actually went down to the level of when physicians were rounding so we could focus more support on the floor or when discharges were the highest,” says Moore. “We really looked at each unit individually to customize support.”

Adds Bordonaro: “Floor support was not one size fits all. We looked at the acuity on the units and if the unit was paper or electronic before and staffed based on the needs of the area, not on the number of beds.”

Physician Buy-In
It is often said that even the smoothest implementation is doomed to fail if the physicians who are expected to utilize the new system reject it. With that in mind, HUMC’s project plan focused heavily on earning physician buy-in from the outset.

It wasn’t a simple task, particularly given that the vast majority of the 1,500 physicians expected to adopt the new system were community based rather than employed. As such, HUMC had to straddle a fine line between coaxing and demanding—particularly given that physicians were expected to complete training that consisted of four hours online and eight hours in a classroom to become certified to use the new system.

 “We understood from a physician leadership level that we had to get the practicing doctors involved and understanding what is expected,” says Jerome F. Levine, MD, MBA, HUMC’s senior medical director of medical administrative affairs and capacity management, who served as the physician liaison from the start of the project. “One important area was getting the medical executive committee to mandate that once we went live, [physicians] had to use the system. It was not an option. If they want to treat their patients at HUMC, they have be certified and use Epic.”

Part of the solution was ensuring that the physicians had a voice throughout the process as well as acknowledging the disruptions caused by the mandatory training and longer round times immediately after go-live. Key to that was maintaining open lines of communication that provided a channel for offering recommendations, expressing concerns, or simply venting frustrations.

“We ended up with about 95% compliance, but it did take a lot of prodding and discussing,” says Levine. “We tried hard not to just say ‘you have to’ but rather explain why. A lot of what we needed to do was one-on-one or one-on-two discussions. We can send out a million e-mails and newsletters, but communication will always be a challenge in a hospital this size.”

Efforts were also made to ensure that the demands being placed on the physicians were as palatable as possible. For example, physicians earned 12 hours of continuing medical education credits for completing training on the system, a significant chunk of their annual requirements.

Another challenge to physician acceptance was dealing with the inevitable workflow changes. Because of its intimate knowledge of HUMC and its various workflows, the newly minted team of clinical systems analysts played a significant role in mitigating many of the roadblocks that can hinder a successful deployment. But success was also due in large part to the efforts made to ensure that physicians, nurses, and every other member of the clinical team understood the process.

“From my experience with other implementations, many times the floors would say the system has to change to fit the workflows. From the beginning, top down, with this implementation it was understood that we were implementing what Epic calls its ‘model system.’ [That means] if workflows needed to change on the floor to fit [the system], that would be done,” says Lauren Koniaris, MD, HUMC’s chief medical informatics officer and a practicing pulmonary care physician. “If we hit a loggerhead, the workflows on the floor needed to change. It’s all about the workflow. The system is the system, but it’s really the workflows that make or break the success of the system.”

However, that doesn’t mean concessions weren’t made within the system design to accommodate clinicians. For example, “hard stop” alerts within the CPOE system were minimized as much as possible to avoid unnecessary disruptions. Implementation of clinical documentation was also delayed by four months to give physicians ample time to get comfortable with CPOE.

Work is now under way to optimize and streamline system functions and to design customized reports that physicians will be able to access in real time to evaluate progress and gauge quality levels.

HUMC is also evaluating whether integrating speech recognition will make it easier for physicians to document their notes and extract important data from the system. As with the other elements of system design, that decision will be made largely based on the needs of the physicians who will be using it.

“You have to have practicing physicians as part of this process. If you don’t, then there are going to be systems imposed on physicians [that] won’t work as good as they could or should. I feel passionately about this,” says Koniaris. “When a system works well, it can augment the physician experience and patient care. When it doesn’t work well, it slows everything down and makes the physician frustrated.”

 Adds Levine: “We believe very strongly that this will improve patient care, quality, and safety. I am absolutely convinced for multiple reasons that this is very important. “

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.


Other Elements of Successful Implementation
When it comes to system implementation, a solid project plan and a clinician-focused design-and-implementation team aren’t the only elements necessary for success. The IT infrastructure and technical support must also be in place to ensure peak performance and little or no unplanned downtime.

Hackensack University Medical Center’s (HUMC) IT team did not disappoint.

IT “did a tremendous job in making sure the equipment was deployed and the hardware was out there because if the performance isn’t there, you’re not going to succeed,” says Terry Moore, DNP, RN BC, NE-BC, HUMC’s director of Epic Clinical Systems.

Working with Epic and its third-party vendors, the IT team took steps to ensure the infrastructure was in place to handle what was expected to be a higher demand than ever before. That included purchasing “capacity-on-demand” technology that gave it the option to tap into an amount that was double what Epic recommended if and when it was needed.

“When we went live, it was with an insurance policy, so if there was an issue with performance, we could enable [the optional capacity] immediately so there was the least impact on the clinicians,” says HUMC Chief Technology Officer Benjamin Bordonaro.

The team also upgraded two data centers, deployed hundreds of extra devices, and staffed to maximum capacity on go-live to address any issues. As it was, throughout the chaos of go-live, there was not a single trouble ticket opened for performance issues and no downtime.

“On our best day ever with the previous clinical system, we had 800 people logged in and working. Within the first three or four days of go-live, we blew past that, doubling to 1,600 concurrent users. We went from 20% CPOE to over 70% after only the first week,” says Bordonaro.

But it wasn’t just the IT and project teams that were critical to the success. Bordonaro and Moore also give credit to the HUMC public relations (PR) department for an internal campaign that centered around the film Transformers. In addition to posters, banners, and t-shirts with logos, the campaign included “Epic Transformation Meal Days” every Friday, pizza parties for the night shift, and other special events.

“That is how we kept the project’s enthusiasm going strong,” explains Bordonaro. “We consider the PR team part of our team.”