Today I had the opportunity to talk with Dr. James Leo, Associate Chief Medical Officer of LBMMC, (Long Beach Memorial Medical Center), to discuss the hospital’s recent EMR/EHR adoption. Hopefully the information here may add some insight into how other hospital CMOs and CIOs around the country can work with staff to implement a successful electronic medical records system.
In addition to being a physician leader at LBMMC, Dr. Leo has practiced Critical Care Medicine and Internal Medicine for 22 years and has participated in many speaking engagements at hospitals and at conferences around the US and California. He also has a real feel for technology and understands the value of how technology helps to increase the quality of health care we receive today.
MemorialCare Medical Centers consists of five hospitals in Southern California, and each hospital has committed to transition to electronic medical records throughout the entire system. LBMMC and Miller Children’s Hospital, located on the same campus, were the next two hospitals in the group to go live, and the first hospital was Saddleback Memorial. Long Beach Memorial Medical Center and Miller Children’s Hospital are two of only 10 percent of the hospitals in the country that have moved to a fully integrated EMR system.
The Jonathan Jaques Children’s Cancer Center located at Miller Children’s Hospital also converted to the same electronic medical records program. Upon converting to electronic medical records, their medication error rates have reduced to nearly zero. Recently I posted about the continued progress at Long Beach Memorial with integrating their Amelior EDTracker(R) RFID into the Epic System, which allows for the tracking of patients, equipment and staff throughout the facility, so at a glance all equipment, patient locations, etc. are readily available.
On with the interview and some history on how it all started:
How long ago did MemorialCare begin the search for electronic medical records?
The search was actually started in 2003, which somewhat put us ahead of the rest of pack, realizing this was the path we needed to take. It was a lengthy process that involved many areas of the hospital, including clinical, administration, etc.
We chose Epic Systems, but getting to that point was a pretty involved process. We had several electronic medical record vendors all vying for the business and we spent hours talking with all of them. The selection process was somewhere along the lines of 9 to 12 months. Given the fact that this was an enterprise wide decision- affecting all 6 MemorialCare facilities and not just the two in Long Beach, and it was going to consume millions of dollars and 5-6 years of directed effort- we wanted to make sure that we got it right. We had each of our vendor finalists come on site for a week showing how their products dealt with 15 specific “pain points” we identified in the then-current manual & paper processes. In that timeframe, we had areas set up with the vendors where physicians and employed staff could actually come in and “take them for a test drive” and provided live demos to see how the record entering process and reporting functions would work with each vendor. We felt it was important to get the feedback from the physicians and clinical staff who were eventually going to be the end users of the software. Involving the staff in this manner was probably one of the best decisions we made to help us in the selection process. At the end of the day, and very helpfully to us, all three key constituencies- physicians, nurses and pharmacists- chose the same product- the Epic inpatient system- as their first choice. Once our selection was made, we purchased the Epic system.
Obviously there’s a big learning curve and training process involved with getting ready and having staff prepared for the day when the system goes live. Can you tell me a bit about how the hospital approached training and support to be ready for the conversion day?
We knew that having training of the right type and amount was critical to our success. We also knew that we had physicians and staff members at all levels of computer literacy and thus needed an approach to capture all to buy in. We had some on staff that barely knew what the mouse did relative to a computer, and then there were those at the opposite end of the spectrum. Our biggest concern was how to train the first group who were not considered computer literate. Before we could even think about the overall training on how to use the medical records, we first had to bring them up to speed on basic computer use and set up training to offer and educate those who needed the basics before moving further. In addition to this vital readiness assessment strategy, we also engaged in a very aggressive set of events designed to help the physicians understand what was coming and the “change strategy”- acknowledging that change was never easy but the resilient organization changes or it does not thrive.
Training was mandatory for everyone, 16 hours for most clinical staff and 8 to 12 hours for physicians with a 4 hour crash course for the “occasional” doctor who may only be visiting the hospital on a very limited basis, not a physician with patients in house on a regular basis. The 4 hour session offered “survival skills” to at least become familiar with the system.
How did your EMR Vendor,Epic come in to play during the training period, were they on premise, how often, and how did this work?
Epic was also very aware of how important training is for a successful implementation. The company was involved in our approach to training but we took full ownership of its conduct. To support our physicians, we developed an innovative strategy- which was new to Epic and which we understand they are now recommending to other customers. This involved hiring a team of Clinical Training Specialists- each assigned a panel of 40-50 physicians- and whose job is was to ascertain and meet that physician’s needs for training (both in computer basics and Epic application skills), their office set-up for remote access- such a valuable part of the project, as well as clinical content (physician’s preferences for order sets and the like). This program was a tremendous asset for us.
Also, what added to our success was identifying what we called “Super Users,” physicians and employees (400 in total) who took on additional training to achieve an extra level of competency in the Epic System. During those first few critical weeks after go-live, when someone had questions or issues related to the software and procedures, they could immediately find someone on staff who was a “Super User” to get help or ask questions.
Having employee and physician Super Users around to help others at and after Go-Live was a huge success, as the hospital is a pretty large facility and there were only so many Clinical Training Specialists available. Additionally Epic as a vendor only allows certified Epic trainers to train clinicians. So early in the process we pulled clinical staff from all areas into the certification process. It was important to have these home-grown experts training our colleagues in the classroom.
When did you begin the training process, how far ahead of “going live” did the training start?
We did not want to start application training too early, as too much time between training and the go-live date means people usually forget everything they have learned. The training began just weeks before the actual live date, and our nurses commented that the transition and training went better than they initially thought. Obviously, training on change resilience and the ascertainment and remediation of basic computer skills for our doctors and nurses started over a year before go-live.
What type of computer hardware is used in the system?
We use both PC desktops and mobile workstations that we call WOWs (Workstations on Wheels), that can be moved and accessed anywhere in the facility. We have had very good success with both, and are not using any mobile hand units such as tablets as of today.
How convenient is it for the physicians to log on to the system, are there several passwords to remember for each area, records, PACS, etc.?
We are using a “single sign on” so all that is needed is one log on for the entire system. This is really almost a must today, as physicians are busier than ever and having to remember and change a series of passwords would be quite discouraging and easy to forget. In addition, although we require passwords to be “strong” (in terms of character mix and length), we do not mandate routine changes. This helps our clinicians a lot while maintaining a strong authentication process.
When physicians are at home or away from the office, do they have a way to sign on to the system, a virtual private network?
We use a Citrix MetaFrame VPN (virtual private network) and the speed is good, as I can be away or at home and the PACS system images come up for review nearly as fast as they do when I am at the facility. The physicians have the VPN available to log on to the system remotely and completely securely.
In addition, we work closely with Talbert Medical Group. Talbert Medical has their own version of the ambulatory (physician's office) version of Epic Systems installed, so they can also communicate and log on to the system. Care Everywhere is an Epic product that allows separate enterprises each with an Epic clinical system to “merge” a patient’s data into a single chart “on the fly”. This allows Talbert and Long Beach Memorial to share and collaborate on patient medical records. Talbert Medical Group has 11 locations and approximately 130 or more physicians that can connect and share medical record information with patients in their system.
The first patient in the world linked through the Care Everywhere system was managed at Long Beach Memorial by communicating and collaborating with Talbert. Since then, hundreds of patients have benefitted from this tool. Simultaneous access to the outpatient and inpatient records has helped us cut down excess costs, such as lab tests or imaging that have already been provided recently at another location. This works well for everyone as patients don’t end up having the same costly tests repeated. Physicians and clinical staff at both ends can also view the lists of medications and other treatments, so again it comes down to providing the right treatment for the patient, and at the same time reducing medical errors from the pharmaceutical side of the chart, knowing allergies, etc. up front.
Is there a portal whereby patients can access their medical records available?
We do not have that module operating yet, so as of now the online viewing of a patients’ record by the patient is not available.
Outside of the Talbert Group, are patient records aggregated and shared with any other facilities?
As of today, they are not, but with the Obama stimulus plan we are striving to create connectivity between our other physicians’ office-based EMR’s and the Epic system. Creating connectivity and coordination between hospitals and the ambulatory setting is a top priority of the Obama administration, and is an important part of the MemorialCare strategy. We are working aggressively with the Long Beach Network for Health- one of 9 federally funded health information exchanges- to provide for such data available throughout our region. We are obviously enthusiastic about this- as we are about CareEverywhere- but are recognize the importance of dealing pro-actively with the security and privacy issues before this all becomes a reality.
What would you say has been the biggest benefit or advantage seen by using electronic medical records?
The biggest benefit for everyone is patient safety. One specific area, for example, is that of medication errors. An incorrectly entered medication order is considered an error, even if it is caught by a pharmacist long before it has the chance to reach the patient. While our number of such errors has historically been low, with the elimination of written orders, we have seen our already low numbers drop even further. After our Epic Go-Live, there was an overnight reduction in transcription and medication errors.
In the news of late we keep hearing stories of patient files being accessed at hospitals without authorization by clinical staff members who are not directly involved with a particular patient’s chart, records or care, none of this at your facility, but if I were a patient at your hospital, can you tell me what safety measures you may have in place to avoid this situation?
That is a good question and yes we do have measures in place with the Epic system to avoid that situation. No one can access a medical record without signing on to the Epic system, which creates an audit trail that can subsequently be tracked. For patients for whom an extra measure of security is needed (such as employees or physicians on staff), Epic has an additional layer of security called “Break the Glass.” For these patients, anyone attempting to access the patient chart has a procedure that needs to be initiated before the patient records are available to view.
In this process the employee or physician must first explain “why” they are accessing the chart. The screen at this point flashes a security reminder, which should provide a deterrent to anyone desiring to access a medical record inappropriately. In years past there were no safeguards in place with paper charts, and anyone could pick up a paper chart and read whatever they wanted to know. But today that is not the case with our advanced technology. Whenever someone “breaks the glass”, that fact and their reason for doing so (which might be quite valid) are included in an e-mail message to our medical records staff who can monitor these actions and request further review by the medical staff office or others, as appropriate.
A full audit trail is created along with a reporting system that allows us to see all aspects of the chart, so even if an individual began the process of accessing the chart and stopped at the “why” screen, the audit trails will identify the employee who wanted to access the patient chart. The system has full audit trails with a reporting system that allows us to keep patient record security in the forefront and monitor access as authorized for patient care. On the other hand, there will be occasions where an employee will need legitimate access to the records, and that is all tracked and shown with the audit trails. In short, insuring complete maintenance of patient privacy and limiting access strictly to that which is appropriate for the care process is a top priority for us. If there is someone in the chart who we deem should not have access, the reporting systems and queries run are capable of letting us know and allowing us to take pro-active action.
The “Breaking the Glass” feature, as well as the standard procedures required for chart access, really make an individual stop and think about why they need access to a particular patient’s chart. All employees are aware of this process and know their tracks will be traced and audited, so preventing unauthorized access to patient charts and protecting patient privacy has been handled in this manner and is working well. The recent Kaiser experience with the octuplets and their actions in dealing with staff that inappropriately accessed those charts was facilitated by their use of the same Break the Glass functionality and we hope sent a good message to everyone about how important that privacy is.
At the same time as we maintain a high level of vigilance with regard to security, it’s important to realize how much electronic records can improve the coordination and safety of hospital care. With paper charts only one individual can see a chart at a time; with electronic records, physicians and staff are able to collaborate and communicate simultaneously with patient records to ensure that the best possible care and treatment plans are determined in a timely manner, and that all aspects of patient care are available for intelligent decisions to be made.
In the news of late I have been reading about the revised “Stark Laws” which have been relaxed to allow hospitals the ability to subsidize and help medical practices obtain electronic medical records, is this something Long Beach Memorial could be looking at?
This is an exciting opportunity and challenge for us, given that we have approximately 1300 physicians on staff. While some of our physicians (such as the Talbert Medical Group) already have ambulatory EMR’s in place, many do not, and the costs of implementing these systems is very substantial. EpicCare Ambulatory EMR is the medical practice solution that seamlessly communicates with the Epic System at the hospital and we are working with many of our physicians to help them implement it at their office locations. We are excited that President Obama’s economic stimulus package included a substantial amount of money for HIT, including reimbursement for physicians who implement EMR’s in their offices. We anticipate working within the framework that will be established as this plan is rolled out, to facilitate our physicians’ implementation of EMR’s in their outpatient settings.
Thank you for your time today and hopefully some of our discussion will serve as motivation and offer some good advice on how hospitals can invest and embrace the use of modern technology with electronic medical records to provide better healthcare for all.