07 Sep No Small Feat

ImagingEconomics | For community hospitals, the challenges of EMR implementation are many, but achieving meaningful use is a must.

When asked to provide advice to community hospitals facing the challenge of electronic medical record (EMR) implementation and demonstrating meaningful use, Keith J. Dreyer, MD, vice chairman of radiology at Massachusetts General Hospital, offered two simple words: “Start now.”

A recent KLAS report suggests that many health care providers are, indeed, well under way. “It’s kind of the new battleground,” said study author Paul Pitcher. “In larger hospital markets, hospitals are moving and doing a lot of clinical stuff. Vendors see opportunities for growth in the smaller community hospital, where there has not been the emphasis in clinicals to this date.”

Adoption Trends

Titled “Community Hospital EMRs Maturing for Meaningful Use,” the report includes insights from 501 study participants who spoke about vendor confidence in meeting Stage 1 meaningful use by 2013. As defined by KLAS, community hospitals are facilities with under 200 beds. Research was concentrated on institutions that were live with a clinical system and also had in place “Advanced Clinicals,” or a minimum of nurse documentation and charting.

Key results include the finding that the majority of participating providers indicated they were confident that their corresponding EMR vendor would deliver on meaningful use requirements. Yet, about a fifth of the market expressed concern and were searching for alternatives to their current product. Pitcher admitted that this substantial percentage who placed themselves in the “flux” category caught him off guard.

“I think that only time will tell,” Pitcher said. “I think that if customers took a look around the market, you will certainly see some make that switch, but I think that a percentage of them will ultimately say that ‘The grass isn’t greener on the other side,’ and ‘We’ve just got to dedicate the resources, and we can get there.'”

Furthermore, Pitcher said he was surprised to see the high degree of nursing usage across all the products examined. “That changed significantly when it came to physician usage, and what really becomes the challenge for these organizations is getting physician adoption,” he said.

Vendors that have excelled at setting deadlines and meeting those dates create much confidence in a customer base, Pitcher continued. “When there is transparency in what they are doing, it creates a lot of confidence,” he said. “The opposite of that is also true. I see one or two vendors in particular who have had challenges in meeting expectations, and there’s a lack of confidence in their customer base.”

Pitcher predicts that there will be a lot of energy around the whole clinical environment in the community hospital space.

“You see a lot of flurry going on,” he said, “for the next few years, as organizations are striving first to achieve meaningful use and test for that in Stage 1. I know there’s going to be a lot of energy in health care IT in these organizations for a number of years.”

Demonstrating Meaningful Use

While there are a number of barriers to EMR adoption, such as financial burden, technology implementation, user education, and physician acceptance, community hospitals embrace its major advantage.”The benefit is universal access to consolidated clinical data,” Dreyer said. “This can help a provider to reduce costs and reduce errors, while improving efficiency and outcomes.”

Citizens Memorial Healthcare (CMH), a rural health network based in Bolivar, Mo, has experienced firsthand how an effective EMR can greatly impact work processes. Nine years ago, the acute care, critical access hospital with 74 beds purchased the Meditech client server Version 5.64. In addition to the hospital, the health system consists of 26 physician offices, five nursing homes with 500 beds, residential care facilities, a home health hospice, and a cancer center. “Over a five-county area, we had a lot of services and we wanted one single medical record that would provide that continuity of care,” said Sherry Montileone, CMH technology manager.

According to Montileone, studies showed that CMH saw eight out of 10 patients repeatedly. As a result, it was very important for the hospital to have a system that could access medical records, showing insurance documentation or allergy information, no matter what door a patient entered. “We just thought it was really important for customer satisfaction and patient safety that we have a single medical record for that entire care area,” Montileone continued.

For CMH, the top priority was integration through all its service lines. However, there were few EMRs that offered all the components for a clinic, an emergency room, a long-term care facility, a home health hospice, etc. “There are packages out there that are very good in any one of those service lines,” Montileone said. “But there were very few that would literally maintain a single medical record and be able to translate values across the service line. And the primary thing for us was being able to have one system and for the patient to be able to maintain their identity across any service we provide.”

After preparing for Y2K and looking ahead to upcoming HIPAA requirements, timing played an important role in CMH’s decision to purchase its EMR solution. “We were going to have to make a major change regardless,” Montileone said. “So we had to make a decision on whether we were going to build our own system or piece together a multivendor solution, and it was just really obvious to us that integration between our service lines was a big deal. We are fortunate because the entire industry has turned in that direction. Ten years ago, it wasn’t that obvious. Who cares whether you could look at a clinical chest x-ray from the hospital? Who cares if you had a paper chart that you have to rely on? Medication reconciliation and all of those things now are such a big deal. Back then, it was just kind of a dream.”

At the end of May, the hospital completed its attestation for Stage 1 meaningful use. It is also Stage 7 for HIMSS Analytics, meaning that the hospital is truly paperless and that clinical information can be readily shared via standard electronic transactions with all entities within health information exchange networks. Furthermore, it can employ “data warehousing and mining techniques to capture and analyze care data for performance improvement and advancing clinical decision support protocols,” according to HIMSS.

“If you meet the HIMSS Analytics Stage 7, you’ve already proven that you have interoperability and can provide information to patients,” said Susan Sanders, the hospital’s telehealth coordinator. “It had a lot of the same requirements. With Stage 7 achieved last year, it made Stage 1 much easier for us.”

Challenges to Implementation

The health care organization funnels all its systems through Meditech. For example, as a customer of McKesson’s HMI radiology and cardiology PACS, hospital staff can open up a patient record, see that a chest x-ray was ordered, launch the study, and use various physician tools — all within the EMR. “We want everything in Meditech,” Montileone said. “We really don’t want the average user ever out of Meditech. We want it to be easy; we do not want to have to maintain multiple systems, train on multiple systems, and maintain multiple names and passwords. We don’t expect users to launch another package and log in. The easier you make things, the more people use them.”

Of course, the road to meaningful use is not necessarily a smooth one. For example, CMH needed to build a very robust wireless network. “We don’t have paper charts,” Montileone explained. “We literally put the paper charts on carts and took them away. If you tell people that the only way you can chart and document is with the EMR, then it had better be up almost 100% of the time.”

In order to accomplish this feat, CMH had to find the right devices. Wireless was required to be perfect in 33 buildings across the county. “Since we’re rural, we don’t have access to high-speed Internet everywhere,” Montileone said. “We literally were creating our own wireless bridges and pleading with the utility company to dig fiber for us.” IE

Moreover, the community hospital ran into normal health care challenges. With its 1,500 employees in 33 buildings who all worked different shifts, it would be a challenge to get everybody trained. As a consequence of that situation, CMH bought HealthStream, a learning management system. “HealthStream is how we roll out that we have a new update or new compliance information so we manage it all through there,” Montileone said. “You publish it, and you can record who’s done it or not. It’s a good way to measure competence.

Perhaps the most apparent issue that community hospitals in particular must resolve is the budgetary one. In CMH’s case, it runs far under the national average for an IT budget, according to Montileone. In addition to making the institution eligible for meaningful use incentive money, the EMR also allowed the health network to grow without adding staff.

Another tough reality that CMH faces is physician acceptance of its EMR solution. Montileone readily admits that there are better modules out there for specific service lines. Therefore, departments that desire best of breed put up some resistance in the beginning. “We had to gather everybody in and say, ‘Hey, you’ve got to begin with the end in mind, and what we want is a supportable system that crosses all service lines with as few interfaces as possible and you will have to sacrifice a little bit to get what we want,'” she said. “Everybody today sees this and is so happy that we did.”

Thinking Ahead

In Dreyer’s opinion, community hospitals must not skimp on researching potential EMR purchases. “Be sure to purchase an EMR solution that is fully certified for both inpatient (EH) and ambulatory (EP) meaningful use programs,” he advised.

Administrative support is also imperative. “One thing that was very helpful for us was getting administrative support right from the beginning,” Sanders said. “To have everybody give support right from the beginning keeps people engaged and on the right track with moving along in their own departments. It shows a really united front.”

Reflecting on her own experience, Montileone believes that the single vendor carries much weight. “In meaningful use, you’d have to certify every vendor and the integration between the vendors. For community hospitals, where they’re not going to have a huge IT staff or a big budget, I would think that a single vendor would be a big deal.”

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