February 19, 2007

EDIS Implementation: What Speed Suits Your Facility?
By Elizabeth S. Roop
For The Record
Vol. 19 No. 4 P. 16

Put the pedal to the floor or downshift into cruising mode? Learn about the advantages and disadvantages of each approach.

When it comes to implementing an emergency department information system (EDIS), there are two schools of thought. One is that the most effective implementation strategy is to take the “big bang” approach, which calls for turning on all the system’s features and interfaces at one time.

The other strategy involves taking a staged approach because it allows the ED staff to become proficient with various features and functions before interfaces to a facility’s primary hospital information system (HIS) are turned on.

There are plenty of proponents on both sides of the implementation coin; however, the approach any given facility takes is often dictated by factors beyond the ED doors. And each requires a high level of advanced planning, training, and ongoing education to make sure that whichever strategy is followed, the end result is improved patient care and safety, streamlined workflow processes, and reduced costs.

One Step at a Time
At ValleyCare Health System, which averages an annual ED volume of 28,000 patients and an urgent care volume of 10,800 patients, the big bang approach to implementation of its HealthMatics ED from Allscripts was the first choice of Nancy Zahradnik, RN, CEN. But because the EDIS implementation was scheduled to happen at the same time the 166-bed nonprofit facility in Pleasanton, Calif., was replacing its entire clinical information system, it had to change strategies.

“My philosophy in wanting to do it in one big bang was that it was going to be a huge, painful change, and ER [emergency room] people really don’t like to be novices. ER people function as experts every minute, and something like this really pulls them back to novice status. It’s very uncomfortable. To me, the philosophy of only putting them in pain once was a really good philosophy,” says Zahradnik, ValleyCare’s nursing director of critical care and emergency services. “However, because we chose to add [the EDIS] at the same time, we had to do it in pieces because the clinical information system for the whole hospital … was an enormous undertaking. Rather than not be successful because we spread our resources too thin, we moved the ED system out a ways.”

HealthMatics ED includes patient information management functions such as patient registration, triage, patient tracking, order entry, nurse and physician documentation, and disposition. The initial phase at ValleyCare included an interface with the admission, discharge, transfer system and implementation of the tracking board. This meant the staff needed to enter enough information in the tracking board to get a complete ED log, while still noting the information in the paper chart.

The patient names could also still be written on the ED whiteboard, leaving some to wonder what benefit the new system provided. And physicians found themselves having to document the discharge diagnosis twice—once in the system and once in the paper chart.

Adding the electronic documentation 13 months later, however, was much less painful, since by then the staff had become accustomed to using the system as a tracking board. But because interfaces to lab and radiology were not turned on for a few more months, the process still involved both paper and electronic documentation.

“It really, truly was extra work, and, bless their hearts, they did it although they weren’t happy with it,” says Zahradnik. “They were living in both environments for 21/2 months. It was not a nice, streamlined process and you could hear them grumbling. But we could say it was coming, and by the time we went live with the interfaces and the results were feeding directly into [the EDIS], it was really, truly a snap. Going live with the interfaces was nothing.”

The pain did ultimately pay off for ValleyCare. Since implementation was completed, it has seen a decrease in “door-to-doc” time and the average length of stay for discharged patients. Physician dictation has declined by approximately 80%, coding timeliness has risen, and nursing productivity and workflow has improved dramatically.

The staged implementation allowed staff to get accustomed to the system before it went live with the interfaces, Zahradnik says. She also mentions that staff were able to work with some functions, such as the tracking board, to familiarize themselves with workflow changes. Yet Zahradnik is still not completely convinced a staged approach is best.

“It does have its benefits,” she says. “But asked if I would do it that way again, I’m not sure. There was a lot of double work and it was not a streamlined process because we had to keep going back and forth between the charts and the computer. I’m not convinced it was the best way to do it, but it did have its points.”

For Lehigh Valley Hospital and Health Network (LVHHN) in Allentown, Pa., the decision to take a staged approach when implementing the T-SystemEV EDIS in its three EDs was both a preference and a necessity.

LVHHN, with an annual average ED volume of 115,000 patients among its three facilities, is one of the oldest and largest teaching hospitals in Pennsylvania and is affiliated with The Pennsylvania State University’s College of Medicine. Getting budget approval for an EDIS took three tries over nearly a decade, but it finally came to fruition when the decision was made to implement a facilitywide computerized physician order entry (CPOE) system.

“We said, ‘That’s a great idea, but we can’t carry a clipboard and work in a paper world then work in an electronic world for our order entry,’” says Richard S. MacKenzie, MD, vice chair of the department of emergency medicine. “We wouldn’t get any benefit from the electronic world because we’d still be looking for the chart to document on. We’d still have the ‘lost chart’ phenomenon.”

T-SystemEV features physician and nurse documentation, registration and triage, patient tracking, and discharge summaries. Implementing it in conjunction with the CPOE necessitated a staged rollout, beginning with electronic medication administration records, followed by CPOE, then the remainder of the T-System features, with approximately one month between each stage.

In hindsight, MacKenzie says, the staged approach was smart, but one month between each step was too long. In particular, splitting implementation of the medication records and the order entry systems “didn’t work. You need to do them at the same time,” he says. “There are still some people who believe a big bang would have been better. My personal belief is that if we would have done a two-week rollout, that would have been ideal.… It’s painful, but you just have to get it done.”

Getting it done has produced results. LVHHN saw dictation drop to an estimated 1% of its previous level, and the ability to share charts has been a huge benefit in care and documentation. The integration of the documentation function into the hospitalwide system has also proven invaluable for every department.

“From the standpoint of workflow productivity, this is definitely a more efficient system,” says Ann Gallagher, RN, T-Systems analyst for LVHHN, adding, “I personally didn’t anticipate the learning curve [required].... If you really, really study your process flows and really understand the flow of your paper chart and what you want to accomplish with the electronic system, it really makes the transition easier.”

Is the Big Bang Better?
For Evangelical Community Hospital, which sees an average of 31,000 emergency patients per year, an ED staff that required little convincing of an EDIS’ potential benefits and had been actively involved in the selection process made taking the big bang approach to implementing its MEDHOST system a natural choice.

“We really had acceptance. They knew this was up-and-coming in healthcare. We’ve been talking about it for so many years and the staff has been involved, so we didn’t have a lot to do [to prepare them for go-live]. The physicians were probably the last to come on board, and they have become the heroes,” says Darlene Rowe, RN, administrative director of the ED at the Lewisburg, Pa. facility. “We know our people and involving them as soon as we could, staff-wise, and integrating the other ancillary services to get them on board early was why ours went so smoothly.”

MEDHOST offers patient tracking, multidisciplinary charting, order entry, and automatic charge capture and reporting. Perhaps the most important feature, however, was the ease with which it integrated with the facility’s existing information system, without which the big bang approach would not have been possible.

“It has significant integration to our core HIS, the Keane System,” says Scott Peterson, vice president of information systems. “It interfaces fully from registration to order entry and results reporting. The interface also takes the final MEDHOST physician report and nursing documentation back into the HIS for everyone to be able to view.… As we were evaluating it, we really took it from the perspective that the technology was not going to be a barrier to the implementation.”

While the Evangelical EDIS is too new to measure tangible return on investment (ROI), both Rowe and Peterson say they’ve definitely seen improvements related to the implementation. For example, the HIS department is no longer receiving 90 charts per day that must be filed and validated because it’s all done online.

ED staff is no longer spending time searching for charts or waiting for another staff member to finish with a chart because the EDIS allows for simultaneous access. Documentation is completed faster and accountability is increased. Even housekeeping is more efficient thanks to the system’s dashboard, which lets them see instantly which rooms are ready for cleaning.

“It’s sort of hitting us right between the eyes, the changes we anticipated that we are now seeing,” says Rowe.

Meanwhile, Overlake Hospital Medical Center’s implementation of the Picis ED PulseCheck EDIS may have raised the bar for any implementation that wants to consider itself “big bang.” Within four months of signing the contract, the Bellevue, Wash. facility, the only Level III trauma center in eastern Puget Sound, had not only completed training but also customized some of the charge-by-documentation interface with the hospital’s BAR module.

On January 18, 2005, Overlake turned on nearly every feature of PulseCheck, including documentation, patient tracking, reporting, prescription writing, speech recognition, remote access, biometric authentication, and document scanning functions. The system also interfaces with inbound and outbound lab and radiology reports and features an interface with a Patient Care Inquiry (PCI) module that shares chart information with the patients’ PCI record.

“It was very fast,” says Gaylen Wright, Overlake’s senior systems analyst.

But speed was essential because Overlake had been notified one year earlier that the vendor would end support of its electronic medical record system, and the system could not be expanded to accommodate any future growth. “That left us in a spot where we needed to do something,” says Shirley Merkle, RN, Overlake’s ED director.

The facility, which averages 50,000 ED visits per year, was successful in its EDIS implementation in part because the ability to interface with its Meditech HIS was the top priority for whatever EDIS they ultimately chose, and because the ED staff had the computer skills to pull it off.

“That’s why we chose to do it this way, because we knew they could do it,” says Merkle. “They are a flexible group, and they worked it out.”

It didn’t take long for the staff to realize the fruits of their labors, either. ROI was quickly realized in hard dollars, streamlined processes, and improved care. In fact, the system paid for itself within two years. [TM e-mailed author to clarify]

Among the highlights: simultaneous chart access, increased chart legibility, significantly reduced dictation costs, faster documentation, accelerated workflow processes, and improved charge capture.

“When we surveyed the staff before going live, the issue was ‘Where, oh, where is the chart?’ That’s gone completely away now. We don’t have doctors coming at the end of the shift saying, ‘I can’t find my chart so I can’t complete documentation.’ That’s been a huge thing,” says Merkle, adding, “I’m now confident that our charges reflect what’s documented because that’s what drives the charges. In the past, nurses picked charges off different forms, and now they match completely.… I think all emergency departments need to be looking at an EDIS for the legibility, the ability to print prescriptions, etc. Before you do it, you need to really know your staff to know how to best implement it. It’s really the staff ability that determines how you’re going to implement things.”

Planning Trumps Process
One point is clear when you hear from those who have survived EDIS implementation of any kind: Success depends on careful planning, thorough training, and ongoing communication with everyone affected by the change.

Establishing multidisciplinary work groups with representatives from any department that may be impacted by the system, training both users and superusers on the system, making practice systems available before go-live, and staffing up in the days immediately following turn-on were all mentioned.

Other recommendations include securing buy-in from the organization’s highest levels and identifying physician champions to rally the troops. Pinpointing workflow processes that will change as a result of the EDIS to keep frustration levels at a minimum and letting individuals adapt at their own pace also come into play.

And finally, “let go of your fear and dive in,” says MacKenzie. “The fear is that electronic documentation is going to slow the flow dramatically. In fact, it doesn’t slow the flow. I would submit that ordering and waiting for tests is the rate-limiting step. It’s not the documentation. We spend too much time worrying about how the system is going to slow the flow, when it’s not the rate-limiting step at all.”

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