# Presentation: 463188

## Midland Memorial Hospital

- AHIC EHR Workgroup
- September 10,2008
- Electronic Health Record
- Deployment and Adoption

## Midland Memorial Hospital (MMH)

- Midland, Texas Population – 101,000
- 320 licensed beds, 2 sites
- Main Campus – Full-Service Acute Care
- West Campus – Women’s and Children’s services
- Medical Staff – 200+/- community-based independent contractors
- Outpatient Imaging Facilities – MRI, DIA, AWI
- Average Census – 150+/-
- Annual Inpatient Admissions – 11,000+/-
- Annual ER Visits – 50,000+

## Milestone Dates

- Oct ‘05	   	Pharmacy go live
- Nov ‘05		Laboratory go live
- Dec ‘05		Order entry (not CPOE)
- Dec ‘05 - June ‘06	Full CPRS (Documentation/CPOE)
- Sept ‘06 - Nov ‘06	Bar code medication administration
- Feb 5, 2007		Fully Electronic Health Record
- Jan 2008		Recognized by HIMSS Analytics as 			Stage 6 Hospital

## Lessons Learned

- Physician buy-in is _hard_
- Significant time commitment
- Early engagement in process
- Remote access is _vital_
- Natural resistance to change
- Enthusiastic support from leaders a _must_
- One-on-one attention is necessary
- Don’t skimp on hardware
- Facilities changes are important
- More computers:  bigger nursing stations

## Lessons Learned

- Conversion is challenging for staff
- Natural resistance to change
- Older staff not computer-friendly
- Difference in work routines
- 	Example:  Nursing admission assessment
- Time to complete has doubled
- Nurses skipping much of manual process
- Forcing MMH to decide what really matters
- Hybrid environment exacerbates frustrations
- Tendency to blame system for everything

## Physician Adoption Strategies

- Pre-project engagement and participation
- VistA Demonstration Project – 1 week
- Physician Advisory Committee
- Inclusion of Chief of Staff in 1 1⁄2 year due diligence process
- Implementation and post go live period
- EDITH Physician Advisory Committee
- Enthusiastic early adopters/champions
- Fully committed
- One-on-one custom training
- Classroom training
- Electronic signature
- Remote Access
- Customized structured documentation
- Customized order sets
- Engage, engage, engage – stalk, stalk, stalk

## Physician Adoption  

- Physician Adoption

## Physician Adoption 

- Slower than desirable
- Time commitment for learning and customization is daunting
- Professional service agreements to pay MDs for their time to train/develop
- _Goals:_		40 percent of orders personally entered
- 			100 percent of transcription e-signed
- 			By 2/5/07, all paper records eliminated

## Physician CPOE Rate

- The percentage of total orders entered via computerized provider order entry improved from an initial post implementation measure of 9.5% (1,617 entered of 16,984 total orders week ending Jul 5, 2006) to 51.8% (14,796 of 28,552 week ending  May 5, 2008).

- Defined as the percentage of total orders entered via CPOE.
- Source: Midland Memorial Hospital IT Department

## Anecdotal or Perceived Improvements

**Clinical Adoption**
- Use of remote access is high and in high demand.
- Reduced count of physician complaints received
- An estimated 109 offices have remote access installed
- An estimated 81 homes (including laptops) have remote access installed
- There an estimated 433 total installs of remote access

## Anecdotal or Perceived Improvements

**Safety and Quality**
- Non-compliance with documentation of date and time has been essentially eliminated.
- EDITH has eliminated the time spent clarifying orders and documentation due to handwritten legibility issues.
- Immediate access and availability has made it easier to conduct chart audits in support of regulatory and accreditation requirements.
- Bar-coded Medication Administration has helped reduce the rates of self-reported medication errors.

## Anecdotal or Perceived Improvements

**Safety and Quality cont.**
- Unapproved abbreviations have reduced significantly. During the recent Joint Commission survey, surveyors found two unapproved abbreviations and they were both handwritten on paper documents.
- Pharmacists are now more clinically focused; they are no longer just a dispensing pharmacy.
- Lost charts have been eliminated.
- Helps radiology staff identify isolation patients and “Do Not Resuscitate” status.

## Anecdotal or Perceived Improvements

**Safety and Quality cont.**
- There are fewer ordering errors made with direct entry.
- Use of topic-focused notes, e.g. documentation requirements for pressure ulcers, has helped improve capture of all components since they are all together in one place in the record.
- Quality Management is now doing concurrent monitoring for compliance with core measures.
- Quality management reports that they “Would not have been able to do the nursing quality dashboard without EDITH.” The pressure ulcer rate was just over 20 percent and has dropped down to 3-5 percent.

## Anecdotal or Perceived Improvements

**Safety and Quality cont.**
- Quality Director reports, “With concurrent review it’s allowed us to set the stage for cultural change; quality is real time and it never used to be.”
- In the Emergency Department, requests for the paper chart would take anywhere from 20 minutes to the next day (if in the middle of the night and the House Supervisor was too busy).  Now access is immediate.
- Timely administration of antibiotics on admission for patients with pneumonia has improved.
- Missed dating and timing of entries has been eliminated.

## Anecdotal or Perceived Improvements

**Operational Efficiency**
- Remote access has helped physicians decrease time spent doing rounds as they are able to come prepared with lab and procedure results ahead of time.
- Time spent reviewing records is now quicker, resulting in faster resolution of patient complaints.
- Delays in retrieving paper medical records have decreased. Pre-implementation it would take on average one week to retrieve the paper record for review. Record is now immediately accessible.
- Financial audits are now quicker (although there has been no Cost Report audit since the EDITH go live.

## Anecdotal or Perceived Improvements

**Operational Efficiency cont.**
- Chart availability helps everyone to fulfill their role and allows for simultaneous access to the same record by different roles.
- Medication verification can now be conducted more timely due to the ability to better allocate pharmacist coverage for this function.
- Information availability on outpatients and Emergency Department patients has helped radiology staff pre-plan interventions and improve continuity of care.
- Time spent reviewing records is now quicker, resulting in faster resolution of patient complaints.

## Anecdotal or Perceived Improvements

**Operational Efficiency cont.**
- Remote access has helped physicians decrease time spent doing rounds as they are able to come prepared with lab and procedure results ahead of time.
- Delays in retrieving paper medical records have decreased.  Pre-implementation it would take on average one week to retrieve the paper record for review.  Record is now immediately accessible.
- Financial audits are now quicker (although there has been no Cost Report audit since the EDITH go live.
- Ability to cut and paste text saves time entering documentation.

## Anecdotal or Perceived Improvements

**Operational Efficiency** **cont.**
- Chart availability helps everyone to fulfill their role and allows for simultaneous access to the same record by different roles.
- Medication verification can now be conducted more timely due to the ability to better allocate pharmacist coverage for this function.
- Information availability on outpatients and Emergency Department patients has helped radiology staff pre-plan interventions and improve continuity of care.
- Physicians can see and search lab and x-ray results and medications quicker.

## Anecdotal or Perceived Improvements

**Operational Efficiency cont.**
- Availability of electronic signature has helped reduce time spent authenticating records.  One physician used to have to go to Medical Records to sign charts once per week or every three weeks.  Now this can be done remotely.  Now can do 50 charts in 20-30 minutes.
- Physician medical record deficiencies have reduced from 37-41% previously to 25% now.
- Charge nurses are rounding with computers on wheels to improve communication.

## Anecdotal or Perceived Improvements

**Operational Efficiency cont.**
- Dietitians can see more patients in less time.  With EDITH dietitians can see about 30 patients in 90 minutes. Using paper charts they could only see 12-15 patients per day.

## Anecdotal or Perceived Improvements

**Return on Investment cont.**
- Lab has eliminated the practice of printing lab reports and placing on the chart resulting in an approximate 99% reduction in lab paper costs.
- Lab has decreased the use of labels combining more tests to an accession number to print on one label; now using generic labels used by the Veterans Administration hospitals in lieu of more costly custom labels.
- Lab has decreased the count of terminals used in the department. They have removed 6-8 terminals due to work flow changes since technologists do not need as much interaction with the system.

## Anecdotal or Perceived Improvements

**Return on Investment cont.**
- EDITH has helped reduce record storage costs by reducing the needs for physical space for storage of medical records.
- The availability of McKesson Interqual and Milliman and Roberts criteria embedded in EDITH has helped with concurrent review.
- EDITH has greatly improved the time it takes to get charts coded due to improved access and availability. EDITH helped the organization catch up on a backlog of $16.7 million of coding records and billing in 4 weeks (about 4500 records).

## Anecdotal or Perceived Improvements

**Evidence-based Decision Making**
- Use of physician order sets has reduced variability
- Physician specific discharge instructions in day surgery are being turned into order sets.