# Presentation: 707396

## midland memorial hospital

- AHIC EHR WG
- July 20, 2007

## midland memorial hospital

- 	_The Story_
- 320-bed community hospital successfully modifies VA Hospitals’ information system for use in private sector
- Free?
- OpenVistA available under FOIA
- Significant consulting, other costs
- Only in America?
- Adopted by hospitals in Finland in mid-1990s
- Recently implemented in Mexican Federal Health System

## midland memorial hospital

- 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+

## midland memorial hospital

- _State of MMH:  November 2002_
- Lost $6.3 million FYE 9/30/02
- $24 million cash on hand (approx. 60 days)
- Pharmacy, lab, overall HIS sunsetting in near future
- Massive capital needs
- New CEO

## midland memorial hospital

- 	_IT Strategy_
- Head off coming crisis
- Manage with very limited capital funding
- McKesson assessment project – mid-2003
- Comprehensive system replacement: Minimum of $20 million
- Conclusion – Much less expensive alternative must be identified

## midland memorial hospital

- 	_VistA – A Revelation_
- Comprehensive electronic health record
- First developed in mid-1970s
- Currently in use in 172 VA hospitals and 850 clinics throughout U.S.
- Continuously updated by VA
- Open source code, available under Freedom of Information Act

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- 	_VistA - Shortcomings_
- Emergency Services
- Obstetrics
- Nursery and Pediatrics
- Surgery
- Flow Sheets

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- 	_VistA – A Revelation_ (cont.)
- 	MedSphere
- Small consulting firm founded by Southern California M.D.
- Mission:  Spread VistA to private sector
- Team includes many founding fathers of VA IT, including Dr. Ken Kizer

## midland memorial hospital

- 	_VistA – A Revelation_ (cont.)
- 	6/03	World VistA Conference
- 	Fall/03	VA site visits with key staff & MDs
- 	1/04      	On-site demonstration project at MMH
- Hands-on experience for MDs and clinical staff
- 	8/04	Enterprise assessment
- MedSphere
- Deloitte Consulting

## midland memorial hospital

- _VistA – A Revelation_ (cont.)
- Project Budget
- VistA software license		$     -0-
- Consulting (primarily MedSphere)	  5,126,000
- Replacement of financial systems	     700,000
- Hardware				     801,000
- Wireless infrastructure		     226,000
- Interfaces, etc.			     140,000
- Remodeling				____100,000_
- 				Total		_$ 7,093,000_

## midland memorial hospital

- 	_VistA – A Revelation_ (cont.)
- 	Project Timeline
- 	11/04	   	Project approval
- 	1/05-6/05		Infrastructure & organizational
- 				development
- 	3/05-Current		Software modification and
- 				training
- 	Go-Live Dates
- 	10/05	   	Pharmacy
- 	11/05		Laboratory
- 	12/05		Order Entry

## midland memorial hospital

- 		_EDITH and NED_
_**E**_lectronic _**D**_ata and _**I**_nformation _**T**_echnology for **H**ealthcare
_**N**_on-_**E**_dith _**D**_ocuments (transfer paperwork; any document requiring patient signature)

## midland memorial hospital

- 		_EDITH_
- 		Go-Live Dates
- 		12/05-6/06		CPRS (clinical 					documentation)
- 		9/06-2/07		Bar Code Medication 				Administration
- 		2/07			Fully electronic 					medical record

## midland memorial hospital

- 	_Current Status_
- Computerized Patient Record (CPR) - implementation complete
- Barcode Medication Administration (BCMA) - implementation complete
- Computerized Physician Order Entry (CPOE) – implementation complete
- Many system improvements ongoing
- remote access
- pathology interface
- streamlining nursing documentation
- Focus on physician adoption

## midland memorial hospital

- 	_Planning for Implementation_
- Take long view and then move back.
- IT, Nursing and Physicians look at chart or computerized patient record (CPR) differently.
- Protocols and Standing Orders
- The better you define the system before you go live the better training

## midland memorial hospital

- 	_Equipment & Space_
- Tendency to underestimate computer and scanner needs
- Electrical supply and storage for computers
- Increased need for counter space in nursing station
- Computer Training Rooms

## midland memorial hospital

- 	_Computer Training_
- Basic computer knowledge of staff prior to transition
- Insure adequate training time prior to go live (8 hours)
- Require completion of computer training in order to access system

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- 	_Computer Training, cont’d._
- Match training session to skill level of participants
- Goal 80% of staff to complete training before go live
- Unanticipated training needs (i.e. 200 LVN/RN students; case managers; quality management staff; agency staff)
- Consider trainer who has the same clinical skill of participant (nurses, unit coordinators, respiratory therapist, pharmacist, physical therapist)

## midland memorial hospital

- 	_Information Technology Staff_
- Project Manager with Nursing and IT experience
- Clinical Analyst – IT Staff selected from clinical staff (RN, Pharmacy Tech, Respiratory Therapist)
- Super-Users – unit or department staff who have additional training

## midland memorial hospital

-  	_Physician Adoption_
- EPAC
- Physician advisory committee
- Enthusiastic early adopters/champions
- Fully committed
- One-on-one custom training and development
- Remote access
- Electronic signature

## midland memorial hospital

- _Physician Adoption_ (cont.)
- Slower than desirable
- Time commitment for learning and customization is daunting
- Coming:  Professional service agreements to pay MDs for their time to train/develop
- 	_Goals:_	40% of orders personally entered
- 			(currently 18%)
- 			100% of transcription e-signed
- 			(currently 26%)
- 			By 2/05/06, all paper records eliminated

## midland memorial hospital

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

## midland memorial hospital

- _Lessons Learned_ (cont.)
- 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 us to decide what really matters
- Hybrid environment exacerbates frustrations
- Tendency to blame system for everything

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- 	_Outcomes_
- Chart available to all clinicians
- Legibility of physician order entry
- Remote access for electronic signature
- Improved documentation

## midland memorial hospital

- _Final Thoughts – Why did we do it?_
- System obsolescence required action
- Financial condition limited options
- VistA represented opportunity to leap forward at low cost
- Patient safety enhancement
- Support of quality initiatives
- Tying to our physicians via superior information access
- Meaningful contribution to the industry

##       Questions
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			Answers

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- midland memorial hospital