EMR: one hospital that got it right: Long Beach Memorial's rip-and-replace approach keeps patients' privacy and security top of mind.

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Long Beach (Calif.) Memorial, part of MemorialCare Medical Centers, is one of a small percentage of hospitals in the country with a fully integrated electronic medical records (EMR) system, well ahead of the national deadline established in the federal stimulus plan. As such, Long Beach Memorial witnessed the benefits of EMR adoption firsthand, according to Dr. James Leo, associate chief medical officer for the center, who can provide some insight into how to implement an EMR system successfully. [paragraph] "While we should expect to see an uptick in EMR adoption as a result of this stimulus plan, we'll see many hospitals struggling with how to take steps toward implementation over the next few years," he says. [paragraph] As outlined in the economic stimulus plan, physicians will each receive a maximum of $44,000 over the course of five years from the Centers for Medicare and Medicaid Services (CMS), beginning in 2011, if they implement and use a certified EMR in their facilities in a meaningful way (as yet undefined by the U.S. Department of Health and Human Services).

In addition, hospitals and healthcare providers that do not implement CCHIT-certified EMRs by 2014 will have their Medicare reimbursement rates cut by up to 3 percent beginning in 2015. The U.S. Congressional Budget Office (CBO) estimates these incentives will persuade nearly 90 percent of U.S. physicians to use EMRs over the next 10 years.

According to a study published by the New England Journal of Medicine in March, however, only 1.5 percent of acute-care hospitals have implemented a fully integrated, EMR, and only 8 percent have a basic EMR in place. Despite the emphasis now being placed on electronic medical records, Leo says, "our country has a long way to go and many challenges to overcome before realizing widespread adoption.

He explains that the act of moving every single-paper record into an electronic system does not come without concerns. One of the biggest is the worry that a patient's privacy and security could be at risk due to the amount of personal medical information involved. Another concern is the high cost of purchasing an EMR, as well as ongoing maintenance needs. An EMR can cost hospitals $20 million to $200 million due to implementation, vendor and hardware costs, staff training and upkeep.

Resistance from physicians and staff members lacking basic IT skills is another cause for concern, Leo says. A recent report by the National Center for Health Statistics, found that only 38.4 percent of physicians reported using full or partial EMRs. "Though this number is on the rise, many physicians are hesitant to adopt because they worry that it might take more time to input patient data into a computer as opposed to documenting it on paper," he adds.

A Challenging Implementation Process

Like all hospitals and healthcare providers, Long Beach Memorial had to consider and address these same concerns. Regardless of how big or small the healthcare system, the implementation process can be challenging and time consuming, Leo explains, often taking years from the early stages of development to full integration.

"We've been fortunate at Long Beach Memorial," he says. "We've completed our transition with very few hiccups, a high rate of adoption from our physicians, initial cost savings, and a wealth of lessons and best practices to share.

With a multitude of EMR vendors competing for the business, Leo advises that determining which of them meet the hospital's specific needs is critically important. The size of the hospital is certainly a factor, he says, as well as what type of software and features are most appropriate. "Some hospitals, for example, choose to implement EMRs in an effort to become entirely 'paperless,'" he says. "If this is your hospital's goal, you'll need to be sure your selected software has a specific set of tools required, as many EMRs were not developed to entirely replace a paper-based system.

"In our case, the vendor search began in 2003. After narrowing down the list to the final three based on factors such as compatibility with our current existing IT systems, and what was most cost-effective, we had each finalist come onsite for one week to thoroughly demonstrate how their system worked."

One strategy that went a long way toward the hospital's overall success was involving staff in the finalist phase, according to Leo. "We let our physicians and nurses test out the finalist demos and offer feedback that was used in our final decision. Because this was a multimillion dollar, enterprisewide decision affecting all facilities in the MemorialCare system, we wanted to make sure we were making the correct one. After nearly one year of evaluation, we selected Epic Systems to be implemented throughout the MemorialCare system."

MemorialCare did not take an off-the-shelf approach to adopting the new EMR. Instead, staff chose a user-driven approach to its system-design process based on workflows known as "design, build and validate" (DBV). DBV is a transparent, participatory process where clinicians are involved from the ground up and share their needs and vision for the future system. "When we did our first hospital EMR implementation in 2006," Leo says, "more than 100 front-line caregivers and 30 physicians provided more than 2,500 hours of advice on system design. This DBV process continues whenever a new application is added to our EMR.

"Though we live in a technologically advanced society, there are still many who do not understand technology's role in the healthcare arena," he adds. "Many physicians lack basic computer skills, such as using e-mail and the Internet. In addition to providing Epic training, we knew that basic computer training was vital for our staff to use the new EMR as effectively as possible."

As a result of the training, the percentage of physicians now utilizing computerized physician order entry (CPOE) at MemorialCare increased to nearly 75 percent within the first 48 to 72 hours of go-live. Since then, other physicians who were once hesitant to use EMRs have embraced the change.

As part of the training process, approximately 400 physicians and employees were designated as "super users." These staff members took an extensive Epic training program to achieve a higher level of competency. When other staff had a question or concern related to the software, they could immediately approach one of the super users for assistance.

Security a Main Concern

With the massive amount of personal patient information involved in an EMR, Leo emphasizes the importance of ensuring that security features are put into place. In addition, he says, the EMR software should be capable of prohibiting access to certain parts of the record to unauthorized users. Long Beach Memorial has invested in security features to make electronic patient information more secure and private so only those authorized can access a patient's medical record.

First, the person must be signed into the system in order to access the medical record, which creates a traceable audit trail used to monitor that person's activity. An added level of security, called "break the glass," forces anyone attempting to access a patient's record at a certain security level to go through a separate procedure before the information is revealed. As part of this process, the employee must provide an explanation as to why she needs to access the medical record and a security reminder is unveiled. Whenever someone goes through this process, additional medical records staff are notified.

Leo and his staff then had to determine when to go live and the amount of time that would be required to make the transition. "The best time is when there is the least amount of activity taking place," he offers, "and hospitals will also need to consider whether to make the transition all at once or in different stages.

"We engaged in a 'rip-and-replace' approach," Leo says, "switching to electronic medical records all at once instead of in separate stages. We also did our switch in the middle of the night to limit the number of patients potentially impacted by this change."

Leo cites several benefits to EMR adoption, including a reduction in operating costs and an increase in efficiency and productivity among hospital staff. For most hospitals, however, the biggest benefit is a dramatic improvement in patient safety, he says.

Typically, when physicians place a medication order, it is handwritten, later transcribed by a secretary and then sent to the pharmacy, which is part of an entirely different system. "The errors that can happen during this process are very real and very dangerous," Leo warns, "which is why we have a number of checks in place. While these checks have historically resulted in a low number of medication errors, we consider any mistake caught by the transcriber or pharmacist an error, even if it never reaches a patient."

With Epic, prescriptions are entered directly into a computer, allowing pharmacists and other caregivers to easily read the information and reducing the possibility of transcription errors. "We saw a huge reduction in medication errors overnight," Leo says.

"CPOE has created the greatest savings in time and efficiency. Minimizing the use of order transcription reduces errors, time from order creation to order action and physician call-backs for order clarification. It also dramatically decreased turnaround time between a physician entering a prescription and the medication becoming available to administer to the patient, sometimes by as high as 80 to 90 percent."

From the Catalog

According to www.epicsystems.com: EpicCare Inpatient Clinical System spans all hospital departments and specialties, giving providers the tools they need to deliver safe, high-quality care. EpicCare is also highly configurable, allowing the optimization of displays, features and information for physicians, nurses, therapists, dieticians and any other provider in the hospital setting. The inpatient system shares user-friendly documentation and CPOE features with the rest of the clinical suite, easing the placement of orders at the point of care, minimizing the administrative workload associated with care documentation, and maintaining a consistent and familiar user interface. At every point in the care process, the clinical decision support system works to protect patient safety and encourage compliance with organizational best practices.

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