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Going all-digital is easier said than done.

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Deciding to build an all-digital heart hospital was easy; implementing all that technology and making it work continues to be a challenge.

The plan was ambitious, but it seemed straightforward--at least at the start.

Pepin Heart Hospital, a 125-bed facility on the campus of University Community Hospital in Tampa, Fla., was expected to be nearly paperless when it opened to patients in February of 2006.

Computers lining the hallway near the patient rooms would allow doctors to check records or view X-rays and diagnostic tests. Patients could use bedside computer screens to check email or watch videos relating to their treatment. Updates on patient care would be sent automatically via email to primary care physicians or nursing facilities.

But today, despite careful planning and the input of a bevy of experts, Pepin is still at least a year away from being fully digitized. Some significant progress has been made. The hospital now has fully operational nursing documentation and integrated patient care monitoring devices in the operating rooms.

But there have also been some notable setbacks from both an operational and an institutional standpoint. The hospital still hasn't reached its goal of implementing electronic medication administration (eMAR) or computerized physician order entry (CPOE).

"It's a lot harder than just pressing a button," said Brigette Shaw, Pepin's chief executive officer. "There's a lot of coordination and expense involved."

But in many ways, the obstacles the hospital faced in trying to implement a paperless system illustrate why health care organizations across the country have been slow to adopt new technology.

From the problems they had convincing engineers to view things from a clinician's point of view, to the reluctance of many doctors to adapt, to the difficulty of keeping up with new and rapidly changing technology the journey to becoming a fully digitized hospital can be fraught with pitfalls.

But Shaw, and others at Pepin, say the troubles they've experienced will be more than worth it once they reach their goal. "This is what you need to do to compete in today's marketplace," Shaw said. "We had to start looking at things in a different way."

Starbucks and style

Walking into Pepin, visitors may think they've stumbled into a boutique hotel instead of a cutting-edge cardiovascular hospital. Dark wood paneling creates a sense of comfort. Colorful works of abstract art line the walls.

The two-story main entrance also features an open staircase and a textured water wall. The leather chairs in the lobby are soft and deep. There's a small snack bar, dubbed the "Heart Rock Cafe," that serves Starbucks coffee and muffins. In back, there's a serenity garden featuring lush landscaping and a waterfall.

The facility is intended to be a first-rate cardiovascular hospital, with a 52-bed interventional unit, 16 critical care beds, a 20-bed surgery recovery unit, 48 progressive care beds and five surgical suites.

Pepin was designed with patient privacy in mind, Shaw said. All of the public areas, including waiting rooms, are on one side of the hospital, while all of the patient rooms are on another. This was done to help preserve patients' dignity and comfort, Shaw said.

Hospital officials also knew early on that they wanted Pepin to be almost totally paperless. Everything from pharmacy to nursing to registration would be done on computer.

The thinking behind this was obvious, said Charles Lamberdt, MD, PhD, MBA, Pepin's medical director. "It's the future," Lamberdt said. "It's where everything else is going."

Technology has many obvious benefits. Supporters say EMRs help improve reliability and decrease the possibility of error. Digital check-in systems are quicker and more convenient for patients, administrators and care-givers alike. Technology has been shown to boost productivity and streamline operations. It helps drive down malpractice costs and reduces the need for expensive transcription.

Also, as one of Tampa Bay's newest hospitals, Pepin's use of technology could help distinguish it from competitors, Shaw said. But developers knew it wasn't going to be cheap. In fact, the total cost is expected to be about $35 million over five years.

"It's a huge, huge transition," said Shaw. "More and more people are putting it on the docket, but it's a very capital-dependent project. You need both money and intellectual capital."

Partnerships and buy-in

The hospital forged ahead by creating a partnership with GE Centricity, one of the more well-known providers of EMR technology. They also hired Lamberdt, who previously served as director of interventional cardiology at the University of Florida and Shands Hospital.

One of Lamberdt's key duties was to serve as a link between the technology providers and the hospital's clinicians. He knew that creating buy-in among doctors was one of the most significant hurdles the hospital had to cross. He also had to convince GE's engineers to tailor their technology to meet the needs of Pepin's employees.

"There's really not a perfect hospital EMR," Lamberdt said. "There are always going to be issues if top-down decisions are made for clinicians by non-clinicians."

Pepin also recruited Christy Kindler to be the director of clinical informatics. Kindler, a registered nurse, came from Indiana Heart Hospital in Indianapolis, which was one of the first in the country to implement an all-digital system. Kindler had seen up-close the benefits of using technology and was excited to see them replicated in a new location.



"Everyone wants the same thing," Kindler said. "Everyone wants to take phenomenal care of their patients. And technology can be a really useful tool."

Everything was in place. What could possibly go wrong?

A wrench in the works

No sooner had Pepin officials embarked on their ambitious endeavor when GE threw an 11th-hour wrench in their plans. GE acquired another company and decided to change its entire operating platform. That meant Pepin had to start over from the beginning.



Shaw said that wasn't the only hiccup they encountered. Despite their best efforts, they had difficulty getting some of the doctors to accept the new technology. "It's a mixed bag," she said. "I think there are a lot of people who are always going to resist."

Hospital officials did their best to circumvent any problems by bringing GE engineers to Pepin and walking them through a typical day for doctors and nurses. The experience was enlightening, and they discovered a big gap in perceptions between the physicians and the technology providers.

For example, the GE representatives were pleased when they cut the time to log in to the computers to 45 seconds. But for doctors, who have to log in to the computer 30 or 40 times a day, it took way too long.

"They can't appreciate the challenges until they've walked in their shoes," Candler said. "Maybe not literally but at least figuratively."

They discovered other problems. Shaw said they quickly realized they needed to include the other organizations in the University Community Hospital (UCH) system in their digital systems.

Because so many of their physicians shuttle between Pepin and UCH, not having a unified system made communication troublesome. So, moving forward, they are looking to broaden the scope of the project, Shaw said.

Another snag: the computer screens they bought, for patients' bedsides are too small to be used as work stations. At just 11 inches, it was too difficult for doctors and nurses to key in information. Also, the UK-based company that manufactures and repairs the units stopped operating in the United States.

But Candler said they have located another company that will be able to perform maintenance. And the bedside computers are very popular with patients.

TVs and Web cams

Despite the setbacks, tremendous progress has been made. Large, flat screen TVs adorn the walls of the waiting rooms. Web cameras hang in the operating suites, allowing physicians to log in and watch surgery. Doctors can even contact colleagues to ask them to weigh in on a consultation. The new digital system also allows physicians to instantly upload EKGs, X-rays and other important documents.

So far, one of the most popular features has been the clinical documentation system, which automatically records patients' vital signs. Under the new system, nurses use a personal digital assistant with bar code technology. Nurses say the new system frees them to focus more on direct care, rather than spending so much time gathering and documenting a patient's pulse, temperature and blood pressure.

The new system is especially helpful if a patient is experiencing distress, said Susan Ruszin, staff nurse in the CSU. Instead of wasting valuable time recording vital signs, she said she can focus on the patient's immediate needs.

"This way I can concentrate on taking care of my patients," Ruszin said. "It saves so much time and it's so much more reliable."

The new system is already making a difference, according to two recent studies conducted by Pepin officials.

The first was a time-in motion study that measured six categories of nurse work behavior in a progressive cardiac unit. The nurses were observed before the electronic health record was implemented and then again a year later.

What the researchers found was a marked increase in the amount of time nurses devoted to direct care after the electronic system was in place. The researchers attributed that to a significant decrease in time spent on administrative tasks--a 12 percent drop overall.

The second study was performed to see whether the new electronic system was more accurate than traditional methods of recording vital signs. First, the researchers conducted a baseline study and determined the error rater for vital signs captured on paper then entered onto a paper chart or electronic medical record was 10 percent and 4.4 percent, respectively.

Then the researchers conducted the study again using the personal digital assistants to capture the vital signs. After reviewing more than 1,154 samples, they determined the error rate to be less than one percent.

Results like these prove that technology is a valuable Investment, said Shaw. She said she's grateful that Pepin has already budgeted the money for the digital conversion, especially in light of the recent economic, downturn.

For Lambert, the embrace of technology is inevitable in the health care industry. As he noted, every other major field is already digital. In fact, the only segment of health care that is currently electronic is billing, and that's becausedt's required by the federal government. But the government can't force the rest of the industry to adapt, Lambert said.

"How are you going to do that in this economy?" Lambert asked. "Require every hospital to invest $30 million?"

Pepin has already become an example for others around the country and even the world. Visitors have come from as far away as Duoai, India, Japan and Qatar to view the hospital and solicit advice from administrators.

Shaw said she tells them to plan ahead. And no matter what, always remain patient. "Hospitals are like big ships," she said. "They don't change overnight."

Carrie Weimar

Director of public relations at the American College of Physician Executives.
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Title Annotation:Health Care Technology
Author:Weimar, Carrie
Publication:Physician Executive
Geographic Code:1USA
Date:Mar 1, 2009
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