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In Pursuit of an Electronic Medical Record For Greenwood Leflore Hospital, Progress has been Steady The 1999 Institute of Medicine Report, To Err is Human1, served as a clarion call for United States hospitals to adopt electronic medical record (EMR) systems for the entry, storage and transfer of patient information. A cornerstone of the Institute's comprehensive approach to help U.S. hospitals improve their safety records, the EMR was recommended as a way to provide decision support while reducing dependence on a paper charting system that is typically poorly organized, difficult to retrieve, and often, illegible. In its 2001 publication, Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute again recommended the use of technology to address the growing complexity of health care, and to obliterate the information "silos" that occur when various physician groups render care without complete information about the patient's condition, history or the services provided by others.2 Concurrently, the Leapfrog Group, a consortium of private and public group purchasers, outlined a patient safety and health care quality strategy that highlighted the use of computerized physician order entry systems. To back its recommendation, the Group cited studies indicating technology's potential to reduce length of stay, repeat testing, laboratory turnaround times and cost expenditures. The use of computerized prescriber order entry system was also among the National Quality Forum's Set of 30 Safe Practices for Better Healthcare, published in 2003. 3 Most recently, the Institute of Medicine issued a report brief describing the use of medication prescribing and dispensing technologies to reduce medication errors.4 At Greenwood Leflore Hospital in Greenwood, Mississippi, administrators, clinicians and IT professionals have embraced the concept of an electronic patient record and have replicated many of their manual systems electronically over the past eight years. Although paper charts are still in use at the 208-bed hospital, clinicians have become avid users of the components that have been duplicated electronically. A Step-by-Step Approach Administrators at Greenwood Leflore began their journey toward an electronic medical record in 1999. "We've had information available by computer for some 15 or 20 years," says John F. Lucas III, MD, Chief Medical Information Officer, who is also a surgeon at the hospital. "For example, we had lab data available electronically, but it wasn't very useful. It was in one color and presented in a way that was difficult to read; plus, previous results were not archived. One of our greatest challenges was to get enough useful information on the computer to make it worthwhile for our physicians to change their habits and go over to the electronic side. Approximately two years ago, we achieved that goal. Our physicians now go to the computer because they can get most of the information they need, and they can get it from anywhere in the world." The first step taken to reach this objective came in 2006 when the hospital implemented Dräger's Infinity® Omega patient monitoring solution in the operating room, perioperative suite, post anesthesia care unit, telemetry unit, emergency department and intensive care unit. Infinity Omega is a two-screen solution that consists of an Infinity Delta bedside/transport monitor which is integrated with an Infinity Explorer critical care workstation. The compact Infinity Delta monitor records patient vital signs; the 17-inch touchscreen Infinity Explorer workstation can be used to view radiology reports, lab or medication data for the in-room patient or any patient in the hospital-all without obscuring vital signs. At the nursing unit, an Infinity CentralStation captures data on all of the unit's monitored patients for central surveillance. "One of the unique features of the Omega and Symphony solution is that the vital signs monitor creates a 72-hour backlog of data," says Dr. Lucas. "This allows physicians to correlate patient signs and symptoms with any changes in oxygen saturation, heart rate or rhythm. If a patient has a major event such as a heart attack, you can look back to see the clinical data that preceded and accompanied the event. You can also create graphs that show, for example, how ST elevations and depressions are linked with changes in the patient's oxygenation status." Wanda Kelly, Greenwood Leflore's Project Manager, Clinical Applications, concurs on the clinical utility of the system. "Previously, if a patient complained of chest pain, the nurse might print and post a few EKG strips to the paper chart," she says. "That left the physician to try to ascertain what was occurring with just a few readings. Today, our physicians can readily access the same screen and go back to events over a 72-hour period. Clinicians can also view events by category, such as all episodes of ventricular tachycardia, couplets or triplets occurring within 72 hours, facilitating diagnosis and streamlining the ability to understand the nature of the patient's problem." Clinical staff have also found the flexibility and portability of the Delta vital signs monitor to be helpful. A single monitor can be used on all units and automatically scales to each area's specific configurations via a docking station. The Delta monitors also function as wireless transport monitors. Dr. Lucas says that this capability, referred to as "Pick and Go(r)," eliminates the need to disconnect and reconnect cables pre- and post transfer. "The monitor can travel with the patient, avoiding the need to change equipment or disrupt the surveillance of vital signs in transit," he says. Implementation a "Non-Event" Greenwood Leflore went live with the two-screen Omega and Infinity CentralStation solution in the O.R. in August of 2006. It provided staff with a flexible monitoring system, as well as access to vital signs and 72-hour, full disclosure data on all monitored patients within the hospital's network. To prepare for implementation, Dräger personnel provided three to four days of training while staff worked individually at multiple workstations. Dräger staff were also on site for each go-live date, and provided 24-hour support. Each successful unit rollout was followed by another, approximately one month later. "Our goal was to take our time and do the implementation slowly and well," says Ms. Kelly. "The biggest challenge was getting our busy nurses to set aside time for the training. But once they did, they caught on quickly. All of our rollouts went smoothly and were basically non-events." Expanded Remote Access Yields Greater Benefits In 2007, the hospital augmented the capabilities of the Omega monitoring system with Dräger's remote viewing applications, including Infinity Symphony, Infinity Gateway and Infinity WebViewer. Infinity Symphony is a set of Web-based applications that enable information stored on the Infinity CentralStation, such as stored waveforms, full disclosure, events and trends, to be viewed on PCs connected to the hospital intranet. Infinity Gateway facilitates the exchange of patient information between the Infinity Network and existing hospital systems. This suite of applications includes remote viewing applications, bidirectional HL7 interfaces, a paging interface, 12-lead ECG export, and a set of developer's tools. When deployed with Infinity WebViewer and VentWatch(r), Infinity Symphony provides near-real-time views of monitored patient information and ventilation data — with a single sign-on and integrated patient selection. Both Infinity WebViewer and Infinity WinView present information in the familiar format of the Infinity bedside display — with the ability to show visual alarms. Concurrent with the implementation of the Dräger solutions, Greenwood Leflore IT staff worked on finding ways to make various components of their paper charts available electronically. Today, with one click, hospital staff can access the patient's history and physical notes, intake and output, EKG tracings, OR notes, discharge summaries, consult notes, lab data and radiology text reports. Plus, the remote view solution makes this information readily available to authorized clinicians from any remote location. Since the installation of the Infinity Omega solution in 2006 and Infinity Symphony, Gateway and WebViewer in early 2007, Greenwood Leflore clinicians have enjoyed numerous benefits. Ms. Kelly says that the new system facilitates diagnosis and ongoing changes to the treatment regimen by maximizing a physician's access to information. "Before, if you wanted historical data on a patient in the ER, or awaiting admission, you'd have to place a call for the old chart and wait," says Ms. Kelly. "This inevitably resulted in care delays. Now, we have immediate access to historical data from the year 2000 forward." Ms. Kelly says that within the next several months, clinicians will also have access to the DICOM radiology images that correspond with these reports. "We believe that having access to more information in a timely manner will lead to even better patient outcomes," she says. Having remote access to current patient data allows physicians to track vital signs changes and new laboratory data and alter the treatment plan based on current values. Remote access is particularly useful when one physician provides coverage for another during weekends or holidays. It enables the covering physician to do an in-depth review of the clinical history and current treatment plan, and make appropriate changes or additions to it. Clinicians at Greenwood Leflore have become strong proponents of the Omega and Symphony, Gateway and WebViewer solutions, which provide them with rapid, easy access to patient information in the hospital, and virtually anywhere in the world. Physicians caring for patients in the ICU, emergency department, telemetry, endoscopy, OR and perioperative units can view live data from the patient's bedside vital signs monitor from their homes, offices, or any remote location. In addition, they can easily locate their patient's electronic medication administration record, intake and output, EKG tracings, medical and surgical history, radiology reports, laboratory results and services rendered by other, affiliated providers. Integration with an Existing Platform During the selection process, Greenwood Leflore IT staff looked for solutions that would meet their information needs while integrating seamlessly with their existing infrastructure. "Dräger allowed us to leverage technology and our existing IT resources," says Dr. Lucas. "Omega, Symphony and WebViewer permitted close integration with our existing software, facilitating implementation of the system." "Health care is too complicated to make the solution complicated," adds Mark Hutson, Chief Information Officer. "Our view of this deployment was to make it as simple and as logical as possible. This system provided platform choices that met our hardware and software preferences. Dräger provided easy integration and links to our current application system." Collaboration Facilitates Implementation and Modification Greenwood Leflore clinicians collaborated with Dräger IT during the installation of Omega and Symphony to improve each system's capabilities. "When systems are developed, it's almost impossible for programmers to plan for every clinical possibility," says Dr. Lucas. "We worked with them to tailor the way some of the information was organized and presented." This occurred when the Omega's capability to graph patient blood pressure, heart rate and oxygenation in one view required modification. If the clinician chose to include a parameter for which the patient was not monitored, the entire system would shut down, forcing the user to start over. Also, in the beginning, important EKG information displayed on-screen was not reflected in the resulting printout. This was also rectified. "This kind of productive communication with the vendor is of vital importance," says Mr. Hutson. "The people behind the system are almost more important than the system itself. They were very open to hearing about things that didn't work and would come back with 'Here's what we did now.' They weren't necessarily worried about being right... they were more concerned about being effective. We can count on Dräger's staff to be supportive, credible and honest. It's the kind of relationship you can grow old with." A Positive Staff Response Staff acceptance and use are key to the success of any IT endeavor. Dr. Lucas and his colleagues knew that a time-consuming or difficult-to-learn system would not be used by busy clinicians. "We wanted to make as much information available at one time and with as few steps as possible to take you there," says Dr. Lucas. "I think we've succeeded in that goal. When I ask for staff feedback, particularly people who are new to the hospital, they tell me the system is 'easy to use.'" At Greenwood Leflore, the IT staff and Dräger partnered to address emerging needs and concerns, which built user satisfaction and acceptance. "One example of a modification occurred when physicians affiliated with several group practices needed to provide coverage," says Dr. Lucas. "They requested that we change the system so that they could not only access patients within their group, but in multiple groups, when necessary." Another change was implemented when it was discovered that the Symphony system's security feature, set to log off users after a period of inactivity, was occurring too quickly. "People complained they were being logged off prematurely," says Dr. Lucas. "We didn't intend to have the old history and physical disappear while in the middle of a dictation. We worked on balancing HIPPA security requirements with user needs while still protecting patient confidentiality." Dr. Lucas adds that many users wanted access to certain kinds of information, such as medication reference sources and patient EKG tracings. "We heard these requests and set about finding products that would meet them," he says. Next Step: Computerized Physician Order Entry Greenwood Leflore is now in the initial stages of implementing computerized physician order entry (CPOE). This will replace handwritten orders with those that are typed or selected from a drop-down list. A powerful evidence-based software component, called a rules engine, ties in to the patient's history to alert the prescriber of duplicate orders, drug allergies, drug-drug interactions and dosage errors. It can even suggest other useful orders based on existing patient information. As a cost-savings measure, the system also notes less expensive alternatives, when appropriate. "With CPOE, we look forward to getting immediacy and enhanced accuracy," says Dr. Lucas. "Orders produced with CPOE will go immediately to fulfillment without needing to be transcribed, further expediting care." An Ongoing Journey IT staff and clinicians at Greenwood Leflore Hospital have worked collaboratively to produce electronic medical record data with remote access that is dependable, user-friendly, and responsive to clinical needs. Successful implementation is an accomplishment shared by the hospital's IT department and clinical users. The system is widely accepted and has become a routine part of the clinical staff's daily practice. Despite the enormous strides made and high system usage, paper charts remain at Greenwood Leflore. "When will our staff say, 'It's OK if I never see another paper copy again,'" asks Dr. Lucas. "That's the question we need to answer. It's all about changing habits." [[Sidebar]] Components of Greenwood Leflore's Electronic Medical Record System
[[Sidebar]] About Greenwood Leflore Hospital Located in the city of Greenwood and the county seat of Leflore County, Mississippi, Greenwood Leflore Hospital is at the eastern edge of the Mississippi Delta, approximately 96 miles north of Jackson, Mississippi and 130 miles south of Memphis, Tennessee. The hospital is the city's second largest employer. Type of facility: Regional, not-for-profit hospital owned by the city and the county. The hospital administers 17 satellite clinics in five counties and serves patients in more than 15 surrounding counties. Number of beds: 208 with 40 long term, acute care beds leased to the Greenwood Specialty Hospital. Inpatient visits (FY 2007): 10,303 Outpatient visits (FY 2007): 111,225 (excluding ER) Clinic visits (FY 2007): 140,906 Emergency visits: 37,499
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