In a busy regional healthcare system with multiple facilities, physicians and nurses often move between hospitals and departments. The ability to place clinical information from all the facilities into one central electronic data repository — enabling clinicians to check on the status of any patient and print charts at any location — provides a major advantage in improving quality of care and optimizing workflow. It also enables the introduction of electronic plans of care, which improve patient outcomes and help meet the increasing requirements of payers and accrediting agencies.

South Texas Health System has five facilities in two cities, McAllen and Edinburg, in the fast-growing Rio Grande Valley. In 2006, the system had 1,100 beds, 35,000 inpatient admissions and 550 affiliated or on-staff physicians. In 2005, the management team at South Texas Health System made the decision to move to a fully integrated clinical information system (CIS) by investing in a major upgrade of both our hardware and software. We had experienced significant growth in patient volume and our goal was to improve overall clinical workflow and improve measurement of patient care.

We installed the OpusClinicalSuite from Opus Healthcare Solutions (Austin, Texas) because our parent company, Universal Health Services (UHS), had previously installed the system in many of its other hospitals and found it to be reliable and effective in improving the overall quality of care. It’s an n-tiered Web-based system, where all data and applications are stored on a central server or set of servers depending on the size of the facility. The hardware can be easily reconfigured to help fine tune the performance of the applications and the data interacts with Microsoft Internet Explorer, which is native to all of our workstations. This helps avoid the maintenance burden our staff would be required to perform with a client/server application.

In addition, all the key clinical information from all five facilities, including patient charts, lab results and medication orders, is stored in one central data repository. This establishes a complete electronic medical record, enabling clinicians from any of our facilities to view patient information, track progress with care plans and manage interdepartmental workflow, including e-mail and rounds reports. The system runs on our Wi-Fi or WLAN enabling physicians and nurses to view patient data from mobile laptops and PDAs.

Implementation and Training

Hardware installation began in March 2006, with the deployment of 600 new desktop computers and 140 laptop computers placed throughout our five facilities. Shortly after, we completed installation of the WLAN, which connects all the hardware in every facility.

We began the software installation by recruiting “super users,” individuals who would be extensively trained, have privileged access to the system and be available to train others. More than 300 individuals signed-up to be super users, but only 124 completed the training. We realized this was not a sufficient number for training 2,000 people and we wound up importing a dozen super users from other UHS facilities during our initial instructional period.

The new CIS went live on Aug. 15, 2006. We divided end users into two broad categories for training: 1) Staff who did not enter clinical orders (e.g., business office, lab, radiology, chaplains) and, 2) those who did order entry (e.g., nursing, respiratory, behavioral, pre-admission nurses).

We had a 4-hour training module for the order management feature and a separate 4-hour unit for the system’s clinical documentation feature. Staff involved in order entry, such as nurses, were required to take both modules (eight hours total), while other groups were assigned to take the order management training only.

During the implementation process, our super user group worked at a master support center with a satellite support staff working in each building to take calls, open up tickets, set and reset passwords, create frequent order screens and tweak minor changes. Having most of the team in one room enabled us to learn from each other’s experiences.

Training of Nurses and Physicians

We required all nurses involved in clinical care to use the new CIS, however we did not make it mandatory for the physicians because their leadership positions within the hospital gave them a strong sense of autonomy, and we felt it was better to educate them about the benefits of the system and then have them voluntarily adopt it.

To accommodate the physician’s schedules, we ran a PowerPoint presentation continuously in their lounges. We also made trainers available to take calls on nights and weekends. For physicians with offices located away from our hospitals, we scheduled onsite training programs for them and their office staff.

By August 2007, one year after our go-live, 90 percent of our physicians were using the new system. About 35 percent of them use the system personally, retrieving data and inputting orders; another 60 percent have their office staff do the keyboard work and about five to 10 percent simply do not want to use a computer and insist on paper records.

As part of the overall transition to the new CIS, hospital leadership required electronic plans of care for all in-patients, which included documenting the diagnosis, treatment, expected outcome and key indicators. Under the old system of paper records, care plans had been recommended, but it was difficult to monitor compliance and in many cases they had not been created or effectively implemented.

The Opus system includes a wide variety of care plan templates. Standardized, electronic care plans have a number of benefits including improving collaboration among multiple disciplines, quick action on meaningful clinical data, monitoring of staff compliance and conformance to new regulatory requirements.

While the long-term benefits of standardized care plans have been widely demonstrated, implementation of the new electronic care plan system added an additional element to training.

While physicians take the lead in making diagnosis and treatment decisions, the burden of documentation and compliance often falls on the nursing staff. Because this meant an important cultural and workflow change, the training process for nurses took on added elements, including discussions with supervisors on roles, responsibilities and expectations during the implementation process.

Results

As noted above, one year after go-live, we had virtually 100 percent of our nursing staff and about 90 percent of our physicians using the system. During the first three months after go-live, we found that clinicians were taking about 45 minutes to complete the patient assessments. In some cases, users would start out with the traditional paper forms and then chart information on the CIS at the end of their shift. Now, with all users fluent with the electronic system, assessment time has dropped to an average of 15 minutes.

Another benefit of the new electronic system is the elimination of illegible handwriting. Also, because of built-in care guidelines (e.g. drug interactions) the system also has reduced errors in medication therapy.

Clinicians are reminded to double-check patients with allergies and special care needs. The information charted on any assessment by the clinicians can flow into the collection screens when creating orders, and the information entered on the clinical profile can update the collection screens when entering orders. The overall increased accuracy, combined with the ability to provide clinical documentation and easily create specific reports, has greatly facilitated meeting our Joint Commission requirements.

Many of our office-based physicians have commented that the new system has reduced paperwork time and made their time with patients more productive. For example, when our physicians are seeing patients who have been referred from the emergency department, office staff can download radiology and lab results and have them ready prior to the patient’s office visit.

While the long-term benefits of standardized care plans have been widely demonstrated, implementation of the new electronic care plan system added an additional element to training.

Our risk management department also has benefited from the new audit capability. When an incident occurs, they can now perform a complete audit trail within minutes; under the old paper record system an audit often took several days.

While it is too early to document overall trends, our hospital leadership believes that overall quality of patient care has improved. For example, our nursing staff reports that the visual cues for critical results provided by the new system have improved decision-making. Lab results are now available immediately and can be viewed across all our facilities, eliminating the old scramble for paper charts.

As Becky Ryder, McAllen Medical Center’s chief executive officer noted, “The [electronic] system has allowed us to bring sophisticated technology to the patient’s bedside. Advanced, integrated clinical systems assist our physicians, nurses and other healthcare practitioners to care for our patients by providing information in a format that’s user-friendly and highly integrated.” It’s one-stop shopping for a busy staff that’s dealing with life and death situations on a daily basis.

SaBrina Macon is systems manager and Rosie Mendiola is assistant administrator for information services at the South Texas Health System in McAllen and Edinburg, Texas. Contact them at [email protected]  and [email protected] .