MUSC was an early adopter of health information technology, and like most academic medical centers, still operates under a “best of breed” IT environment; doing business with many vendors and not having much leverage with any. The organization accumulated more than a decade of experience with a clinical data repository (CDR) and a clinical results viewer (CRV) - the Oasis open systems technology tool kit technology from Telus Health Solutions.
An ambulatory EMR was installed in the mid-'90s, but failed to gain much use beyond primary care physicians. Document imaging, laboratory, pharmacy, PACS and radiology systems for radiology and cardiology were implemented by the early 2000s. By 2004, the clinical IT momentum had stalled, and implementation of the more advanced point-of-care clinical systems (nursing documentation, order management, bar code medication administration and physician order entry) had not yet been undertaken. And there was very little integration of outpatient and inpatient clinical data. MUSC's clinical environment is a closed staff model; the more than 1,000 practicing physicians are employees of the organization. Some caregivers only see patients in clinics, some see patients only in hospitals, and some see patients in both care settings.
As CIO, it struck me that the organization had the opportunity to create an IT environment that reflected the clinical environment, thus providing caregivers easy access to patient information, regardless of the care setting in which it was captured, and offered our patients a seamless care delivery system. When I put this vision in front of the MUSC IT Governance Committee, they agreed. Plans were set in place in 2005 to create a clinical IT model that scaled across the inpatient and outpatient care settings. We felt that providing caregivers with timely access to clinical data - regardless of where it was captured - would improve the quality, safety, and efficiency of care.
Our initiative to create an enterprise clinical IT environment was expected to take three to four years. We started in mid-2006 and dubbed the initiative eCareNet.
Our caregivers liked the Oasis CDR/CRV functionality and its presentation. Its open system feature and development toolkit gave us the flexibility to react quickly to necessary changes and provided the critical mass around which we felt we could aggregate all clinical data. The CRD/CRV was becoming the center of our clinical IT universe.
One of our first steps was performing a gap analysis of what clinical IT functionality we had already installed and what we still needed. Our plan was not to obtain a vendor's stand-alone niche solution, but rather to acquire pieces of robust functionality or technology engines that would scale across departments, services lines, and care settings. In the inpatient setting, we expected to acquire functionality that would give us a “closed loop” medication process. That process would require an eRx system, clinical documentation, medication administration, and physician order entry. The eCareNet project called for us to obtain functionality module upgrades (and/or acquisition of additional systems/modules) touching many phases of clinical care across myriad settings, including:
Complete revamping of the clinical systems infrastructure
Replacement of pharmacy system, nursing documentation, ED patient tracking boards and clinical documentation
Replacement of the surgery scheduling and OR management system
Anesthesiology documentation
Upgrade to existing outpatient EMR functionality and infrastructure
Bar coded medication administration
CPOE
Upgrade to existing CDR and CRV
Upgrade to PACS and voice recognition implementation in radiology.
Much of the advanced point-of-care technology was obtained from McKesson, the OR/Anesthesiology systems from Picis and upgrades to PACS from Agfa. However, it was the Oasis development toolkit that would knit all of this functionality together around the CDR/CRV.
The out-of-pocket expenses (hardware, software and implementation services) for these additions and improvements were approximately $30 million, with the five-year total cost of ownership estimated at around $37 million. The project timetable reflected the desire to complete implementation of these core systems within three years. This would, to a degree, possibly establish a closed-loop medication process in the hospitals, and subsequently, a highly desirable market position though safer care.
The goals for the MUSC eCareNet project mirrored the Institute of Medicine's eight core care delivery functions for an EHR. We now feel that most of the functions will be part of the meaningful use requirements from CMS.
Three-and-a-half years into the project, most of the advanced point-of-care functionality (clinical documentation, medication administration, CPOE) has been installed in the hospitals, and all major upgrades of existing systems have been completed. As with any large implementation, we have refined and/or added capabilities and functionality, primarily around the CRD and CRV. We continue to import additional clinical data from both care settings into the CDR, and increase the ability to launch task- specific/transaction processing activities from within the CDR/CRV. One example: a caregiver can launch either CPOE with patient context or launch the document imaging system from within the CDR/CRV environment.
Additionally, we have started work on automating the medication reconciliation process from with the CDR/CRV, which requires a bidirectional interface with the ambulatory EMR. Inpatient physician notes and discharge summary is planned for this fall and will be done using the Oasis toolkit within the CDR/CRV environment. And finally, eRx implementation is being finished in the outpatient setting.
With our eCareNet environment, MUSC has created an ubiquitous clinical IT environment where caregivers can operate without regard to the care setting. The flexibility of the CDR/CRV framework and toolkit allows MUSC to react quickly to caregivers' needs and regulatory changes. We feel quite confident that it will meet meaningful use criteria in both the hospital and physician practice when it is defined by CMS, and that we will be well positioned to take advantage of the ARRA Stimulus incentives for both hospitals and physicians.
Lessons learned
During the early planning stages of the project, the leadership team acknowledged the need to “work smarter” by gleaning as much knowledge and experience from institutions that were currently going through or had already gone through a similar implementation. Key members of the project team made visits to two academic medical centers and had numerous conversations with key people at these institutions. In addition, visits made to two community-based hospital systems, along with interactions with experienced people from several organizations, have helped MUSC avoid mistakes. But try as we might, and in spite of the admonitions, we still learned a number of lessons.
I strongly recommend that caregivers spend more time discussing and thinking about how clinical automation will radically change their workflow and processes, and the unintended consequences that result from moving from paper to an electronic format. Even though we thought we had planned for sufficient support staff, we still came up short both on the IT and user sides.
Given what we have in place and what is currently being developed, MUSC hospitals and physicians will be well-positioned to take advantage of the stimulus incentive funds for the meaningful use of an EMR starting in October 2010. We expect that many hospital-based delivery organizations will move their clinical IT environment in a direction similar to what has been described above, and for that reason, will want to share the story.
