Catastrophic events affecting thousands, such as last fall’s California wildfires, may be the truest indicator of how electronic health records (EHR) are helping to transform patient care. That was the experience of San Diego-based Sharp HealthCare, an integrated regional healthcare organization that includes four acute care hospitals, three specialty hospitals, three medical groups and a number of other facilities and services.

With some 2,600 physicians on the hospitals’ medical staff, 1,500 physicians in affiliated medical groups and more than 14,000 employees, the Baldrige Award-winning healthcare system is a recognized leader in California healthcare. In 2005 — two years after the last devastating wildfire and two years before the recent conflagration — two of Sharp HealthCare’s three medical groups, Sharp Rees-Stealy and Sharp Mission Park, began the process of implementing TouchWorks, an ambulatory EHR system from Allscripts. While optimum care for Sharp’s large patient population was the driving force behind the implementation, the events of the week of Oct. 21, 2007, revealed an unanticipated benefit.

The Approaching Danger

Long before sunrise on Monday, Oct. 22, as southern California residents slept, wildfires were already wreaking destruction up and down the state. Around 4 a.m. on Monday, the Sharp HealthCare executive team began to receive calls from leaders informing them of reports from police and fire departments that fires were approaching several Sharp medical facilities. Brent Steineckert, Sharp Rees-Stealy and Sharp Mission Park’s ambulatory EHR manager, prepared for the worst. “The fires grew so quickly and fast that by early Monday morning, we knew we’d need to close at least two clinics in close proximity of fire ground zero,” says Steineckert.

Pages went out to administration and physicians giving them news and instructions. Conference calls with key administration and physician leaders occurred multiple times a day to develop plans, communicate updates and route resources as needed. “A challenge faced right off the bat was that our existing clinics that remained open expected staffing shortages due to numerous mandatory evacuations and school closures,” says Steineckert.

Sharp Rees-Stealy operates a centralized patient contact center which typically handles more than 5,000 calls per day from patients scheduling primary care appointments and leaving messages for their doctors. Fortunately, the call center is located in an area that was not affected by the fires. Since the call center was operating 24/7, it was the ideal communications hub to interact with patients in need of medications and medical advice. Decisions flowed from the administration and physician leadership team, which included the associate medical director, the CEO, VPs and key directors, who gathered twice a day for a conference call to decide which clinics to keep open or close, based on road closures, air quality and staff availability.

Monday

Early Monday morning, a large Sharp Rees-Stealy clinic was closed in the Rancho Bernardo area of San Diego County as simultaneously a smaller clinic met the same fate in the Carmel Valley/Del Mar region. The two clinics house anywhere from 40 to 50 physicians and more than 200 staffers, and see an average of a thousand patients each day. Within three hours of the first two closings, Sharp Rees-Stealy was forced to close a third clinic due to fast-moving smoke and fire. The approaching evening would see even more closures, finally reaching a total of five.

Across San Diego County, more than 100,000 people were evacuated with little notice and few resources, making employee tracking of those without cell phones difficult at best. The overloaded cell networks made cell phone communication unreliable as well. “We employed whatever means to get information out, such as establishing central call-in lines with numbers posted on the Sharp Web site, so if someone tried to contact us anywhere within the Sharp HealthCare organization, they could be routed to the appropriate party,” says Steineckert.

In order to deal with people calling in with smoke-related and other medical problems, the decision was made by the administration and physician leadership team to put several physicians in the call center to assess these types of calls. “In many cases, the physician was able to take care of the patients concerns completely, right over the phone, primarily due to the availability of the EHR,” says Steineckert.

Call Center

Theresa Siefken, D.O., Family Medicine department at Sharp Rees-Stealy, was one of the physicians asked to work the call center. Siefken’s clinic, which is near the border in the Otay Ranch area, had already been closed by Monday afternoon due to smoke. Procedurally, several “runners,” which consisted of the call center manager, supervisors, leads and a scheduling systems analyst and a scheduling systems specialist, would print out the tasks for each patient calling in and alternate dropping them off to each physician working the phones in the call center.

Physicians in the call center worked at least eight hours with a short break, as patient calls were continuous. In addition to filling prescriptions, call center physicians worked with a number of patients in some type of physical distress in real time. “We were able to find out enough about their situation and handle it over the phone like an office visit. We’d advise them, with some needing to be routed to urgent care or the ED, and then we’d document the task,” says Siefken. “There was no anxiety in dealing with unfamiliar patients because of the significant time we had all spent using the EHR under more normal circumstances. Procedurally, everything felt like business as usual.”

Training Protocols Pay Off

Steineckert explains that during the original ambulatory EHR rollout in 2005, physicians were encouraged to sign up for secure remote access. This not only gave them access during regular circumstances, but also gave them the ability to handle patients of colleagues in normal or crisis situations. “If the same thing had happened prior to the EHR implementation, there would have been a lot less that the physicians could have done because they didn’t have access to patients’ medical histories and current courses of treatment for effective decisions in the moment,” says Steineckert. “What that meant for patients is that many would have had to be directed to EDs in order to err on the side of caution (keeping in mind that EDs are already overloaded), or we would have had to direct them to wait.”

Sherrie Lynn Dasalla, EHR process analyst at Sharp Rees-Stealy, had been part of Steineckert’s rollout team doing workflow analysis and workflow redesign for the ambulatory clinics’ transitions to the EHR platform. Additionally, Dasalla works with the training coordination effort, which includes three other training coordinators. “We all work together to organize all training efforts, including the creation of role-based training curricula; training materials and documentation; online training modules and Webcasts; and, post-training support for all of the staff at all of our clinics throughout San Diego County,” says Dasalla.

Training involved nearly 400 providers across 26 different specialties and a clinical staff of more than 1,800, including medical assistants (MA), licensed vocational nurses and registered nurses, as well as support and administrative staff. Two-hour classroom training sessions were employed for the modules rolled out at that time, which included the successful completion of mandatory prerequisite Web-based modules.

Prior to the fire, Sharp was using the TouchWorks EHR Version 10 and was in the midst of training for the Version 11 upgrade at the time of the fires. “We hired internal staff as trainers during the rollout because they were already Sharp Rees-Stealy employees who could train from experience, understood clinic workflows and could easily provide reliable answers to questions as a result of their first-hand knowledge of clinical processes,” says Dasalla. “Our trainers also act as an invaluable resource since they are a fresh set of eyes for the EHR team, especially when it comes to creating training curricula and documentation.”

The Web-based nature of TouchWorks and its modular configuration had not only been prime selling points for Sharp, but were also now critical to their use of the EHR during the fires. “With many EHRs, you have to install these very large resource-intensive programs on a specific PC in order to run the record. Our EHR allows us to essentially take any off-the-shelf PC, plug it into our network and within five minutes, a physician can log in and access patient records,” says Steineckert.

Part of the security protocol of the system in addition to user name and password, are security key fobs issued to each physician. “Security key fobs work by accessing a secure digital number that changes every minute, so even if someone has a physician’s password and username, they wouldn’t have the security key fob, which stays in the physician’s possession,” says Steineckert.

Tuesday

Physicians and staff access information on more than 7,000 patients a day utilizing the ambulatory EHR system. Of the five Sharp Rees-Stealy sites closed, two were among the medical group’s largest sites. The fact that no clinics could be reopened on Tuesday required more triage at the call center and more patient management telephonically.

Other staff whose performance was critical to Sharp Rees-Stealy’s success included Senior Training Coordinator Monika de Leon, who assisted in organizing a deployment plan each morning for the trainers, and MAs Thomas Howard and Cristal Razo-Tarazon, who volunteered to deploy to other sites where the need for clinical staff was most needed.

By Tuesday, the decision was made to cancel scheduled elective procedures. “This is significant because even though TouchWorks is an ambulatory system, our specialists use it quite a bit in the hospital when they are doing surgical procedures as well as rounds,” says Steineckert.

The influx of calls to the call center weren’t slowing by late Tuesday afternoon, so additional physicians were brought in for a night shift. According to Siefken, the number of calls per hour depended on the complexity of the patient’s needs, but averaged anywhere from 30 to 60 calls each day per physician. “I am fluent in Spanish, but it is my second language, and therefore it took a little bit longer to take care of the Spanish- speaking patients,” says Siefken, who also took calls that were forwarded from the non-Spanish-speaking physicians.

The Smoke Begins to Clear

By Wednesday, the Santa Anna winds began to lose force and first responders were getting a handle on the situation. Although the displacement, damage assessments and water drops weren’t over, Sharp Rees-Stealy returned to some sense of normality as memos of the medical group’s plans to continue with EHR training, normal procedures, and in-patient and ambulatory workflows began to be scheduled for the coming days and weeks.

The healthcare industry will continue to debate, resolve and improve its understanding of the importance of EHRs and other increasingly vital health IT under “normal” circumstances. Siefken feels that in order to be successful with implementing a new EHR, physicians need a team of educators available to train them as they go along. “As each module unfolded, we were trained on it and had a support team constantly available to us throughout the day,” she says.

“Physicians are so busy that it’s necessary to have people come in regularly to support, re-educate and help them through the learning curve. That’s what we’ve had,” says Siefken. “Once a medical group implements an EHR and gets past the training, there’s no going back to paper. It’s natural to resist change, but it’s well worth it in the end.”

May 2008