Paper to EMR: A Successful Transition

Oct. 1, 2006

For Children’s Healthcare of Atlanta, involving users in a robust selection process and gaining user buy-in was key to a successful implementation.

In today’s information-driven healthcare industry, it is more important than ever for hospitals to stay on the cutting edge of technology. Children’s Healthcare of Atlanta (Children’s), one of the leading pediatric healthcare systems in the country and a not-for-profit organization, is recognized for excellence in cancer, cardiac, neonatal, orthopedic and transplant services, as well as many other pediatric specialties.

For Children’s Healthcare of Atlanta, involving users in a robust selection process and gaining user buy-in was key to a successful implementation.

Tal Senior, R.N., serves as clinical informatics specialist for Children’s Healthcare of Atlanta. Contact him at [email protected].

In today’s information-driven healthcare industry, it is more important than ever for hospitals to stay on the cutting edge of technology. Children’s Healthcare of Atlanta (Children’s), one of the leading pediatric healthcare systems in the country and a not-for-profit organization, is recognized for excellence in cancer, cardiac, neonatal, orthopedic and transplant services, as well as many other pediatric specialties.

To maintain and enhance Children’s reputation as a leader in pediatrics, the Executive team, made up of the Chief Information Officer, Chief Financial Officer, Chief Operating Officers, Vice Presidents of Clinical Operations, Senior Vice President of Medical Affairs and Director of Pharmacy, decided in 2003 to implement an electronic medical record (EMR) system with the ultimate goal of eliminating paper charts. The team knew that gaining user buy-in was crucial to the success of their EMR implementation, so they incorporated feedback from hundreds of stakeholders, including front-line staff, directors, managers and physicians, into the decision-making process. The stakeholders participated in a two-day vendor fair with the top four EMR vendors, after which they completed evaluation forms.

In May 2005, the Children’s Leadership Team selected the final cart—the 1750 from Flo Healthcare. The team was composed of the Chief Information and Financial Officers, Vice Presidents of Clinical Operations, Vice President of Quality, Director of IS&T Implementations, Director of Clinical Informatics and Medical Directors of Informatics.

The Selection Process
Moving from paper to EMR was no small task for a system the size of Children’s. Operating three hospitals with more than 500,000 patient visits annually, Children’s has 452 staffed beds at its Egleston, Hughes Spalding and Scottish Rite campuses.

The first step was to choose the device with which employees would access the EMR. Because there are so many devices on the market, each with their own pros and cons, decision makers narrowed the selection process down by closely studying the workflow of paper charts. For instance, patient charts constantly are moving around the hospital, from the nurses’ station, to a patient’s room, to a conference room and back again. The leadership team felt that for its EMR implementation to be a success, the access devices must mimic the portability of paper charts. Since portability was paramount, the hospital quickly eliminated wall-mounted computers as an option. Although many hospitals use wall mounts, it was soon realized that a stationary device would change the clinicians’ workflows.

The team knew that users would be more open to the new technology if there were fewer changes to the daily routine. Wall mounts would force clinicians to come to the computer every time they needed to access patient information or input patient data, as opposed to bringing a device from room to room, as they did with paper charts.

That left PDAs, tablet PCs, laptops and carts with thin clients attached from which to choose. After a little digging, the team learned that Children’s existing EMR was not compatible with PDAs, eliminating that category of devices. Tablet PCs and laptops seemed like a viable solution. However, once the team considered cost and the risk of theft and damage, they quickly changed their mind. Clinicians tend to be rough on equipment; therefore devices would ideally need to rest on a surface to reduce the risk of accidental drops or falls. Carrying them from room to room would be a risk in itself because of the drop factor. Moreover, it was felt that tablet PCs and laptops were small enough that they could potentially be stolen without anyone immediately noticing.

Once the team considered all of the devices, it chose carts with an attached thin client. The carts would keep the thin client stable, minimizing the risk of damage, and their larger size meant that few people would be bold enough to try to take one from the hospital.

Vetting the Vendors
Children’s went through a series of steps to select the right cart vendor. First, they held a vendor fair in July 2004, inviting several cart vendors to participate in a multiday trial. One hundred twenty champions were chosen to act as their department’s point person. Each vendor held a 10-minute discussion about its cart, after which the department champions filled out evaluation forms. From these forms, the leadership team developed a list of the most important features a cart should offer, in order of importance.

Photo courtesy of Children’s Healthcare of Atlanta

The next step was for the team to draft a request for proposal that specified the features the hospital wanted in a cart, based on the department champions’ top criteria listed in their evaluation forms. Children’s hired Marietta, Ga.-based EDI Consulting Services to help find cart vendors that met the department champions’ requirements. In February 2005, EDI and Children’s project managers attended the 2005 annual HIMSS conference to personally review the various cart vendors. They also researched other vendors online, overall evaluating 32 different vendors. In the end, EDI created a short list of the top three vendors who met Children’s requirements and invited them to Atlanta for a full-scale assessment.

The top three contenders visited Children’s in Atlanta during March and April 2005. Each vendor provided Children’s with six carts that the healthcare system could place at two campuses for a five-week period. The carts from all three vendors were placed side-by-side, so that users could conduct a fair comparison. They moved the carts, floor-by-floor and unit-by-unit, throughout the two hospitals so that each department could use the carts for a full 24 hours.

Overall, about 800 clinicians used the carts. Children’s told the three vendors that they could not service the carts in-house during the evaluation process because they wanted to see how intuitive the carts really were. After the various departments evaluated the carts, Children’s summarized the feedback from the clinicians.

Going Live
In May 2005, the Leadership Team selected the Flo 1750 from Flo Healthcare, based on user evaluations, the cart’s battery life and the vendor’s maintenance agreements. Children’s ordered 300 of the wireless mobile workstations, and had added to each one an Identix Biotouch 200 USB biometric fingerprint reader, an Ensure Technologies Xyloc proximity reader, a Wyse thin client, a keyboard, a mouse, a 17-inch flat panel monitor from HP and a NiMH battery. The carts arrived fully assembled with each component already integrated, which was an added bonus for Children’s, since no time was spent waiting for parts to arrive or assembling the carts in-house.

Children’s went live with the new carts and the first clinical components of the EMR in November 2005, and it has been documenting all order entry and medication administration, as well as admission assessment ever since. By the first quarter of 2007, all documentation will be electronic, including vitals. Physician order entry will go completely paperless by the second quarter of 2007.

Since the original goal was to gain user buy-in in order to gain wide-scale implementation of the EMR, the leadership team measured its success by user feedback. At the end of December 2005, Children’s invited approximately 600 nurses, physicians, respiratory therapists and social workers to rate their satisfaction with the new functionality based on their experience with the system. The survey showed an 85 percent average satisfaction rate with the EMR.

Gaining user buy-in is always a tricky thing, and Children’s took several steps to increase EMR uptake. First, it involved the end-users in the selection of the cart. Next, it made carts accessible by placing one mobile workstation between every two bed spaces in general care areas, and one at every bed space in the ICUs. Third, it made access to the EMR quick and easy via wireless capability.

Educating end-users about the carts and working closely with internal engineering, biomedical engineering staff and Flo Healthcare ensures the carts are in working order at all times. Thanks to a successful cart implementation, Children’s is now well prepared for the full-scale implementation of its EMR.

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