With its carrot-like incentives, HITECH has placed severe demands on healthcare providers throughout the country to adopt electronic medical records and computerized physician order entry. And while paying for such systems is difficult, inducing clinicians, especially independent physicians, to use them can be the highest hurdle in the race to leave paper behind. One institution grappling with these challenges is Warsaw, N.Y.-based Wyoming Community Health System, comprised of a 63-bed acute care hospital, a 12-bed mental health facility and a 160-bed skilled nursing facility. Recently, HCI Editor-in-Chief Anthony Guerra spoke with IT Director Jane Beechler about her plans for clinical IT implementation and adoption.
GUERRA: We’d like to get a better sense of how small institutions like yours are dealing with HITECH.
BEECHLER: We’re a little behind the eight ball. We first hired Vince (Ciotti, an HCI Blogger with HIS Pros consultancy) back in the spring of 2008 to find a clinical information system for our facility. Right now, all we have is pharmacy and lab that’s computerized, and a portion of the nursing homes. We’re at the tail end of that. We’ve narrowed it down to two companies. I hope to have a decision finalized in September. We essentially know who we’re going to pick right now, but we haven’t made it official. The CEO met with both companies in early August.
GUERRA: That’s about a year-and-a-half process?
GUERRA: It that how long you think it should take?
BEECHLER: Well, that’s the beauty of HIS Pros. They come in and say, “This is how much money the hospital makes. These are the vendors that you should be looking at. Any other vendors are probably way above your head. You shouldn’t even consider them because they’re way too much money.”
Vince dropped it right down to six vendors at the beginning. We looked at them throughout the year. We dropped two out in the first quarter that nobody liked. So then we concentrated on four that were appropriate for our size facility. Vince helped us get right to the meat of the matter quickly so that we were not wasting a lot of time with RFPs.
GUERRA: So it was very helpful bringing in a company like that?
BEECHLER: I feel it was, yes. He knows all the vendors out there that are selling EMRs, so we don’t have to waste time on a company that will never lower its price down to a point where we can afford it, or is just simply too big.
GUERRA: Spring 2008 is when you brought Vince in. So that means internally you decided to go out and get an EMR in early 2008/late 2007, which was far before HITECH.
BEECHLER: Nursing administration put pressure on the hospital administration saying that we have to get an EMR, that it was the way everything’s headed, that we’re going to be mandated to have an EMR. They wanted to get their clinical notes and the physician notes computerized. Plus, the third-party payers were requiring certain parts of the medical record in order for us to bill – they were coming back and saying they needed more clarification than what was written in the medical record. Everything started pointing to the fact that we had to function electronically and not on paper.
GUERRA: Was that in ’07?
BEECHLER: Yes. In fact, we saw a tradeshow of vendors that Vince organized in August of ’07, I believe. That’s when administration started getting on board, saying, “Let’s just start looking to see what’s out there.”
GUERRA: What do you mean by a tradeshow?
BEECHLER: In Chicago, Vince had 10 vendors come to one place where they demoed their software in front of us for two days.
GUERRA: At first, was the hospital administration receptive of this? Was there a general budget that they were comfortable with?
BEECHLER: One day, the CEO called me and asked me, “Would it be more than $2 million for an EMR? How much did these vendors in Chicago cost?” And I said it was anywhere from $1 to $8 million. He said he could probably get the planning committee to sign off on anywhere from $1.5 to $2 million, and wanted to know if it was going to be more than $2 million. So that was my first indication that they were on board, and I had some idea of what the dollar amount had to be.
GUERRA: So the math showed you could afford something.
BEECHLER: Yes, after seeing what some of the vendors were showing.
GUERRA: You’re an IT director, how long have you been an IT director at this facility?
BEECHLER: Since 1998.
GUERRA: Have you ever implemented an electronic medical record system?
BEECHLER: No, not an EMR. We’ve done conversions, but not an EMR.
GUERRA: So this is a new process to you.
BEECHLER: It is.
GUERRA: Are you getting implementation help?
BEECHLER: We have had conversations with organizations that implemented the software we are considering, to find out how it went. We even visited the hospitals and they offered guidance and suggestions.
GUERRA: So you’re not going to have anyone formally helping you roll this out and train users?
BEECHLER: No, that’s not in the plans right now, other than what the actual vendor will offer us.
GUERRA: Are any physicians that practice in the hospital employees of the facility?
BEECHLER: No. We have about 40 independent community physicians with privileges at the hospital. When we first bring on a new physician, we offer income guarantee but that’s only for two years and then they’re on their own.
GUERRA: Have you had any preliminary conversations with the doctors? Do you have any sense of how they’ll receive CPOE?
BEECHLER: I do have a sense as far as what the physician involvement was in the selection process, which was out of all 40, we had approximately three that were active and got involved. We tried very hard to get them involved, offered them meals along with the meetings, the demonstrations, and nobody really came, except for these three. We did use one of their meetings – a medical exec meeting – to force it upon them. A lot of them offered suggestions, but the feeling I get is they’re going to ask the nurse to key it in; they’re not going to do it on their own. CPOE is going to really be a hard one to push, I believe, because they’re just too busy. I’m hoping that if I can show them the advantages of CPOE, they’ll start using it and buy into it. I just don’t know.
GUERRA: What will you tell the nurses to do if the physicians are asking them to key in orders?
BEECHLER: I’ll have the nurses tell someone, whether it’d be me or administration, and I’ll have the administration back us up. The CEO here at the facility has only been here five years. He implemented an EMR at the hospital nearby and said that he had the problem of the physicians not doing it, not doing enough of it on their own. So they went to the physicians and asked them, “What can we do so that you start entering your own orders?” They said they just needed a separate place from the nursing station, so they built or had this room blocked off with three PCs in there for physician access only. They put a coffee pot in there and it worked for at least 50 percent of them.
GUERRA: What do you take from that – that they just wanted a quiet place to enter their orders?
BEECHLER: Right, and they wanted computers that would be available to them immediately.
GUERRA: Are you going to try the same approach?
GUERRA: So the hospital’s position on this will be that it’s not appropriate for a nurse to enter orders for a physician.
BEECHLER: That’s correct.
GUERRA: And then I suppose you’ll take a carrot-and-stick approach to get compliance?
BEECHLER: Yes. It will be tough, but we’ll just have to be persistent. It’s like walking on eggshells because we have to be careful. We don’t want to get them all angry at us. I mean, they are our bread and butter, the physicians – they’re the ones that bring the business in. We want to listen to them and communicate. The big thing is communicating with these physicians when they say, “Yes, well, I tried using it and it didn’t do this for me.” And it might be something we could readily fix, so I want to be talking to them all the time and making sure their needs are met.