Hospitals across the country are currently working to meet the various stages of meaningful use. Some, primarily large integrated systems, have already met the criteria of the most advanced stages, while others are just embarking on electronic medical record implementation. Kadlec Health System in Richland, Wash., is one of the latter. In August, the system, anchored by a 201-bed independent hospital, managed by Quorum Health Resources, implemented an outpatient EMR in the offices of its employed physicians. On Nov. 1, it went live with the inpatient counterpart. While the process wasn't problem free, many of the physicians and staff were supportive of the change and are already beginning to improve their productivity with the new system. Here, Rand Wortman, president and CEO of Kadlec since 2000, discusses the hospital's journey toward meaningful use and key learnings from the organization's EMR implementation.
Question: When did Kadlec first discuss installing an EMR and what led to the final decision to move forward with the process?
Rand Wortman: Prior to 2007, we did not have any employed physicians. [Today the system employs roughly 80 providers, including physicians and mid-levels.] It became clear to us around 2005 that if we did not offer an employment model, we would not be able to effectively compete for quality physicians because so many new residents and fellows were looking for employment. In 2007, when one of the local practices joined us and became part of Kadlec, we recognized we were going to need an IT system with a single database that could store information for both the outpatient physician practices and inpatients. We wanted to allow patients to move through the system without multiple registrations, and regardless of where the patient was in the system, caregivers would have access to the most current and same information. It became clear to us that we were not going to achieve this functionality with two separate systems, and we weren't going to be able to build sufficient interconnectivity. In 2009 we began to look closely at the Epic EMR, which would provide us a single database and functionality across inpatient and outpatient platforms.
Q: How does EMR installation fit within Kadlec's overall strategic objectives?
RW: Historically, most of our capital expenditures were either for facilities or equipment with some funding for HIT. HIT was just one of many capital needs of the institution. Around 2009, we had identified a couple of future major facility projects, but we also recognized the need for better IT and better integration of our inpatient services and outpatient services. We eventually determined that it was more important to have a solid IT system to integrate all data than it was to build another building or expand our physical facility. We felt we could probably reduce our length of stay with better information flow and an integrated system, which would delay the need for building more inpatient buildings. So, with that in mind, we began to look seriously at the cost and placed our expansion project on hold so we could use our funds for the EMR.
One of the challenges with the cost of the installation is that although the government is making funds available through the HITECH Act for meeting meaningful use, you can't get the money until after you meet the criteria. If you want to borrow the money, it would require a very knowledgeable lender who understands what you're doing. Software isn't exactly a piece of collateral, which is what you have when funding a new building project. You basically have to use your existing debt capacity or reserve funds.
Q: Kadlec went live with its outpatient EMR on Aug. 1 and its inpatient record went live on Nov. 1. How did those two days go and how are providers adjusting so far?
RW: We implemented the outpatient record first, and it went reasonably well. Of course, there are going to be glitches, but we dedicated a significant amount of time and expense training and supporting the physicians and their office staff to minimize this. We had some physicians who picked it up very rapidly; others were a bit more technologically challenged. The inpatient side was more of a challenge, because you are training physicians and their staff, who are not employed by Kadlec. We had to work around their schedules, sometimes training them on nights or weekends.
You cannot over train. You have to commit huge resources upfront and have people available at the time of implementation to assist. One thing we didn't adequately anticipate was how much productivity would be decreased for a period of time. In August, volume in our employed physicians' offices was down because they couldn't see as many patients. Now that we're several months into it, the productivity appears to be back to normal levels. We've also had a number of physicians tell us they are actually more productive after taking time to develop templates, but it just takes time to learn the system and build their tools in it.
On the hospital side, productivity was down significantly for the first two weeks but has already started to recover. It was most difficult for the surgeons, who have to create an op note, pre-op assessment and post-op note for each patient. In the past, they had dictated these, and they are now prompted to enter text. We've worked to support them, but at the end of the day, these are physician-generated notes; not something hospital staff can do for them. They can use templates to eventually become more efficient, but there is going to be a learning curve.
Q: Now that you've implemented the EMR, how is your journey toward meaningful use coming along?
RW: We have essentially met meaningful use stage 1 for our physician practices in terms of having the required capabilities. We plan to apply for stage 1 certification in the very near future and anticipate receiving funds in late 2012. On the inpatient side, we will probably apply in 2012 and receive the funds sometime in 2013.
Q: Does Kedlac have any plans to offer its outpatient EMR to independent physicians who practice at the hospital?
RW: We are planning to offer our EMR to the independent physicians, but we want to make sure it works well first. The last three months we have focused totally on our inpatient side, so we didn't have resources to offer the system to outside physicians yet. We plan to do that soon, however.
Q: What key learnings were uncovered throughout the implementation processes?
RW: For one, it's difficult for key users of the system to really understand the importance of training and participating in clinical decision making — such as developing order sets — until the EMR has launched. Kadlec launched our EMR and order sets at the same time. There was a realization by some physicians that they should have spent more time building consensus around order sets. That's not meant as a criticism to the physicians; you just can't understand what you haven't experienced first.
We actually went live before we had 100 percent of our order sets built. The reality is there are so many processes surrounding your go live date that it would be incredibly disruptive to delay implementation. However, in retrospect, I would recommend committing whatever resources needed to make sure all order sets were complete before go-live. However long you think it's going to take to build order sets, add 20-30 percent.
Q: Kedlac recently announced an affiliation with PMH Medical Center in Prosser, Wash., and sharing an EMR is part of the agreement. What led to that partnership?
RW: PMH approached us a few months ago about a partnership, not just on an EMR system also on a possible alignment of referral systems and clinical programs. We haven't signed the deal yet, but, as you mention, we're moving forward with the intent to put our Epic record system in the 25-bed critical access facility, so they can meet meaningful use. Epic has given us the latitude to make its EMR available to some of the smaller institutions in our region.
Q: With inpatient and outpatient EMR implementations, you've had a busy 2011. What's on tap for Kadlec in 2012?
RW: Having gone through so much transition in the last year, in 2012 we really would like to slow down the rate of change in our institution. In addition to our EMR, we also implemented some lean processes throughout the hospital and had a lot of success with it. However, with changes and processes and changing our software over to Epic, we've challenged our staff and next year we plan to let the dust settle.
Strategically, we're going to focus on preparing to accelerate our growth in the region. Our state as well as the federal government is considering ceasing cost reimbursement for Medicaid hospitalizations at critical access hospitals. While we don't get cost reimbursement, there are about 10 hospitals in our part of Washington and Oregon that do. My concern is that if they lose this type of reimbursement, they could be at great risk financially. If any of these institutions close, I'm concerned it will be difficult for us to access the capital needed to grow fast enough to accommodate these patients. The challenge when all is said and done is to adapt to meet the needs of our community when we may have a huge amount of patients at our doorstep without sufficient capacity or access to capital.
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Question: When did Kadlec first discuss installing an EMR and what led to the final decision to move forward with the process?
Rand Wortman: Prior to 2007, we did not have any employed physicians. [Today the system employs roughly 80 providers, including physicians and mid-levels.] It became clear to us around 2005 that if we did not offer an employment model, we would not be able to effectively compete for quality physicians because so many new residents and fellows were looking for employment. In 2007, when one of the local practices joined us and became part of Kadlec, we recognized we were going to need an IT system with a single database that could store information for both the outpatient physician practices and inpatients. We wanted to allow patients to move through the system without multiple registrations, and regardless of where the patient was in the system, caregivers would have access to the most current and same information. It became clear to us that we were not going to achieve this functionality with two separate systems, and we weren't going to be able to build sufficient interconnectivity. In 2009 we began to look closely at the Epic EMR, which would provide us a single database and functionality across inpatient and outpatient platforms.
Q: How does EMR installation fit within Kadlec's overall strategic objectives?
RW: Historically, most of our capital expenditures were either for facilities or equipment with some funding for HIT. HIT was just one of many capital needs of the institution. Around 2009, we had identified a couple of future major facility projects, but we also recognized the need for better IT and better integration of our inpatient services and outpatient services. We eventually determined that it was more important to have a solid IT system to integrate all data than it was to build another building or expand our physical facility. We felt we could probably reduce our length of stay with better information flow and an integrated system, which would delay the need for building more inpatient buildings. So, with that in mind, we began to look seriously at the cost and placed our expansion project on hold so we could use our funds for the EMR.
One of the challenges with the cost of the installation is that although the government is making funds available through the HITECH Act for meeting meaningful use, you can't get the money until after you meet the criteria. If you want to borrow the money, it would require a very knowledgeable lender who understands what you're doing. Software isn't exactly a piece of collateral, which is what you have when funding a new building project. You basically have to use your existing debt capacity or reserve funds.
Q: Kadlec went live with its outpatient EMR on Aug. 1 and its inpatient record went live on Nov. 1. How did those two days go and how are providers adjusting so far?
RW: We implemented the outpatient record first, and it went reasonably well. Of course, there are going to be glitches, but we dedicated a significant amount of time and expense training and supporting the physicians and their office staff to minimize this. We had some physicians who picked it up very rapidly; others were a bit more technologically challenged. The inpatient side was more of a challenge, because you are training physicians and their staff, who are not employed by Kadlec. We had to work around their schedules, sometimes training them on nights or weekends.
You cannot over train. You have to commit huge resources upfront and have people available at the time of implementation to assist. One thing we didn't adequately anticipate was how much productivity would be decreased for a period of time. In August, volume in our employed physicians' offices was down because they couldn't see as many patients. Now that we're several months into it, the productivity appears to be back to normal levels. We've also had a number of physicians tell us they are actually more productive after taking time to develop templates, but it just takes time to learn the system and build their tools in it.
On the hospital side, productivity was down significantly for the first two weeks but has already started to recover. It was most difficult for the surgeons, who have to create an op note, pre-op assessment and post-op note for each patient. In the past, they had dictated these, and they are now prompted to enter text. We've worked to support them, but at the end of the day, these are physician-generated notes; not something hospital staff can do for them. They can use templates to eventually become more efficient, but there is going to be a learning curve.
Q: Now that you've implemented the EMR, how is your journey toward meaningful use coming along?
RW: We have essentially met meaningful use stage 1 for our physician practices in terms of having the required capabilities. We plan to apply for stage 1 certification in the very near future and anticipate receiving funds in late 2012. On the inpatient side, we will probably apply in 2012 and receive the funds sometime in 2013.
Q: Does Kedlac have any plans to offer its outpatient EMR to independent physicians who practice at the hospital?
RW: We are planning to offer our EMR to the independent physicians, but we want to make sure it works well first. The last three months we have focused totally on our inpatient side, so we didn't have resources to offer the system to outside physicians yet. We plan to do that soon, however.
Q: What key learnings were uncovered throughout the implementation processes?
RW: For one, it's difficult for key users of the system to really understand the importance of training and participating in clinical decision making — such as developing order sets — until the EMR has launched. Kadlec launched our EMR and order sets at the same time. There was a realization by some physicians that they should have spent more time building consensus around order sets. That's not meant as a criticism to the physicians; you just can't understand what you haven't experienced first.
We actually went live before we had 100 percent of our order sets built. The reality is there are so many processes surrounding your go live date that it would be incredibly disruptive to delay implementation. However, in retrospect, I would recommend committing whatever resources needed to make sure all order sets were complete before go-live. However long you think it's going to take to build order sets, add 20-30 percent.
Q: Kedlac recently announced an affiliation with PMH Medical Center in Prosser, Wash., and sharing an EMR is part of the agreement. What led to that partnership?
RW: PMH approached us a few months ago about a partnership, not just on an EMR system also on a possible alignment of referral systems and clinical programs. We haven't signed the deal yet, but, as you mention, we're moving forward with the intent to put our Epic record system in the 25-bed critical access facility, so they can meet meaningful use. Epic has given us the latitude to make its EMR available to some of the smaller institutions in our region.
Q: With inpatient and outpatient EMR implementations, you've had a busy 2011. What's on tap for Kadlec in 2012?
RW: Having gone through so much transition in the last year, in 2012 we really would like to slow down the rate of change in our institution. In addition to our EMR, we also implemented some lean processes throughout the hospital and had a lot of success with it. However, with changes and processes and changing our software over to Epic, we've challenged our staff and next year we plan to let the dust settle.
Strategically, we're going to focus on preparing to accelerate our growth in the region. Our state as well as the federal government is considering ceasing cost reimbursement for Medicaid hospitalizations at critical access hospitals. While we don't get cost reimbursement, there are about 10 hospitals in our part of Washington and Oregon that do. My concern is that if they lose this type of reimbursement, they could be at great risk financially. If any of these institutions close, I'm concerned it will be difficult for us to access the capital needed to grow fast enough to accommodate these patients. The challenge when all is said and done is to adapt to meet the needs of our community when we may have a huge amount of patients at our doorstep without sufficient capacity or access to capital.
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