Electronic Health Records

Electronic Health Records

EHR Implementation:
A Vendor’s Diary

Editor’s Note
This is the first in an occasional series chronicling the implementation of an electronic health record in a small community hospital system in rural New Hampshire. Serious discussion about the implementation began in 2009, during a time of seismic change in healthcare and healthcare IT.

The story is told in a diary authored by the EHR vendor’s CEO. The hospital system, LRGHealthcare based in Laconia, New Hampshire, is comprised of two community hospitals, 137-bed Lakes Region General Hospital and Franklin Regional Hospital, a 25-bed critical access hospital. LRGHealthcare serves as a Level III Trauma Center and has been designated a Rural Referral Center and Sole Community Hospital under Medicare.

After a series of discussions, on July 1, 2009, LRGHealthcare signed an agreement to purchase an EHR (electronic health record) from IntraNexus Inc., based in Virginia Beach, Virginia, which developed SAPPHIRE, a web-based EHR that incorporates a comprehensive suite of clinical applications ranging from CPOE to clinical documentation and lab and radiology. In a rare opportunity for an inside look at an implementation from the vendor’s perspective, Rick O’Pry, CEO of IntraNexus, has agreed, with LRGHealthcare’s approval, to provide PSQH with a diary as the implementation rolls out.

We believe this is significant on a couple of levels. First, few vendors or clients want to share the inner workings of an implementation, warts and all, for fear it may cast a negative light on either partner. We applaud both LRGHealthcare and IntraNexus for their willingness and forthrightness in telling this story. Second, in the national discussion about meaningful use, large academic medical centers and health systems grab most of the attention, while small, independent community hospitals, which account for roughly a third of all hospitals, are often forgotten. Yet these hospitals are the most likely to need help in achieving meaningful use, especially given the oft-spoken warning that a hospital which hasn’t begun implementing an EHR by now won’t be able to reap incentives and may even have to pay penalties. IntraNexus would like to solve that need with a light-footprint-yet-comprehensive EHR that can operate anywhere there’s a web browser. Here is their story.

The Conversation Begins

We’ve had a professional relationship with LRGHealthcare since the 1990s when we worked as consultants with Lakes Regional General Hospital before it became LRGHealthcare. We were their support vendor for the ALLEGRA® product. IntraNexus built the SAPPHIRE client server when the two hospitals merged.

Kathleen Patentreger, our VP of client services, has been our main contact with the client, talking mostly to CFO Henry Lipman and CIO Red Hutchinson. However, one of the early supporters was CMO Peter Walkley, MD, who wanted a system to support clinical documentation.

They currently have lab, radiology, and pharmacy from a major HIT vendor but were looking for a way to reduce costs and improve turnaround time for upgrades and enhancements. Early in 2006, senior management raised the possibility of replacing their entire clinical information system suite. We were able to achieve that integrated EHR, partly through SCC Soft, our partner for lab and radiology. We started discussions with LRGHealthcare in November 2008 and signed the contract July 1, 2009.

July 2009

LRGHealthcare has ordered a comprehensive EHR that includes orders & results, pharmacy, CPOM (computerized physician order management) advanced clinical documentation including document management, enterprise-wide scheduling, lab, and radiology. We’re bringing in a third-party firm to conduct a clinical review and clinical readiness assessment that will look at processes and provide documentation of current state and future state. The report on workflow processes is due in October.

We’re much more ready today than we were in the 1990s. We saw the need for a web-based system and began developing the SAPPHIRE product. Our ALLEGRA system was extremely strong on patient financials, but we realized that we needed to do something to stem the flow of customers to other clinical systems. We decided we needed a system that was web-based and tool-based, which meant providing the client with a set of tools they could use to design their own order-entry templates and documentation. We think that’s hugely important to clients because it allows them to modify and customize their own systems so they’re not forced to take expensive upgrades and the time delays that usually go with them.

Our approach has always been to give our clients the flexible tools they need to make many of their own modifications to our system. This not only saves them time, but also keeps support costs low. And it makes for happier clients.

It’s hard for hospitals, especially smaller community hospitals, to maintain that kind of ongoing cost. That’s why we came up with an umbrella plan with a fixed dollar amount. We don’t have extra, hidden costs for individual modules like CPOE. When you purchase the system, you get the whole system. We’re trying to work with our customers. LRGHealthcare seems pleased with our approach. Though LRGHealthcare looked at several other vendors, in the end they selected us. The system we proposed met their needs at a price they could afford. We were cost competitive and the deal finally came down to our relationship.

Independent Clinical Review
Our first step at LRGHealthcare is to bring in an independent Clinical Review Team, a group of four experts—a nurse, physician, lab professional, and administrative systems guru—to spend weeks onsite to determine current state and future state of the hospital’s work flow processes. They work in two phases, first to analyze orders and charges from which they develop flow diagrams. Then they return to the floors and validate those diagrams with operations staff and finally work with us to change the processes and implement new ones to be supported by the automation. The Clinical Review is a 7-week process: 2 weeks onsite, 2 weeks offsite, 2 weeks developing, and then 1 week onsite.

The second step involves a similar 7-week cycle in which the Clinical Review Team acts as advisors, meeting with the LRGHealthcare physician advisory panel, for example, to find out what their struggles are. Both the hospital and IntraNexus benefit from this process because it helped ensure that we were doing the best job possible with implementing all this automation.

After the initial clinical review, the installation occurs in parallel with the second step because they’re really focused on workflow. Information gathered during the clinical review helps us in process redesign and set-up.

The first module—orders and results—was to begin in October 2009 and finish 2 months later in December. Another interesting point is that LRGHealthcare wanted the entire contract phased in over 2-and-a-half years. They wanted to stage it, and the CFO wanted to go to the board with the whole cost. Originally monthly support was to last until 2015.

Meaningful Use
ARRA meaningful use deadlines have complicated negotiations. In March 2009 we had to go back and change some of the language in the contract to state that when the government publishes the final definition of meaningful use, IntraNexus will meet that definition for LRGHealthcare. By starting the EHR rollout this past October, we are looking really smart. Of course we were headed down this path anyway. It still makes me a little nervous that the final certifications and meaningful use definitions aren’t final. It seems that the federal government is really rushing this process without fully appreciating the complexities. And then there is healthcare reform, which could still potentially throw some curves at us. This business is not for the faint of heart.
The highs and lows of these deals are unbelievable. We were just about done with our negotiations when the bottom fell out of the banking world last March. Related directly to that crisis, LRGHealthcare had to do some scrambling to refinance a loan about that time. That finally all got settled in June. We are collectively holding our breath.

November 2009

The Clinical Review Team just completed the current and future state analysis, and we formally presented the report on Wednesday, November18 to the senior team, which includes CEO Tom Clairmont and all VPs, including CMO Peter Walkley. A few days prior, we sent them a 60-page PDF document of the report with lots of colored charts. It’s kind of an “Aha” moment. Nurses doing EKGs, for example, can see how their lives are going to change. The key is the workflow changes that the software supports. It’s what automation brings to the table.

I usually meet once a month with the CEO and the senior team. We presented the clinical review report to them. It’s wonderful to meet with the team because you have all the people in the room to make decisions right on the spot.
We always make a commitment that one of the senior executives at IntraNexus will be on the steering committee. If they want to yell at us, they can. They just hired a new project manager, who’s been very helpful.

The clinical review meeting went well, although there were a couple of surprises for the senior team, particularly about how their people were viewing adoption of the system. There were surprises for us, too. When you speak with that many people, you are going to find some who are not happy that they were not consulted in the system selection or whose opinions they felt were not considered. The bulk of the people from whom they heard complaints had BEEN invited to multiple demonstrations of the product over the years but never showed up.

We need 100% CPOE implementation by 2013, so obviously we need physician buy-in. They’re busy. They’re trying to do their work. They’re asking, “Who made this decision?” It’s the nature of the healthcare business. It’s hard to get physician buy-in. The issue is they’re not going to go sit in a room and learn how to use the new system. Physicians don’t want to look like they don’t know what they’re doing. That’s where the web-based system really comes through—it’s so intuitive that they can have their 10-year-old sons and daughters train them online in the comfort of their own home.

The whole thing is intuitive. They literally can get anyone to help them. Sure, you can put a PC in the physicians’ lounge for training, but that creates potential for them to foolish in front of their peers, and they’re not going to do it.

We’ve ordered the hardware and are expecting the delivery any day now. Delivery has been really slow, but it’s beginning to trickle in. We worked with CIO Red Hutchinson and his IT staff to develop specs for devices like web servers, application servers, and database servers. Our chief technology officer Doug James and RJ Ratajczak, our director of networks, do all the sizing based on the number of concurrent users, volume, etc., make sure everything is redundant, and certify that what the hospital gets is what it ordered. LRGHealthcare decides on the hardware vendor and has selected a local supplier.

It’s critical to us that all of our systems are set up as virtual machines or “VMs,” which complicates the sizing question. For example, sizing of the VMs depends on how many environments we designate. VMware takes a server and chops it up into different environments. You get a whole lot more for your money that way. Instead of designating one device or computer for a particular function, you can create a bunch of different environments on that one machine. Unfortunately many, many vendors out there won’t certify their systems to run on VMs. Heck, we insist on it. It saves the hospital a lot of money in hardware.  I’m pleased with the way things are going. However, all of the hardware ordered by the hospital was still not in and operational by the end of December 2009.

April 2010

For the first quarter of 2010 we have all been working hard. Physicians have been meeting to redesign their workflow, which will be reflected in the CPOM, and we have been finalizing the development and implementation of Phase1, which includes the web application and EMR repository.  These will serve as the building-block foundation for the entire system. It’s required lots of time to develop and test each step of the way to be sure the client is involved and pleased with the final outcome. We are very excited and looking forward to the go-live date for Phase 1 sometime in early June. Then it’s on to pharmacy and CPOM. Stay tuned.

Rick O’Pry is CEO of IntraNexus Inc. a web-based EHR software and consulting company founded in 1992 and located in Virginia Beach, Virginia. He can be reached at ropry@intranexus.com.