Operation online

PHYSICIAN

leaders are not necessarily cheerleaders but we need them on board. They will ask the tough questions that we need.

–NANDA LAHOUD, PMP

The idea of a fully electronic health system isn't exactly revolutionary. Yet even in today's Web 2.0 world, the prognosis for going paperless has been less than promising. Texas Health Resources (THR), a 14-hospital network based in Arlington, Texas, USA, knew it was in for some resistance, but it also knew the payoff would be worth the effort.

“The underlying motivation is that we needed better ways of capturing and communicating information on our patients,” says Patricia Johnston, vice president of Care Connect, THR‘s information services department responsible for the project. “But we faced a combination of technology challenges and cultural issues. Getting to electronic health records meant pulling caregivers, including physicians, into the electronic era.”

The team did it by figuring out where the knowledge of healthcare experts would yield the greatest return in project work, building smart strategies to get user buy-in and bringing training—often an afterthought in similar projects—to the forefront.

Now implemented in five of THR‘s hospitals, the system affects 75 percent to 80 percent of employees at each site. And the changes extend all the way from patient intake to bedside care.

“Instead of having a folder or file where caregivers document things like vital signs, they use a laptop on a cart,” says Sallie Moore, PMP, THR‘s former senior project manager and training manager on the project and now director of information services strategy and business services. “That way, anyone treating the patient has immediate access to patient information. Rather than having doctors writing an order on paper and faxing it to the pharmacy, they can enter it on the computer and send it directly. It reduces the time lapse between order and delivery.”

Designing and building a system capable of serving the needs of more than 18,000 employees, including more than 3,600 mostly independent physicians, is certainly a big job. And getting those caregivers to adopt the system was another project altogether.

One of the first things the project team did after choosing an IT vendor was to set up a governance framework that addressed issues such as conflict resolution and communication processes.

“We had to have the right governance structure,” says Ms. Johnston. “We couldn't have implemented these changes without executive, medical and leadership support.”

To give the project added credibility within the medical community, the team formed a physicians’ steering committee for each hospital.

And it picked those committee members carefully.

“We included some fierce opponents on the steering teams,” says Nanda Lahoud, PMP, THR‘s former director of project management and business operations for the project and currently administrative director of value realization. “Physician leaders are not necessarily cheerleaders but we need them on board. They will ask the tough questions that we need.”

Next, a multidisciplinary committee loaded with healthcare professionals did a high-level workflow overview, setting down a number of foundational process decisions designed to serve as system guidelines.

“We tried to agree on as many guiding principles ahead of time as possible,” says Ms. Johnston. “For instance, we decided that we would document information at the point of care. This is a huge cultural change, because in the paper world, a nurse would go into the room, take vital signs, write them down on a piece of paper and then take them back to the nurse's station for input.”

The potential for cultural repercussions played a huge role in how the system was created. The comprehensive project was designed as a broad umbrella to take advantage of best practices across the THR network. But the team made the project more approachable to user input by breaking it into modules such as nursing, clinical documentation, pharmacy and order entry. Within each module, the team recruited clinicians— including nurses and lab professionals— in designing the system workflow.

“We broke it down and even looked at different specialties, such as the process for medication in the intensive-care unit,” says Ms. Johnston. “It was a huge plus.”

The design phase involved clinicians from every network hospital as the team strove to build a communication network that would help ensure stakeholder buy-in.

“Some of the meetings could have more than 200 people,” says Ms. Johnston.

The project team knew it wouldn't get people to use the system unless they were properly trained. Now it just had to find a way to convince the executives to put sponsor weight and budget behind the effort.

So the team set to work building charts and graphs that “quantified the staff hours required for training and helped people understand the impact it would have on the hospital,” says Ms. Lahoud.

It worked.

Yet even with the executive sponsors on board, the training team still faced a mammoth task. It now had to actually build the training modules that would attract a user base that wouldn't be exactly rushing to make the switch. Most of the doctors on the THR network were independent physicians, meaning that they could take their business elsewhere if they didn't care for the system.

“For lots of doctors, it takes more time to type in an order as opposed to telling a nurse to give the patient a shot of something,” says Ms. Lahoud. “Few community-based hospital systems have been able to get significant usage of these systems by doctors voluntarily. We believe we did because we were able to train them effectively.”

PAPER CHASE

To get them into the training, though, the team had to dangle some awfully big carrots.

“If they participated, doctors got opportunities to get some of their continuing medical education trips paid for,” says Ms. Lahoud. “There were some pretty significant prizes.”

The team also discovered some workers lacked computer basics.

18,000

The number of employees who will use the paperless system

“A lot of clinicians by nature have gone into a field where there is a lot of interpersonal dialogue rather than technology use, and we found a surprising lack of computer literacy,” she says.

The team responded by kicking off computer proficiency training while the system was still being designed and built.

“We hit the portions of the Microsoft suite that had functions similar to what we would be doing,” says Ms. Lahoud. “For example, some things in the electronic medical record look and feel like Excel. It was a small chunk we could do ahead of time.”

Given the chronic shortage of healthcare clinicians, the training team didn't want to burden each hospital by pulling people off the floor to teach. So it used contract instructors whose core skill base was teaching rather than clinical knowledge.

“When we first started the process we thought that only clinicians could train clinicians,” says Ms. Lahoud. “But when we bumped up against the nursing shortage, we went out on a limb and partnered with a local professional training organization, getting people with no clinical background but strong computer and teaching skills.”

The team found the instructors did just as well—and sometimes better— than the clinicians.

“Based on user feedback, we found that students couldn't tell who were contract instructors and who were clinicians,” says Ms. Moore.

Before they were allowed to teach, all instructors had to complete a weeklong credentialing course targeted to their individual needs. For example, clinicians with little teaching experience were given lessons in people skills and presentation tactics. To pass, each instructor had to teach a class to a panel of core trainers and “super”-users.

“We would pepper them with some pretty tough questions to rattle them,” says Ms. Lahoud.

The team wanted users trained as close to the “go live” date of each hospital as possible, so each initiative turned into almost a conveyor belt of teaching.

“At one hospital, we trained 3,600 employees in four weeks,” says Ms. Moore. “We taught in shifts of 20 hours a day, using probably at least 75 percent contract instructors. We had a training machine going.”

Ms. Moore and Ms. Lahoud primed the pump at future sites by identifying clinician trainers at the next hospital slated for training and recruiting them to teach at the one already under way.

“Creating these ambassadors helped the next site feel more prepared and helped ease staffing crunches at the hospital being trained,” says Ms. Lahoud.

With an implementation that spans several years and thousands of users, changes to both the system and training materials were inevitable.

So even though the team used a workflow engine to simulate the environment for each application, testing often revealed that certain processes needed tweaking as real-life workers started using the system.

To keep the process flexible and responsive, the staff built a combination of online and instructor-based training, using stand-alone modules that could be modified without affecting the bulk of the materials. And then the team relied on a collaborative technology in conjunction with a hierarchy of reports and team meetings to ensure the training, testing and build teams were all up-to-date on changes and feedback.

The team is a little more than halfway through the implementation, and the training process has been standardized and folded into the general project structure.

After the system went live, project leaders dropped the niceties. Users couldn't log onto the computer unless they'd gone through training, for example. While the paper-based system still functioned that wasn't a problem. But once files such as lab reports started migrating online, doctors and clinicians needed to get onto the computer—and the laggards began to cause workflow problems.

FOR THE MOST PART,

we are achieving targets. In areas where we don't, the information we get helps us go in and tweak the design process, or change the workflow.

-PATRICIA JOHNSTON

“Ultimately, each hospital reaches a point where it can't live in a half-paper, half-electronic world, and the medical staff ends up mandating that all medical staff must do orders electronically,” says Ms. Moore.

Throughout the THR network, the project is showing some healthy returns.

“We've got the momentum going from other hospitals, and the medical staff knows that this will really work,” says Ms. Johnston. “It's easier in a way because once you have a certain amount of physician engagement, you can just keep building on that success.”

Although the implementation is ongoing, Ms. Johnston has already seen benefits at the hospitals that have gone live with the system. Before the project kicked off, the team did baseline studies on metrics such as documentation compliance and efficiency issues like order-turnaround time. A comparison of those results with the data generated after implementation of the new system reveals consistent improvements in quality, efficiency and safety, as well as in the bottom line. Medical costs potentially decrease because the system ensures compliance with medical formularies—converting from intravenous medications to less expensive, orally administered drugs, for example.

“For the most part, we are achieving targets. In areas where we don't, the information we get helps us go in and tweak the design process, or change the workflow,” says Ms. Johnston. “It gives us very useful data regardless.”

And, in the final analysis, it adds yet another teachable moment to a project built on them. PM