IT Successes and Challenges in Opening an All-Digital Hospital

1. IT Successes and Challenges in Opening an All-Digital Hospital Larry T Hegland, MD, MMM Chief Medical Officer Saint Clare�s Hospital The Diagnostic and Treatment Center Weston, WI

2. Ministry Health Care A values-driven health care network of aligned hospitals, clinics and other providers based in Wisconsin and Minnesota 15 Hospitals Ministry Medical Group with more than 150 physicians serving out of 25 locations Affinity Medical Group with nearly 200 physicians serving out of 17 locations Health insurance plan Hospice care, long term care, dialysis services and home health services

3. Saint Clare�s Hospital 86-bed community hospital opened in October 2005 and currently providing general medical and surgical services Built for a new market and not as a replacement facility All-digital facility (�paperless�) with a comprehensive electronic medical record and physician order entry system (CPOE) Electronic ICU using VISICU via a telemedicine service Medical staff of over 300 providers primarily from the Marshfield Clinic, a 740-physician multi-specialty practice located across north central Wisconsin

4. Diagnostic and Treatment Center Joint venture between Ministry Health Care and the Marshfield Clinic providing outpatient services and ancillary services to Saint Clare�s Hospital and other entities on campus Radiology and women�s imaging services Heart services including cardiac testing and catheterization Radiation oncology services Laboratory services Physical, occupational and speech therapy services Ambulatory surgery

5. IT Strategy Best of breed approach with numerous interfaces required EMR provided by Marshfield Clinic and Ministry Health Care allowing access to almost 30 years of physician office records Tight integration of clinical and administrative practices to IT systems Convertible tablet PC�s used by practitioners with full system access available in the hospital, office, home or anywhere a high speed Internet connection is available Extensive planning for system redundancy and downtime including multiple backup strategies Comprehensive staff and physician training program using classroom, on-the-job and other approaches to learning

6. Key IT Clinical Successes Access to patient records in both the hospital and office setting has resulted in numerous benefits, especially in the emergency room Highly stable network with easy accessibility from any location with Internet access All-digital world with virtually no paper, avoids problems of dual systems Electronic patient records are immediately available to clinicians and staff Has contributed to an extremely low rate of �delinquent� or incomplete medical records (<3.5%) Allows concurrent record review for performance improvement, case management, patient safety and other support staff

7. Key IT Clinical Successes Clinical testing results immediately available to the clinician Successful integration of VISICU e-ICU technology with hospital IT structure and service implementation with full access to hospital IT system by telemedicine intensivists Successful deployment of telemedicine capability in hospital emergency department Successful deployment of �smart� IV pumps and PYXIS machines as part of our IT system

8. Key IT Clinical Successes Introduction of decision support and best practices to medical care helps reduce unexplained variation in treatment approaches Mandatory CPOE system has markedly reduced the most common medical errors seen in the paper world (but new risks created) CPOE has increased the speed with which medical therapy is initiated Time of order to release of medication on med-surg unit medication dispensing devices is less than 15 minutes on average Similar results seen in response times for laboratory testing

9. Planning Phase Culture design Management team brought in up to 2 years prior to opening Personalysis � personality assessment tool Team building and culture development meetings Selecting Winners � employee selection tool Customer service program Benchmarking All-digital facilities Top performing clinical facilities Joint Commission Resources

10. Planning Phase Project management Facilitation Barrier identification Consistency Deadline management Coordinated 89,000 man hours in formal project plans Process mapping Over 8400 detailed process maps developed Teams included IT, clinical and administrative members for integrated process mapping Process maps reflect clinical processes and/or operational workflow, with links to the appropriate IT systems

11. Planning Phase CPOE development CPOE team meetings Over 1000 order sets created Incorporated evidence based, best practices Failure modes and effects analysis (FMEA) to anticipate and prevent potential CPOE associated medical errors Physician champions Active participation of system Chief Information Officer and Director of Information Technology Involved in clinical and IT process mapping and barrier removal

12. Planning Phase Education/Communication Extensive staff training sessions (4 weeks for new hires) Customized physician training Medical staff communications via meetings, e-mail and newsletter Manage expectations and do not over promise Patient simulations Actively tested clinical and IT systems via numerous patient simulations Requires involvement of clinical, administrative and IT staff

13. Opening Phase (months 1-3) Clinical and IT SWAT teams For the first month, entire clinical and administrative management team, IT staff and clinical managers met daily Later, clinical and IT SWAT teams were created to deal with day-to-day problems as they arose Inpatient and Combined Operations Groups Inpatient Operations Group (IOG) focused on more complex problems derived from the Clinical and IT SWAT teams for the hospital Combined Operations Group (COG) focused on more complex problems derived from Clinical and IT SWAT teams for both the hospital and the Diagnostic and Treatment Center

14. Opening Phase CPOE/EMR team Ongoing order set development and order set refinement Processing of suggestions and complaints regarding IT issues Leader rounding Issue identification Maintain high visibility �Blue Shirt� IT support program 24/7 in person physician and staff support provided by large number of specially trained staff �Got questions?� campaign IT Command Center for coordination of staff and immediate problem solving

15. Opening Phase Communication/Education Focus shifted to communication of IT system updates and changes via e-mail and newsletter Development of �advanced� refresher training Staged opening Medical-surgical floors (3) opened at 0, 3 and 6 months Interventional cardiology and cardiac surgery planned opening in summer of 2006 All other services available at time of opening Staging was needed to accommodate difficult recruiting environment and extensive training requirement of all new hires

16. Operations Phase(months 4-present) Transition process to operations Ongoing CPOE, Clinical and IT SWAT teams , IOG and COG meetings �Super-users� IT support program 24/7 service to replace bulk of contract �Blue Shirt� staff Consists primarily of highly proficient front line staff who go through a 1 month training program to give even greater proficiency Focused on physician support, especially the low volume user

17. Operations Phase Clinical Applications Coordinators Highly trained IT/Clinical specialists with in depth knowledge of applications EMR System and customer champions Liaison between IT analysts and clinical users MD and other user training and support Downtime procedures support (flexible schedule and on-call) and security requests Work with users to identify future system improvements Integration testing and testing of new functionality

18. Operations Phase Education/Communication Ongoing communication of IT system updates and changes via e-mail and newsletter Development of �lunch and learn� training Leader rounding Post-implementation learning Extensive, facilitated survey of system users regarding experience and suggestions for future improvement Lessons learned meetings to provide system guidance for future all-digital hospital projects Comprehensive report produced to encapsulate critical learning derived from this process

19. Planning Phase Challenges Lack of road map in building all-digital hospitals Limited benchmarking opportunities and few best practices available Architects never come back Lack of a medical staff prior to opening Building consensus difficult Physicians joining staff over period of six months created education and communication difficulties Staged opening Increases difficulty of consistent staff training

20. Planning Phase Challenges Operational talent does not always translate into planning/implementation talent Vendor failures Project management helped surface vendor failures There is never enough time �Weekends are workdays without meetings�

21. Post-Opening Challenges There is never enough time �We�ve discovered the eighth working day of the week� Be prepared for �meltdowns� within the leadership team It is easy to become trapped in the moment and feel overwhelmed by problems Physicians have one commodity to sell�time The all-digital world makes physicians feel less efficient despite some of the benefits the system creates for them Planning/implementation talent does not always translate into operational talent

22. Post-Opening Challenges It is difficult to overestimate IT training and support resource requirements Long term commitment to IT resources being available on 24/7 basis is required Telephone support is frequently inadequate Low volume users of the system are extremely difficult to make successful � the �personal handlers� solution IT training needs never go away and it is very difficult to deploy additional training to physicians Physicians frequently feel �dumb� in the all-digital world Need someone dedicated to communicating system improvements to users

23. Post-Opening Challenges Benchmarking all-digital staffing needs to the paper world is futile The all-digital environment slows everyone down in terms of documentation It appears that all-digital environment increases staffing time requirements about 10-15% (much higher at opening) Process mapping cannot be too detailed Gaps in process map details created early breakdowns in several care systems such as heparin and insulin drip protocols The interface back to the paper world can be difficult Complaints from long term care, rehab and other facilities

24. Post-Opening Challenges All-digital systems are fragile Problems need to be analyzed systematically for software, hardware and network related causes A single malfunctioning wireless system antenna caused a two month search for hardware/software related problems that did not exist Patient registration systems must accurately capture key patient demographic data Even with excellent network stability, downtime procedures must be clearly specified and �simulated�

25. Post-Opening Challenges CPOE related problems Order sets often not intuitive and require too many clicks (the problem of �ADCVANDISSEL�) Constant modification of system to address physician concerns creates training/communication problems and a sense of perpetual change CPOE facilitated errors Selecting wrong patient, drug, dose, etc. Assuming computer is doing more than it is really is Alert fatigue Undetected errors in order sets and software bugs Difficulty with very complex or �if-then� orders

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27. For more information contact: Larry T Hegland, MD, MMM Chief Medical Officer Saint Clare�s Hospital The Diagnostic and Treatment Center 3400 Ministry Parkway Weston, WI 54476 (715) 393-2487 larry.hegland@saintclareshospital.org