The Digital Hospital: Transforming Care Delivery With eHealth Records

It’s the beginning of Staff Nurse Mary Hill’s shift at Fletcher Allen Health Care in Vermont. She confers with Tamara Gomez, R.N., who is ending her shift. Together, they look at a computer monitor at a patient’s bedside. Mary is getting a complete view of the patient’s care history. It’s all there – recent medications, vital signs, allergies, test results, and more – on one screen.

The view is courtesy of an electronic health record system called PRISM. The Patient Record and Information Systems Management (PRISM) system, which uses application software by Epic, is putting this academic medical center on the map. By the end of 2010, Fletcher Allen Healthcare will be in the top 3 to 4 percent of healthcare organizations in the U.S. that have a fully integrated electronic health record (EHR) system. (Read Five Tips for Successful EHR Implementation.)

As part of a clinical transformation project led by CSC, PRISM improves patient care, confidentiality, provider communications, and security, among other benefits, while putting Fletcher Allen on the road to qualify for federal funding within President Obama’s healthcare reform plan.

Under the American Recovery and Reinvestment Act of 2009, hospitals will begin to qualify for payments from Medicare and Medicaid starting in October 2010 for the successful implementation and use of EHRs. Hospitals that do not meet federal guidelines by 2015 face reductions in Medicare reimbursements.

With PRISM, Fletcher Allen’s inpatient operations are positioned to meet the requirements established for receiving incentives based on “meaningful use” of EHRs. Once fully implemented in December 2010, the system will serve all of Fletcher Allen’s 45 facilities and clinics, including the approximately 1,100 providers who are credentialed at Fletcher Allen. “We adopted an electronic health record to improve safety and quality of care for patients,” says Sandra Dalton, senior vice president of Patient Care Services and chief nursing officer at Fletcher Allen. “With CSC’s healthcare expertise and track record in clinical systems implementation and improvement, we have succeeded in completing the first phase of our project on budget, on schedule, and in just 15 months. We hope other hospitals are encouraged by our achievement.”

Moving beyond paper

PRISM has transformed clinical care delivery at Fletcher Allen from paper-based processes to a fully electronic system. Since going live in June 2009, staff embraced this new system after realizing the benefits.

Prior to the implementation, most information at Fletcher Allen was written in one of two patient charts. In order to view all of the patient’s information, a nurse would have to locate the charts – one on the door and the other that could be with a physician or another clinician. PRISM went live initially in Fletcher Allen’s inpatient areas, pharmacy and emergency departments, and a walk-in care center. CSC continues to offer IT consulting services during the second implementation taking place now, which includes ambulatory clinics, Beacon Oncology, and MyChart – a feature that allows patients to securely access portions of their electronic health record via the Web.

The system’s capabilities most notably include Computerized Provider Order Entry (CPOE), a process where physicians, advanced practice nurses, and physicians’ assistants enter orders in the system at the point of care. These orders are signed and transmitted through the network to departments responsible for fulfilling the order, such as pharmacy, laboratory, or radiology. CPOE decreases delays in order completion, reduces errors related to handwriting or transcription, allows order entry at point of care or offsite, provides error checking for duplicate or incorrect doses or tests, and simplifies inventory and posting of charges. Other advantages of PRISM include viewable medication and allergy lists, e-prescribing, clinical documentation, and quality reporting. Health information exchange is also possible as is electronic submissions to public health agencies and immunization registries.

Transforming a clinical program

CSC partnered with Fletcher Allen to complete the clinical transformation side of the EHR project. We handled all the clinical process workflow for the 15-month implementation period, says Jerry Howell, CSC’s client partner for Fletcher Allen.

From a clinical point of view, CSC mapped out how Fletcher Allen used technology, from medication management, work flow, users, and future states, to customize PRISM appropriately. We also allocated the right amount of resources to build, test, and bring the system to life, as well as provided additional personnel for training support.

Training was also a major challenge because Fletcher Allen decided to take a big-bang approach to go live. Basically, everyone in in-patient care roles needed to start using the system at the same time.

Succeeding at a new model

Pharmacy Director Karen McBride, R.Ph., says pharmacists have found several benefits to working in PRISM that were previously unavailable, such as improved documentation of pharmacy intervention to avert medication errors, an ability to view a complete overview of a patient’s health history and current diagnosis, and better educational opportunities as each pharmacist can pull his or her interventional data and share it.

For example, Clinical Pharmacist Wes McMillian, a critical care specialist, uses his own intervention data to develop a curriculum for residents coming through critical care. The data obtained through PRISM offers the opportunity to change behaviors.

Working with the clinical planning group, pharmacy staff is more clearly defining interventions into 37 categories, including dose change, drug change, medication reconciliation, nonformulary to formulary, and renal adjustment review. About Fletcher Allen Health Care Fletcher Allen Health Care serves a dual role as Vermont’s Academic Medical Center, in partnership with the University of Vermont, and as a community hospital. . The regional referral center provides advanced-level care to approximately one million people. It is also a training site for about 400 medical students, 550 nursing and allied health students, and 280 residents in training.

By the Numbers

122: Number of clinical transformation improvements PRISM teams designed during the project

96%: CPOE utilization for all orders, including medications

60%: Decrease in near-miss medication events

20%: Increase in daily fall assessment

25%: Reduction in number of patient charts needing to be pulled.