1 Running Head: EPIC AT ROGUE VALLEY MEDICAL CENTER

Course Project: Epic at Rogue Valley Medical Center

HIT 120- Introduction to Health Information Technology Jane Doe December 11, 2011

2 EPIC AT ROGUE VALLEY MEDICAL CENTER

Course Project: Epic at Rogue Valley Medical Center

Electronic health records (EHR) contain data and information that helps clinicians plan and implement the most advanced evidence-based care, allows the patient to become actively involved in the management of their own health, and provides swift access to important documents. The EHR also serves essential secondary purposes such as education of health care professionals, identification of at risk populations, and research investigation. An EHR should contain the four quality characteristics of accuracy, accessibility,

3 EPIC AT ROGUE VALLEY MEDICAL CENTER comprehensiveness, and consistency (Johns, 2011). This manuscript will explore the initial planning and development of an EHR at Rogue Valley Medical Center while keeping the quality attributes in mind. Rogue Valley Medical Center Rogue Valley Medical Center (RVMC) is 378-bed regional referral and trauma center located In Medford, Oregon (Asante Health System, 2011). Medford is positioned in the beautiful Rogue Valley which is in Jackson County, Oregon. Currently home to 203,206 people, it is the sixth most populous county in Oregon (US Census Bureau, 2011). RVMC serves all ages and stages of development with specialties including: Critical care, complete medical-surgical services, neonatal intensive care and childrens services, inpatient dialysis, inpatient and outpatient cancer care, and hospice and palliative care. RVMC, Three Rivers Community Hospital (TRCH), and other healthcare partnerships throughout the region are all part of the Asante Health System; Asante is a community owned and governed system serving as the largest healthcare provider for over 550,000 people in nine counties in Southern Oregon and Northern California (Asante Health System, 2011). RVMC is accredited by Det Norske Veritas (DNV) which is an accrediting body approved by the Centers for Medicare and Medicaid Services (CMS) (Det Norske Veritas, 2011). DNV has also certified RVMC as a Primary Stroke Center. RVMC is licensed and regulated by the Oregon Health Care Regulation and Quality Improvement Program which surveys facilities for quality and investigates complaints to evaluate adherence to state and federal licensing rules as well as Centers for Medicare and Medicaid (CMS) conditions of

4 EPIC AT ROGUE VALLEY MEDICAL CENTER participation. The Oregon Health Authority Public Health Divisions administrative rules for health care facilities are called OAR's (Oregon Administrative Rules) and ORS's (Oregon Revised Statutes) (Oregon Health Authority:Public Health Division, 2011). Users of the EHR There is a diverse range of uses and users of the EHR; uses can be separated into two purposes: primary, or associated directly with the provision of patient care (Johns, 2011, p. 30) and secondary which concern the environment in which the care is provided and includes matters such as research and regulation (Johns, 2011). Primary users are varied and include clinicians such as physicians, physician assistants, and nurse practitioners who use the record to place orders and view results of tests in order to direct the care of their patients. They also view entries made by nursing and other service providers to get an overall view of patient need and response. Nursing staff such as charge nurses, bedside nurses, nursing assistants, and clinical nurse specialists will use the EHR to gain knowledge about the patient; view orders so that they can carry them out, devise care plans, record data such as vital signs and document information such as response to treatment, educational needs, and nursing assessments. Allied health providers such as dieticians, pharmacists, physical therapists, occupational therapists, respiratory therapists and speech-language therapists will utilize the EHR similarly in that they will access it to help plan, deliver, and communicate care provided to the patient. Diagnostic service providers (radiology, laboratory, nuclear medicine) use the EHR to receive, verify, and carry out orders for specific tests; the results of which will be placed into the health record. Management can use the EHR to evaluate performance of staff and identify areas for patient care improvement, allocation of resources, and trends in care delivery. Risk management staff and performance improvement departments will review the record to ensure quality.

5 EPIC AT ROGUE VALLEY MEDICAL CENTER The HIM professional and support services staff use the EHR for both primary and secondary purposes. They can monitor records for coding and billing accuracy, analyze trends in the community, and extrapolate reports for use in performance improvement projects, research and development, and licensing requirements. Consumers of healthcare are also users of the EHR and can access these records for inclusion in their personal health record and to play an active role in the management of their own health. Secondary users of the health record include lawyers and legal staff should a visit come under contention, third-party payers such as managed care organizations and commercial health care companies, and accrediting and policy-making organizations such as DNV and CMS respectively (Johns, 2011).

Access to Information Current Hybrid State

6 EPIC AT ROGUE VALLEY MEDICAL CENTER At RVMC, there currently exists a hybrid record which means that the patients medical record is as a combination of electronic and paper records. Siemens Soarian is the software that serves as the partial electronic patient record. With the type of a password, direct patient care providers and support services staff can log into any in-house computer and look up lab and imaging results, past medical records, and dictated reports. RVMC also utilizes a barcoded medication administration system (referred to as MAK-vendor unknown) for patient safety. Access to the electronic records is simple and multiple users can view the same record at the same time whether they are a HIM professional coding the visit, or a nurse looking at lab values. One issue with the electronic record is that it is only a partial record of the visit. Other electronic systems in use include a GE system for RVMCs womens and childrens department, an unknown system used by respiratory care services, and an ancient system called Bossanova used to print patient armbands and some order sets. Although these electronic systems have helped to improve documentation, the bulk of care provided by patient care staff (nurses, nursing assistants, allied health providers) is still documented on paper records. What is more, providers still place orders on paper. The complete record is the paper chart which is kept on the unit where the patients bed is. This makes access to the paper chart difficult at best; if someone from another department or service wishes to view the chart they must travel to the department where it is. Furthermore, it can only be viewed by one person at a time and must also follow the patient wherever they travel in house. The last time DNV came to trace a patients stay they spent twenty minutes waiting their turn to view the chart.

7 EPIC AT ROGUE VALLEY MEDICAL CENTER Future: Meaningful Use The Health Information Technology for Economic and Clinical Health Act (HITECH) passed by Congress authorizes incentive payments for the adoption of EHRs. However, it is not enough to just have an electronic record, it must be one of meaningful use which means that their use by providers to achieve significant improvements in care. The legislation ties payments specifically to the achievement of advances in health care processes and outcomes (Blumenthal & Tavenner, 2010, p. 1). RVMC embraces this challenge and sets its sights on incorporating an electronic system into practice to improve the delivery of patient care. Information System Current Hybrid State: Soarian RVMC was well on its way towards achieving a full EHR with the Siemens Soarian line of products. A design team had developed Soarian nursing clinical documentation and had rolled it out at TRCH in January of 2011. Education was underway at RVMC with plans for house-wide implementation of clinical documentation to be complete by June, 2011. In February, 2011, the system crashed and 24 hours of patient records disappeared for good. This event and the investigation that followed proved to the Asante Board of Directors that Siemens did not have the mettle to provide the services they deemed vital to guarantee the safety and security of such important information and that they needed to have one system with excellent interoperability. They voted to immediately halt any further implementation. Asante then partnered with KLAS, a company that provides ratings of healthcare technology, and selected Epic as their electronic health record system (KLAS Enterprises, LLC., 2011).

8 EPIC AT ROGUE VALLEY MEDICAL CENTER Epic Epic is a private, employee-owned organization founded in 1979. They produce integrated software which spans clinical, access and revenue functions and extends into the home (Epic, 2011). The Epic EHR software that Asante is acquiring will make other systems obsolete as it includes applications for pharmacy, barcoded medication administration, revenue integrity (billing and coding), computerized physician order entry (CPOE), point of care (POC) charting for all specialties, picture archiving and communications systems (PACS), and r-ADT system functionality (registration: admission, discharge, and transfer). An information system should perform the activities of input, processing, output, storage, and controlling (Johns, 2011); the Epic EHR is a clinical information system that will perform these functions. Epic also provides operation support systems including a transaction-processing system with the ADT module. Epic serves as a management support information system by providing management with the ability to run reports on data. This can help the manager make crucial decisions for their department. Additionally, Epic serves as a decision support system (DSS); clinical DSS tools serve to reminder clinicians of guidelines, urgent notifications such as contraindications and results, and links to best-practice repositories on the web. Other DSS functions include providing analysis of performance improvement or other data to help administrators make knowledge-based decisions. Epic includes an EIS (executive information system) that will give top brass a snapshot of all levels of the organization.

9 EPIC AT ROGUE VALLEY MEDICAL CENTER An interview with Michelle Hollenback, Director of Medical-Surgical Services at RVMC provides an in-depth look into the nursing clinical documentation of Epic software. Michelle serves as the Nursing Champion for Epic development and implementation at RVMC. Functions. The nursing clinical documentation application serves to manage the patient and provide documentation of the patients stay from admit to discharge. It helps to organize the nurse and prioritize delivery with a feature that shows past-due, current, and future doses of medications and tasks and alerts the nurse of new orders that need reconciliation. The patient record is wholly viewable within the nursing application and includes vital information such as allergies and code status in the patients header so that it is easy to find. It has links to data such as lab and imaging results, vital signs that can be graphed to easily identify trends, past history, and current information (M. Hollenback, personal communication, November 9, 2011). Interoperability. According to M. Hollenback, Epic interfaces with a variety of systems; this is likewise stated on the Epic site with the following statement Epic software interfaces easily to hundreds of HIT systems (Epic, 2011). Usability.

10 EPIC AT ROGUE VALLEY MEDICAL CENTER Epic is absolutely user-friendly but this depends heavily on the user. There will be resistance from older, less technically savvy nurses and physicians but the younger crowd will easily learn to operate the system (M. Hollenback, personal communication, November 9, 2011). Security. Epic was chosen in part for its dedication to maintaining the privacy, security, and confidentiality of the information it holds. There is an analyst team dedicated to security both from outside the facility and within the facility (M. Hollenback, personal communication, November 9, 2011). Vendor Support. When a facility chooses Epic they get a forever partner. Epic has proven records for providing excellent care and service to their facilities. Upgrades and routine maintenance are included in the purchase price unlike Siemens where each upgrade had a cost. Downtimes are well planned (M. Hollenback, personal communication, November 9, 2011). Strengths. According to M. Hollenback, the strength of Epic lies in the knowledge and expertise of her people. Epic takes pride in providing a proven, secure, and evidence-based product that incorporates meaningful use criteria into its software. Another strength which is may also be a weakness is the emphasis on not varying from the core package to suit the needs of the individual customer. As Epic

11 EPIC AT ROGUE VALLEY MEDICAL CENTER incorporates proven practice documentation elements into its core product, veering from the norm often means straying from best practice (M. Hollenback, personal communication, November 9, 2011). Weaknesses. A weakness of Epic may well be the same as the strength described above. By not incorporating unique aspects of the patient population and needs of Asante we may be losing out on important data and information. Another weakness may be the young age of the analysts; for some to put their confidence in such a young group may be difficult (M. Hollenback, personal communication, November 9, 2011).

Design and Implementation. Currently, RVMC is through the planning and analysis phases and into the design phase of the system development life cycle (SDLC) (Johns, 2011). Epic analysts have been conducting informational sessions with end users of the system asking questions such as how interactions occur and how they should occur, and where the information should feed to. They have been showing screen shots of their basic build model and walking users through the processes they will use to complete aspects of patient care such as an admission or transfer. This phase will last for some time as it will include incorporation or building of Asante-specific information into the system. Full implementation is expected to occur by March of 2013.

12 EPIC AT ROGUE VALLEY MEDICAL CENTER Conclusion An EHR should be accurate, accessible, comprehensiveness, and consistent. Asante Health System recognizes the importance of these qualities and has chosen Epic as the software vendor for their information systems. Epic will be utilized for both primary and secondary uses and serve as clinical, administrative, decision, and transactional support systems. Users of these systems will be as varied as its uses and access will be easily obtained with the entry of a password and a few clicks of a mouse. Epic seems like an excellent fit for RVMC and Asante. They have knowledgeable staff that understand both the needs of the organization and the constraints under which healthcare facilities operate. With Epic, it seems like adhering to stringent CMS guidelines and providing quality, evidence-based care will be more achievable. The system helps clinicians to practice better and safer medicine with features such as bar-coded medication administration and CPOE. Epic has built a standard package that incorporates quality measures and will help facilities to achieve meaningful use; they encourage companies to take advantage of their proven expertise. Individuals and establishments alike sing their praises; it seems that with Epic, the sky is the limit. However, if it seems too good to be true it probably is; not all is perfect with Epic. With the insistence to stick to model, Asante may be missing some unique and important elements that should be incorporated. Requesting changes or saying, that does not work for us has resulted in some very pale and nervous Epic analysts looking awkwardly at one another. This, in turn, has made some staff very nervous about the functionality of Epic. Some physicians, resistant to change, have not been convinced by the usability of Epic, complaining about having to make too many clicks. The young analysts seem unsure of how to address these admittedly massive egos.

13 EPIC AT ROGUE VALLEY MEDICAL CENTER HIM professionals, revenue integrity, and performance improvement have yet to be shown how they will benefit from Epic; they wonder how reports can be run, how the data is stored and accessed, can they choose which data and information will appear where? This author does not doubt that EHRs are superior to paper records hands down. As Blumenthal & Tavenner (2010) state, EHRs will improve caregivers decisions and patients outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers (p.1). Time will tell if Epic can deliver the outstanding EHR they promise; even with some weaknesses, this author believes the potential is there.

References Asante Health System. (2011). About us. Retrieved February 9, 2011, from Asante Health : http://www.asante.org/About-Us/index.aspx Blumenthal, D., & Tavenner, M. (2010). The "Meaningful Use" Regulation for Electronic Health Records. The New England Journal of Medicine, 1-4.

14 EPIC AT ROGUE VALLEY MEDICAL CENTER Det Norske Veritas. (2011). Managing risk: Healthcare. Retrieved from http://www.dnvusa.com/industry/healthcare/index.asp Epic. (2011). Epic interoperability. Retrieved from http://www.epic.com/software-interoperability.php Epic. (2011). Epic: About us. Retrieved from http://www.epic.com/about-index.php Johns, M. (2011). Health Information Management Technology: An Applied Approach (3rd ed.). Chicago: American Health Information Management Association. KLAS Enterprises, LLC. (2011). KLAS: Who we are. Retrieved from http://www.klasresearch.com/about/company.aspx Oregon Health Authority:Public Health Division. (2011). Responsiblitiies of HCQRI program. Retrieved from http://public.health.oregon.gov/ProviderPartnerResources/HealthcareProviders/Pages/responsibilities.aspx US Census Bureau. (2011, June 3). State & county quick facts: Jackson County, Oregon. Retrieved from http://quickfacts.census.gov