The days of associating small hospitals with low-tech facilities are slowly fading in the past. One reason is that the small, including critical access, hospitals (CAHs) are not exempt from the HITECH programs carrots … or sticks. But sometimes being small does mean being resource constrained and, in that environment, doing any kind of rip and replace is often impractical. Washington County Hospital CIO Kim Larkin recently grappled with that challenge and, thanks to some timely vendor M&A, came out on top. To learn more about this fortuitous turn of events, and just how creative small-facility CIOs need to be, healthsystemCIO.com editor Anthony Guerra recently chatted with Larkin.
I think, from a CPOE standpoint, our biggest challenge is going to be having an opportunity to provide some orientation, some training to those physicians in the ER.
It’s a matter, more often than not, of juggling priorities and figuring out how far the money can go because there’s never enough of it.
GUERRA: You’re still in the process of rolling out the inpatient clinicals?
LARKIN: Right, those will come up live the end of this calendar year. We are anticipating that, by the end of January, we will pretty much be at Meaningful Use at Washington County, and Salem is anticipating getting there in December. You know, the timing for us worked out perfectly with NextGen and the opportunity to be one of their test sites or demonstration sites. I hesitate to use the word beta because the products aren’t in beta, but some of the changes and the rewrites and the new code and so forth will be beta testing of a sort. For us, it was the right time to go ahead and do it.
GUERRA: What’s your plan to get the physicians going on CPOE? First of all, give me an idea of the number of physicians who have privileges at your hospital and then your plan for getting them engaged and getting them to use the system.
LARKIN: Well, we have five employed physicians here at Washington County that are all working in our little health clinic, and they’re already using NextGen ambulatory, so they’re already accustomed to putting in all their own orders — they order their own labs, their own x-rays, their own meds, everything. Since they put in their own orders here, when they walk across the hall to the floor into an inpatient room, I don’t think it’s going to be a big deal — they’re already accustomed to doing it.
We have one physician here in town — who is actually employed by another system — who does send us patients, and he’s more excited about this than anyone else and more willing to put in his own orders. He says, “At least that way I can put them in the way I want,” and I just smiled and said, “That’d be great, Dr. Gilford.”
The bigger challenge for us on the CPOE front is our ER. Most small hospitals, and even many of the bigger ones, contract with ER companies to provide physician staffing. Typically, we’ve had good luck with that where we’ve had six or eight physicians who tend to rotate through, but they’re contracted. They’re not necessarily familiar with your system. They’re working at five other hospitals in a given month on five other systems. The rules are different everywhere they go, so I think, from a CPOE standpoint, our biggest challenge is going to be having an opportunity to provide some orientation, some training to those physicians in the ER and, contractually, we can let them know that they have to put their own orders in, but there’ll always be nursing staff there to help them if they’re not familiar with our system. We’ll keep them on track because, if you’re working in four or five systems, it’s going to get kind of crazy for them.
GUERRA: Your support will be to help them, not to put the orders in for them.
LARKIN: That’s right. Opus allows you to put in a verbal order. The nurse can actually put the order in, but then it queues up for the physician to signoff on the order, much like we do now on paper. A nurse can take a phone order or verbal order, write it on the chart, and the next day the physician will come in and sign that order. Opus will have the functionality to do the same thing in the system, but when you’re running your numbers and you’re trying to show that 10% of the orders are placed by a physician, the orders that are done that way (as a verbal order and signoff later) are not counted as a physician order, they’re counted as a nurse order which is the way it should be. Otherwise, the docs will just have the nurses ordering everything and signing off on it later.
GUERRA: It’s important that the physicians put in their own orders even if they’re getting some assistance from the nurses, correct?
LARKIN: Absolutely. We won’t meet the requirements if the nurses are putting those orders in and the docs are signing off on them afterward. We’re planning to roll it out with all the providers putting all their own orders in. The nursing staff will be very well-trained and able to provide support and guidance and help them, but our expectation is the physicians will do it.
GUERRA: You’ve heard talk of people using scribes. What are your thoughts on that?
LARKIN: I don’t think it meets the requirements for Meaningful Use. If you’ve got a scribe, that scribe’s the one putting the orders in, not the provider. I think it’s the workaround to avoid making the physicians put their own orders in. We’re not going to use scribes here.
GUERRA: Did you mention how many independent physicians practice in the hospital? I know you mentioned the employed physicians and then the contracted ED physicians.
LARKIN: We have one other physician here in Nashville who practices in town. He’s actually employed by a hospital system 25 miles away, but he supports the hospital. He has a lot of older patients who don’t want to travel. We’re also about 50 miles from Saint Louis and we probably have 15 different specialists down in Saint Louis who come out and do clinics. Some come once a week, some come twice a month. They typically don’t admit inpatients, but they do surgical procedures, they do a lot things here so they’re going be somehow involved, at some level, in our EHR.
I’m not real sure at this point if we’ll actually expect them to place orders in it. It’s more likely their orders will be done as an outpatient order and we probably won’t have them order within Opus, but it’s kind of interesting. A couple of the specialists who we have coming in right now are already using NextGen ambulatory, so I’m starting to talk to them and say, “Hey, wouldn’t you like to start pushing your data? Then we won’t have to copy those records when we refer patients to you, and you won’t have to carry your charts around.” It’s starting to get kind of interesting as well.
GUERRA: Have you found that since HITECH was passed you get a lot more support from the rest of the C-suite in terms of the budgetary needs you have and the support you need to roll these things out?
LARKIN: I don’t think HITECH really had anything to do with that. I think we have a very close-knit C-suite here. The CEO is a nurse. She’s been here 14 years. I’ve been here 15. We’ve been working together for a long time. The CFO, the chief nurse, I mean we’re all at the table; we’re talking to each other every single day. It’s not an issue of buying in for us, it’s a matter, more often than not, of juggling priorities and figuring out how far the money can go because there’s never enough of it. You know, everything we do is touched by IT. There’s virtually nothing we do anymore that isn’t a technology project of some sort, so it’s not an issue of buying-in or anything like that.
GUERRA: What kind of staff do you have?
LARKIN: When we started with the NextGen ambulatory, we added some staffing. My title is CIO but about a third of my time goes for running the imaging department. In a previous life, I was an x-ray tech. Another third of my time is more administrative. I’m the head of privacy and security and the compliance person and so forth, and then I have the IT hat.
GUERRA: You stay busy.
LARKIN: That’s for sure. I have a helpdesk PC tech sort-of person who’s been here like 30 years who is absolutely priceless, who handles all of those password resets and loads software and all those things that have to be done. I have a network specialist who is certified in all the things you can come up with. He has more alphabet soup after his name than anyone else, and then I have a clinical informaticist, an RN, and between the four of us we pretty much do everything.
Now, before we brought in NextGen ambulatory, I tended to contract out the heavier IT work to ICAHN — the Illinois Critical Access Hospital Network. They have some technical staff available to support the 50 hospitals, and I’ve just found them to be just a wealth of knowledge and experience and help. They’re not consultants trained to sell anything else, so it’s not like you have to second guess their recommendation. It was just really nice to have them. I don’t have to use them so much now that I have staff, so having the expertise that we have between the four of us is really nice because we all work well together and compliment each other.
In-house, we have the depth of knowledge with having an RN in the department, with having a network specialist who knows how to handle virtual servers and all of the higher tech stuff that we’ve gotten into in the last few years. I don’t know how I would do it with any less. I’d actually tell you I need at least one more, but you know there’s no money to keep adding staff so we do it the best we can, and we actually do pretty well.