John Stanley is no rookie when it comes to health IT. The senior VP and CIO at Riverside Health System, a 5-hospital network based in Newport News, Va., has been deploying technologies for 35 years. What has his experience taught him? To position his organization ahead of the curve when it comes to initiatives like Meaningful Use, and to have a ‘bullish’ attitude about meeting requirements. In this interview, Stanley talks about his organization’s long-standing relationship with Siemens, how he and his team are working to create an environment of interoperability, and why sometimes you need to bring in help to deal with the complexities of order sets.
- About Riverside
- An early Siemens Soarian adopter qualifies for Stage 1
- The problem with problem lists, and the goal of tying them to physician progress notes
- The CPOE challenge — finding consensus on order sets (Zynx for content)
- Specialist reception to an enterprise EMR
I kept using the word ‘bullish.’ I said that if in fact these regulations are going to be final; if in fact there’s really going to be money there to recognize our investments that we’ve been making, I’m feeling pretty confident about this.
One of the beauties with Soarian is the workflow process; if you have structured diagnosis or problem lists, it just makes life even easier to identify those patients for whom you want to apply and rules, and to notify caregivers. This one of those things that wasn’t just for Meaningful Use—we needed to get that in there anyway.
The pushback we would get is, ‘I want to do things differently’ or maybe, ‘My partner does things in a completely different way.’ And that’s where the Zynx content came in. We had a good group of folks who were working with the physicians to get some of that consensus.
We did not make our order sets to be the pure cookbook variety where there’s only one way to do it. These are evidence-based guidelines, and are meant to be guidelines for them to follow… But every patient is going to be a little different, and there are times when they must deviate or override an order set. We understand that.
Guerra: Good morning, John. Thank you for being with me today to talk a little bit about your work at Riverside Health System.
Stanley: Good morning.
Guerra: Let’s start with an overview of Riverside. Tell the readers and listeners a little bit about the organization, and we’ll go from there.
Stanley: Okay. Riverside is a health system located in the southeastern part of Virginia. We comprise four acute care hospitals, a few other specialty hospitals—rehab and behavioral health, and have a number of what we call senior services and lifelong health facilities. Those would be nursing homes, assisted living, retirement communities, and home health, in addition the usual cadre of diagnostic centers and ambulatory surgery centers. We do have a medical group of over 400 physicians, one of the largest here in Virginia, and we’re facing a lot of the same challenges that many people around the country are.
Guerra: So those 400 physicians—are they employed by the hospital?
Stanley: Those are all employed physicians, correct. Actually it’s more like 450 when we include the physician’s assistants and nurse practitioners.
Guerra: And you also have independent community physicians that refer in to the hospitals?
Stanley: We do, at all of our hospitals.
Guerra: Any idea of approximately how many are credentialed?
Stanley: In terms of how many are credentialed across the four hospitals, the last time I checked, I would say probably in the 750-physician range when we combine all our hospitals.
Guerra: So about 450 employed and 700 independent physicians?
Stanley: No, a large number of the employed are credentialed, but not all primary care physicians generally are credentialed.
Guerra: Okay, so you have a good mix there; you have both the elements to deal with
Stanley: We do.
Guerra: Let’s talk a little bit about Siemens and Soarian. I believe you started with Soarian in 2004—definitely one of the early adopters, and then you were an early attester to Meaningful Use. Tell me about the run-up in terms implementing Soarian and then having Meaningful Use come along—did you have a lot of work to do right at the end to meet some of the mandates, or were you in pretty good shape when things came out?
Stanley: First off, we did begin early implementation of Soarian at one of our smaller hospitals. They were the pilot for our health system. We worked with Siemens on the early versions of Soarian and then rolled out Soarian to the other facilities about two or three years ago—I would say in the 2008 range. At the newest hospital that joined our health system last November, we brought in Soarian. Actually, we brought up 21 different modules—not all of them Siemens—at that hospital in November, and just last month brought up CPOE, medication administration, bar coding, and medication reconciliation. So we’ve been busy.
When the regulations came out on Meaningful Use, I took a look at them and right away determined that we were going to be in pretty good shape. There was a lot of education and discussion with our executive management group, with our management team and our boards, and I kept using the word ‘bullish.’ I said that if in fact these regulations are going to be final; if in fact there’s really going to be money there to recognize our investments that we’ve been making, I’m feeling pretty confident about this. And that’s exactly what happened as the regulations moved into the final stage. And of course, even though they were final and there were 700-plus pages, still there was a lot of interpretation and question as to what they mean by giving patients discharge instructions electronically. So we’ve worked with Siemens on some of those interpretations and we’ve attended webinars and read regulations and FAQs, and again, I continue to feel bullish about the process.
The actual Meaningful Use version of Soarian, which was certified last fall, we put into place in November of 2010. And even at that point, we were checking off boxes and had done a number of the requirements. We worked towards what we thought were maybe holes or where we need to shore up certain requirements. Problems lists were one—we didn’t necessarily have 80 percent of our patients having one problem identifying the structure field. So we shored those up during the fall and winter, and we were able to use the January 1 to March 31 dates to meet the Meaningful Use regulations for three of the hospitals. The one that’s just come up on CPOE obviously was not in that group; we’re working on that meeting those requirements for that hospital this summer, and to attest in the September time frame.
So that’s where we are. We felt very good and we were going to do April 2, but the website wasn’t quite ready. The ONC wasn’t quite ready with the website, and then when they did finally make it available, we chose to wait a day and use the second day to make sure everything was stable.
Guerra: Right, let them work the bugs out.
Stanley: Yes, and actually, we did find a little bug on there. For our largest hospital, one of the optional requirements was to have a laboratory test available electronically, and when I went to put the denominator in, we had over a million and it would not accept seven digits. Fortunately, we had qualified in more than the five optional requirements and we were ready, so we threw that one away and decided to do patient education one instead, which we had also met.
Guerra: You mentioned problem lists as being an area that needed some shoring up and some work, and I’ve definitely heard from other CIOs that that’s a big one. Tell me why you think problem lists are tricky.
Stanley: Well, actually I’d say CPOE is probably the hardest one to do. We were fortunate because we were already committed to that path and already had CPOE underway, so everyone I talk with says, ‘Oh my gosh, CPOE—that’s a big process.’ In terms of problem lists, we historically had coded problem lists after a patient is discharged. I mean, it’s generally a function for the HIM or medical records department, and we had some pretext that we had dealt with, but we hadn’t nailed down the official problems. We sort of left that to open physician documentation, and again, let the medical records professionals do that after the fact. So the chore for us was to get that upfront at the point of admission, or very close to the point of admission, and we had been striving to do this anyway.
One of the beauties with Soarian is the workflow process; if you have structured diagnosis or problem lists, it just makes life even easier to identify those patients for whom you want to apply and rules, and to notify caregivers. This one of those things that wasn’t just for Meaningful Use—we needed to get that in there anyway. We had various options open to us, and we’re still working on slowly making sure that our problem lists are up to date. What we would like to do is actually tie it to physician’s progress notes, but we’re not up on electronic progress notes. That’s our next task, to really complete the full automations on the physician side.
So meanwhile, what we did is we used some of the workflow and rules that are available in Soarian and said, ‘Well, if the physician is ordering a pneumonia order set, we can put a problem of pneumonia on there, and we can have the system actually pre-populate that.’ So for those obvious ones, that’s what we were doing. And in addition, at least until we can do these progress notes, we have folks—we call them Charge Description Master Process (CDMP)—in place, and they work with physician’s documentation to make sure we’re documenting all the problems and the comorbidity and the conditions to make sure we have the right documentation on there. We engaged them to make sure that at least until we can do progress notes, we were meeting Meaningful Use problem list requirements. So through was a combination of using some automation and augmenting that with some manual labor—folks checking on the problems, we were able to meet that requirement. But eventually, we want to be an off-shoot of our progress notes of physician documentation.
Guerra: You mentioned CPOE as possibly being more difficult than dealing with the problem list, and you also talked about your physician mix. Have you seen a major difference in terms of fostering adoption between the employed physicians and the independents?
Stanley: Not now. We chose about two and a half years ago to do CPOE, and we chose to do it with our hospitalists first, who happened to be employed. We would get the majority of our admissions, and it was an employed group, so we took our largest hospital and took 20 hospitalists and came up live with CPOE. But shortly thereafter, we started rolling it out specialty by specialty. That’s how we did it. We really did not make a distinction between employed and non-employed.
In order to do this, of course, you have to have order sets and consensus on order sets. The orthopedic surgeons need to get together, and so that was a combination of employed and non-employed physicians, and to get that consensus on those order sets, that’s perhaps one of the most important parts. So there really was no ‘Let’s do employed physicians first,’ other than the fact that the first specialty we chose to bring up live was hospitalists. Now at the last hospital, Shore Memorial, which we just brought up live on CPOE at the end of April, we went house-wide with all specialties. Plus we had orders sets already developed at the other hospitals over the last couple of years.
Guerra: Did you use a third party for order sets?
Stanley: We used Zynx for the content. We were a customer of Zynx and they formed a partnership with Siemens, which made life easier for us that the content can be developed in the Zynx process and then it feeds over into the CPOE design. So what the physicians agree on can be then said into the Soarian CPOE system. So yes we did use a third party, and we’re better for it. It made the process much faster, and we do recommend that you do have content to use a content developer. We’re very happy with that.
Guerra: You mentioned going specialty by specialty. Did you see significant pushback from any particular specialties as far as wanting a system that was more designed particularly for their field?
Stanley: The biggest thing we got from physicians is that they wanted their own customized order set, but we had established very early on that that was not going to be the case. But we would be happy to set up some favorites when they needed to go outside the established order sets. The pushback we would get is, ‘I want to do things differently’ or maybe, ‘My partner does things in a completely different way.’ And that’s where the Zynx content came in. We had a good group of folks who were working with the physicians to get some of that consensus. We could build the order sets, and for those items we couldn’t absolutely nail down and get consensus, we might have some dropdowns where there’s still a choice between one dosage and a higher dosage that another physician uses, or a different drug.
Guerra: How does that work if the physician wants to go outside of the order set? Do they have that ability, and do they have to document why they went outside the agreed-upon order set?
Stanley: Great question. For some order sets, yes. In our facilities, patient care is number one. We must take care of the patient, and if they need to go outside the order set, then so be it. And how they would do that is they would do a search and find the specific drug, lab test, or radiology scan, or it could be in their favorites. We have favorites if they find that they need to do that. But we did not make our order sets to be the pure cookbook variety where there’s only one way to do it. These are evidence-based guidelines, and are meant to be guidelines for them to follow, whether it’s pre-surgery or pneumonia or any of the order sets. But every patient is going to be a little different, and there are times when they must deviate or override an order set. We understand that, and we do keep track of those things.