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LESLIE: While most HIM leaders find it exciting to be moving toward EHRs, facing new challenges and inevitably some frustrations requires patience, perseverance and courage. In our interviews with these brave leaders over the years we have observed truly inspirational leadership.
PATTY: The lessons these leaders share with us are valuable because the path to the EHR is not linear. Every HIM leader is dealing with different legacy information systems, a variety of vendors and their own unique organizational resource issues and internal politics.
LESLIE: This month we speak with Eve-Ellen Mandler, MS, RHIA, CCS, director of HIM and privacy officer at St. Clair Hospital, a community hospital of 330 beds that serves the residents of southwestern Pennsylvania. Eve-Ellen please tell us how you see your role in leading the way to the EHR.
EVE-ELLEN: My principle job with regard to the EHR is to motivate all the stakeholders and make sure people have what they most need to do their jobs. I am a passionate advocate for moving toward a paperless record and my boss and members of administration see me as an expert resource on e-HIM and EHR.
PATTY: Where are you in the journey to the EHR?
EVE-ELLEN: Like so many organizations, our clinicians and our hospital staff are growing accustomed to working online. I started with my staff. All of the MTs have been working remotely since 2001. In 2001 they were put on a pure pay-for-production compensation system. We needed to re-engineer their jobs to do this. By removing all clerical support tasks from the MTs and creating a position for one transcription support clerk, we were able to send everyone home.
LESLIE: Are there other HIM functions performed remotely?
EVE-ELLEN: Yes. In 2002 we transitioned to a remote coding function. Because we do not have a complete EHR, we implemented a document scanning solution with short term data storage, specifically for the coding function. Three full-time clerks scan records so coders can remotely access the records. We also have one clerk who supports the remote coders by providing additional information as needed. Other HIM functions such as severity of illness abstracting, analysis, correspondence and administrative tasks are still done onsite at the hospital. We have 67 HIM employees, half of who work remotely, and we provide services 24/7.
PATTY: How has the organization benefited from remote transcription and coding?
EVE-ELLEN: We are more competitive in recruiting and retaining qualified people in two functions for which there are considerable shortages. We can easily staff all three shifts and we recaptured space that was dedicated to those functions.
LESLIE: How would you rate progress in moving toward the realization of a total EHR?
EVE-ELLEN: It is moving along, but slowly. Our clinical system is our EHR. Right now we have hybrid medical records, part paper and part electronic. Results of laboratory and imaging studies, and diagnostic cardiology procedures, as well as all transcribed reports are available online, so we have stopped printing those documents. We implemented a hybrid medical record policy and continuously update it to specify whether documents are in the clinical system or in the paper record. Recently nursing, physical therapy, respiratory therapy, occupational therapy and dietary began doing their documentation in clinical manager as well, further reducing paper documents.
PATTY: How soon do you think you will be able to transition what is left of the paper record to an electronic format?
EVE-ELLEN: This is one of my biggest challenges. Our leadership believes it may take a number of years.
LESLIE: Why so long?
EVE-ELLEN: We need to decide when and how the remaining paper components of the record will become part of the clinical system, for example consent forms. I believe a document management system will be needed to achieve a paperless record anytime soon. However, the medical staff does not see the value since records aren't scanned until after the patient is discharged from the hospital, thus it won't create efficiencies while patients are in-house. The IT department has expressed concerns because we are highly interfaced, which makes implementation more complicated and time-consuming. And we haven't yet been able to demonstrate a significant return on investment. Document management systems still carry a hefty price tag and while some labor intensive tasks might be phased out, new tasks are required to scan records, perform quality control, etc., which limits any great savings in the short term.
PATTY: From a leadership perspective, how do you overcome these obstacles and move things along?
EVE-ELLEN: First, I am working with our physicians. Many of them are not yet comfortable working with records in an electronic format, so we are helping them prepare for an eventual EHR by encouraging them to use the functionality that is available. Several physicians are already creating their progress notes in the clinical system, but we have a long way to go and many on the medical staff are far from ready for that transition. We have also implemented an electronic signature program for authenticating transcribed reports and verbal phone orders, which gives physicians an opportunity to experience the conveniences of a paperless system. We want to bring them along little by little.
LESLIE: I see how laying the groundwork with physicians now will serve everyone well in the future. How are you approaching the leaders in the organization?
EVE-ELLEN: I advise the physician committee that governs the use of the clinical system about the additional components available for that system, and I communicate frequently with administration about my vision for a paperless HIM department. Since 2005, I have included, in my annual budget request, capital funds for a document management system. However, these requests haven't been approved. I tried a new approach this year. Our patient financial services department and lab have documents they want scanned and available, thus I advised that adopting the document management system might show a better return on investment now because more than one department would realize greater efficiencies. This year there are other hospital priorities, but I thought it was the right way to go and will continue to assess more opportunities for return on investment.
PATTY: What is the most significant EHR related problem for you at this time?
EVE-ELLEN: Without a doubt the biggest problem is responding to requests for records from outside the institution. When we print the record from the clinical system it is voluminous. This clinical system wasn't designed to be a printed record or to support retrospective release of information. Right now it might take 30 printed pages to represent labresults, vitals, I & O sheets that you can view on one screen. We get record requests from insurance companies or for research or legal purposes that might result in 3,000 pages of documents for one patient record. It is costly and inconvenient for those who must use these records. However, as long as our clinical system is the hub of the EHR, the burden falls on the IT department to program printing functionality so the electronic portion of the record can be printed as it is displayed on the screen.
LESLIE: As you talk with us, I hear your optimism about the future, but also your frustration with the present. Are you getting discouraged?
EVE-ELLEN: No. I just keep working to develop a better business case for a paperless record and most pressing, printing requirements to fulfill release of information requests. It is my responsibility to keep bringing my ideas forward to senior management. I know they share my vision; however, there are a lot of competing priorities. The EHR is inevitable and we will get there. I will do my best to keep the vision front and center.
PATTY: What tips do you have for our readers?
EVE-ELLEN: Always keep up with the latest developments in EHRs. Keep bringing up ideas that will benefit the organization. Make sure to let people know you are constantly monitoring the technology and regulatory developments so they will naturally turn to you for help. Never give up.
LESLIE: Thank you so much for sharing your experience and insights with our readers. I appreciate your willingness to share the "inconvenient truth" that as much as we all want to move the EHR forward quickly, we must be aware of the multiple priorities and challenges facing all stakeholders and work collaboratively to bring about thoughtful solutions that result in optimal benefit to patients, clinicians and the institution.
PATTY: We wish you the best of luck to you in achieving your paperless record vision. It is well worth making the journey.
Leslie Ann Fox is chief executive officer and Patty T. Sheridan is president, Care Communications Inc., Chicago. They invite readers to send their thoughts and opinions on this column to lfox@care-communications.com or ptsheridan@care-communications.com.
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