DorlandHealth

Managing Editor Richard Scott sits down with Betty Pyle, RN, MS, FAACM, CMCN, CMC, the Director of Care Management at Oregon’s Salem Hospital, to talk about her department’s role in expanding the use of electronic medical records, including obstacles she has faced and tips for creating a streamlined flow.

Could you describe your role at Salem Hospital? How large is the CM department there?

I am the Director of Care Management. The department is comprised of a staff of 49 including care management, social services, and spiritual care.

Leadership staff is comprised of a director and manager of care management, two assistant managers, documentation specialist supervisor, mental health evaluator supervisor, and the resource center coordinator. Staff includes care managers, clinical documentation specialists, appeals coordinator, discharge coordinators, Medicare specialists, social workers, social counselors, mental health evaluators, and chaplains. We are unit-based and cover 10 units, Rehab, and the ED.

I understand case managers at Salem have played a role in the education of physicians regarding electronic medical record use. First, what is the importance of this area today?

Every hospital must begin implementing the electronic medical record, as this is vital to ensuring that all providers have access to the patient’s medical history to ensure that they are able to address the patient’s needs appropriately. It leads to improved patient safety, efficiency and communication, and it reduces errors. No more illegible hand-writing issues to resolve. Keeping up with technology’s advances is simply the right thing to do.

Why the urgent call for action?

We need to build a safer health system. The Institute of Medicine pointed out that 44,000 to 98,000 people die from medical errors in U.S. hospitals each year.

The deadline for hospitals to have an electronic medical record is 2012. It takes a lot of preparation to be able to have an electronic medical record that meets the needs. Success will come in many ways: 100 percent legible orders, 100 percent timed and dated orders, 100 percent signed orders, improved time from order to patient receiving care, improved communication from physician to nurse, improved communication from physician to all care providers and improved order management from hospital entry to exit.

Why do case managers make a good fit for this role?

Case managers have a role of reviewing charts for information that they must relay to the payers for certification for medical necessity so they know what needs to be included in the medical record and the ease of finding the information that is needed. As nurses, they know the difficulty a nurse has in documenting pertinent information that the physician needs for making decision for patient care.

The care managers and clinical documentation specialists work closely with hospitalists and attending physicians to assist in their clinical documentation of codeable language so they are aware of the needs for the physicians and are used to working closely with physicians on patient care plans and coordination of care. We work closely with physicians and nurses and have many great opportunities to teach as we work together as a team.

Where does Salem stand in this process? Is it an ongoing process?

Our medical community has been on an Epic journey (Epic provides electronic medical records) for five years—a trip that has placed Salem Hospital among leaders in using electronic medical records. We’re proud of being among the top 2 percent of hospitals using EMR in the U.S. Epic came live in 2006 and clinicians can now retrieve patient-specific data in seconds.

We are now ready to implement CPOM, Computerized Provider Order Management, a tool to help physicians and medical service providers enter orders on a computer in February 2010. It’s part of our Epic electronic medical records system that allows providers (e.g., physicians) to enter medical orders at the computer.

Our system focuses more managing orders, not just entering. Orders include diagnostic and treatment services such as medications and lab tests. The computer can compare the orders against standards for dosing, check for allergies or interactions with other medications and warn the physician about potential problems. We believe that CPOM is needed for a straightforward reason: To improve patient care. In fact, we’ve adopted the phrase For Our Patients as a tagline. We realize CPOM is a best practice and is expected by our patients.

Medication reconciliation will be done entirely through CPOM; no paper needed. It is an ongoing process as we have updates of our system regularly to improve processes. We have committees that work on requested changes to the system. We have a specialized department to educate and work to test and implement these changes.

What obstacles have you faced throughout this process?

Some physicians and nurses have been resistant to change and the age of computers and have made decisions to retire early rather than embrace the new technology.

Nurses and unit clerks have assisted physicians in finding information they need instead of insisting physicians learn this themselves. Physicians have not attended educational sessions to learn how to use all modules of Epic. We expect (and others have found) that while implementing CPOM, efficiency of practice may fall 30 percent for several weeks and will slowly rise. However, with CPOM implementation, we are confident that with classroom training, elbow help, playground use and a general willingness to participate, we will have the most successful go-live CPOM has ever seen.

What tips do you have for other departments looking to achieve the same results?

We have a physician who is the Chief Medical Information Officer who works closely with Epic and our IT staff to ensure physicians have an influence in the design of our electronic medical records.

A Steering Committee has been meeting for 18 months to bring CPOM to Salem Hospital. This group was picked by specialty, reputation and willingness to serve. Members will share the CPOM message with colleagues and act as sounding boards about concerns and fears. I also urge that you find physician champions to encourage peers to be active in creation of new modules to assist them in their workflow.

“Superusers” have been vital when new updates go live. Having dedicated staff roam nursing areas to assist anyone with problems the first three weeks after going ”live” relieves stress. Special help centers are set up in each nursing unit to focus superusers’ assistance.

We use a Communication Command Center approach for the first three weeks after going “live” also to quickly identify and fix issues. Having playgrounds available for physicians to play with before updates go live allows them to practice on their own to feel comfortable with change before going live. We also have a physician web page to highlight changes.

In light of the proposed health care reform, how will this affect Salem’s CM department?

Compliance of new rules and regulations always impacts workflows and issues for care management. If health care reform results in different payers, we will need to adjust to their utilization regulations.

Keeping abreast of changes and proactively making changes in work flows is necessary to be compliant.

If you would like to recommend a professional for an interview, please contact Managing Editor Richard Scott here.