EHR Deployment Can Rattle Hospital Revenues

LAS VEGAS – Plan for a dramatic loss of productivity and drop in revenue when anticipating the myriad changes that accompany rapid deployment of an electronic health record system.

"We thought volume would drop like a rock, 50% for the first 2 weeks, and then everybody would get used to the system, and volume would pop right back up. But that’s not what happened at all," Frank DiSanzo, chief information officer of the Saint Peter’s Healthcare System in New Brunswick, N.J., said at the Healthcare Information and Management Systems Society annual conference.

Patrice Wendling/Elsevier Global Medical News

When the system’s 478-bed acute care Saint Peter’s University Hospital and its 81 clinics switched to a single electronic health record (EHR) system, patient volume dropped 30% in the first month, another 16% in the second month, and another 5% in the third month. The losses were additive, and despite the urging of vendors to plan for this eventuality, the hospital was unprepared for the accompanying loss in revenue.

"You really have to plan for this on a cash-flow basis," said Mr. DiSanzo, also vice president for the health system.

The hospital, a "Marcus Welby–like" facility, as he described it, had involved a multidisciplinary, multispecialty project management team from the inception stage through optimization that included two part-time chief medical informatics officers and seven full-time IT members working 6 days a week.

Some staff threatened to quit if they couldn’t be involved in the 9-month project from the ground up, while others balked.

"Physician pushback is surprisingly strong, even among builders and superusers," he said.

The hospital created a smaller SWAT team of physicians, nurse informaticists, core IT staff, and superusers, all of whom were given carte blanche on decisions regarding work flow and patient flow. Each team was responsible for creating individual templates, with an emphasis on maintaining consistency within service lines and throughout the patient experience. Of the more than 1,200 templates created, only 300 were custom, he said.

Training was extensive, and rapid prototyping was used to get the project up and running quickly. Surprises were built into the system and potential scenarios tested using a board game approach and flash cards so responses and corrections could be programmed into the applications before going live. Patient visit cancellations were quickly anticipated, but what they didn’t count on was the myriad of tests often preordered for these visits.

"When we tried the board game approach and flash cards, we soon had a pile of cards of downstream orders that were never going to be cancelled because we had completely forgotten to build that in," Mr. DiSanzo said.

The hospital had modified the patient schedule for the launch, but still patients arrived who couldn’t be seen. Hospital leaders early on had wrestled over whether to notify patients about the EHR project, with two opposing camps emerging. One felt the hospital shouldn’t air its dirty laundry and that telling patients might just raise concerns, while the other felt that patients should be part of the process, Mr. DiSanzo said.

The full-disclosure camp won, and "I really think it was the right thing to do," he added. The hospital posted signs in all of its clinics and handed out cards during registration that detailed EHR benefits such as potential reduction in error, faster and more efficient care, and coordination with local pharmacies.

"The patients were really very good about it and were happy to see we were moving forward in an effort that they really thought was aimed completely at them, relative to providing them better care," he said. "That was a big win for us."

Mr. DiSanzo recalled that the new electronic charts looked great and made it easier to share information; however, clinicians and nurses were working longer hours entering the necessary data. Workers all received at least 12 hours of training, regardless of their role. Quick reference cards were created and "tips and tricks" were published daily, weekly, and monthly.

Still, there was a learning curve that took about 6 months to flatten out, Mr. DiSanzo observed. User age and familiarity with typing and computers were not necessarily factors. Commitment to the project was.

One of the biggest "operational nightmares" after the system went live was scanning the precipitous volume of paper that patients brought to a visit. In the past, these documents were easily slipped into the paper record, but now each had to be indexed, scanned, and retrieved. The time commitment needed to do this is huge, he said.

Another surprise was the mismatch that occurred between processes as mapped out for the EHR and what actually happened in the clinics. Nurses and physicians inevitably developed shortcuts relative to registering patients or shuffling visits to treat a more urgent case.

Mr. DiSanzo suggested that an unspoken schism between management’s expectations for EHR implementation and what really occurred in the clinics may also have contributed to the large drop in patient volume. When the volume really started to drop, the hospital worried that patients would go somewhere else, but that hasn’t happened.

In fact, billing has increased 22%, medication reconciliation and computerized physician order entry are both 100%, and patient volume is up 13% this year, even after accounting for other factors, he said.

The hospital is still wrestling with exactly what this means, but suspects that as staffers get more familiar with the EHR system, they’re finding new ways to increase their workflow or are having better patient encounters that result in patients following-up at other clinics within the system.

"Our culture isn’t cutting edge, bleeding edge, completely electronic," he said. "We’re like the nice friendly hospital down the block that you go to and receive this Marcus Welby kind of patient care; and, if we can do it, anybody can do it."

Mr. DiSanzo reported no relevant conflicts of interest.

LAS VEGAS – Plan for a dramatic loss of productivity and drop in revenue when anticipating the myriad changes that accompany rapid deployment of an electronic health record system.

"We thought volume would drop like a rock, 50% for the first 2 weeks, and then everybody would get used to the system, and volume would pop right back up. But that’s not what happened at all," Frank DiSanzo, chief information officer of the Saint Peter’s Healthcare System in New Brunswick, N.J., said at the Healthcare Information and Management Systems Society annual conference.

Patrice Wendling/Elsevier Global Medical News

When the system’s 478-bed acute care Saint Peter’s University Hospital and its 81 clinics switched to a single electronic health record (EHR) system, patient volume dropped 30% in the first month, another 16% in the second month, and another 5% in the third month. The losses were additive, and despite the urging of vendors to plan for this eventuality, the hospital was unprepared for the accompanying loss in revenue.

"You really have to plan for this on a cash-flow basis," said Mr. DiSanzo, also vice president for the health system.

The hospital, a "Marcus Welby–like" facility, as he described it, had involved a multidisciplinary, multispecialty project management team from the inception stage through optimization that included two part-time chief medical informatics officers and seven full-time IT members working 6 days a week.

Some staff threatened to quit if they couldn’t be involved in the 9-month project from the ground up, while others balked.

"Physician pushback is surprisingly strong, even among builders and superusers," he said.

The hospital created a smaller SWAT team of physicians, nurse informaticists, core IT staff, and superusers, all of whom were given carte blanche on decisions regarding work flow and patient flow. Each team was responsible for creating individual templates, with an emphasis on maintaining consistency within service lines and throughout the patient experience. Of the more than 1,200 templates created, only 300 were custom, he said.

Training was extensive, and rapid prototyping was used to get the project up and running quickly. Surprises were built into the system and potential scenarios tested using a board game approach and flash cards so responses and corrections could be programmed into the applications before going live. Patient visit cancellations were quickly anticipated, but what they didn’t count on was the myriad of tests often preordered for these visits.

"When we tried the board game approach and flash cards, we soon had a pile of cards of downstream orders that were never going to be cancelled because we had completely forgotten to build that in," Mr. DiSanzo said.

The hospital had modified the patient schedule for the launch, but still patients arrived who couldn’t be seen. Hospital leaders early on had wrestled over whether to notify patients about the EHR project, with two opposing camps emerging. One felt the hospital shouldn’t air its dirty laundry and that telling patients might just raise concerns, while the other felt that patients should be part of the process, Mr. DiSanzo said.

The full-disclosure camp won, and "I really think it was the right thing to do," he added. The hospital posted signs in all of its clinics and handed out cards during registration that detailed EHR benefits such as potential reduction in error, faster and more efficient care, and coordination with local pharmacies.

"The patients were really very good about it and were happy to see we were moving forward in an effort that they really thought was aimed completely at them, relative to providing them better care," he said. "That was a big win for us."

Mr. DiSanzo recalled that the new electronic charts looked great and made it easier to share information; however, clinicians and nurses were working longer hours entering the necessary data. Workers all received at least 12 hours of training, regardless of their role. Quick reference cards were created and "tips and tricks" were published daily, weekly, and monthly.

Still, there was a learning curve that took about 6 months to flatten out, Mr. DiSanzo observed. User age and familiarity with typing and computers were not necessarily factors. Commitment to the project was.

One of the biggest "operational nightmares" after the system went live was scanning the precipitous volume of paper that patients brought to a visit. In the past, these documents were easily slipped into the paper record, but now each had to be indexed, scanned, and retrieved. The time commitment needed to do this is huge, he said.

Another surprise was the mismatch that occurred between processes as mapped out for the EHR and what actually happened in the clinics. Nurses and physicians inevitably developed shortcuts relative to registering patients or shuffling visits to treat a more urgent case.

Mr. DiSanzo suggested that an unspoken schism between management’s expectations for EHR implementation and what really occurred in the clinics may also have contributed to the large drop in patient volume. When the volume really started to drop, the hospital worried that patients would go somewhere else, but that hasn’t happened.

In fact, billing has increased 22%, medication reconciliation and computerized physician order entry are both 100%, and patient volume is up 13% this year, even after accounting for other factors, he said.

The hospital is still wrestling with exactly what this means, but suspects that as staffers get more familiar with the EHR system, they’re finding new ways to increase their workflow or are having better patient encounters that result in patients following-up at other clinics within the system.

"Our culture isn’t cutting edge, bleeding edge, completely electronic," he said. "We’re like the nice friendly hospital down the block that you go to and receive this Marcus Welby kind of patient care; and, if we can do it, anybody can do it."

Mr. DiSanzo reported no relevant conflicts of interest.

LAS VEGAS – Plan for a dramatic loss of productivity and drop in revenue when anticipating the myriad changes that accompany rapid deployment of an electronic health record system.

"We thought volume would drop like a rock, 50% for the first 2 weeks, and then everybody would get used to the system, and volume would pop right back up. But that’s not what happened at all," Frank DiSanzo, chief information officer of the Saint Peter’s Healthcare System in New Brunswick, N.J., said at the Healthcare Information and Management Systems Society annual conference.

Patrice Wendling/Elsevier Global Medical News

When the system’s 478-bed acute care Saint Peter’s University Hospital and its 81 clinics switched to a single electronic health record (EHR) system, patient volume dropped 30% in the first month, another 16% in the second month, and another 5% in the third month. The losses were additive, and despite the urging of vendors to plan for this eventuality, the hospital was unprepared for the accompanying loss in revenue.

"You really have to plan for this on a cash-flow basis," said Mr. DiSanzo, also vice president for the health system.

The hospital, a "Marcus Welby–like" facility, as he described it, had involved a multidisciplinary, multispecialty project management team from the inception stage through optimization that included two part-time chief medical informatics officers and seven full-time IT members working 6 days a week.

Some staff threatened to quit if they couldn’t be involved in the 9-month project from the ground up, while others balked.

"Physician pushback is surprisingly strong, even among builders and superusers," he said.

The hospital created a smaller SWAT team of physicians, nurse informaticists, core IT staff, and superusers, all of whom were given carte blanche on decisions regarding work flow and patient flow. Each team was responsible for creating individual templates, with an emphasis on maintaining consistency within service lines and throughout the patient experience. Of the more than 1,200 templates created, only 300 were custom, he said.

Training was extensive, and rapid prototyping was used to get the project up and running quickly. Surprises were built into the system and potential scenarios tested using a board game approach and flash cards so responses and corrections could be programmed into the applications before going live. Patient visit cancellations were quickly anticipated, but what they didn’t count on was the myriad of tests often preordered for these visits.

"When we tried the board game approach and flash cards, we soon had a pile of cards of downstream orders that were never going to be cancelled because we had completely forgotten to build that in," Mr. DiSanzo said.

The hospital had modified the patient schedule for the launch, but still patients arrived who couldn’t be seen. Hospital leaders early on had wrestled over whether to notify patients about the EHR project, with two opposing camps emerging. One felt the hospital shouldn’t air its dirty laundry and that telling patients might just raise concerns, while the other felt that patients should be part of the process, Mr. DiSanzo said.

The full-disclosure camp won, and "I really think it was the right thing to do," he added. The hospital posted signs in all of its clinics and handed out cards during registration that detailed EHR benefits such as potential reduction in error, faster and more efficient care, and coordination with local pharmacies.

"The patients were really very good about it and were happy to see we were moving forward in an effort that they really thought was aimed completely at them, relative to providing them better care," he said. "That was a big win for us."

Mr. DiSanzo recalled that the new electronic charts looked great and made it easier to share information; however, clinicians and nurses were working longer hours entering the necessary data. Workers all received at least 12 hours of training, regardless of their role. Quick reference cards were created and "tips and tricks" were published daily, weekly, and monthly.

Still, there was a learning curve that took about 6 months to flatten out, Mr. DiSanzo observed. User age and familiarity with typing and computers were not necessarily factors. Commitment to the project was.

One of the biggest "operational nightmares" after the system went live was scanning the precipitous volume of paper that patients brought to a visit. In the past, these documents were easily slipped into the paper record, but now each had to be indexed, scanned, and retrieved. The time commitment needed to do this is huge, he said.

Another surprise was the mismatch that occurred between processes as mapped out for the EHR and what actually happened in the clinics. Nurses and physicians inevitably developed shortcuts relative to registering patients or shuffling visits to treat a more urgent case.

Mr. DiSanzo suggested that an unspoken schism between management’s expectations for EHR implementation and what really occurred in the clinics may also have contributed to the large drop in patient volume. When the volume really started to drop, the hospital worried that patients would go somewhere else, but that hasn’t happened.

In fact, billing has increased 22%, medication reconciliation and computerized physician order entry are both 100%, and patient volume is up 13% this year, even after accounting for other factors, he said.

The hospital is still wrestling with exactly what this means, but suspects that as staffers get more familiar with the EHR system, they’re finding new ways to increase their workflow or are having better patient encounters that result in patients following-up at other clinics within the system.

"Our culture isn’t cutting edge, bleeding edge, completely electronic," he said. "We’re like the nice friendly hospital down the block that you go to and receive this Marcus Welby kind of patient care; and, if we can do it, anybody can do it."

Mr. DiSanzo reported no relevant conflicts of interest.