• May 2008 FEATURE ARTICLES •
PHRs/EHRs/EMRs: Case History
The Fire Next Time
Sharp HealthCare’s effective use of an ambulatory EHR during the California wildfires meant uninterrupted healthcare for displaced patients and clinicians.
By E. Victor Brown, Senior Editor
Catastrophic events affecting thousands, such
as last fall’s California wildfires, may be the truest indicator
of how electronic health records (EHR) are helping to transform
patient care. That was the experience of San Diego-based Sharp
HealthCare, an integrated regional healthcare organization that
includes four acute care hospitals, three specialty hospitals,
three medical groups and a number of other facilities and
services.
With some 2,600 physicians on the hospitals’
medical staff, 1,500 physicians in affiliated medical groups and
more than 14,000 employees, the Baldrige Award-winning
healthcare system is a recognized leader in California
healthcare. In 2005 — two years after the last devastating
wildfire and two years before the recent conflagration — two of
Sharp HealthCare’s three medical groups, Sharp Rees-Stealy and
Sharp Mission Park, began the process of implementing TouchWorks,
an ambulatory EHR system from Allscripts. While optimum care for
Sharp’s large patient population was the driving force behind
the implementation, the events of the week of Oct. 21, 2007,
revealed an unanticipated benefit.
The Approaching Danger
Long before sunrise on Monday, Oct. 22, as
southern California residents slept, wildfires were already
wreaking destruction up and down the state. Around 4 a.m. on
Monday, the Sharp HealthCare executive team began to receive
calls from leaders informing them of reports from police and
fire departments that fires were approaching several Sharp
medical facilities. Brent Steineckert, Sharp Rees-Stealy and
Sharp Mission Park’s ambulatory EHR manager, prepared for the
worst. "The fires grew so quickly and fast that by early Monday
morning, we knew we’d need to close at least two clinics in
close proximity of fire ground zero," says Steineckert.
Pages went out to administration and
physicians giving them news and instructions. Conference calls
with key administration and physician leaders occurred multiple
times a day to develop plans, communicate updates and route
resources as needed. "A challenge faced right off the bat was
that our existing clinics that remained open expected staffing
shortages due to numerous mandatory evacuations and school
closures," says Steineckert.
Sharp Rees-Stealy operates a centralized
patient contact center which typically handles more than 5,000
calls per day from patients scheduling primary care appointments
and leaving messages for their doctors. Fortunately, the call
center is located in an area that was not affected by the fires.
Since the call center was operating 24/7, it was the ideal
communications hub to interact with patients in need of
medications and medical advice. Decisions flowed from the
administration and physician leadership team, which included the
associate medical director, the CEO, VPs and key directors, who
gathered twice a day for a conference call to decide which
clinics to keep open or close, based on road closures, air
quality and staff availability.
Monday
Early Monday morning, a large Sharp Rees-Stealy
clinic was closed in the Rancho Bernardo area of San Diego
County as simultaneously a smaller clinic met the same fate in
the Carmel Valley/Del Mar region. The two clinics house anywhere
from 40 to 50 physicians and more than 200 staffers, and see an
average of a thousand patients each day. Within three hours of
the first two closings, Sharp Rees-Stealy was forced to close a
third clinic due to fast-moving smoke and fire. The approaching
evening would see even more closures, finally reaching a total
of five.
Across San Diego County, more than 100,000
people were evacuated with little notice and few resources,
making employee tracking of those without cell phones difficult
at best. The overloaded cell networks made cell phone
communication unreliable as well. "We employed whatever means to
get information out, such as establishing central call-in lines
with numbers posted on the Sharp Web site, so if someone tried
to contact us anywhere within the Sharp HealthCare organization,
they could be routed to the appropriate party," says Steineckert.
In order to deal with people calling in with
smoke-related and other medical problems, the decision was made
by the administration and physician leadership team to put
several physicians in the call center to assess these types of
calls. "In many cases, the physician was able to take care of
the patients concerns completely, right over the phone,
primarily due to the availability of the EHR," says Steineckert.
Call Center
Theresa Siefken, D.O., Family Medicine
department at Sharp Rees-Stealy, was one of the physicians asked
to work the call center. Siefken’s clinic, which is near the
border in the Otay Ranch area, had already been closed by Monday afternoon due to smoke. Procedurally,
several "runners," which consisted of the call center manager,
supervisors, leads and a scheduling systems analyst and a
scheduling systems specialist, would print out the tasks for
each patient calling in and alternate dropping them off to each
physician working the phones in the call center.
"We were set up in cubicles with access to
our standard screens in the EHR where we would display patients’
charts with their prescriptions and medical histories," says
Siefken. "Then, we’d return their calls and help them to find
familiar pharmacies that they could reach."
Physicians in the call center worked at least
eight hours with a short break, as patient calls were
continuous. In addition to filling prescriptions, call center
physicians worked with a number of patients in some type of
physical distress in real time. "We were able to find out enough
about their situation and handle it over the phone like an
office visit. We’d advise them, with some needing to be routed
to urgent care or the ED, and then we’d document the task," says
Siefken. "There was no anxiety in dealing with unfamiliar
patients because of the significant time we had all spent using
the EHR under more normal circumstances. Procedurally,
everything felt like business as usual."
According to Steineckert, electronic medical
records had been available to physicians for approximately 18
months by the time of the fires, so they were already familiar
with what they needed to do in terms of patient triage. "Our
data center and network backbone were intact and unaffected so
they were able to operate remotely," says Steineckert. "We also
utilize Citrix for remote access, so many of our physicians that
weren’t at specific Sharp Rees-Stealy locations were actually
handling their patients work from their homes."
Training Protocols Pay Off
Steineckert explains that during the original
ambulatory EHR rollout in 2005, physicians were encouraged to
sign up for secure remote access. This not only gave them access
during regular circumstances, but also gave them the ability to
handle patients of colleagues in normal or crisis situations.
"If the same thing had happened prior to the EHR implementation,
there would have been a lot less that the physicians could have
done because they didn’t have access to patients’ medical
histories and current courses of treatment for effective
decisions in the moment," says Steineckert. "What that meant for
patients is that many would have had to be directed to EDs in
order to err on the side of caution (keeping in mind that EDs
are already overloaded), or we would have had to direct them to
wait."
Sherrie Lynn Dasalla, EHR process analyst at
Sharp Rees-Stealy, had been part of Steineckert’s rollout team
doing workflow analysis and workflow redesign for the ambulatory
clinics’ transitions to the EHR platform. Additionally, Dasalla
works with the training coordination effort, which includes
three other training coordinators. "We all work together to
organize all training efforts, including the creation of
role-based training curricula; training materials and
documentation; online training modules and Webcasts; and,
post-training support for all of the staff at all of our clinics
throughout San Diego County," says Dasalla.
Training involved nearly 400 providers across
26 different specialties and a clinical staff of more than
1,800, including medical assistants (MA), licensed vocational
nurses and registered nurses, as well as support and
administrative staff. Two-hour classroom training sessions were
employed for the modules rolled out at that time, which included
the successful completion of mandatory prerequisite Web-based
modules.
Prior to the fire, Sharp was using the
TouchWorks EHR Version 10 and was in the midst of training for
the Version 11 upgrade at the time of the fires. "We hired
internal staff as trainers during the rollout because they were
already Sharp Rees-Stealy employees who could train from
experience, understood clinic workflows and could easily provide
reliable answers to questions as a result of their first-hand
knowledge of clinical processes," says Dasalla. "Our trainers
also act as an invaluable resource since they are a fresh set of
eyes for the EHR team, especially when it comes to creating
training curricula and documentation."
The Web-based nature of TouchWorks and its
modular configuration had not only been prime selling points for
Sharp, but were also now critical to their use of the EHR during
the fires. "With many EHRs, you have to install these very large
resource-intensive programs on a specific PC in order to run the
record. Our EHR allows us to essentially take any off-the-shelf
PC, plug it into our network and within five minutes, a
physician can log in and access patient records," says
Steineckert.
Part of the security protocol of the system
in addition to user name and password, are security key fobs
issued to each physician. "Security key fobs work by accessing a
secure digital number that changes every minute, so even if
someone has a physician’s password and username, they wouldn’t
have the security key fob, which stays in the physician’s
possession," says Steineckert.
Tuesday
Physicians and staff access information on
more than 7,000 patients a day utilizing the ambulatory EHR
system. Of the five Sharp Rees-Stealy sites closed, two were
among the medical group’s largest sites. The fact that no
clinics could be reopened on Tuesday required more triage at the
call center and more patient management telephonically.
According to Dasalla, many of the EHR
trainers were MAs and could therefore assist at other sites
experiencing clinical staffing shortages. Although she was part
of the training team and did not possess a clinical background,
Dasalla was still able to assist with incoming messages for
providers. "I only went to one site to assist with callbacks and
front desk duties, but the trainers and the coordinators from my
team who had MA training were deployed to different sites each
day based on the clinical need," says Dasalla. "Towards the end
of the week, we began to get back into the planning mode for
training as the crisis began to pass."
Other staff whose performance was critical to
Sharp Rees-Stealy’s success included Senior Training Coordinator
Monika de Leon, who assisted in organizing a deployment plan
each morning for the trainers, and MAs Thomas Howard and Cristal
Razo-Tarazon, who volunteered to deploy to other sites where the
need for clinical staff was most needed.
By Tuesday, the decision was made to cancel
scheduled elective procedures. "This is significant because even
though TouchWorks is an ambulatory system, our specialists use
it quite a bit in the hospital when they are doing surgical
procedures as well as rounds," says Steineckert.
The influx of calls to the call center
weren’t slowing by late Tuesday afternoon, so additional
physicians were brought in for a night shift. According to
Siefken, the number of calls per hour depended on the complexity
of the patient’s needs, but averaged anywhere from 30 to 60
calls each day per physician. "I am fluent in Spanish, but it is
my second language, and therefore it took a little bit longer to
take care of the Spanish- speaking patients," says Siefken, who
also took calls that were forwarded from the
non-Spanish-speaking physicians.
The Smoke Begins to Clear
By Wednesday, the Santa Anna winds began to
lose force and first responders were getting a handle on the
situation. Although the displacement, damage assessments and
water drops weren’t over, Sharp Rees-Stealy returned to some
sense of normality as memos of the medical group’s plans to
continue with EHR training, normal procedures, and in-patient
and ambulatory workflows began to be scheduled for the coming
days and weeks.
The healthcare industry will continue to
debate, resolve and improve its understanding of the importance
of EHRs and other increasingly vital health IT under "normal"
circumstances. Siefken feels that in order to be successful with
implementing a new EHR, physicians need a team of educators
available to train them as they go along. "As each module
unfolded, we were trained on it and had a support team
constantly available to us throughout the day," she says.
"Physicians are so busy that it’s necessary to have people
come in regularly to support, re-educate and help them through
the learning curve. That’s what we’ve had," says Siefken. "Once
a medical group implements an EHR and gets past the training,
there’s no going back to paper. It’s natural to resist change,
but it’s well worth it in the end."