Health Information Management

Health system makes EHR implementation its No. 1 priority

JustCoding News: Inpatient, December 9, 2009

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Electronic health record (EHR) implementation is not simply on the to-do list at Health Quest, a three-hospital system in Poughkeepsie, NY—it’s the number one priority.

“We see this as a strategic imperative. We’ve got to get it done and do it correctly the first time,” says James H. Braden, the health system’s corporate director of HIM.

The system’s CEO recognizes that implementing a successful EHR will aid other initiatives, such as HIPAA 5010, ICD-10, and incentives available pursuant to the American Recovery and Reinvestment Act, says Braden.

“It’s not something for the weak of heart. It’s not something that you sort of do when you have time,” he says. “You really have to be positioned as an organization to do it. You really have to be focused on quality of care.”

Making this project a priority is one reason Health Quest is on its way to a successful implementation. HIM involvement is the other.

“What some health systems don’t realize is that they really need HIM at the table,” says Braden. Health Quest’s early realization that HIM involvement is not only necessary, but essential to successful ongoing implementation, is refreshing, he says.

Braden oversees three HIM directors; each manages one of the system’s three hospitals—Northern Dutchess Hospital in Rhinebeck, Putnam Hospital Center in Carmel, and Vassar Brothers Medical Center in Poughkeepsie. All four play a major role in what the health system calls its Monarch Strategic Initiative.

The initiative, which focuses on systemwide EHR implementation, appropriately reflects its namesake—the monarch butterfly—a metaphorical symbol of transformation, says Braden.

The transformation began in 2008. At the time, all of Health Quest’s hospitals’ records were primarily paper-based. Each had fairly efficient processes in place, but those processes were very different, says Braden.

“Each hospital had legacy processes, legacy systems, and legacy culture,” he says. “It’s sort of like bringing all of the relatives together around the Thanksgiving table. There needs to be some alignment, and sometimes this can be challenging.”

Each hospital needed to examine its processes and forgo methods that were no longer efficient, says Sandra Canizares, RHIA, director of HIM at Putnam Hospital Center. “We all have to think outside our box and look to what is best for the organization using best practice,” Canizares says.

Health Quest bridged the gap by bringing together the three hospitals’ key stakeholders, including clinical, business, and financial representatives. Our intent was to design, build, and implement successful technology that would solicit buy-in and achieve the greater goal of more efficient care, Braden says.

Health Quest has approached EHR implementation as a transformation of its clinical and business processes rather than an overhaul of its technology, says Braden. “When you really think of it, it’s changing how we do business,” he says.

Close examination of preexisting clinical and business processes is an important part of the rollout, says Braden. It could reveal certain inefficiencies and dysfunction that, when not detected early, could become automated with an EHR, he says. For example, if medical record forms don’t include a bar code that associates with a particular form index, this could be problematic when forms are scanned. Staff members may be unable to auto-locate them.

Examine clinical processes, seek input

On the clinical side, there are several teams, including a clinical advisory group and a physician advisory group, that meet regularly to discuss policy decisions regarding systemwide process standardization.

Clinical input has been essential to implementation because it fosters physician buy-in and ownership of the solution systemwide, says Braden. This input led Health Quest to adopt a best-of-breed approach, selecting Cerner for its front-end clinical system and McKesson’s Horizon Enterprise Revenue Management product for its back-end revenue cycle solution.

The organization considered its options from various perspectives and decided against a single solution, says Braden. “But together, [the two solutions] can be highly integrated and meet the benefit realization objectives we set out to achieve,” he says.

Currently, the pharmacy, laboratory, nurses, and physicians are participating in the clinical design process for the Cerner system. As Health Quest completes the design phase, it will begin the building phase. It hopes to start testing the technology in various units in late autumn or early winter, says Braden, adding that the next step is development of integrated testing and a comprehensive training strategy.

Involve HIM in the process

On the business side, there will be a phased-in implementation of McKesson’s technology beginning in early summer 2010. This will set the stage to begin a phased-in implementation of McKesson’s Horizon Patient Folder, which will serve as Health Quest’s document imaging solution. This technology will be deployed throughout HIM and be integrated with other core HIM electronic record capabilities.

As the clinical and physician advisory groups meet regularly, so will Braden and the three HIM directors. They plan to convene twice monthly for a leadership roundtable focusing specifically on HIM process and policy decisions. They are currently discussing how Health Quest will coordinate a systemwide release of information commensurate with the EHR implementation. Other recent topics have included:

  • Beginning an engagement with four consultants
  • Developing a comprehensive forms revision process at each hospital 
  • Establishing a corporate forms committee 
  • Standardizing the format and bar coding for all medical record forms systemwide

Braden says he envisions the eventual creation of a record center that is centrally located and operational around the clock. The intent is for the center to serve as a consolidated file room and the hub of the system’s document imaging preparation. Remote coding is another possible function for this off-campus location.

Create a long-term vision

A long-term vision of the HIM department is an essential component of EHR implementation, says Braden. His plans include an organizational structure based on a hybrid operational state. A key difference between the current and future structure is that the HIM director positions will be function- rather than location-based. Each director will focus on one of three functions:

  • Document imaging—Preparation of the form template, form index, form library, and standardization of document preparation
  • Identity management—Implementation of an enterprisewide master patient index (MPI) and MPI cleanup
  • Clinical abstract reporting and documentation improvement—Collaboration with the medical staff to improve core measures reporting and documentation specificity

“I don’t see the HIM directors or their roles going away at all,” Braden says. “I see them morphing into new and very exciting e-HIM roles.”

Editor’s note: This story was originally published in the November issue of Medical Records Briefing.

E-mail Braden at

E-mail Canizares at

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