Paper Chase Highlights - University of Colorado Hospital

Volume 4 | Issue 21 | Through May 10, 2011
Hard to let go of the paper chart?
Paper Chase Highlights Round
Two of Epic Ambulatory Go Live
By Tyler Smith
Beth Swenson pulls out a thick notebook and lays it on one of the
many desks that line a large, busy space on the fourth floor of the
Leprino Building. The heavily tabbed binder – an icon of a paperbased organization – seems oddly out of place in the nerve center
of a massive, ongoing project that will ultimately consign it to the
dustbin of history.
Swenson is a senior systems analyst for University of Colorado
Hospital’s Epic team, one of hundreds of staffers responsible for
implementing an integrated electronic medical record (EMR) that
will replace not only dozens of discrete software applications, but
also shelves of manila folders, towering stacks of paper and, not
least, fat notebooks of the type Swenson displays.
The march to the future continued Tuesday when the second
“wave” of Ambulatory clinics went live on EpicCare, Epic System’s
ambulatory EMR. The big event followed months of preparation
that included improvements the Epic team made from experience
gleaned from the first mass Ambulatory go-live Feb. 1 (see
accompanying story, this issue).
For most of the seven clinics (see box) involved this week, the
switch meant discarding an electronic medical record they knew
(TouchWorks) for another they were only beginning to learn.
But for two others – Obstetrics/Gynecology and Cardiology – the
change meant moving from paper patient records directly into the
electronic age.
Change comes slowly. The metamorphosis from paper to an
electronic clinic required something on the order of a long-running
modern magical trick from Swenson and fellow analysts Kathy
Barnum and Masooda Durani. Each has been working with the OB/
Gyn Clinic to help ease the transition. The tabbed binder, Swenson
said, holds the key components of the paper record the clinic relied
on until yesterday.
Epic analysts (left to right) Masooda Durani, Kathy Barnum
and Beth Swenson helped the OB/Gyn Clinic transform its
paper records to the electronic medical record.
Flipping through it, she pointed to patient letters; consent forms;
patient education and teaching materials; physician, nurse and
procedural documentation forms and much more.
“We had to evaluate every single piece of paper the clinic used,”
she explained, “and figure out if we could put it in Epic.”
It turned out the new system could cover electronically almost all
the clinic’s paperwork needs, Durani added. But the challenges
hardly start or end there, and will take time to overcome.
There’s the matter of learning how to complete a progress note,
document treatment, triage a patient, order medications, write a
letter or even send messages within the clinic – the everyday tasks
of patient care – without resorting to pen and paper for hastily
scribbled notes and voluminous handwritten documentation.
Fear of the unknown. And of course there’s the fear and
anxiety that come along with letting go of what’s familiar for
something entirely new and, at least for the time being, foreign
and frustratingly slow.
Continued
Volume 4 | Issue 21 | Through May 10, 2011 | Page 2
“Everything today is auto-pilot,” OB/Gyn Practice Manager Kearin
Schulte said less than a week before go live. Clicking open a folder
on her computer screen, she pointed to some 80 Word document
icons, each representing a different workflow her clinic follows to
complete its daily business. The tasks haven’t changed, but the
documentation and communication media have – radically.
chart,” she said, “where you could see past data in written form
and you knew where to look.”
“When everybody is on the new system, the processes will be slow
for everyone initially, “agreed Barb Trujillo, practice manager for
the Cardiac & Vascular Center (CVC). “But as folks become more
familiar with Epic, it will save lots of time for everyone – medical
assistants, nurses and physicians.”
Betwixt and between. Trujillo’s clinic straddled a strange hybrid
world halfway between the paper and electronic ages. She pointed
to a seemingly non-descript white board, a symbol of the chaotic
world that would soon vanish. Names were written in magic
marker; some included the notation “TW”; others didn’t.
OB/Gyn Clinic Practice Manager Kearin Schulte with piles of files
to be abstracted – and chocolate, a small enticement for staff.
“It’s hard to wrap your head around that,” she said. “It’s a huge
challenge to providers to change the tools they use. They may feel
there is a separation between their ability to do medicine and their
ability to use the tool.”
OB/Gyn, she added, features a blend of people whose reactions to
Epic range from “savvy” to “concerned.” For those physicians not
as comfortable with an EMR, the Epic team provided “concierge
training,” or targeted one-on-one assistance. “That sets people
up for success much better than all-day training,” she said.
She said she was also pleased that for the mandatory physician
training sessions, Epic created blocks of 20 seats for OB only so that
“that they could all ask questions that related to their specialty.”
CVC Practice Manager Barb Trujillo with white board that until
Tuesday displayed which physicians worked on TouchWorks and
which worked on paper.
“We have some docs on TouchWorks and some on paper,” Trujillo
said. “Some have access to TouchWorks but continue to use paper.”
That can be particularly confusing for a float medical assistant or
nurse; hence the white board with the notations. It had been an
outsized cheat sheet for tracking which physician prefers what
kind of record.
As Swenson puts it, “Providers are concerned their interactions are
going to be different with patients. They may feel the information
they get from them can’t be put in a box. They wonder ‘How do
I document with a patient who has 10 different problems?’”
Tuesday’s launch eliminated the need for the board, but not the
splintering of documentation it symbolized. Epic system analysts
Greg Cooley and Nguyen Nguyen and Ambulatory Nurse Champion
Amy Vigil helped the CVC sort out fragmented records that posed
a challenge for a busy clinic.
The move from paper to computer screen may be especially difficult
for some, Barnum added. “It can be hard to let go of the paper
The CVC sees 150 patients on an average day, Trujillo said, and most
of them have received care documented on paper. Many arrive with
Continued
Volume 4 | Issue 21 | Through May 10, 2011 | Page 3
paper orders for treadmill tests and echocardiograms from within and
outside the hospital.
Finding those orders and other records of patient care was a
“free-for-all,” Trujillo said, with information scattered between
huge paper charts, TouchWorks and Clinical Workstation, the
massive electronic data repository Health Information Management
uses to store all patient data generated by the hospital’s various
clinical information systems.
As of Tuesday, however, all the information was available in one
spot for the first time. Staff could retrieve documents scanned into
TouchWorks from a link in the patient’s EMR. An “archive button”
linked Epic to the complete patient record in Clinical Work Station,
Vigil said.
shelves filled with manila folders that contained vital information for
expectant mothers approaching their due dates. The meticulously
detailed records include information on prior pregnancies, prior
medical history pertinent to the development of the child, labs, fetal
development, problems and plans to address them – everything,
Schulte said, an OB practice needs to deliver a baby.
Setting a delivery cut-off date of June 1, the clinic trained 18 staff
members to “abstract” this key data from some 700 paper charts
to Epic. It’s a formidable task, Schulte conceded. Staff members
complete a minimum of two charts per workday – on top of their
regular duties – and put in extra hours on the weekend. But she
believes the effort will pay off.
“On the day we go live,” she said last week, “our providers will
be prepared to practice on Epic. They will be able to go into the
electronic record and look at an OB encounter.”
The abstraction process also helped to demystify the EMR, Schulte
said. “It gave people an opportunity to get involved with Epic and
see that they are not looking at a monster anymore.” The Epic
analysts, Swenson added, held weekly one-hour meetings with the
clinic’s medical assistants, nurses and providers that provided more
hands-on experience
“We let them drive the system so they could get familiar with it,”
she said.
Trujillo said she sent email updates and added an Epic section to
the weekly letter she provides staff. But ultimately, it’s hands-on
work that will help the most to ease the transition.
“Once one piece gets to be familiar,” she said, “the process will
begin to speed up.”
Folders with records for expectant mothers
await conversion to the electronic record.
“We don’t anticipate the clinic will have to do much additional
scanning of paper records, other than for urgent orders like
treadmill tests and outside records for new referrals,” she noted.
On go-live day, the CVC began scanning paper records directly into
Epic, Trujillo added, where providers can see and read them.
Dealing with abstractions. Dealing with a paper past was also a
challenge for the OB/Gyn Clinic. Schulte said she and her staff faced
One thing that won’t change is the amount of time the Epic
team will devote to supporting the clinics. Epic analysts plan
to be on-site to lend support for three to four weeks after go-live,
said Barnum.
“It can seem so easy in training, but then people are looking
for a button in Epic,” she said. “Things that can seem straightforward, like sending messages back and forth, can be much
more complicated and have more dimensions than people
anticipated in the live environment.”
Continued
Volume 4 | Issue 21 | Through May 10, 2011 | Page 4
The Seven
The Ambulatory clinics that went live on the
Epic EMR Tuesday:
»» Boulder Family Medicine
»» Cardiac & Vascular Center
»» Obstetrics/Gynecology
»» Park Meadows Family Medicine
»» Seniors
»» Westminster Family Medicine
»» Women’s Integrated Services in Health (WISH)
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