Case Study

$65,000 transcription cost reduction
Improved quality and legibility of records
Safer and more efficient care with ease of access to records

Dr. Lisa Shea and her colleagues had quite a few reasons to commit to implementing an EHR at Butler Hospital in Providence, RI.  At such a busy facility—one which saw almost 9,000 patients in 2008—they felt an EHR would benefit their employees, physicians, and patients by creating a single integrated medical record for each patient.  Butler was already utilizing electronic software on their business side and knew that it had improved charge capture and cost management, enhancing the revenue cycle. Recognizing that this was a worthwhile investment, Dr. Shea and colleagues committed to implementing an EHR in 2003.

In conjunction with its enterprise organization, Care New England, Butler began a rigorous selection process.  In the winter of 2003, the team went on site visits to other hospitals that used EHRs, including behavioral health hospitals.  After a period of evaluation, the Butler team chose to purchase ­­­­­­­­­­­­­­Avatar in December 2004.  With the selection process behind them, their challenge was a successful cultural transformation and EHR implementation. 

To prepare for an implementation, Dr. Shea believed it was essential to create an environment that was receptive to purposeful change, accomplished by having the commitment of senior management and maintaining regular and ongoing communications.  "Butler had a big kick off meeting, and everyone was talking about it. We had town meetings and device fairs, and we put computers in the units ahead of time so people could begin to feel comfortable with them—even to learn how to check e-mails."  Whatever methods of communication you use, Dr. Shea says, make sure your goals are clear and share them often. A core team, consisting of two doctors, two nurses, members of the clinical informatics team, and a project manager, was empowered to empanel workgroups of clinical staff to establish process flows, specification design, education modules, and mechanisms for end-user feedback.  Executive sponsorship was also key in sustaining focus.

Perhaps most critical to the success of EHR implementation is that the computer has to follow the provider workflow, and not the other way around. For Dr. Shea and her team, that meant “working with the staff and templates ahead of time, changing the order of items, and taking the opportunity to make the workflow better.”  The time and effort upfront meant that staff enjoyed a better workflow.  "When we worked with paper the same information would appear in a lot of places.  The EHR allowed us to eliminate that duplication where it didn’t make sense. Given that we have tons of forms, the benefit is enormous."

Their strategy was a model they called the "The 3 Ts: Tweak, Test, and Train."  Dr. Shea found the "train the trainer" approach, where vendors train key internal staff who can then train everyone else, to be very effective, and using physician champions and coaches from each department also improves the process and saves significantly training costs. Every physician had to complete 6 hours of training in 4 sessions, which incorporated computer literacy assessment and goals to be completed after each one. The mandated trainings were offered with flexible scheduling times and CME credits.

Dr. Shea believes end-user input for design and post-implementation, and suggestions for ongoing modifications and enhancements, are very important. Transparency needs to be established from the beginning. At Butler, a lively e-mail physician forum was established, allowing both concerns and suggestions for improvement to be addressed quickly.

Another important strategy was having resources to support staff at the point of care during go-live. Butler implemented a rolling go-live by unit. During the first two weeks of implementation on a unit, peer coaches, technical staff, and extra on-line clinical staff were present 24/7 to assist staff with using the EHR without a dramatic interruption in workflow pace.

Butler has seen substantial increases in revenue since implementing their EHR. Physicians are coding more accurately, and they have the documentation to support it. "Doctors will tell you documenting takes longer, but the quality is better and it’s legible. We have raised the bar."  Dr. Shea said one of the more surprising benefits was that Butler saved $65,000 in  transcription costs in 2008 alone. Efficiencies and safer care have been gained through ready access to medical information from previous admissions, a streamlined information gathering process, and easier transfer of information to the next level of care.

Because of the reliability of the EHR and its impact on standardizing documentation, physicians use the EHR to increase quality control.  "Now we know that all critical elements are included in patients' records, and we are developing score cards to report on how we are performing. We have also seen positive results in our HBIPS measures [psychiatry's core measures]."

"We can check any date frame and run any report, and we no longer have to filter through records and papers to understand the data.  It would have taken us a whole new staff person to do this, but now, it can be done because of the way we designed our input screens."  The next benefit will be utilizing their EHR for automated reporting on everything from physician competencies and time of entry requirements to missed appointments and drug allergies. "There is no question that implementing an EHR was the right decision for Butler Hospital and our physicians."

Butler is planning to implement the EHR in its outpatient clinic, with go-live scheduled for later this year.  Dr. Shea and colleagues feel good about their return on investment, not only in terms of dollars, but also in providing more informed care and using tools that facilitate evidence-based practice.