Byline: Howard J. Anderson, Executive Editor
RED OAK, Iowa-While the nation's giant integrated delivery systems and academic medical centers grab the headlines, staff members at hundreds of small, rural hospitals are quietly making tangible progress in making the most of information technology.
Nestled in the rolling hills of southwestern Iowa, Montgomery County Memorial Hospital is among those making I.T. inroads. After implementing numerous clinical applications, the hospital is bringing electronic health records to the physician practices it owns.
Why is the 25-bed critical access hospital investing so heavily in I.T.? A big reason, says CEO Allen Pohren, is to build loyalty among physicians, especially 18 specialists from the Omaha area who visit the hospital in Red Oak about once a week. 'Patients don't just come running into the hospital and jump into bed,' Pohren says. 'You've got to have physicians to admit them.'
Pohren, who has been with the hospital nearly 37 years, remembers the day when he acquired the facility's first computer to help with payroll and receivables. Today, the hospital has a nine-person I.T. staff led by CIO Ron Kloewer.
Here's just one example of how far the rural hospital has come in its use of I.T.: One area neurologist who splits his time between Pakistan and Iowa can access data on patients while he's out of the country, thanks to the hospital's portal. 'I never thought I'd see the day that would happen,' Pohren confesses.
The small-town hospital CEO views I.T. as an essential tool for improving patient safety as well as staff efficiency. 'If we did not have I.T., we would be doing so much stuff manually that we'd have a lot more employees around here,' he says.
Help from Uncle Sam?
Pohren is optimistic that the hospital and the physician practices it owns will qualify for electronic health records financial incentives under the federal stimulus program.
The hospital, now ranked 3.2 on HIMSS Analytic's seven-point scale for clinical automation, likely will have to advance to a ranking of 4.0 to qualify for maximum incentives, predicts Kloewer, the CIO. HIMSS Analytics is the research arm of the Chicago-based Healthcare Information and Management Systems Society.
To achieve that ranking, the hospital, which already enables nurses to document care online, will add physician documentation as well as computerized physician order entry. Also on the horizon is an electronic medication reconciliation system, including bar coding.
For more than a decade, Montgomery County Memorial Hospital has been phasing in various components of clinical and financial systems from Keane Inc., Boston. Soon it will upgrade its clinical system to Keane's latest Optimum release.
Clinicians can sign on via an intranet to access nursing notes, test results and more. 'I do 90% of my documentation online,' says Teresa Jennings, R.N., a nurse manager. 'I don't have to go through all the old paper records trying to find information.'
Hundreds of documents, including physicians' transcribed notes, are scanned into the electronic record. But nurses have yet to automate their care plans, which they still update daily on paper, Jennings laments. The clinical system's care plan functions proved too cumbersome to use, the nurse manager says. 'To put in the things that we wanted was very difficult. You had to go from screen to screen to screen to pull things together. There were too many steps. Our paper care plan is very easy.'
Once the hospital upgrades to the next-generation clinical system, however, nurse care plans will be automated, Kloewer notes.
A key factor in helping older nurses get used to computers, Jennings says, was the training that three nurses who work in the I.T. department provided. 'Those nurses have all worked on the floors before, so all the older nurses knew them,' she says. 'Our younger nurses caught on very, very quickly, and they also helped out with Athe training.'
Nurses usually retrieve medications for patients using one of four automated medication cabinets from Pyxis, now a unit of CareFusion Corp., San Diego. The cabinets are useful because the hospital only staffs its small pharmacy for the daytime shift, Kloewer explains.
Low Turnover
Unlike some smaller hospitals, Montgomery County Memorial has yet to experience a nursing shortage, Jennings says. The nurse manager says the newer building, equipped with the latest in diagnostic equipment, has helped keep turnover among its staff of 90 nurses low.
The hospital has a CT scanner, digital mammography, and digital X-ray equipment, eliminating the need for a film processing and storage room. Area residents also gain access to MRIs when a mobile unit comes to the hospital three days each week.
In recent years, the hospital has acquired local physician practices with four doctors. Their offices are adjacent to the hospital, along with a five-physician practice affiliated with Methodist Health System in Omaha.
Two years ago, the practice owned by Methodist rolled out Practice Partner electronic health record and practice management software from McKesson Inc., San Francisco. Now, the practice is outsourcing the hosting and maintenance of the applications to the hospital's I.T. team.
Next up, the hospital will help its owned practices implement Practice Partner, eventually enabling all the doctors on campus to share their clinical data. They already can access all hospital data from any location via a virtual private network.
The Methodist practice learned some important lessons in moving to an EHR, including the need for a physician champion. In fact, the practice had two physicians, Warren Hayes, M.D., and William Artherholt, D.O., leading the way.
'Dr. Hayes is the technical champion who understands it all,' Artherholt says. 'He was the point person to bring us to the next step and the next step. I was the visionary champion who kept us going and pushed us in this direction.'
Hayes acknowledges that the first few weeks using EHR software proved difficult until physicians learned how to navigate through point-and-click templates, occasionally typing in additional notes. Today, only one of the five doctors still relies on dictation and transcription.
'An EHR is a necessary evil,' Hayes says. 'I wouldn't go back to paper. My desk is messy enough. Documentation has improved immensely as has our access to information.'
Over the long haul, Hayes is hopeful that all the doctors who practice on the hospital's campus will conduct some meaningful outcomes research fueled by data in the outpatient and inpatient records systems. For example, the physicians could research local asthma cases to determine if there are patterns that could pinpoint causes, such as chemical sprays used by farmers.
Physicians at the Methodist practice primarily use tablet computers from Hewlett-Packard Co., Palo Alto, Calif. Some nurses use laptops mounted on computer carts. Frustrated by the high costs of carts, Hayes took it upon himself to construct two low-budget models from household PCV pipes. On one recent day, a nurse was using one of the homemade carts while a high-tech cart nearby stood idle.
At the hospital, physicians and nurses primarily use thin client devices from Wyse Technology, San Jose, Calif., located mainly at nurses' stations. Some also use laptops mounted on carts and linked to a wireless network. The HP laptops serve as the equivalent of a thin client, with all applications residing exclusively on servers, Kloewer explains.
'Thin clients allowed us a lower total cost of ownership,' the CIO says. 'Chasing around to manage desktops is labor-intensive.'
The hospital originally paired the thin clients with application delivery technology from Citrix Systems Inc., Fort Lauderdale, Fla. But it eventually shifted from Citrix to Microsoft Terminal Server software, which Kloewer determined would be less costly yet efficient.
When it installs new servers, such as to support the new outpatient EHR, the hospital is primarily using blade servers from HP paired with virtualization software from Microsoft rather than more costly conventional servers.
The hospital is about half-way through construction of a $15.6 million addition for an expanded emergency department and outpatient facilities.
The addition also will house a new data center, which will consolidate equipment now located in four sites around the campus that will be converted to wiring closets. The hospital will rely on two backup data centers provided by a local telephone company once the new data center is complete. For now, it simply backs up data to tapes stored offsite.
To hold down the cost of a new phone system, the hospital bought used equipment from a former Maytag plant in Iowa that shut down.
For Montgomery County Memorial Hospital, the quest to improve efficiency through automation will continue for decades to come. Kloewer, for example, that eventually specialists in Omaha could remotely manipulate surgical robots at the hospital in Red Oak.
'Once you get into I.T., it's never-ending,' says Pohren, the CEO.
From the I.T. Mission Statement:
'Health care delivery is continually improved by using information systems that are increasingly integrated, accessible, complete and secure. Patient safety, information security, financial viability and improved productivity are further gains with the effective and wise use of these technologies for which the entire staff at MCMH plays a vital role.'
Montgomery County Memorial Hospital
Red Oak, Iowa
* 25-bed critical access facility with nine observation beds
* Independent government entity with publicly elected board and property tax support
* Owns the practices of four physicians
* Employs 300; largest employer in town of 6,000
* 60% of patients on Medicare
* $24 million in estimated net patient revenue for fiscal 2009; $825,000 in estimated net income
* $1.3 million I.T. budget for fiscal 2010
* Rated 3.2 on an automation scale of 1 to 7 by HIMSS Analytics
* Constructing $15.6 million building addition to be completed in June 2010
