The 360-bed Holy Name Medical Center in Teaneck, New Jersey, has always been keen on using technology to enable its mission of providing compassionate and personalized care to a diverse population of patients.

THE PROBLEM

Nearly 30 years ago, the hospital developed its own electronic health record – long before they were prevalent or mandated in the industry. But times change, and the organization realized the need to be more efficient and use technology to enable and streamline processes. It was time to update the EHR. 

The question was: Buy or build?

"Holy Name believes in a healthy mixture of build and buy, but we did not have faith that any of the 'big box' EHRs would be able to address our need for a truly person-centric approach with technology-enabled workflows," said Jessica Cox, RN, director of product solutions at Holy Name Medical Center.

"Holy Name is New Jersey's last remaining independent health system, drawing patients from across the New York City region to its specialty centers and robust physician network," she explained. "So, we needed a system that looks at the population the way we do – as people and not numbers. If a patient sees several physicians in the network, why should they be viewed as 6-7-8 people in these disparate systems?"

The information must be centralized, she added. Many of the off-the-shelf systems claim to be interoperable – and they are – but they do not address the needs of an enterprise with multiple physician practices, health centers and hospitals in the network, she contended. So the decision was made to build a new custom EHR.

PROPOSAL

Healthcare information technology should enable rather than disable users, Cox said.

"Clinicians need more time to provide personalized care versus spending time looking at the computer screen, and that is what we were looking to do," she explained. "We recognized that we couldn't build the optimal solution by developing all the required functionality internally, so we identified several third-party solutions to incorporate into the platform.

"As a key initiative, we partnered with Medicomp Systems to provide a clinical database to facilitate intelligent charting and help physicians quickly find relevant clinical details within provider workflows."

"Traditional off-the-shelf EHRs do not meet the needs of every healthcare organization."

Jessica Cox, RN, Holy Name Medical Center

The provider organization's road map includes machine learning over time – decision support that is intelligent for physicians. It needed more than a database of findings, but a database with intelligence, with links among the clinical findings that could provide the narrative physicians are looking for and the intelligence behind it, she noted.

"I have had a longstanding relationship with the folks at Medicomp," she said. "I started my career in healthcare IT as a MEDCIN specialist – one of the charting technologies that Medicomp has offered for years. I knew of MEDCIN, but didn't know about their Quippe Clinical Data Engine. Quippe drives bi-directional interoperability links between medical concepts and standard nomenclatures such as SNOMED-CT, RxNorm, LOINC, ICD-10 and others.

"So it normalizes structured data and analyzes data sets by problem. So it essentially mirrors the way physicians think, which in turn drives physician efficiency and satisfaction," she continued. "And since all that information is mapped to the various terminologies and code sets, our system is ready for the 21st Century Cures Act."

Physicians get to spend more time doing what they should: spending time with patients, she added. So staff knew they needed to integrate Quippe to help make the in-house EHR a clinically intelligent and usable product for physicians and nurses, she said.

MEETING THE CHALLENGE

The point of the project – and the overarching challenge – was to make it person-centric. That's why the staff named it Harmony EHR. Staff wanted one centralized, harmonious record among all care settings for the patient.

Meanwhile, there are multiple systems to integrate. Staff began the implementation in May 2021 (during COVID-19) beginning with the ER. A huge part of that implementation is the registration of patients coming into the ER – to get all the person data in Harmony EHR in perfect sync with the 30-year-old legacy system, which had previously maintained all the integration with external systems.

But there were many duplicate records, so the first objective was to have all person data managed by Harmony EHR to ensure there were no duplicates.

"As far as who will use the system, initially the registrars, as new patients enter the ER, and all of our ER clinicians – physicians, PAs, nurses, medical assistants, technologists – you name it," Cox explained.

"Our roadmap calls for enterprise scheduling and registration in early 2022. Ultimately, anyone who registers a patient throughout the health system will enter into that single patient record, and anyone who deals with the care, coding, billing and patient record-keeping – nurses, physicians, coders, medical records – they'll all use it, just like any EHR."

For the Harmony EHR to function well, it must be well integrated with other systems. One of the most challenging and important integrations in this early phase has been with the legacy EHR.

"Now we also have integrations with lab information systems including Sunquest and LabCorp, with our radiology system, with Medispan for medication and allergy data, Krames for patient education and discharge instructions, and, of course, with Medicomp for Quippe and charting functionality," Cox said. "There are others for floor management and other functions.

"Our road map calls for expansion throughout the health system, and that's where the person-centric model will really come into place," she continued. "Early next year we'll go live on the practice management side. That is where we have an opportunity to do things that you do not see in other health systems today."

A patient is treated by a primary care physician in the network. He or she also has a cardiologist in the network, and then must go to the ER.

"The beauty of this is that when this patient presents to the ER, not only are we going to have any episode or visit history of prior ER visits, but that ER doctor will have full access – not the disjointed access that we may see today, but full access in the same system of all EKGs, labs, echos, that have been done over time," she explained.

"The vision is to provide the ability to trend the patient's vital signs and labs over time," she continued. "This will provide a better picture of what's going on with this patient, aside from what he or she presents with today."

Implementation is never easy, but this one has gone exceptionally well, Cox observed.

"We are the first hospital to use Medicomp's Quippe solution in a homegrown EHR, and I can't envision our new charting feature without Quippe's functionality," she said. "Managing physician, nurse and clinician documentation is a challenge because you need to reduce the clicks and seconds required – and provide them all with a comprehensive, comprehendible, end-to-end patient story.

"The decision to engage Medicomp to provide the database of clinical findings, and the ability to identify the relationship between those findings, has allowed us to not only furnish the data required for reporting and quality measures, but to tell that essential patient story," she added. "This charting capability is one of the most valuable features in the entire system."

RESULTS

Cox identifies three key areas of results to date.

"Quality performance likely is the most important metric," she said. "Quality metrics must be reported to regulatory bodies, but we care beyond the score that the hospital gets. The goal, naturally, is improved patient care. And I believe our quality numbers will show that.

"In the ER, specifically, we'd look at, for example, sepsis patients, stroke patients or patients that have a cardiac event," she continued. "The amount of time between when we identify that a patient may be experiencing one of these problems, and when we can initiate treatment, is key. So timing is everything."

The staff feels that the efficiency of the software, its usability and the workflow will help address this. The whole product was designed in partnership with the physicians and nurses. They believe the workflow lends itself to a more streamlined path, and they're hopeful they will see an improvement in the timing between diagnosis and initiation of care.

"Overall throughput is another important metric," Cox said. "Talk to any ER employee and this is top of mind. But it matters. It's the amount of time between when a patient comes through the door and is discharged. There are certain milestones within the patient's episode lifecycle within the EHR, and each is highlighted and presented front-and-center along the way. And by focusing on this continuum, we believe we can improve overall throughput."

Coding/billing and revenue reimbursement is yet another key area of study.

"With the metrics measured earlier, quality performance and overall throughput, we feel that this EHR is more user friendly, and it's easy for a nurse or other provider to document what is required to get the patient out the door and to meet quality measures, to review pending documentation, and sign off the chart," she said.

"So if the nurses or providers sign off sooner, that means it gets to the coders faster," she continued. "We've integrated coding calculators into the EHR for our coding colleagues, which makes it easier and faster for them to code. And this means a claim gets out the door faster, and we can get reimbursed."

ADVICE FOR OTHERS

"Traditional off-the-shelf EHRs do not meet the needs of every healthcare organization," Cox stated. "Providers that want a solution that better suits their users' needs and aligns with their organization's mission should consider developing an EHR from scratch. To meet or exceed user expectations and create a state-of-the-art solution, project leaders must prioritize collaboration with colleagues from across the organization."

An interdisciplinary approach ensures that existing challenges are understood, and needs are identified, she advised.

"Leaders must also be willing to embrace innovative technologies, whether built externally or in partnership with third-party vendors," she said. "The project must have strong support from organizational leaders, who must be willing to dedicate appropriate resources to ensure success.

"With the right focus and dedication, an organization can even overcome extreme challenges – even a worldwide pandemic – to deliver a solution that outperforms available market options and provides a patient-centric solution that is well accepted by users."

Health systems considering building their own EHRs must be willing and able to dedicate the required financial and personnel resources, Cox further advised.

"Leadership must be committed to creating an environment that supports collaboration between IT, clinicians and other staff," she said. "Project leaders should be open to incorporating third-party technologies that extend the functionality of the internally developed solution.

"The organization should remain nimble as the solution is developed and implemented, ask for user feedback, and continually work to optimize workflows, features and functions that meet or exceed the needs of users."

Finally, Cox advised for her peers to remember: Slow and steady wins the race.

"Today we operate in an agile world, but in enterprise software development, we are in a continual learning environment, fine-tuning features and technology to better suit the needs of users," she concluded. "We want to move at lightning speed, but must continue to engage with our colleagues to gather their input. So, slow and steady will get you there."

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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