L.A. Downtown Medical Center (LADMC) is a 212-bed hospital serving a culturally diverse patient population in downtown Los Angeles.

THE PROBLEM

Physicians were frustrated by the cumbersome user experience of their EHR, which made for endless clicking and time-consuming documentation. Many felt like the EHR had been designed more for regulatory compliance and billing than for improving patient care.

The EHR also was exorbitantly expensive, executives said, especially for a smaller hospital like LADMC. It was an on-premises solution, as well, so there were significant IT, maintenance and consulting costs involved.

"Another problem was that our EHR wasn't interoperable with other EHR systems," said Dilip Niranjana Jay, IT administration lead at LADMC. "As an inner city hospital, a lot of our patients are not seeing our hospital exclusively. If a patient's medical data was with a hospital whose EHR wasn't interoperable with ours, it would be difficult to get a complete picture of their medical history, impeding our ability to ensure continuity of care."

Finally, the workflows in the old EHR were static and difficult to customize without complex coding changes or expensive service requests, he added. This created disjointed systems that impeded the flow of patient data across departments and care settings.

"The impact of this siloed data was most acutely felt with behavioral health," he noted. "LADMC has an entire campus dedicated to behavioral health, but our EHR was holding us back from leveraging these resources across our patient population. Patients' behavioral health impacts every other aspect of their health, so their care plans should be inclusive of their behavioral health needs. We needed providers of all specialties to be able to collaborate on the same case at the same time in the same system."

PROPOSAL

In 2019, Azalea Health proposed to LADMC to deliver an EHR offering that would be easy to implement and adapt, lightweight, and straightforward to integrate with other technologies, Jay recalled. The documentation and patient charts would be configurable by workflow, provider type and patient population – without coding changes or the involvement of IT resources.

"This would reduce reliance on change requests and expensive consulting services to customize our workflows, lowering maintenance costs," he said. "Fields could be expanded, hidden or customized based on specialty and need, ensuring the data would be relevant to the providers using them."

The Azalea EHR also promised to give LADMC providers more time with patients.

"More than 80% of a clinician's work could be done from one screen, reducing clicks," Jay said. "A consistent layout across the application simplified navigation. This eased the cognitive load on our providers to mitigate burnout. And because it was intuitive to use, we could spend less time on testing and training."

"If a provider doesn't already have a solution that can support the data exchange and intelligence required in this new reality, they need to take a serious and hard look at their EHR."

Dilip Niranjana Jay, L.A. Downtown Medical Center

One of the biggest draws to the EHR was that it was entirely cloud-based, which would virtually eliminate LADMC infrastructure and maintenance costs and reduce the demand on internal IT resources, he explained. Because it was web-based, it also would be easier to integrate across departments, he added.

"The solution also included a proprietary health information exchange, which would improve the flow of data across care settings, close gaps in the patient record, and improve care coordination and patient safety," he said. "The EHR is built around an open API to enable integration and data exchange."

MARKETPLACE

There are many vendors with electronic health records systems on the health IT market, including Allscripts, athenahealth, Cerner, DrChrono, eClinicalWorks, Epic, Greenway Health, HCS, Meditech and NextGen Healthcare.

MEETING THE CHALLENGE

LADMC selected Azalea Health as its new EHR vendor in February 2019. Within five months, the EHR platform was fully operational and staff was leveraging the solution to manage multiple workflows across departments.

One of the biggest improvements staff saw was being able to bridge the gap between behavioral health and other inpatient and outpatient services, enabling providers across disciplines to collaborate and coordinate care plans like never before, Jay reported.

"When the pandemic began in early 2020, LADMC saw a surge in new behavioral health patients," he said. "At the time, surveys found that upwards of 57% of people in Los Angeles County were experiencing mild to severe psychological distress. LADMC's location is in the middle of several working class neighborhoods, which meant that many of our patients were either hard hit by the pandemic recession or at increased risk of exposure as essential workers, exacerbating mental health stressors."

The new EHR's highly customizable workflows enabled staff to keep pace with the rapidly changing needs of patients, he added. The EHR also helped staff build a COVID-19 interface so they could meet state reporting requirements and share data critical to tracking the pandemic, he said.

"Due to COVID-19 restrictions, we had to limit the number of patients in our hospital, so demand quickly increased to surpass the supply of beds," Jay remembered. "At the same time, LADMC was getting referrals from other hospitals in the region that couldn't keep up with demand, straining capacity even further. We leaned on telehealth to meet the surge in demand for behavioral health services, in addition to other health services, while keeping our patients and providers safe."

The cloud-based system made it easy for behavioral health providers to access their patients' records during telehealth appointments no matter where they were, he added.

RESULTS

LADMC is one of only two hospitals in the city of Los Angeles to receive a five-star rating from the Centers for Medicare & Medicaid Services in January 2020, Jay reported.

"This journey has been supported by the Azalea EHR, which has delivered the scalability and flexibility to support our growth and clinical quality excellence," he said. "This growth has included a 24% increase in revenue, a 25% increase in beds and a 77% increase in patient volumes between October 2019 and October 2020."

The EHR's cloud backbone enables the kind of scalability staff needed to support growth, while also delivering the elasticity required to adjust to changing patient volumes and demands, he added.

"COVID-19 proved a real testing ground for the EHR," Jay noted. "We quickly delivered on provider requirements without code or change requests, met reporting and compliance needs through quick and easy access to our data, and ensured patient care continuity across the provider community here in the L.A. area."

As LADMC continues to expand and grow, the EHR's inherent qualities that make it easy to customize and adapt will help ensure revenue continuity, care quality and transparency into data, he added.

ADVICE FOR OTHERS

Jay recommends his peers move into a cloud-based EHR system.

"Not having to host the infrastructure on-premises makes a huge difference in maintenance costs and enables our IT team to focus on the business," Jay advised. "Hospitals are taking a big hit financially from this pandemic, especially small and mid-sized hospitals like ours. Having a cloud-based EHR eliminated a lot of overhead costs at just the right time. It also makes it easier for patients to access their data, which allows them to be more engaged with their care."

Another piece of advice Jay offers is that hospitals should not overlook smaller health IT vendors.

"What we've found is that the major IT providers like Epic, Cerner, Allscripts and Meditech cater to the needs of larger health systems with bigger budgets and more IT resources, leaving smaller hospitals behind," Jay said. "These vendors also make it difficult to share data with EHR systems that aren't their own. The new interoperability rules will certainly change this, but as we've seen with Azalea, you don't need to wait for these rules to take effect to make health data accessible."

Finally, Jay highlights the importance of interoperability and data accessibility. COVID-19, he said, made fuzzy concepts like interoperability and data liquidity tangible. As the country grappled with the pandemic, LADMC easily and almost instantly delivered the data and reporting insights required by other providers and government agencies.

"And we did this with very little involvement from internal as well as vendor resources," he concluded. "COVID-19 has permanently changed population-level health needs and IT expectations. If a provider doesn't already have a solution that can support the data exchange and intelligence required in this new reality, they need to take a serious and hard look at their EHR."

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