Lindsborg Rural Health Clinic is Converting to Electronic Medical Records Program

By Sarah Hawbaker

Lindsborg News Record, November 2010

The world today seems to demand the immediate: unlimited amounts of information right at our fingertips through the internet and computers, information readily available through apps on cell phones and other handheld devices. We can access bank accounts and pharmacy records instantly from almost anywhere. We log on, we upload, we download, we Tweet and we update our statuses all in a matter of seconds. We can know instantly when an old friend has posted new pictures, or the score of the big game. This is the digital age.

We have access to just about anything we want, when we want it, and how. Something most of us don't have instant access to, however, are our medical records. Even sharing medical records among doctors at the same hospital or clinic can be a challenge. The medical chart must first be located by someone, who must track down the doctor or physician who needs to review it. Next, the doctor must find time to sit down and flip through the pages. Sometimes handwriting must be interpreted; perhaps, even, the chart couldn't be located in the first place because it hadn't yet been re-filed.

Try sharing a paper chart with a doctor or specialist at another location entirely, whether it be five miles or 205 miles away, and the task is near impossible. Often tests get repeated, which, of course, costs money and takes time.

This is where electronic medical records (EMR) and electronic health records (EHR) can make good medical care not only more effective and more efficient, but also cheaper for the patient, provider and insurance companies. Within the past two years, Lindsborg Community Hospital has entered the EMR and EHR worlds. Just over two months ago, the Lindsborg Rural Health Clinic joined in as well.

So what is an EMR and an EHR? An EMR is an electronic version of the paper chart. It is a record of patient health information kept by one particular provider - a patient's primary care physician, for example.

In contrast, an EHR is the compilation of a patient's health history from more than one provider. For example, if a patient sees a primary care physician and a heart specialist, and had seen a different primary care physician in the past, these individual EMR's would be combined to form the patient's EHR. It would include past medical history, medication lists, notes, lab results, radiology reports and immunizations from each different provider.

Larry VanDerWege, CEO of Lindsborg Community Hospital and Lindsborg Rural Health Clinic, said although EMR's and EHR's are a step in the right direction for patients, the challenge is in implementing the new system while continuing to provide quality care.

For a small hospital and clinic, electronic records are especially important when patients must be transferred to a larger facility or when scans or test results need to be reviewed by a specialist who is not located on site. VanDerWege said that when a patient is transferred to Salina Regional Hospital, for example, an electronic version of that patient's test results, x-rays, and other information can be sent immediately for a doctor to review before the patient even arrives.

But electronic charts don't just make it easier for sharing information from place to place, they also make processes more efficient within the same facility. Labs, x-rays and rehab all can be ordered electronically. Medications can be prescribed and administered electronically. This eliminates some chance of human error in comparison with a system of handwritten orders. Now, when a nurse enters a hospital room to administer a medicine to a patient, the nurse will scan the patient's ID bracelet as well as the medication to be administered. If the medicine or the dosage do not match what the physician previously had ordered through the system, the nurse will be alerted.

Lab and x-ray results can in turn be reviewed electronically. Digital x-rays can be viewed and inspected as if they were digital photos. The contrast can be changed, the x-ray can be enlarged and rotated to give the physician a better look. X-rays can be sent half way around the world to be viewed by a radiologist in minutes, rather than days. Or if a lab result comes back abnormal in the middle of the night, the patient's physician can log on to a secure site from home to view the lab patterns himself without relying on a nurse to dictate to him over the phone or without the need for the physician to make an extra trip into the hospital.

VanDerWege said electronic records also give the hospital and clinic the opportunity to capture certain data that could be used to measure the effectiveness of patient care and to study data that can help in making future decisions to improve care and improve patient outcomes.

In Lindsborg, the first initial steps toward an all-electronic system began in 1995 when financial records were converted to digital at Lindsborg Community Hospital. In 2006, VanDerWege said, the entering of doctor orders, such as for x-rays or medication, began electronically. Then, in 2008, bedside documentation by nurses began in the hospital. COWS, or Computers on Wheels, are pushed from room to room when a nurse visits a patient. Larger hospitals, in which rooms are full most of the time, have a stationary computer in each room. VanDerWege said a system like that didn't make sense for Lindsborg because the rooms aren't always full.

Two main issues come hand-in-hand with establishing an electronic medical record system: Money and security.

VanDerWege said planning for the implementation of the transition from paper to electronic records for both the hospital and clinic had been part of a long term strategic plan before it became a federal mandate.

In 2004, President George W. Bush set a goal for all Americans to have electronic medical records by 2014. Currently, the Obama administration has set a deadline of 2015 for all providers to comply with "meaningful use" guidelines of adopting an electronic medical record system. Under the American Recovery and Reinvestment Act, providers who meet the "meaningful use" guidelines will be rewarded with incentive payments.

"Meaningful use" is a set of 15 core objectives - 14 for hospitals - that providers must meet. These objectives include, among other things, that a certain percentage of prescriptions be transmitted electronically and a certain percentage of doctor's orders be entered electronically. The list goes on, and in more detail, than there is space available in this report.

"We are in a good, strategic position to meet 'meaningful use'," VanDerWege said.

But since the ARRA incentives come only after the system has been put into place, providers must come up with the capital to implement the EMR programs.

VanDerWege explained that the budgeting process at Lindsborg Community Hospital for the last six or seven years has included capital costs for improvements as recommended by a committee charged with developing a time line for implementation of EMRs. Shortly after VanDerWege became CEO, a restricted fund was developed to designate or direct gifts to help pay for the technologies required for total implementation. A grant was received from the Lindsborg Community Health Care Foundation to assist with bedside charting, and two capacity-building grants were received from the Sunflower Foundation in Topeka.

In addition, VanDerWege said three estate gifts were directed to the technology fund. The largest gift was from the estates of Clyde Lindstrom and Glenn Lindstrom. "It is fair to say that without the generosity of that particular gift, we would not be as far along as we are," he said. Six additional grants were submitted but not funded.

In addition to the monetary cost, security of electronic medical records is another big challenge. Jeremy Snapp, Information Technology specialist for the hospital and clinic, said that the goal is of course to ensure that patient records are secure. And there are many safeguards in place to ensure such security.

EMR software systems face the same type of concerns as banking and other industries in which security is a high priority. VanDerWege said there are numerous built-in safeguards to keeping the information safe and secure. Records are backed up on a nightly basis, copied and sent to an off-site, secure location for safe-keeping.

A question that arises is not only how much information each staff member needs to have access to, but what information patients can access. For example, should patients carry their medical records on a flash drive? VanDerWege said there are concerns with practices such as this when it comes to the transferring of computer viruses that a flash drive may carry. It would take a matter of seconds to crash an entire system by plugging in an infected flash drive.

Also, the web portals that providers use to access these records, both onsite and remotely, are just as secure and password-protected as an online banking system.

Currently the Lindsborg Rural Health Clinic is in the midst of implementing an electronic medical record system. VanDerWege said a big challenge of switching to an electronic system is converting the old paper charts to new electronic charts. Questions arise regarding, for example, how much information to include and how far back to go in a patient's medical history. VenDerWege said the decision was made not to not convert a patient's entire medical history, but rather to focus on the past year or two. Of course information that is scanned is kept for some time before it eventually is shredded, while older parts of the paper chart that aren't scanned are stored indefinitely.

At the clinic, charts are being converted little by little. General patient information and demographics are entered, and paper charts are scanned and downloaded into a patient's electronic chart. The new electronic charts can then be accessed by using a traditional computer, or a handheld tablet computer that a physician may carry.

Dr. Bryce Loder, a primary care physician at Lindsborg Community Hospital, and Lindsborg Rural Health Clinic, referred to the conversion of paper to electronic as "slow and sometimes painful."

"But the results are rewarding, because I know that it is a one-time conversion of these records on each patient, and I'll never handle that thick paper chart again," Loder said. But none of these transitions happened overnight. There was research to choose a vendor to provide the software, computer systems had to be updated, software had to be downloaded and staff had to be trained. Some staff members were sent to the software vendor's headquarters to be trained as "super-users." Snapp said that super-users gain the most comprehensive training and in turn are able to train co-workers.

The software company then came on-site to train all staff members and also were present on "Go Live" day, Snapp said.

"One of our biggest challenges has been training staff to learn a new system without any downtime from seeing patients and working hard to still provide a high level of quality patient care," said "super-user" Julie Harding.

Harding said the clinic also has weekly conference calls with the software company to resolve problems that arise in customizing the system to fit the clinic's needs. Even with intense training and conference calls, there remain issues to overcome. One, Harding said, is simply learning to use such a sophisticated software system. But as with anything new, Harding said, the software seems to come easier for some than it does for others.

"Another issue really deals more with what we call 'Workflow,'" Harding said. "In other words we are accustomed to doing our clinical work and seeing patients in the paper world with a paper chart and that has changed to a different way of doing things in the electronic world with an EMR. We are developing new ways to do our work electronically and while this has caused some growing pains for us as a staff, we are adapting, learning and changing," Harding explained.

Loder said although converting to EMRs won't revolutionize medical care initially, the benefits will grow as time passes. "We'll spend more time doing critical thinking and less time documenting the same medication or treatment in three or four different locations in the paper chart," he said.

Although entering patient information electronically isn't necessarily faster than doing it by paper, Betty Hedberg, Director of Nursing, said "it does allow for many opportunities to provide better patient teaching, safety and documentation of nursing care."

"I do believe if we use the technology in the way it is intended, we have all of the tools needed at our fingertips to provide wonderful patient-centered care at the 'point of care.' That means at the bedside with the patient," Hedberg said.

Loder said that so far it has been fun watching staff members teach and support each other throughout such a stressful project. "I love to be in the loop on this constant learning that is going on at Lindsborg Rural Health Clinic. In the middle of the fatigue and stress of this conversion process, I see excitement about learning something new and knowing that our patients will ultimately benefit from this," he said.

On a lighter note, Loder said he jokes with co-workers that he is glad he has lived long enough to finally see the clinic take the step toward EMRs. He admits the medical care profession has been slow to adopt this technology because the cost in money and time is significant. "We'll succeed at this transition, and we hope to be a good example to other clinics facing this same process," he said.

Loder said converting to EMRs is a necessary step. "When we have completed the conversion to all electronic records, we'll still be in the first twenty-five to thirty percent of clinics in the nation to have done so. Our patients deserve this, and they are helping us through this process with their understanding and great attitudes combined with curiosity and encouragement."