As of March, 160,890 eligible professionals had received Medicare meaningful use incentive payments, 83,765 eligible professionals had received Medicaid meaningful use incentive payments and 3,858 eligible hospitals had received meaningful use incentive payments from Medicare, Medicaid or both programs, according to recent data from CMS.
In life you hear how it is not so much about the result, but the journey. When you think of the Life Cycle of most EHRs it is all about the result and the journey can kill you. So how do you make wise choices? Not only do you have to look at EHRs you have to look at the Vendors, then take a deep look at the IT staff that are in place to create, design this product into something that maximizes end user intuition into something relevant. The salesperson is not the one laying on a gurney in the ED or the physician caring for them and 10 others. The salesperson is not the one depending on an EHR to protect patient safety. The salesperson is not the one who faces malpractice situations. That EHR you select will ultimately drive your workflow, so it needs to be designed that way with an outcome of patient safety. Hold your vendor accountable to design and development specifications. Make sure that you can work with a vendor in the complete life cycle. Make sure you and your organization can survive the politics involved. Hands down Epic has the customer service arena wrapped up, and Cerner has a long ways to go.
Being a practicing clinician as well as EHR consultant, I have used numerous EHRs which have taught me how user interfaces affect the workflow, end user buy in, as well as patient safety. Another note to consider is that you can take an EHR right out of the box and set in different hospitals across the USA, and it will react different in each of them. EHRs need to go through end user testing by real physicians, clinicians and end users. If you put the effort in the beginning of the Life Cycle, you will see the results of that effort in the Go Live and Implementations. Obama Care results have been common problems with EHRs and short cuts with radical cost cutting measures. Bring in the tools that design, and build tools that improve your work flow. You need designs that work intuitively that are reliable, especially repetitively. You need a person that just focuses on finding gaps.
Our implementation of Cerner Millennium Power Chart was successful, and we have had a successful implementation with CPOE at both of our facilities, in the last year. We just finished our attestation for meaningful use Stage 1, and now we are well into completing Stage 2 by implementing some additional Cerner tools. At this point Cerner is performing well, and the clinicians seem happy. At this facility, our partnership with Cerner seems to be going well.
Cerner notes are very good, and the dynamic documentation is especially good. They are working on finalizing the tagging function where we can touch certain things, like labs and then they flow right into the notes. This will allow notes to be formed as we are seeing patients, such a payoff in terms of quality outcomes.
When I worked with Epic, I could create a smart trace and reuse it. In Millennium PowerChart, I am not able to do this function, and I have to type it every time. I can use favorites as a work around, but it isn’t the sleek design that Epic has. Even with this, Millennium PowerChart is intuitive, easy to use, relatively easy to learn and the EMR GUI one of the very best.
Concerning medication reconciliation functionality, I had to give praises to Cerner. Nurses have huge variables in their documentation, and that is usually where EHRs fail. When done correctly it works really well. Cerner is working on upgrading that functionality even more, and I look forward for that to come out. Clinicians viewing patients with long histories in the past were a challenge, but now with the enhanced performances, it is appreciated.
Mobile devices have been an area of challenge for us and Millennium PowerChart. It seems to be a large gap in Cerner being on the front lines of EHRs.
A side comment is that the expectation is that we adapt to Cerner, but I believe that Cerner needs to adapt more to us, our needs and workflows. Cerner is better than Epic in their choices here, as Epic tends to hire technical over clinical.
I’d recommend Cerner Millennium PowerChart to any of my colleagues at a number 4.5 rating.
FirstNet is the Emergency Management module from Cerner. As part of the EDIS team, interviewing the vendors was a daunting task in itself. When endeavoring on a huge job as this as you know you have to look at the whole picture, then consider that in your decision. Keep in mind we were going from paper to EHR, virgins of the EHR world. We went with FirstNet for many reasons and I’d like to share some of those reasons with you as well as some of the not so good things we ran into. Remember that how you move into this will also make a difference like, Big Bang or not and for us we took two years to prepare. Emergency Management was the first bite of the elephant that we tackled. After having that under our belt and information flowing we went full bang for the rest of the facility. It was a nice transition as then the information that the clinicians needed was there for them from the ED. Our experience with Cerner was relatively a good one. Cerner has a tendency to send new associated to handle roles they have not yet been vetted in. We were all for that, but then didn’t see the support. Cerner hires more clinical personal and that clinical experience. Epic doesn’t seem to care about the clinical aspect as they care about using the young and technical. I’ll save some of that for another review experience I had.
Our objectives included: improved usability, improved patient safety, increased efficiency, having happy Providers, reduce the length of stay, identify bottlenecks and the ever concern of increasing revenue. Cerner helped with a true validation of the design in our own environment and provided testing under actual workflow conditions.
ED Summary – ED Timeline
We knew our real-estate was at a premium, so we strove to reduce the information on the screen and made divisions according to the workflow.
We were able to hover to view and locate information, verses clicks and scrolling. An Alert popping up for significant events and having the ability to hover over them to view the comment or note allows, you to keep moving in your workflow. At this point, you also had the option to view more information or launch to the nursing documentation from the flagged event. The design followed intuitive workflows that providers and nurses would usually do when treating patients. We did notice a difference when the Cerner associates were clinical or not, or had ED experience. It did make the journey more challenging as well as frustrating.
Reducing scrolling and clicks within Triage Documentation
Overall FirstNet was found to be more rigid in adaptability to our dream wish list, and if flexibility was available it came at a cost like, specialty reports. If your facility is report centric, know that up front going into a relationship with Cerner or any of the top EHRs.
When you hover over the Alert, you will see that the nursing documentation has been flagged. The Tracking board was an intensive labor of love for the ED. All the way from selecting the icons to what was important enough to see on the Tracking Board was in the decision making of the EDIS team. The Tracking Board gives you a quick bird’s eye view of the ED including where staff are, what rooms are clean, where the Chaplain is at, where the patient in room 6 is, what test results are back or ordered, showing in what phase a patient is towards discharge, what is coming in and LOS (Length of Service) just to mention a few of the activities visible. You can see other views like the Triage area that give you a quick view of how many patients are waiting, patients needing to be roomed in ED, acuity levels of those waiting, any tests ordered, treatments, etc. If an ambulance is coming in, for example, it can help you manage rooms to make available for that patient, equipment needed, possibly call a code team or have a crash cart waiting when the patient arrives. Patients that come in with a similar name or a name that sounds like another name, FirstNet, italicizes the name, so you make a mental note. Name cells can be colored coded by sex, like blue and pink. The Tracking Board is a vital part of ED management and Cerner is one of the few to bring the workflow to design, to reality in a functional way according to ED workflow.
Due to EDs becoming so competitive in marking services we needed to publish wait times to web pages and outside sources. Cerner provided us the tools so that we were able to meet those goals. Overall some of the additional usability improvements that Cerner has managed to design with a high success; is the quick launch of a note from the tracking List, a suggestion of patient education by recognizing age and gender, discharge components, tracking control integration with IView, publish ED wait times (LOS), layout report enhancements, presenting a real time dashboard, multi-facility tracking and documentation management improvements.
Having said all this, the one complaint with Cerner that we heard was the number of clicks it takes to do the simplest tasks. I think that we need to review some of our expectations of completing tasks to our expectations of the availability, extraction of information to have available at out finger tips, a goal that needs attention even in the availability of requested information.
When you begin to look at the top EHRs remember it is not only the software that you need to look at, but the company and how they will help you meet the facility, State and National goals. Cerner has had complaints of wining and dining till the contract is signed and then disappears. In our research, we heard facilities voice that they felt abandoned because they weren’t as big as other facilities or that they weren’t in the major cities, lacking in their customer care and being customer centric. We not only interviewed the showcase sites that Cerner provided, but we did research to find other facilities using Cerner and interviewed them to facilitate our decision. It was a key decision, as we were just beginning to select solutions for the future of our facility. Reminds me of a sign I saw in Alaska, which stated to choose your rut wisely, for you will be in it for the next 7 miles. Choose your EHR wisely!
We needed an EHR system that would drive change as well as organizational redesign. We needed a system that plays a critical role in safety initiatives that were found in CPOE – Cerner. Cerner Millennium architecture provided a comprehensive EMR that was connected bringing up decreased times from medication order to meds cabinet access, significantly. Transformation grew out of that adhesiveness thus driving safety and efficiency with significant improvements. I no longer have to wait for someone else and now have more control.
The wielding benefit of order entry is found in integrated care where nurses, physicians and pharmacists all see the same information. If you do not have that, that is where the risk comes in and patient safety fails. You see this more in Hybrids than in software like what Cerner offers.
Reliability is another plus I’ve experienced with CPOE – Cerner. When an order is placed for a Chest XR, I can trust that it will be received and completed by radiology. Through transformed workflows and these new tools, we have found improvement. We have seen efficiency in our workflows presently taking on these changes, then how we used to do things. With the staffing, we were able to reduce our HUCs by half and then the remaining HUCs the focus is now more customer-centric. Nurses used to complete charts at the end of the shift, and now it is mostly being done closer to the actual delivery of care. We found a reduction in elapsed time between dictation and physician signatures as well as a reduction from code to bill time.
Within CPOE, the order sets have improved patient safety. With real time documentation, you cannot help improvements with JCHO standards and advanced directives. In the ED so many times, the allergies were never documented and now with hard stops, it is always being completed. Patients were getting missed for isolation sometimes for almost a week, and now the required patients are placed in isolation immediately. CPOE presents the right information at the right time for patient care and safety. More times than I’d like to admit CXRs were ordered with no reason. Now we place the orders and document at the same time thus increasing insurance collection with less time in research by support staff or denial. Advance directives compliance has improved with the entering of height, weight and allergy documentation. This just gives everyone the needed information for the most effective decisions and care available.
In the ED, we are totally CPOE, and we were able to replace the old grease board with large plasma monitors that give you an instant integrated view of the ED. If you see Child Life signed in with a suture nurse you know that support is taking place and Child Life will be tied up for the awhile. Lobby management is no longer a guess; you will know what it out there. Triage can see what beds are open. If a patient is in radiology and no longer in their room, we do not spend time looking and asking where the patient is. We can see at a glance if labs are back or how many are still out. We found communication of bed availability saved valuable time, enabling continuity of care from the ED to inpatient. CPOE effectively reduces drug-related injuries and adverse drug events, as well. We saw a reduction in preventable ADEs after the implementation of CPOE.
In summary, we have seen almost a 100% change in compliance driving safety and efficiency with significant improvements all the way around our health system. Cerner CPOE was the best investment.