Chapter 11: Medical Records and System Design for Faster Work and Better Patient Care
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Description
In this segment, Ms. Houston explains a number of devices and services that IS has implemented to facilitate work at MD Anderson. She first talks about the Alkek Hospital Bed Expansion, and how the building’s design made it necessary to give nurses the VOCERA hands-free communication device. She explains why the attempt to install tablet computers in patient rooms to document vital signs and other information was unsuccessful (and how other computers are being installed) and explains the electronic white boards installed to monitor patient status. Next, Ms. Houston explains the decision made in 2005 to adopt ClinicStation. She talks about the assessment strategy and what this software allows. She explains that Information Systems has developed ClinicStation into a certified Electronic Medical Records system that meets government standards, The government takes an interest, she says, because electronic records should bring down the cost of healthcare. At the end of this segment, Ms. Houston talks about how Information Systems customized ClinicStation to suit MD Anderson needs.
Identifier
HoustonDA_02_20120727
Publication Date
7-27-2012
City
Houston, Texas
Interview Session
Topics Covered
The University of Texas MD Anderson Cancer Center - Building the Institution; The Administrator; Institutional Processes; Devices, Drugs, Procedures; Building/Transforming the Institution; Professional Practice; The Professional at Work; Diversity at MD Anderson
Transcript
Tacey Ann Rosolowski, PhD:
Yeah, yeah. I know in 2010, there was the new expansion of the Alkek Hospital. To what degree did you work on that—installing the electronic system for that?
Deborah Houston:
We had IT people involved, of course, in the building. One of the things—you want me personally, what I personally did?
Tacey Ann Rosolowski, PhD:
Yeah. I’m just curious.
Deborah Houston:
One of the things was the way they new units are configured. They don’t have line of sight of the reception area. Does that make sense?
Tacey Ann Rosolowski, PhD:
No. Actually, for the recorder, let me just say that what we are talking about is the bed tower expansion of the Alkek Hospital, which was completed in November of 2010.
Deborah Houston:
Yeah.
Tacey Ann Rosolowski, PhD:
It had a lot of really interesting electronic bells and whistles.
Deborah Houston:
Right.
Tacey Ann Rosolowski, PhD:
What does that mean, the line of sight issue?
Deborah Houston:
Well, when you go into a nursing unit or on a floor, frequently there is a central nursing station. Rooms are either down the hall on either side of it or they’re around it—most of our rooms here, there is a station and rooms are around it in some kind of configuration. In this facility, the new building, there is—at that nurses’ station, there is usually a clerk or somebody that is sitting there all the time, answering the phone, directing people, looking at charts or the computers or whatever. The way it is set out now is there are little pods of room and there is no real nurse station anymore. The receptionist that is answering the phone or whatever is really kind of around a corner. You come in—the hallways go like this and the rooms are kind of back there. If you need help or you need somebody else, they are not right out there at the nurses’ station. They are down other hallways and things. One of the things we had implemented in the outpatient clinics is a device called a Vocera communication badge. It is like a hands-free device—I say hands-free—you push a button to make it work. You log onto the system everyday and it knows which device you are carrying. When you want to call somebody, you hit a button and it talks to you and you say, “Call Debbie Houston, or call Dr. So-and-so, or page somebody” or whatever. You can call to a phone number. You can call to another person’s badge. You can call to a pager. We implemented that for the nursing staff on those new units because if they are down in a hallway, they’re in a room or something, and they need help, they can use that to call for assistance or find somebody.
Tacey Ann Rosolowski, PhD:
Why were those units designed on that pod configuration in the first place?
Deborah Houston:
I have no idea.
Tacey Ann Rosolowski, PhD:
Oh.
Deborah Houston:
I was not involved in that at all.
Tacey Ann Rosolowski, PhD:
You came in with the Vocera system basically to kind of do a little trouble-shooting—
Deborah Houston:
Well, yeah. (talking at once). We had been using it in the outpatient clinics for a while, and it worked well. We thought it would work. It has been helpful. Now we’re expanding that to all of the nursing units—inpatient units. We have had them in the clinic, but we are putting them in the inpatient units, as well.
Tacey Ann Rosolowski, PhD:
What do you find it enables?
Deborah Houston:
Quick communication. The main thing is you call a physician. You tell the clerk to page Dr. So-and-so. He calls back. You’re in the room with a patient. They don’t know where you went. They don’t know who called him. The doctor hangs us. You come out, “Did Dr. So-and-so call?” “Oh, yeah. I didn’t know where you were.” You call him again. You’re in another room. This way they can call back right to the badge. They can call back and talk to you—you can be in a room with a patient and it says, “Can you accept a call from—?” You can answer it, go out in the hall and talk to him, go to a phone and talk to him or whatever. It is really nice. When you’re in the room—when they say hands-free—if you have your hands full of stuff, you don’t have to do anything. You can just talk to it, and it does what you want.
Tacey Ann Rosolowski, PhD:
Wow. That’s amazing.
Deborah Houston:
You can have the conversation. Yeah. It’s nice.
Tacey Ann Rosolowski, PhD:
What other projects did you work on with—?
Deborah Houston:
That one and, then, we put tablet PCs—computers—the small tablet computers in the patient rooms for the nurses to utilize to document vital signs and use for documentation purposes. That hasn’t been as successful as we thought because of the size of the device. The rooms were not wired to have computers in the room at the time they built the building. I shouldn’t say they weren’t designed that way. Well, no, they weren’t designed that way because we’re running them wireless. Again, the designing of buildings is years and years before you’re going to do anything. Now, we’re having to go back in and change that. They are going to be putting some type of wall-mounted computer in all of the rooms. We are going to end up with them in every patient room. We will have to do wiring for that.
Tacey Ann Rosolowski, PhD:
What was the problem with the tablets?
Deborah Houston:
The smaller device? We actually gave them to the nurses on the units they were one before they moved to the new unit so they could get used to them. I think, again, it is process. It is habit. They’re used to going in and taking vital signs, writing them on a piece of paper, and going out and charting it. All of these rooms have computers, most of them right outside the door, as well. The idea was you’re in there and you do it while you’re—
Tacey Ann Rosolowski, PhD:
Yeah, you’re not doubling your work.
Deborah Houston:
The idea was a good one. I think we just didn’t have enough for them to do on the device at the time. A couple of other things—when patients get admitted, we check their medications. There is an application that runs on it that they can do that. I think part of it was we didn’t have enough working on it. They’re expensive. They’re more expensive than a regular computer, so we’re not buying anymore.
Tacey Ann Rosolowski, PhD:
What are you going to be doing with the ones you’ve got now?
Deborah Houston:
They’re leased, so they’ll go back.
Tacey Ann Rosolowski, PhD:
Oh, okay. Yeah, interesting. So the larger computer will be—enable more things to be done on it, so they’ll be more of an incentive?
Deborah Houston:
Well, not necessarily more things to be done it. It’ll be easier to see. It’ll be a regular—the other thing was if you—it didn’t have a—the keyboard that works with it was over away from the patient because when you took it out to use it by the patient’s bedside—when you take it out to use it at the bedside, the keyboard is on the screen. When you open up the keyboard, the screen shrinks down. It’s harder to use. There is a keyboard that you can mount. There is a little mounting thing with the keyboard, but it’s here and the patient is over there. They are going to mount one of those reticulated arms that will have a keyboard drawer and a monitor—a big monitor—so it will be easier to see and a regular keyboard.
Tacey Ann Rosolowski, PhD:
A more ergonomic thing.
Deborah Houston:
Yeah. The nurse can use it. The physician can use it when they’re in the room.
Tacey Ann Rosolowski, PhD:
Right. I can see how that—if the keyboard is on the other side of the room—
Deborah Houston:
Right. That’s what we should have done anyway. We were trying to do something—
Tacey Ann Rosolowski, PhD:
Were there any other things you worked on?
Deborah Houston:
Those are the main things that I was involved in. There are some subsequent things that have happened. We have put in something called white boards, which are like—well, we did do that for those new buildings—those units, now that I think about it. On all the nursing units, we have a big grease board where they have the patient’s room number and their name and the doctor and kind of things that might be going on with the patient—cryptic things—people walking by wouldn’t know what it was. There was no wall. That was not planned for in the new facility, so we did an electronic version of that. It is a big monitor on the wall that is the same kind of functionality that shows rooms patients are in, doctor. The nurses go in and can put things in the other columns. It shows when new orders are written for the patient. The nurses can look and see. Again, because the nurses’ station where the charts would have been located or are located is not where—it is around where this clerk is, and she has a fifty-two-bed unit—well, they’re half-and-half, so twenty-seven or whatever—twenty-six patients on each side. The charts are there, and they’re not—back in the back.
Tacey Ann Rosolowski, PhD:
These white boards are kind of in where all the pods are—
Deborah Houston:
Yeah. It’s like you see status boards in airports and things like that—that kind of a status board, that kind of function. We implemented that. We had a version of that in the Radiology Department and in the Emergency Center, so we implemented that. That’s going to all units now.
Tacey Ann Rosolowski, PhD:
What’s the advantage of that?
Deborah Houston:
It’s neat. I mean, you know, it’s up-to-date. As soon as a patient changes a location, it changes. As soon as an order is written, it puts a flag up there so you know.
Tacey Ann Rosolowski, PhD:
It’s really an immediacy kind of thing. It’s directly connected to the computer, so it updates itself without a person having to go in—
Deborah Houston:
Yes, yes.
Tacey Ann Rosolowski, PhD:
Oh, that’s very cool.
Deborah Houston:
Some of the stuff the nurses have to go in to update. As we get more and more functionality built within ClinicStation, a lot of it will be more automated.
Tacey Ann Rosolowski, PhD:
You mentioned ClinicStation before in the context of writing prescriptions. I think I read in one of the background materials that the wireless network in Alkek wasn’t powerful enough to handle ClinicStation, or did I misunderstand that?
Deborah Houston:
When we first—okay—the institution’s wireless network has had to be upgraded in the last couple of years. When we first—the new Alkek units had the new upgraded wireless network when they opened. That’s why we could have Vocera and use those tablet PCs on the wireless network. The lower Alkek floors and the Purple Zone, the Lutheran Pavilion, did not have the upgraded wireless network at the same time, so they couldn’t use Vocera. Wireless worked sporadically. Since then, we have completed the upgrade of the wireless network, so we’re rolling out Vocera —hope to roll Vocera out to everywhere else.
Tacey Ann Rosolowski, PhD:
What was the issue with ClinicStation?
Deborah Houston:
I don’t—
Tacey Ann Rosolowski, PhD:
Okay, so I must have—
Deborah Houston:
Yeah.
Tacey Ann Rosolowski, PhD:
Yeah. Okay. I was curious about that.
Deborah Houston:
One of the things—I don’t know that we every talked about was we made the decision back in 2005 that ClinicStation would become our electronic medical record for the institution.
Tacey Ann Rosolowski, PhD:
No, we didn’t talk about that. How was that—?
Deborah Houston:
We had tried three other commercial vendors prior to that in different variations that were not successful in our environment. Back in 2005, when we reorganized IS and everything, one of the things that was done at that point, as well, as assess our EMR strategy. The decision was to use ClinicStation. ClinicStation had been built originally as a data viewing tool for radiologists. When radiologists want to look at x-rays, they like to know history of the patient, and they couldn’t get charts or they couldn’t get results or it was difficult in the old computer systems to see x-rays and old x-ray reports and lab reports and whatever. So the guys that work in ClinicStation today developed an application that pulled all that data for the radiologist so he could see the x-ray image on the computer and he could see over here—here’s the patient’s pathology report or here is what his doctor said at the last visit so they could collaborate and consolidate results. Other physicians started seeing that, and it was like, “Well, we could use that as our EMR.” That’s how it came about. Subsequently to that, we developed ClinicStation into our electronic record and it is a certified electronic health record for both in- and outpatient use.
Tacey Ann Rosolowski, PhD:
What does that mean, “certified?”
Deborah Houston:
It’s a governmental regulatory thing that we applied for, and you have to meet standards. We got that certification last year, I guess, which is a springboard to sort of other things the physicians can get reimbursed for, because they’re using a certified electronic medical record.
Tacey Ann Rosolowski, PhD:
Oh, really?
Deborah Houston:
There’s a program called “Meaningful Use of Electronic Medical Records,” and the government is giving physicians money to do that, so much per year based on certain things they have to be doing with an electronic record. We couldn’t apply for that until our system was certified. Now we’re in the process—well, the system as of July has everything in it to meet the first phase of meaningful use. Our physicians will be starting this fall. Right after the first of the year, they will be applying for monies. The institution will get money per physicians that are eligible.
Tacey Ann Rosolowski, PhD:
Now, why is the government doing that?
Deborah Houston:
Well, the idea is that if the electronic records—the whole idea is if electronic records—if patient’s records are electronic, they can easily “be transmitted” and transferred among providers and institutions, so your care is more collaborative. You’re not duplicating tests. You didn’t go here and have a chest x-ray, and you go somewhere else and he can’t see this chest x-ray, so you have another chest x-ray, for example, or you get a lab test repeated over and over because you don’t know what the last one said. That’s kind of the idea is that it is going to overall decrease the cost of healthcare in the end, because we’re going to prevent duplication.
Tacey Ann Rosolowski, PhD:
What’s your view of that?
Deborah Houston:
I think it will happen. I don’t know if it will happen in my lifetime. I think it will happen. As we build things like orders that tell you, “You just ordered that test—” it’s not something that is going to change in twelve hours or there should only be so many chest x-rays ordered on somebody. An example is our patients, because they see many different providers, you could order and x-ray and I could order an x-ray and you may not know I ordered the x-ray and two different clerks are scheduling it and they don’t bother to look. The patient gets two x-rays. Some of our patients, bless them, don’t know enough to say, “I just had that done this morning. Why am I having it done again?” or “I just had a lab drawn.” That will help. With electronic order entry, you can build in alerts and things like that that say, “You just ordered that” or “Don’t give that medication, the patient is allergic to it,” or “Don’t give that medication or that dose of a medication because the patient’s kidney function isn’t good enough, or they are too old, or it’s too much for the size—or their weight or whatever.” Those are things—it’s safety and productivity and decrease in cost—are some of the main reasons why the government is interested.
Tacey Ann Rosolowski, PhD:
After you decided on ClinicStation in 2005, were there particular ways in which you tweaked the system to make it more useful for MD Anderson or was it great just from the beginning as-is?
Deborah Houston:
The system was built, again, as a viewer of results. That was the original intent of the system. We were doing some data entry into it at that point. The nurses were putting in vital signs. We were putting in medications for medication reconciliation, which is a list of all the meds the patient has taken home so that when they come in and out of the hospital we know what they have been taking. Their allergy information was in the record. The tweaking that was done originally was more, “Let’s add this result. Let’s add these video files of swallowing studies by the speech pathologist” or “Let’s add this new cardiac test,” or “Let’s add reports from physical therapy,” for example. I don’t know. Things like that. That has been done consistently over time. What we are doing now is we are implementing features where the nurse, the physician, all the clinical providers are interacting with it. They are entering orders. They are entering documentation. That is a real change in practice—a change in behavior that we are having to deal with; entering prescriptions electronically instead of writing them on a piece of paper.
Tacey Ann Rosolowski, PhD:
What are some of the challenges that come with that? I mean, you mentioned about the prescriptions earlier and how that kind of created a lot of—
Deborah Houston:
Well, it’s a change in—well, it’s very easy for physicians—a lot of them have been used to—let’s say in the outpatient clinic. They had a chart or the nurse had their papers. They don’t even have the charts anymore because they can see a patient without the chart. They can look at stuff on the clinic, but he would have a piece of paper that would be the requisition for what the patient needed to have done when he came back the next day—the next visit. It already had the patient’s name on it. It was already there. The doctor would go, “Three months, chest x-ray, check some labs.” Sign it. That was it. I mean—very quick. Now, when he wants to do his orders, he has to go to the work—which they were doing in a work room. He has to log onto the computer. He has to select the patient. He has to go to the orders. He has, depending on how he has it set up, hopefully, it has been set up correctly and he has a favorites tab that says “returning patient” that he clicks on and he orders everything. Most physicians are creatures of habit. We all are. Our physicians are so specialized that they’re seeing breast cancer patients. They probably order, probably ninety percent of the time or more, the same tests on a breast cancer patient that is of a certain status—A post-op patient or a post-chemo. They are ordering primarily the same things. We have a function where it is set up where all those tests are already pre-selected for them. Click, signs it, and he’s done. It’s different. It’s a different way to work, so getting people to learn to do that. “The computer is slow. I can’t get a computer. I can’t find my tests. That’s not the way I—.”
Tacey Ann Rosolowski, PhD:
Well, I’ve noticed myself going to the doctor when there is a computer present, part of your conversation with the physician becomes about what the computer is doing. Like, “Oh, I can’t find this. Hang on a minute.” Yeah, it’s interesting.
Deborah Houston:
Yeah.
Tacey Ann Rosolowski, PhD:
It’s like a presence as the person is learning how to navigate it.
Deborah Houston:
Right. So, that’s it. They’re busy, and they’re used to stacking all that up and doing it at the end of the day, which they can still do it at the end of the day, but that’s not really helping anything. It’s just different work. It’s different work. We’re trying to make things as painless—I wouldn’t say easy—but painless for the providers as we can because they’re going to dump it all on the mid-level provider that’s just not helping anything. We get—we deal with—“Is this going to take me more time. Is this going to slow me down? You want me to do more.” When I go with staff to meetings to present things, I’m the one because I know a lot of these people because I’ve been here forever, and they know me. I’ve worked with a lot of them in my various jobs when I was in nursing. They are not yelling at me but, you know, telling me. I’m like, “I understand. We’re going to try to make it work for you.” I think it helps because they know I know the work they do. I can’t always make it better for them, but we try. That’s what we’re trying to do as we roll out functionality now is make the system work and show them the end result. The orders are going to get to the pharmacy faster. When you’re in the hospital, you’re going to get things quicker. “But you’re making me do all the work—making the most expensive provider do the work up front.” That’s a very common thing we hear. The physician is the one that should get the alerts in the system when they’re ordering things incorrectly.
Recommended Citation
Houston, Deborah A. and Rosolowski, Tacey A. PhD, "Chapter 11: Medical Records and System Design for Faster Work and Better Patient Care" (2012). Interview Chapters. 894.
https://openworks.mdanderson.org/mchv_interviewchapters/894
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