The Road to Electronic Health Records Is Paved With Operations

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Supplements and Featured Publications, Special Issue: Health Information Technology — Guest Editors: Sachin H. Jain, MD, MBA; and David B, Volume 16,

Electronic health records best support process improvements when win-win situations are created to achieve both organizational benefits and team member work flow improvements.

The University of California, Los Angeles (UCLA) Health System seeks to align its purpose of “healing humankind” with its approaches for people and performance management. These approaches include lean process improvements initiatives, sustained by efforts to impact daily team member work flows. The electronic health record (EHR) serves as a powerful supportive instrument in improving processes and sustaining performance. For UCLA, the secret to EHR effectiveness lies in creating win—win situations, where organizational objectives are achieved and team member work flows also are improved. Recent UCLA initiatives with medication bar-coding and a stroke telemedicine network highlight such opportunities. Carried out on a national level, such efforts can significantly affect healthcare in the United States. The US Recovery and Reinvestment Act of 2009’s EHR provisions provide a national impetus for broad improvements in healthcare.

(Am J Manag Care. 2010;16(12 Spec No.):e289-e292)

The University of California, Los Angeles (UCLA) Health System, with its David Geffen School of Medicine, is an academic medical center focused on leading-edge patient care, education, and research. The health system’s vision of “healing humankind” is pursued through 4 hospitals and more than 100 outpatient clinics and centers. With an operating budget of $2 billion, 2000 physicians, and 10,000 staff members, UCLA seeks to align its purpose with people and performance management. The health system creates this alignment through an approach called the UCLA Operating System. This system integrates the UCLA mission, vision, and goals into day-to-day metrics, processes, and work flows. Through use of lean improvement efforts and “active daily management” approaches to sustain performance, not only does the organization win by achieving its objectives, but staff and physicians also win as their work becomes more meaningful and waste and delays are reduced.1 Implementation of the electronic health record (EHR) has provided UCLA with an enhanced mechanism to align objectives with day-to-day operations and to further deliver on this win—win proposition.

UCLA OPERATING SYSTEM

Central to improving performance and sustaining improvements is the proposition that operational changes need to improve value to patients, while also delivering work flow benefits to team members. Process improvements benefit patients as team members map out operational processes and eliminate steps that do not add value, resulting in shorter turnaround times, improved access, and fewer errors. These approaches simultaneously improve work flows for staff members and physicians as processes become more reliable, less time is wasted on redoing work, and delays are reduced. The elimination of non—value-added activities allows staff members to focus on their core jobs, rather than spend time on redoing work or on work-arounds. Accordingly, effective processes end up being highly satisfying for staff and physicians, whereas excess running around for forms, delays in testing, and errors can be very demoralizing.

A recent operations improvement effort in UCLA’s Neurosurgery Clinic demonstrates such a dual success in improving both the patient experience and physician and staff work flows through process redesign and information technology. UCLA’s Neurosurgery leaders were finding that some patients were being scheduled for outpatient clinic evaluations without first securing the diagnostic imaging studies necessary for a neurosurgeon to provide a complete consultation. These patients would ultimately become disappointed after traveling to see a UCLA subspecialist only to find that a definitive opinion could not yet be rendered. Moreover, a neurosurgeon would find he was spending his scarce time in non—value-added clinic visits. In addition, when films were secured in advance, the neurosurgeon found that he was spending excessive time during the visit uploading images from patient CDs obtained from outside imaging centers onto the UCLA picture archiving and communication image viewer system. This uploading process caused further delays to patients during the clinic visit and suboptimized neurosurgeon time.

Accordingly, a process improvement effort was undertaken (1) to ensure that the scheduler secured appropriate images in advance of the clinic visit and (2) sometimes to secure the images in advance of booking the appointment to make sure a patient’s condition was appropriately matched with a neurosurgeon’s specialization. This scheduling modification helped reduce the number of unnecessary clinic visits and freed up neurosurgeon time from non—value-added activities. The improvement effort also involved automating the process for uploading outside diagnostic images. This reduced the patient wait time during the visit and reduced the time the physician spent during the clinic visit manipulating images.

In addition to process improvements, the UCLA Operating System recognizes the importance of active daily management approaches for sustaining performance. These approaches include staff involvement in development of evidence-based best practices for standardizing work, regular training of staff in such evidence-based practices, tracking of performance through dashboard metrics and direct observation rounds, regular team huddles or meetings for reinforcement of approaches, and continuous improvement efforts to further raise performance levels.

For example, UCLA’s C-ICARE patient experience program consists of specified processes and daily activities each hospital team member should undertake to support delivery ofpatient-centered care. Such best practices, for which annual training is provided, have been developed by the staff and physicians of UCLA. These practices are reinforced in brief daily staff meetings called huddles. Management team members conduct observation rounds to speak with staff and patients to further reinforce these activities. Additionally, customer service measures are tracked and posted across the organization. The effectiveness of C-ICARE and these active daily management approaches is reflected in UCLA’s flagship Ronald Reagan Medical Center achieving customer service scores in excess of the 90th percentile of all hospitals in the United States, as per the Centers for Medicare & Medicaid Services Hospital Consumer Assessment of Healthcare Providers and Systems surveys.

The UCLA Operating System’s lean performance improvement and active daily management approaches provide benefits for both the organization and its staff. The organization, along with its patients, wins as objectives are achieved and sustained. Staff and physicians win as they spend more of their time on value-added activities.

ALIGNMENT OF PURPOSE WITH PEOPLE AND PERFORMANCE MANAGEMENT

At UCLA the EHR plays a major role in aligning purpose with people and performance management. The EHR directly supports process improvements as it fundamentally changes how care is delivered. It directly supports active daily management efforts to sustain performance, as attention is given to work flow design, training, and new system metrics. Patients benefit from improved safety, quality, access, and service, while staff benefit from improved work flows, reduced delays, and more job satisfaction.

On a national level, the American Recovery and Reinvestment Act of 2009’s promotion of EHRs has the potential to play a greater role in improving healthcare effectiveness and efficiency than even the broader health reform bill. As we at UCLA strive to be leaders in patient care, education, and research, successful EHR efforts give us tools and degrees of freedom that we did not have before. Moreover, EHR efforts not only allow us and other organizations to expand the improvement horizons for our organizations, but also to create positive network externalities outside our organizations. For example, as a nationwide health information network is eventually formed, patient care information will be shared across providers to improve outcomes and avoid redoing work. In turn, the entire healthcare industry will become more effective and efficient, generating even greater value to beneficiaries as more organizations enter the network.

At UCLA we have an EHR oversight board that has charged our project team to move as quickly as possible to enable the following sustainable priorities:

• Ensure the availability of information within UCLA and between UCLA and other providers and settings.

• Facilitate easy capture and analysis of data to support performance improvement, outcomes management, public reporting, transparency, and clinical research.

• Enable integration of clinical research into the care process by collecting, aggregating, and providing access to appropriate data.

• Promote UCLA’s position as a national leader, innovator, and destination for clinical care, medical education, and clinical research.

• Contribute to UCLA’s ability to recruit the best and brightest students, residents, fellows, faculty, and staff.

• Use a certified EHR to exchange health information to improve quality and submit clinical quality measures to governing bodies.

In and of itself, the EHR will not magically improve care. We see the EHR as part of a set of tools, along with other lean process improvement and active daily management activities. Electronic health record implementation efforts are most effective when underlying processes are examined and unnecessary work steps are removed, resulting in fewer handoffs, fewer errors, and reduced turnaround times.

Electronic health record efforts are best sustained when impacts on staff work flows are considered and active daily management approaches for sustaining best practices are understood. For example, approaches are needed for physician and staff training and retraining. Physicians and staff raise such questions as who decides whether there is 1 approach for an order set or if multiple approaches will be allowed. They raise questions as to who reviews whether standardized approaches are being adhered to, or if these approaches need to be modified. The answers to these questions are not automatically given.

Moreover, there are time and work flow costs associated with EHRs. The up-front design requires significant time and involvement. There sometimes is more work for providers in entering front-end orders or in providing fuller online documentation. The promise is that more work on the front end of care processes will reduce downstream rework, excess communications, and errors.

In spite of these challenges, the EHR effort at UCLA has resulted in both fulfillment of organizational objectives and improvements in team member work flows. Benefits for patients include improvements in access, safety, efficiency, and effectiveness. Benefits for staff and physicians include less running around, less rework, and greater role satisfaction.

POSITIVE IMPACT OF THE ELECTRONIC HEALTH RECORD

The EHR’s positive impact at UCLA in supporting alignment of purpose with people and performance management is nicely demonstrated in our Bar-Coding/Electronic Medication Administration Record project and in our UCLA Telestroke Network Partner program. Indeed, both of these efforts leverage information systems to improve quality, safety, effectiveness, and efficiency. As a result, both organizational objectives and team member work flow improvements are being achieved.

Bar-Coding/Electronic Medication Administration Record

The Bar-Coding/Electronic Medication Administration Record project seeks to reduce the chance for medication errors while improving staff work flow processes. Patient safety is enhanced as the information system facilitates the right patient being given the right medication. Before administering a medication, a nurse uses a bar-code reader to scan both a patient’s bar-coded patient identification wristband and a barcoded medication package. The computer system then checks to see that the medication being administered is indeed in consort with the medication order previously placed into the system and that the correct patient has been selected. For the nursing units that have rolled out the system to date at UCLA, there have been zero wrong patient medication errors.

Although patient safety enhancements have been impressive, this project has resulted in equally compelling staff work flow improvements. Implementing an electronic medication administration record in conjunction with bar-coding saves time and reduces the risk of errors for a nurse. By using the bar-coding process, the system automatically documents administration of the medication for the nurse, so that she does not have to spend time documenting the medication manually into the medication administration record. If bar-coding had been implemented for safety checking without simultaneously implementing the electronic medication administration record, the nurse would not see as much of a work flow benefit from doing the bar-code scanning. Actually, it would simply end up being an additional step, and thus might be a more difficult process to sustain over time. Accordingly, work flows have been designed so that the ideal medication process ends up requiring the least amount of work steps for staff. That has in turn nearly eliminated variation in the medication administration process.

In addition to typical functionalities that came with the bar-coding system, several enhancements were added by UCLA to facilitate staff work flow. For example, icons were added to the system to inform the nurse of the location of the medication (eg, refrigerator, Pyxis, cassette, on demand). As a result, the nurse does not need to hunt for a medication, reducing the amount of non—value-added searching time. Additionally, a medication administration “stagger” protocol has been designed so that if a patient is off the floor for a procedure and is unavailable to receive a scheduled mediation dose, the computer staggers the due times to adhere to the standard administration schedule.

Online messaging functionality also has been designed into the system, allowing the bedside nurse to directly communicate with the dispensing pharmacist. This allows for quick messaging on safety questions and eliminates travel time to the satellite pharmacy for simple conversations. To further reduce nurse work steps, bar-code medication administration software has been installed onto the same workstation on wheels that is used by the nurse for other charting functions, instead of using the vendor’s separate medication system. This reduced the number of systems the nurse needs to use, which in turn further reduced non—value-added time, work steps, and chances for errors.

Telestroke Network Partner Program

The UCLA Telestroke Network Partner program is another example of information technology supporting alignment between purpose and people and performance management. The program gives emergency departments at community hospitals the opportunity for direct, immediate video consultation with stroke neurologists at the UCLA Stroke Center. This program is a developmental advance from a previously well-established UCLA Stroke Hotline, in which UCLA had been working with emergency physicians and neurologists throughout Los Angeles county and beyond. With the new UCLA telestroke program, UCLA neurologists are available to provide collaborative care recommendations to emergency physicians for patients with acute stroke, transient ischemic attack, and stroke-like conditions. Moreover, the UCLA team can work in collaboration with local neurologists, providing emergency coverage for time periods when local specialists are not available.

When a possible stroke patient is evaluated in a network partner hospital and telestroke consultation is desired, the emergency physician contacts the UCLA telestroke consult hotline. Within 15 minutes, a UCLA stroke neurologist can be interviewing and counseling the patient and family, and performing the stroke-specific neurologic exam through a 2-way video connection. The UCLA stroke specialist also views local computed tomography and other diagnostic images through a picture archiving and communication system. Based on this information, the UCLA physician can offer an expert opinion on the diagnosis and the most advisable treatment plan. Management recommendations may include supportive care, additional diagnostic tests, the use of a clot-busting tissue plasminogen activator, or if available, use of acute endovascular interventions approved by the Food and Drug Administration, such as mechanical clot retrieval (Merci Retrieval System) or clot aspiration (Penumbra System). A consultation report is immediately completed by the UCLA neurologist and entered into the patient’s local medical record.

The telestroke program indeed provides a win—win scenario, both for the community and its healthcare organizations and for organizational team members. Patients and community hospitals benefit from improved access to subspecialized care, without necessarily incurring the cost and effort of transferring patients to UCLA or recruiting specialists to local hospitals. The telestroke program allows UCLA team members to leverage their expertise outside their organizational walls and also creates new avenues for research and education collaborations. Provision of remote consultation and avoidance of unnecessary transfers in turn become more rewarding and time-saving for UCLA’s subspecialists, who can focus their resources on more acute cases.

CONCLUSION

At UCLA Health System we seek to align our purpose of healing humankind with our people and performance management processes. Our UCLA Operating System for pursuing this linkage involves improving processes and sustaining such changes through active daily management of work flows. The EHR serves as a powerful instrument to both improve processes and sustain performance. We believe that the secret to the EHR’s effectiveness lies in creating win—win situations, where organizational objectives are achieved while team member work flows also are improved. Carried out on a national level, we see such efforts as having the ability to significantly impact healthcare in the United States. The American Recovery and Reinvestment Act of 2009 has provided a unique incentive and imperative to implement these efforts on a national level.

Author Affiliations: From UCLA Health System (ADR, VAM), Los Angeles, CA.

Funding Source: The authors report no external funding for this work.

Author Disclosures: The authors (ADR, VAM) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (ADR); drafting of the manuscript (ADR, VAM); critical revision of the manuscript for important intellectual content (ADR); and administrative, technical, or logistic support (VAM).

Address correspondence to: Amir Dan Rubin, MBA, MHSA, Chief Operating Officer, UCLA Health System, 757 Westwood Plz, Los Angeles, CA 90095. E-mail: arubin@mednet.ucla.edu.

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