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Using Electronic Health Records to Transform Care Delivery

Buswell, Lori MSN, NP, OCN; Reid Ponte, Patricia DNSc, RN, FAAN

Journal of Nursing Administration: April 2011 - Volume 41 - Issue 4 - p 159-161
doi: 10.1097/NNA.0b013e31821184da
Departments: Book Review

Author Affiliations: Vice President, Nursing and Clinical Services-Satellite Centers (Ms Buswell), Senior Vice President, Patient Care Service and Chief Nurse (Dr Reid Ponte), Dana-Farber Cancer Institute, Boston, Massachusetts.

Correspondence: Ms Buswell,Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02115 (

In the face of healthcare reform and consumer demand for high-quality, safe and affordable healthcare, the book, Connect for Health: Using Electronic Health Records to Transform Care Delivery,1 is a "must read" for healthcare executives, clinical leaders, and information technology leaders. This book's main objective at first glance is to describe the implementation of an electronic health information system across Kaiser Permanente (KP), the largest not-for-profit integrated healthcare delivery system in the United States. We would argue that the book's editors and chapter authors do so much more. They describe not only a large-scale electronic health record (EHR) implementation ($4 billion), but also a healthcare system and leadership at its best both strategically and operationally.

The authors describe their experience with creating and communicating a vision, sustaining organizational commitment, managing a large-scale change, and advancing a culture of continuous quality and process improvement. The authors reflect how they effectively communicated and managed this organizational transformation and massive change. The project management approach that resulted in a successful journey that truly transformed healthcare delivery within the KP system is well worth the reading. The KP board of directors, leadership team, and entire system should be applauded for their outstanding success in both leading this effort and disseminating it so quickly in this book.

The book is organized in 4 major sections: Setting the Course, Laying the Tracks, Harvesting the Value, and Future Directions. One of the most helpful components of the book includes a "Lessons Learned" summary at the end of many sections describing pearls of wisdom.

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Setting the Course

Several key factors formed the business case for the new KP chief executive officer, George Halvorson, to launch this enormous EHR implementation. The burning platform included the Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, as well as KP's decreasing market share, regulatory agencies' requirement for public reporting of quality outcomes, patient satisfaction and safety reports, and rising healthcare costs.

KP's leadership team demonstrated their commitment to this project by prioritizing the initiative throughout the organization and providing not only the financial resources but also foresight to bring in expertise to contribute to the overall success. The outside expertise included entities such as the Institute for Healthcare Improvement and IDEO, a firm specializing in innovation, to assist with quality and process improvement. One of the most important lessons in this section was the visioning process. This process unified leaders and care team members and set the stage for guiding principles and decision making throughout the course of the project.

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Laying the Tracks

This section of the book describes the nuts and bolts of the project from design to implementation. It includes descriptions and strategies for change management, standardization, collaboration, project sponsorship, structure, and governance. Leadership strategically involved key stakeholders from all regions of their health system in each aspect of the project. This included communicating the vision within their own regions and healthcare facilities; selecting the vendor; configuring the system; developing clinical content, training, and deployment; and optimizing the use of the EHR after implementation.

One of KP's most challenging tasks was to build a system that supported 80% of their workflows throughout the entire enterprise. This meant standardization. KP historically was an organization where each region had designed and built its own system. They set up teams to work collaboratively to standardize processes and system requirements and agreed that exceptions would be made only when a strong case was presented. Leadership involvement, frontline support, adopting best practices within, and using evidence-based practices assisted them in establishing common goals to achieve a high degree of standardization.

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Harvesting the Value

Many healthcare organizations who implement EHRs often fail to define what success would look like through proactive definition of quality indicators that could later serve as measures to be monitored and improved over time. This is probably the most important section of the book (and their project). They describe how they set up their information technology system databases and reporting capabilities to collect data on clinical quality, patient safety, patient access and engagement, care delivery, cost, operations, and research. They then were able to use those data to produce quality dashboards and benchmark internally and externally. They translated their index scores and rate data to more understandable terms of "numbers of lives saved" and "number of patients where harm was prevented," which resonated more broadly with staff and patients.

A well-designed EHR and sophisticated databases and reporting tools allowed them to be a data-driven organization, and therefore, they were able to improve the care and outcomes of specific patient populations over time. Examples of this include embedding evidenced-based care pathways into the EHR, monitoring concordance, and proactively developing systems to reduce the variation in care delivery or treatments and/or to simultaneously reach out to patients where gaps in care or variation in practice occurred and ultimately improve outcomes. Several other examples of innovative approaches to care are described and resulted in quality and process improvements; increased provider, patient, and family satisfaction; and positive financial outcomes.

The implementation of a patient portal is also presented with the intent of increasing patient engagement in their health management. They discuss principles governing patients' health data access, items to include in the patient portal, their approach to implementation, and the adoption, satisfaction, and usage throughout the organization.

Patient safety aspects of the EHR implementation are also highlighted in this section. KP shares its approach and guiding principles used to improve safety, minimize variation, reduce reliance on memory, improve access to information, flag harm, use force functions, facilitate follow-up, and engage the patient as a partner in safety. The safety initiatives they implemented included closing the loop on laboratory and test results, computerized provider order entry, and bar coding for a closed-loop medication administration system. They also describe triggers to alert providers to potential harm. Examples of this are medication alerts such as drug-drug interactions, duplicate therapy checks, and dose rate monitoring.

Last, the authors describe the vast opportunities this new and expansive data set offers because of the EHR implementation. The implications for improved KP member health and satisfaction as well as the contribution to overall public health are discussed, given the power of the data now available for analysis and use in the future.

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Future Directions

The final section of this book is dramatically forward thinking. The authors describe a vision and plan of how the combination of a well-designed EHR database and a mathematical model will enable us to select a setting, a target population, interventions, and a report design, and then pressing a "calculate" button gets the answer within minutes to the question posed. This technology would allow the user to change conditions and assumptions and rerun the data as needed. Historically, research like this would take years and thousands of manpower hours. The possibilities and positive implications for improved healthcare seem endless with tools such as this.

In summary, this book is incredibly informative and instructive. KP's experience can truly serve as a blueprint for organizations embarking on implementation of an EHR and/or transformation in their organizations. It is a description of healthcare transformation and reformation, at its best. As Don Berwick (administrator of the Centers for Medicare & Medicaid Services and former president and chief executive officer of the Institute for Healthcare Improvement) writes in the book's foreword: "The story of KP HealthConnect and its impact on the delivery of safe, effective care is dramatic and compelling-hopefully, a glimpse of the future."

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1. Liang LL, ed. Connected for Health: Using Electronic Health Records to Transform Care Delivery. San Francisco CA; Jossey-Bass, 2010.
© 2011 Lippincott Williams & Wilkins, Inc.