Porter struggles with electronic records system, sees big cost overrun

MIDDLEBURY — Porter Hospital has fallen behind in its multi-year effort to implement an electronic medical records system designed to improve patient care by replacing outdated paper recordkeeping.
Officials at the Middlebury hospital said they underestimated the technical complexity of rolling out new computer hardware and software to the institution’s various departments and 11 physician’s practices around the county, and they misjudged the speed with which they could get staff up to speed on a system that introduces not just procedural changes but also cultural ones.
In total, the hospital and its practices provide primary care for at least three-quarters of everyone in Addison County.
“I can’t think of anyone who is not affected by this, it changes just about everything,” said Porter Vice President Jean Cotner. “Electronic medical records replace manila folders. That changes how communication happens, how we document patient care, how we interact with the patient and with each other.”
The delays in the project have resulted in an estimated cost overrun of 63 percent. The hospital budgeted $4.3 million when the project was initiated in 2010; late last week the state regulator approved a plan to spend $7.1 million on Porter Hospital’s health information and electronic medical records system, known as an HIS/EMR.
In approving the spending increase, the Vermont Department of Financial Regulation chastised Porter management, but said it would not fine the hospital because it would only harm Porter’s ability to provide good health care.
“It is impossible to order Porter to remove its HIS/EMR system and it is impossible to recover the money it has spent,” said DFR Commissioner Steve Kimbell, “and fining the hospital … would be counter-productive.”
Kimbell did require Porter to submit monthly reports on the progress of the project, which is now slated to be finished in  the middle of 2014.
Porter originally got the go-ahead from regulators in 2010 to begin the project, which in part was encouraged by changes in funding from the federal government. It also fits into the Vermont Blueprint for Health, a state-led initiative to integrate patient information, improve patient care and reduce overall health care costs.
It began by installing the MedHost software in the emergency department and the MediTech software in other parts of the hospital. It accomplished some of the goals, like making it easier for doctors in the emergency room to view and update patient status on a big computer screen rather than with a marker on a white board.
But hospital officials found that there was a lot more hands-on work getting the software customized to the Porter environment than they had assumed. Cotner and Ron Hallman, Porter’s vice president of public relations, said they spent a year doing things like creating a standard dictionary of terms for the physicians practice software and defining the steps in the software that would mirror or improve the processes in handling patient information.
“One of the early criticisms is that the MediTech folks would hand you a box and say ‘Good luck, do you have any questions?’” Hallman said.
As the complexity of the big information technology project came to light, Porter hired David Frazier, an IT consultant with Dell Systems who has extensive experience in health care, to take charge as project manager last June.
“We realized that we needed somebody at the top of the pyramid to co-ordinate all the components,” Hallman said . “The buck stops with him.”
Frazier works onsite four days a week, and Porter recently extended his contract for three months.
The goal now is to get all of the systems in the hospital operational by the end of September. Porter Cardiology plus five of the 11 medical practices have the new IT system up and running, including Addison Family Medicine, Bristol Internal Medicine, Little City Family Practice, Neshobe Family Medicine and Porter Internal Medicine. The other practices will go online beginning next fall with completion by mid-2014.
But simply getting the old stuff to work with the new is time consuming. Once the processes were defined, just transferring data from paper records to electronic ones continues to take many hours.
“We have 80 years of patient history in some of these files, and we have to decide what to scan and what will be useful,” Hallman said. “There may be 200 pieces of paper in a file, and it takes 90 seconds to scan each one, and there are 11 medical practices.”
And training doctors, nurses, technicians and front-office staff is no trivial matter.
“The whole thing of going to a new system requires a lot of culture change,” said Porter CEO James Daily.
Porter did a lot of training, including providing online applications that would provide staff five-to-10-minute lessons on some aspect of the new system. Extra technical help is available onsite at the doctors’ offices for the first few months after the system goes live.
Nevertheless, Porter found that the productivity of doctors took a big hit each time the software was rolled out at a new practice. Learning the standardized procedures and changing their habits takes times for all those involved. Officials said it has not been unusual for a doctor who normally saw 20 patients an hour to be able to see only 10 or 12 once the productivity-enhancing software was introduced. Returning productivity to previous levels and better is a priority, Daily said.
That hit, combined with the unfortunately timed loss of some physicians due to professional career changes, led to all of the Porter practices to discontinue accepting new patients for a time over the past two years. Cotner, who oversees the affiliated doctors’ offices, said some of the practices are once again accepting new patients now.
Although one overall goal is improved patient care, Cotner said patients have felt the implementation of the new systems for good and bad. Some patients had to wait longer than usual to see their doctors, she said, while others braced themselves for the change but found it remarkably easy.
And hospital staff said strides have been made. Prescriptions are being filed to the pharmacy electronically now. Doctors are getting the results of lab tests sent directly to their electronic devices rather than having to hunt down the results in a paper file, Hallman said.
All those involved say the hospital has done all it can to maintain the quality of care.
“It’s been like trying to fix an airplane while it’s still flying in the air,” Hallman said.
Ultimately it is hoped that getting medical information into electronic databases will slow the increase in the cost of health care. But Porter and the regulators had to decide how to pay for the $2.8 million cost overrun. Daily and Porter Medical Center board chairman Bill Townsend said that after the need for extra funding came to light in the fall of 2011, Porter approached Commissioner Kimbell and began a conversation.
Daily said the cost overrun will be paid for out of the $69 million budget approved by regulators last fall. Some of the money originally slotted for capital expenditure and reimbursements for certain pharmaceuticals will make up the difference, he said.
Townsend said the boards of directors that oversee the hospital take some blame in the cost overruns and they are taking steps to improve their governance structure and clarify responsibilities. He acknowledged that mistakes were made, but said none of it was intentional and he didn’t expect anyone to lose their jobs.
“This has been a difficult experience,” he said.
Daily said they are committed to addressing the rise in health care costs and improving patient care.
“This is required of the future, for the health of our patients,” Daily said. “There may come a day when you are on vacation in Florida and, god forbid, you get sick, and the doctors there will be able to call up all your records and see all your allergies.
“We’re seeing better communication and coordination … It’s up to us to find a way to make this work.”

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