Good things come to those who wait. “Ten years later we go back to the market and see the type of technology we envisioned,” remembers Bertram Reese, Sentara's senior vice president and chief information officer. After working up the possibilities, he reported to the CEO, “David, it's going to be better than you ever imagined. Technology has moved that far.”
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And Sentara has moved far with the technology. Less than five years after selecting Epic Systems Corp. as the vendor for an electronic health record, the Norfolk, Va.-based system, now known as Sentara Healthcare, landed six of its eight hospitals on an elite list of facilities judged to be at the highest possible level of EHR sophistication and completeness. For the remaining two hospitals, Reese says it's only a matter of implementation time before they go live at the same Stage 7 status awarded the others by HIMSS Analytics, the market research arm of the Healthcare Information and Management Systems Society.
Sentara's plans called for more than a year's worth of improving 18 major healthcare processes before the IT design work got seriously under way, the software reflecting all the newly streamlined routines. The first hospital went through a careful, measured implementation to accomplish Bernd's desire to “build once, roll many”—with computerized order management handled separately after all the other parts of the system were in place.
Before the last implementations were scheduled, the clinical and business benefits from the first ones started rolling in. In 2009 alone the use of the EHR accounted for clinical cost avoidance, operational savings and additional revenue totaling $29 million. That amounted to more than a 10% return on investment that over 10 years is expected to total $270 million.
The highly developed EHR and clinical communications system, dubbed Sentara eCare, brought new and different IT capabilities to Sentara's 20,000 employees, but the use of IT itself in the clinical setting had been in the system's portfolio for improving clinical and business effectiveness since the 1980s.
“We've always taken sort of a different approach to IT, going back 10, 15, 20 years under Bert's leadership,” Bernd says. “It's always been a strong part of our strategic performance and strategic planning.”
Incremental IT improvements over the years helped drive clinical results that put Sentara high on prestigious lists of top integrated health systems and best-performing hospitals, plus the Eisenberg Patient Safety and Quality award in 2005.
“Dave will tell you that clinical quality will eventually equal economic vitality,” Reese says. “You just have to have the tenaciousness to go look for where that is.”
Bernd, 60, has had decades to perfect that approach at Sentara, where he was first hired as assistant administrator at Sentara Norfolk General Hospital in 1973 after earning his master's degree in hospital and health administration from the Medical College of Virginia. He became executive vice president and chief operating officer of the Sentara system in 1985 and CEO in 1994.
His top officers are similarly tenured: Howard Kern, president and COO, joined Sentara in 1980 and Reese a year later. The way Reese describes the executive interaction on initiatives involving IT, “Dave envisions it; he gives us the rudder underneath it. I do the details and Howard keeps me on track.”
The notion of a systemwide EHR had become an established goal of IT in healthcare by the early 2000s, but the high cost and risk of such a venture hung in the air.
“When David got up and said, ‘We need to do this, and it's going to cost over $250 million,' there were a number of deep breaths around the table. We can build a 200-bed hospital for that,” says Marc Sharp, chairman of the Sentara system board of directors since last November and a board member when Bernd and Reese presented the blockbuster proposal.
“He had guts,” says David Levin, vice president of medical informatics and a family-practice physician. “This was a courageous thing to do in 2005; it still is in many ways.”
Sharp says Bernd's articulation of a solid game plan helped get the board quickly behind it. “The combination of David Bernd explaining the business case and Bert Reese explaining the technology and what we were getting for the money, it was a very dynamic duo,” he says. “I think it really only took one meeting.”
Bernd's insistence on calculating a total cost of creating, managing, rolling out and tracking benefits of the project over a 10-year period also set properly long-range expectations that prevented overreaction to periodic budgetary free-falls or missed milestones.
The capital cost typically associated with an EHR purchase was $67 million, about one-fourth the projected $270 million total cost. Staff time and consulting costs were built in for re-engineering the targeted 18 processes, such as bed management, clinical communications, medication management and emergency department flow.
It was time well-spent, even if it delayed fundamental IT design work by more than a year, Bernd says. “We tied together the outpatient diagnostic areas, the physicians' offices, the inpatient into one software program, that's totally interoperable, and I think that's why we got such great results from our implementation,” he says.
At the six hospitals on the EHR system throughout 2009, Sentara:
- Achieved $9.3 million in benefits related to reduced lengths of stay and a reduction in adverse drug events that can tack days onto hospitalizations.
- Reaped $9.4 million in savings attributed to increased efficiency of nursing units, including a higher retention rate for nurses and its spillover benefits such as lower overtime and contract labor—the most significant costs of nursing turnover.
- Increased the number of outpatient procedures for a dollar benefit of $4.4 million, aided by shorter cycle times—essentially the ability to do things faster and reduce delays.
- Averted more than 88,000 medication errors.
The health system had expected $17 million in return on its investment in 2009; it attained $12 million more than expected.
With the basic benefits of better safety and efficiency now developing a rhythm, the next phase of work is “the ability to mine data—to direct resources where they're needed, to identify problems in care, to identify the best outcomes for different types of procedures and so forth,” says Sharp, the board chairman.
And it's becoming infectious, but in a good way, Levin says. “We're starting to have the problem of so many great ideas (for using EHR data and functions) and so many people who want to move this forward that it's a challenge to sort them out and prioritize them—which is a wonderful place to be.”
