ACCOUNTABILITY Sub-menus let OR nurses record whether cases are delayed by surgeons, anesthesiologists, nurses or something else.

The University of Texas Southwestern Medical Center in Dallas was ahead of the curve when it came to EMR implementation, thanks in large part to Robert Foglia, MD, division chief of pediatric surgery and surgeon-in-chief at the children's hospital, who has led his facility's digital efforts since 2006. We caught up with Dr. Foglia to talk about overcoming initial obstacles and the progress UTSMC has made since.

Q: How much resistance was there when you began to implement the system?

A: Almost everyone understood that we were going to move to an EHR, so there wasn't a tremendous amount of resistance. As you'd expect, we had 10% or 20% of people who were early adopters. Then, as things moved along, a majority got onboard. We also had some people who were curmudgeons. The anxiety-provoking part is before you get started. The hospital did a good job of setting up some training programs and modules. That helped.

Q: What were the "curmudgeons" anxious about?

A: The prevailing misconception is that it's going to be unwieldy. It's going to slow me down. Most people don't like to change. Surgeons have been using a paper chart for 10 or 20 or 30 years and they know where the progress notes are, where the laboratory data is, and so forth.

Q: Did those fears turn out to be unfounded?

A: Sometimes it's harder to find things. Our software vendor told us that our workflow and efficiency will decrease for about 4 months as you begin to use it, and that if you see 16 people in your clinic every day, the first couple of weeks you ought to see 8 or 9 and then gradually ramp up.

Q: Were things rocky at the beginning?

A: Yes. The first year you spend trying to learn how to use it. Then, at about the end of the year, you have an aha moment: Oh my gosh, we could use this effectively.

Q: Are there other issues you're still dealing with?

A: If the program crashes, you have to have a contingency. We had a crash about 8 months ago and people didn't know how to bring people back to the operating room because there was nothing documented. You have to have a mechanism that lets you switch over to paper at that point. Some can't type, but the counter to that is that most people can type and the clarity is far better than trying to read someone's chicken scratch. We now use a voice-recognition program called Dragon, and it works pretty well. Another problem is that unfortunately, people sometimes cut and paste. So instead of getting all the information from the patient or the patient's family, they'll cut and paste somebody else's information. That's problematic in that mistakes can be carried over.

Q: How did the EMR help improve your on-time start rate?

A: For many years, we were looking at on-time starts in a binary fashion. A case either started on time or it didn't. But by 2010, we realized we could put some sub-menus in and have the OR nurses record whether the case was delayed due to the surgeon, the anesthesiologist, the nurse or other. Then we could collect that data, bring it back to our service chiefs and they could talk with the people who were responsible. What we found was that a very small number of people — 5 out of 71 surgeons — accounted for about 30% of the delays. That becomes very powerful when you can bring that data back and show people. Surgeons and anesthesiologists are pretty competitive, and none of them want to be thought of as the tail-dragger. So initially we showed the information at our OR Executive Committee meeting, and then we started socializing the data by publishing it and putting it up in the main OR and the OR lounge.

Q: Could you compile that kind of data before the EMR?

A: We'd thought about it, but everybody thought it was going to be too labor-intensive. Our software lets us do an extract transfer load — a data dump, if you will. So if I had a surgeon in my office right now, with 4 clicks I could show not only the block utilization for his service for the month, I could also show the block utilization for each of the surgeons in his group of 10 people, and I could break it down by days of the week. Trying to do that stuff by hand would have been a bear.

It becomes very valuable. We have a rule that if your block usage is more than 10% below the mean for 3 months, your time can be reallocated. Now we can look and see that on certain days your block goes to 5 o'clock, but that you very infrequently go beyond 2 o'clock. We ended up having an initiative where we cut 180 hours of block out in a month's schedule, which resulted in a big savings on the labor side with staffing. And when people saw the data — this is scary — we got absolutely no pushback from the surgeons.

Q: What kind of pushback did you used to get?

A: Let's say you have 10 general surgeons doing lap cholecystectomies, and you separate them out by quartile in terms of cost of equipment. Then you go to those in the most expensive quartile and try to pull those people down to the mean, and ultimately you try to pull the mean down to the most frugal group. Of course the most expensive group will say their patients are sicker. Oh, gee, I hadn't thought about that. Let's take a look. No, it turns out they're not. So they'll say, well, my outcomes are better. You diplomatically say: Gee, I hadn't thought about that either. Let's take a look. And no, the data is clear: They're not having better outcomes. Of course you have to be absolutely sure about the data integrity. If you show me 5 pieces of data and I identify one as incorrect, it poisons the other 4.

Q: These are the kinds of initiatives you're undertaking now that you couldn't do before?

A: Yes, we internally benchmark now, and we want to externally benchmark with some of the other children's hospitals on operations issues and costs. You want to get to the point where people want more information. We're finding that a number of the surgical chiefs are asking for more and more, which I think is a major step forward. They're becoming much more proactive. You're getting people engaged and other people are seeing it and wanting to do the same thing.

Q: Where do you go from here?

A: We're learning more and more. We're probably using 10% of the system's capability. With the stuff we've tried to improve on here, we're maybe 35% to where I want to be. Going forward, almost everything we do is going to be done electronically. We'll be able to provide better and better care by looking at case-mix index, the acuity of patients and so forth.