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Project Success, Connecting Care

In 2003, as part of ongoing strategic patient-safety initiatives, Cottage Health System set out to develop an electronic health record (EHR) that could support the unique needs of a multi-entity environment and teaching hospital.

Our not-for-profit, community-based health system � formed in 1996 with the affiliation of Cottage Hospital in Santa Barbara, Calif., with nearby Goleta Valley and Santa Ynez Valley Cottage Hospitals — sought to provide clinicians with secure access to patient information. This commitment included providing remote access to speed patient care and streamline the workflow of our 540 medical staff members.

Currently, approximately 27 full-time-equivalent employees in the information technology (IT) department manage — from a centralized data center at Santa Barbara Cottage Hospital — all sites within the larger organization. With our small IT staff, we do not conduct any software development in-house and we routinely outsource project-management resources. With this approach, IT has conducted highly aggressive deployments of clinical applications as we progress toward completely Web-based applications in Cottage's high-touch, high-tech environment.

Information technology solutions and processes have been standardized to all locations. The 1,100-plus workstations deployed across the health system offer a standard desktop for the system's 2,500 health care professionals, who manage more than 20,000 admissions, 100,000 patient days, 60,000 emergency visits and nearly 80,000 ambulatory visits each year.



An EHR can provide measurable benefits that reach beyond monetary terms. Additionally, an EHR can take many forms, from optical archiving of the paper medical record to online documentation and access. For Cottage's EHR project, we sought to achieve a measurable increase in patient safety, improve efficiency and workflow, and achieve greater system acceptance and utilization and a higher rate of compliance with organizational policy and regulations among our user community.

A clinical documentation system, in place since 2000, provided universal, online access to results and documentation — including all nursing documentation. Additionally, a 1998 PACS implementation helped the health system become completely filmless.

With these systems, we wanted to improve clinical workflows and provide system-wide computerized physician order entry (CPOE) as the foundation of our EHR initiative.

To provide that foundation, we selected Sunrise Clinical Manager from Eclipsys, a company with a solid history of helping us to deploy and standardize IT across the health system, including our clinical documentation and financial information systems. The financial systems, for example, have helped us reduce average billing holds from $10 million to less than $1 million. We've also increased average monthly collections from $14 million to $21 million, and reduced net days receivables outstanding to 67 days.


Multiple applications

In addition to CPOE, our EHR plan included new emergency department (ED) documentation and fetal monitoring solutions from other vendors. Thus, it was crucial for IT to be able to manage multiple applications, multiple users, diverse clinical workflows and diverse user interfaces.

We achieved one level of integration using an interface engine and the HL7 standard. We reached another level of integration by standardizing the workstation environment, which provided access to all applications from a common desktop. At that point, clinicians asked us to reduce the number of sign-ons and passwords necessary to access the information they needed to document patient care. As we worked to determine the best way to make the set of systems user-friendly, it became clear that we needed a means to improve application-to-application navigation and minimize the steps required to maneuver between systems — all without compromising security.

A recommendation from our clinical systems vendor led us to our solution: single sign-on and context management from Sentillion. This solution would provide a Clinical Context Object Workgroup (CCOW)-compliant solution that would enable context sharing and provide a single point of entry to the clinician desktop and clinical applications.

Implementation of the single sign-on product was fairly simple. The solution didn't require alterations to basic code or functionality of any participating systems, an important factor in our decision. However, it did require compliance from the vendors representing the various applications. Each participating vendor had to enable CCOW in a manner defined by Cottage. This meant that user authentication would be driven by Microsoft's Active Directory and all applications would set and follow patient context.

As we expected, introducing single sign-on has improved workflow by reducing the time it takes to log on to applications and the time it takes to find patient information. Today, signing on to the set of applications takes less than 7 seconds, where previously it could have taken over 40 seconds — a significant improvement that won over our busy clinicians. The amount of time it now takes to find the complete patient record across all applications is 10 seconds, down from nearly a minute prior to the implementation.

Compliance of caregivers signing off of the systems when they have completed their session has risen as well. Today, 55 percent of all physicians sign off the systems themselves, with the others signed off by other clinicians. Previously we had no compliance in this area. Additionally, 100 percent of all other clinicians sign off the system when their session is finished, up from 60 percent. Clearly, this has an important impact in both confidentiality of patient data and the demands placed upon our information system as a whole.

And, of greater importance, single sign-on and user and context passing to the systems comprising our EHR has improved patient safety and care quality. We're dramatically reducing the potential for avoidable medical errors that could be caused by reviewing or inputting data on the wrong patient.

By providing secure remote access to the Cottage EHR from appropriate clinicians' offices or homes — or virtually anywhere else they have Internet access — the clinicians have come to rely on the system as an integral part of their patient-care "toolkit." In particular, use of the CPOE system has risen significantly across our organization. Ease of use and access — coupled with new remote-access capabilities — have dramatically improved the value of our IT investment to our clinicians, patients and the health system.

Having achieved navigation among the disparate systems comprising our EHR, Cottage Health System measures the competitive impact in two key areas: (1) safeguarding patient safety and confidentiality while (2) improving workflows that help us improve satisfaction and our ability to acquire and retain the best caregivers. The resultant workflow and safety improvements also support our ability to provide a superior level of care cost-effectively and have positioned us for further development of the EHR at Cottage Health System.


Mr. Kywi is CIO of Cottage Health Systems. He can be reached at

Source:  Vol. 11 •Issue 6 • Page 16 , Project Success, Connecting Care, Single sign-on meets clinicians' challenge to keep things simple as part of Cottage's 'high-touch, high-tech' commitment,

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