The administrators at Cone Health knew they were in need of transformational change. A large North Carolina network with six hospitals, a plethora of outpatient centers, and more than 75 physician practices, Cone recognized the necessity of a technology-driven solution to address the reality all providers on the frontline of health care have always known — the strong, vital correlation between access to lifesaving information and quality of care. Tapping into this information to understand the nuances of a patient’s condition can make all the difference, particularly in an emergency situation.

Understanding the shortcomings of the current systems and taking action on resolving them wasn’t nearly enough. While it’s true that broader use of IT holds the potential to help clinicians connect the dots and make better decisions, effectively harnessing today’s sophisticated electronic medical record (EMR) systems — and the people behind them — is an outcome that doesn’t come about without difficulty. Where technology leaves off, the human condition picks up and raises a number of challenges, from crafting well-mapped workflows to training physicians and other users to flex the system to its highest potential.

Steve Horsley, Cone Health’s Chief Information Officer, understood these potential impasses early on and has smartly taken the long view regarding successful IT integration on its new EMR system. From the outset, he says, “We knew we were dealing with much more than an IT project.” Horsley notes that progress has happened “in stages over time,” crediting the considerably evolved state of their current EMR system to “an organizational initiative for transformational change. Organizations that just make this an IT project will fail.”


Cone Health decided early on to put the responsibility for technology-enabled transformational change in its rightful place — with site presidents and their management teams. “We already had done culture work with Insigniam in our organization that helped create strong accountability and better teaming between work groups,” says Horsley. “That coincided with our next-generation EMR development and implementation. We had a foundation for transformation that we were able to build upon.”

The employees and leaders of Cone Health knew that, while they may have had mixed feelings about the new technology, delivering exceptional, leading-edge care depended on them embracing change at all levels. “The right kind of culture is critical and essential for this kind of transformation,” says Shideh Sedgh Bina, Insigniam’s co-founder. “Unless the culture has very strongly aligned leadership that has in turn mobilized the workforce to build a bold, inspiring future, established deep tracks for cross-functional collaboration, and instituted clear structures for accountability and execution, the implementation of a game-changing technology like an EMR system is doomed.”

Putting structure and form to the foundation began by creating Site Planning and Adoption Councils (SPACs) to drive organizational leadership and change management. Horsley says it was the initial work through these cross-functional councils that drove the agenda, leading to a true change management strategy. “We realized that we had to help everyone understand what would be different if the strategy was to be successful,” Horsley states. “We also knew that the organizations had to own their part of it and celebrate their wins.”


A key variable to make the strategy work was winning physician support. The changing workflows were dramatically different for them, and it was clear that their questions and concerns had to be addressed. The biggest changes were in the areas of order entry and documentation, where “it’s quicker to scribble on a piece of paper or give a verbal order, versus taking the time to enter it online,” Horsley explains. “When you are trying to get information in a structured way, it changes the burden. Training is a huge part of proactively answering these questions that arise.”

However, from the first “go-lives,” it became clear that to get more physician engagement they needed to reduce physician time in the classroom. For a practicing physician, time in a classroom not only means a reduction of their incomes, but more significantly, it means being unavailable for urgent patient needs. To accommodate the physician schedules, they increased what Horsley calls “training at the elbow,” coaching physicians as they go about caring for patients. Meeting these demands called for a new team of health informatics professionals, which Cone calls Informaticists. Essentially tech-savvy clinicians, they provide hands-on training, while also optimizing workflows and managing system redesigns. Two operational hurdles that immediately landed on their radar involved changes in the way appointments were scheduled for surgeons and more structured systems for increased data input that utilized system-wide voice dictation software. The Informaticists stressed the integrated nature of the EMR system while helping the physicians feel comfortable with an organized, logical process flow to view and enter information. Just as importantly, ongoing training to reinforce these changes and compensate for workflow improvements has eased the real-time implementation of processes during the transition.

Cone’s intensive effort to help its physician population become more efficient on the EMR is working. In a recent survey, 33.14 percent of responding physicians indicated that they are “doing fine” using the new system, with another 43.02 percent responding that they are “comfortable, but need to improve their speed.” Another 20.35 percent say they “have the basics down, but need help,” while only 3.49 percent indicated they are “struggling with the basics.”

For the approximately 25 percent who still need more help, Horsley says Cone has already launched what it is calling an “optimization project.” This involves more “at the elbow support” to assist providers in becoming more comfortable with the system and looking for ways to streamline their workflows.


The hospital began seeing the payoff of improved patient care almost immediately upon launching its broader EMR implementation. “From day one of launching the EMR system, we were preventing medical errors,” he explains, citing an example where the system alerted a nurse to a patient’s medication allergy, despite it being missed by other means. “Fortunately, the bar-coding system flagged the error, prompting the nurse to contact the physician and receive new orders.”

Similarly, the health information exchange component available in the new EMR system also has proved particularly helpful in Cone Health’s emergency departments (ED). “We are able to get records from other health care organizations when a patient presents in our ED, which helps us make better decisions,” he explains.


While Horsley says it is gratifying to see the strides that his hospital system has made through the broader use of IT, he has a clear picture of the challenges that lie ahead, in particular around revenue cycle management. “We need to change old processes to optimize the new system,” he explains. “You can’t lay technology over poor processes and expect to get good results. They need to be overhauled.”

The irony, he adds, is that revenue cycle, while not directly connected to patient care, “does impact how patients feel about us.” This impression isn’t always positive given poor cost estimating and multiple bills for services. “We are consolidating where we can, but it is a lofty problem,” he says. “Billing systems for a lot of the services are separate.”

As the health care industry continues to rapidly evolve, Cone Health has built a sturdy foundation based on IT integration — with the understanding that the process is still in its infancy. “This is just the beginning of more transformation to come,” Horsley states. “This is not the end game. This is the beginning.”

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