Upgrading Infrastructure: The roll-out of electronic health records

By Joey Kragelund & Douglas Whiteaker

Healthcare facilities are among the most infrastructure-intensive building types. Integrated mechanical-electrical systems, fire safety and security systems, medical equipment and communication networks promote patient safety and operational efficiencies. Federal, state and local codes regulate virtually everything within a facility — from the physical structure to operational processes to patient care. All this is with one goal in mind — improve patient care and safety.

As such, healthcare facilities are essentially “organic” machines, humming rhythmically while continuously evolving with changing codes, technology and care-delivery methods — always undergoing renovation and expansion to meet new demands.

In this state of continuous facility evolution, healthcare organizations face new challenges as they upgrade — and in many cases, implement for the first time — comprehensive electronic health records to meet federal mandates under the Affordable Care Act.

Because of the technical complexity of healthcare facilities, healthcare organizations have always been on the leading edge of medical technology. Yet the adoption of electronic health records has varied from provider to provider over the past decade. Many healthcare organizations started small in such areas as electronic imaging, and slowly integrated more comprehensive EHR systems as technology advanced. The pace of EHR integration has accelerated over the past five years, with the ACA giving a final push for all organizations to be fully operational by 2014 or face potential fines if they fail to meet EHR standards by 2015. The American Recovery and Reinvestment Act, in fact, has given some organizations a head start by channeling funds toward healthcare organizations adopting EHR systems.

As technology becomes more mobile, the patient and physician benefits of EHR become clear. In a large, integrated healthcare system, for instance, patients can often access secured records from mobile devices or home computers as they communicate with their physician or pharmacist from a remote location. Doctors and specialists can share patient statistics across locations for diagnostic purposes. In rural locations, electronic health records help bridge the geographic distances between locations, often enabling patients to stay home while receiving consultation.


System-wide infrastructure upgrades
Developing an integrated, facility-wide EHR system is largely a matter of infrastructure upgrades, starting with routing new cabling and wiring, installing power and data outlets, enabling Wi-Fi access and identifying information technology rack closets.

Yet because many healthcare facilities are complex, multichannel organizations that have grown incrementally over the years, a building’s existing infrastructure often poses challenges to seemingly simple cabling upgrades. State and federal codes, for instance, often stipulate that if a new system touches an older system, the older system (or room) and path of travel must be upgraded to meet current codes. The IT closets also pose challenges as the architect identifies appropriate locations — usually within found space such as occupied offices or existing utility closets or even required storage spaces — and then monitors potential heating-cooling loads to determine HVAC upgrades as necessary. For most facility owners, conducting a building analysis beforehand will help minimize cost escalation and surprises as a project progresses.


Case studies in implementation
To better coordinate care between patients and caregivers and to meet consumer demand for increased connectivity, not-for-profit Sutter Health began implementing the Sutter EHR, an integrated electronic health record system in the late 1990s. The healthcare network initially focused on implementing the Sutter EHR in its medical foundations (physician and outpatient organizations), with the first go-lives at physician offices in Davis, Los Altos and Modesto, Calif. in 1999. By 2012, all five medical foundations throughout northern California were live with the Sutter EHR. Nearly 1 million patients have opened accounts that provide online access to their personal medical records.

In 2008, while in the midst of its medical foundation implementation, Sutter Health began a phased roll-out of the EHR system across its entire network of hospitals and other facilities, starting with Mills-Peninsula Health Services in Burlingame and San Mateo, Calif. Today, Sutter Health has implemented the acute care version of the Sutter EHR in 15 facilities, including all four campuses of California Pacific Medical Center in San Francisco and Alta Bates Summit Medical Center in Berkeley, Calif. and Oakland, Calif. More than 20,000 healthcare professionals use the Sutter EHR to provide care to patients. Sutter Health will continue rolling out the Sutter EHR to its acute care facilities throughout California including Novato, Lakeside and Santa Rosa in 2014, and complete its system roll-out with the Greater Sacramento area in 2015.

Together, Sutter Health and its architect, HGA Architects and Engineers, developed a process map from the earliest phases of defining EHR through design, construction, clinician and staff training, implementation and go-live. With the support of contractors Unger Construction and Rudolph and Sletten, the team designated a Core Group to drive the planning and leadership of the project. This group also developed comprehensive documentation of all the required project steps, including code compliance and cost estimating for the State of California Office of Statewide Health Planning and Development approvals process before design started. The Core Group also used Lean methodologies to facilitate decision-making for topics as varied as selecting locations of new IT closets, selecting general contractors early in the design process, use of weekly commitment logs and pull-planning sessions with all the stakeholders to determine how to collaboratively meet or beat the deadline.

On another campus in southern California, the Los Angeles County Department of Health Services followed a similar approach to implementing its electronic health records information system. The Los Angeles County DHS provides acute and rehabilitative patient care, trains physicians and conducts research through affiliations with the University of Southern California School of Medicine and UCLA School of Medicine at four hospital sites (Harbor-UCLA Medical Center, LAC+USC Medical Center, Olive-View Medical Center and Rancho Los Amigos National Rehabilitation Center) and several community-based health centers.

Part of a system-wide EHR upgrade program, the eight-story Harbor-UCLA Medical Center and its 14 ancillary buildings (a mix of converted army barracks from its days as a U.S. Army base to newer medical office buildings) serves as a prototype scheduled to go live October 2014. The implementation process involved a campus-wide architectural and engineering systems analysis of existing mechanical, electrical, wireless and data conditions; detailed EHR construction documentation; OSHPD and Building and Safety permit construction documents and identifying flexible adjacencies for phased construction without disrupting operations. Central to the EHR upgrades is a new heating-and-cooling tower to handle the increased loads from the newer IT closets and equipment.

As more healthcare organizations implement system-wide electronic health records to meet federal mandates, owners will face similar challenges — integrating newer systems with existing systems, meeting state and federal building codes, phasing construction while remaining operational, ensuring patient safety and comfort during construction and establishing an attainable go-live date. The benefits of electronic health records will increase as mobile technology and other electronic communication systems continue to impact the healthcare industry. A well-planned implementation process between owner, architects, engineers, contractor and other stakeholders helps achieve a successful go-live date.

Illustration: Giovanni Meroni/istockphoto


Author: Joey Kragelund & Douglas Whiteaker
Joey Kragelund, AIA, is associate vice president and healthcare principal with HGA Architects and Engineers in Los Angeles, Calif. Douglas Whiteaker, AIA, LEED BD+C, is associate vice president and healthcare principal with HGA Architects and Engineers in Sacramento, Calif.

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Posted February 1, 2014

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