The road to meaningful use of health information technology is riddled with detours, potholes and yield signs. Yet the 2012 H&HN Most Wired Survey proves that hospitals with well-crafted and well-mapped plans can motor their way toward successful adoption.
A record number of hospitals — more than 200 — earned Most Wired status in this, the 14th annual survey, which gauges how organizations are planning for, utilizing and securing information technology across the entire enterprise. While there is a certain amount of cachet that comes with being associated with Most Wired, as with many other lists throughout health care, the survey is less about the designation and more about serving as a roadmap for how hospitals are using IT to transform their organizations. Perhaps the most significant development over the past couple of years is the greater strategic role IT and IT departments now play in hospitals and health systems.
Given the dramatic changes taking place in health care, and the ever-increasing importance of data, IT systems must be more than just plug-and-play toys; they need to be high-powered analytical tools that can deliver real-time, actionable data to clinicians and executives alike.
"It's probably been in the last 24 months that we've seen the conversations become more strategic," says Rose Higgins, vice president of payer and provider solutions at McKesson, an information technology firm and sponsor of the H&HN Most Wired Survey. "Organizations are having conversations around their strategic imperatives for the next three to five years: What kind of organization do they want to be and how can they sustain that in the long run? People are very focused on IT's laying the groundwork and foundation."
Driving toward value
So much of the focus on information technology over the past year or two has been on clinical applications — computerized provider order entry, clinical decision support, health information exchange and more — and the potential to improve patient safety and create greater efficiencies. That's in large part due to the federal government's push to digitize health care and to regulations governing meaningful use. But officials at Most Wired hospitals note that their emphasis goes beyond what's prescribed by those mandates. "It's not just about meeting the letter of the law. It's about meeting our definition of meaningful use," says Timothy Sullivan, M.D., a family practice physician at Thayer County Health Services, a rural health system in Hebron, Neb. Sullivan championed IT adoption at the 19-bed critical access hospital and its clinics.
While that definition varies from organization to organization, it almost always includes a focus on value and data. The dramatic shift to a value-driven delivery system, where reimbursement is much more aligned to quality measures and outcomes, demands that IT systems are used to promote evidence-based care and, at the same time, provide executives with a holistic view the organization's operations. Health IT is "fundamental" to the success of a value-driven system, says Tara Jones, vice president of acute care services and chief information officer at Vanguard Health Systems, headquartered in Nashville, Tenn.
"Until recently, we've been in the era of getting data into our HIT platforms," says Joe Boyce, M.D., chief medical information officer at Heartland Health, St. Joseph, Mo. "Now, the fun part of getting knowledge and wisdom out — evidence-based care, actionable alerts, patient engagement, population health management dashboards and real-time decision support at the point of care — is taking center stage. The conversations are changing from 'Why are you making me do this?' to 'Can it do that?'"
Setting the standard
The accompanying charts show areas in which the Most Wired are excelling in their use of IT for operational efficiency, patient safety and patient satisfaction, along with significant advances in security protocols. Although the year-over-year data show gains in areas such as CPOE and medication management, it does not mean that everything is on a glide path. There are still significant hurdles, especially in relation to some core meaningful use criteria. Hospitals continue to struggle to record patient demographics as structured data, the same for problem lists. That is a major reason several organizations failed to achieve Most Wired status this year.
Chantal Worzala, director of policy for the American Hospital Association, says the survey also points to a need for providers, vendors and regulators to come to terms on standards. "Learning to use standards is an underappreciated aspect of getting to meaningful use," she says.
Standards are instrumental not just to ensure that electronic health records act in a predictable way, but also, ultimately, for the seamless exchange of data between providers. "It is all about the information flow that is going to support more informed, more logical and better care," Worzala says.
Faces of Most Wired
Overall, Worzala says, the Most Wired data show hospitals and health systems are moving in the right direction. "I look at the Most Wired to see where leading organizations are taking the field," she adds. In particular, she's encouraged by the growing use of remote monitoring for disease management and telemedicine. These are examples of the benefits that can be achieved when there is linkage to providers from outside the care setting.
What follows are profiles of three Most Wired organizations that are themselves on the leading edge. Each has a vastly different background and story. One, a critical access hospital in Nebraska, made patient safety the driving force behind its rapid adoption of IT. At a public health system in Atlanta, the IT department is finally viewed as a strategic partner across the organization. And an independent hospital, nestled in the mountains of Southern California with two other competitors, proves that working with physicians can lead to big things.
Rural Nebraska isn't the first place you'd expect to find a hospital on the cutting edge of the digital revolution. Yet in the southeast corner of the state sits a pioneer user of health IT. Joyce Beck, CEO of Thayer County Health Services, in March 2010 became one of the first patients to have a medical record sent over the Nationwide Health Information Network.
Her medical records were transmitted from her home base of Hebron, Neb., to a doctor 1,600 miles away in Healdsburg, Calif., and back again. "It's the coolest," says Beck. "It is the way we need to deliver health care in the United States."
Beyond the cool factor, TCHS, which has a service area of roughly 5,000 people, is at the forefront of utilizing IT to reduce errors and deliver better patient care. But it wasn't always that way. "We were using a legacy system and paper charts, and everybody was griping about how nothing worked well," says Timothy Sullivan, M.D., a family practice physician at TCHS. "Joyce said, 'Why don't you go find something better?'"
So he did. After attending a conference of family medicine practitioners, Sullivan came back to Hebron singing the praises of electronic health records. In 2008, TCHS was awarded a $1.6 million federal grant to implement electronic records within 18 months. That was in addition to $25,000 TCHS had received from the hospital's foundation and guild.
For Beck, going digital always has been about one thing — patient safety. Working with the University of Nebraska, TCHS discovered that in the first quarter of 2004 there were 48 medication errors. "That lit my fire," she says.
Armed with the new financial resources, TCHS charged ahead with implementing its EHR and related technologies. Medication errors plummeted to around six per quarter. Previously, the hospital's medication reconciliation rate was around 23 percent; it now stands at 100 percent for physicians who e-prescribe.
That's not to say that everything is perfect. As with most rural areas, bandwidth is a major concern. Beck says there are also limitations as to what the available software can do. "I always dream bigger than what we can get out of the programs," she says.
Sullivan wishes the technology was more intuitive and user friendly, but he can't imagine going back. "We do have increased patient safety," he says. "It will work even better once people realize that we need physicians on the ground floor designing these systems."
TCHS is on its second technology partner, having started with HMS and recently spending $1.4 million to transition to CPSI.
Three months into her job as senior vice president and CIO at Grady Memorial Hospital, Deborah Cancilla wondered if she had walked into a death trap.
It was 2008 and Grady, one of the largest public hospitals in the United States, was hemorrhaging money. Technology investments weren't even an afterthought. Clinicians were overwhelmed by work and underwhelmed by the level of IT support.
"They had to go through 14 different systems, along with a paper record, to get a complete picture of what was happening to the patient," Cancilla recalls. "The phone system was vintage 1980. We had no ability to troubleshoot problems. Worst of all, the IT department was wounded. It didn't have the training, knowledge or tools to have credibility within the organization."
Later that year, a coalition of state and community leaders threw a lifeline by creating a nonprofit corporation to run the hospital. The Grady Memorial Hospital Corp. board went on to raise $325 million in philanthropic money. While those funds were earmarked for a variety of projects, one of the first major undertakings was to build a strong IT foundation, including a $19 million network overhaul.
Simultaneously, hospital leaders were ready to wade into the application waters. After selecting Epic, the hospital embarked on an 18-month journey to deploy clinical and financial systems. But before the full implementation could happen, Cancilla had one last change to make, and this was maybe the toughest. She turned over nearly 85 percent of the IT staff. She also found a group of physician leaders to champion the digital migration.
Since the go-live in November 2010, there have been ups and downs. Cancilla says that there are challenges getting universal use of order sets. However, 100 percent of orders are done via CPOE.
There's a tangible financial benefit as well. "We have much better information and revenue cycle processes," says John Haupert, who joined Grady as CEO in 2011, noting that collections across all payers have nearly doubled since the pre-Epic days.
And, Grady is working with other major health systems in the market — all but one of which is on Epic — to share health information, including creating some disease-specific exchanges.
"We are taking a leadership role in population health," Haupert says.
Haupert and Cancilla say that IT has earned its way to becoming a trusted business partner to drive change. "IT is seen as one of the leading support services in the hospital," Haupert says.
Building an IT oasis in the California desert | Eisenhower Medical center, Rancho Mirage, California
David Perez knew that it was time to get on the bus, literally. The chief information officer and his fellow executives from Eisenhower Medical Center in the mid-2000s had determined that they wanted the Rancho Mirage, Calif., institution to be a leader in adopting information technology. So they went on a tour of institutions that already had started down that road.
"We learned that it would not be easy," Perez says. "We learned that there were pros and cons to every system. The most important thing we learned, though, was that this had to be something that the whole executive team supported and wanted to do."
Eisenhower's path to going fully digital actually started a few years earlier when in 2002 core information systems such as scheduling, registration and billing were being replaced with an enterprisewide solution. Clinical systems were next in line.
After selecting McKesson as its technology partner in 2006, EMC moved swiftly to deploy the new electronic health record. The medical center has spent $63 million on its IT rollout, including replacing those core nonclinical information systems.
One of the biggest challenges EMC faces is getting physicians to come along, especially since 90 percent of them are independent. And, there are two competing facilities in the area. Most of the physicians have privileges at all three institutions.
"The other two hospitals were lagging behind, which was going to make mandating use of the EHR and CPOE tough for us, because they weren't going to do that," Perez says. "We made it mandatory — with a lowercase 'm.'" Physicians were encouraged to use the system, but were not penalized for failing to do so. Instead, EMC's chief medical information officer worked — and still works — to get them on board. According to EMC's Most Wired Survey, 96 percent of physician orders — inpatient and emergency department — are done electronically.
Connecting with patients is also a big part of EMC's strategy. In 2010, a service linking patients and clinicians launched. More than 210 physicians and 9,500 patients have signed up. Patients can get an e-consult, request a prescription refill or an appointment, receive lab results and more. Patients with chronic diseases can enter self-test results online. They also can update clinicians on compliance with medication therapies via a secure email.
Sustaining progress is one of Perez's biggest challenges. "You have to dedicate resources and time," he says. "You don't want to be penny-wise and pound-foolish."
Data and Analysis
Hospitals are leveraging new communication channels such as social media that offer engaging and supportive programs to enhance the patient experience. Nearly half of Most Wired hospitals use social media for crisis communications compared with one-third of total respondents. More than 25 percent of Most Wired hospitals offer care management messages and chats with physicians. "By developing consumer personalized medicine tools such as our patient portal and utilizing social media, we can create better outcomes through personalization and support for adherence, says John Doulis, M.D., assistant vice chancellor, health affairs, and chief operating officer of the Informatics Center, Vanderbilt University Medical Center, Nashville. "This also supports efforts to reduce readmissions and increase patient satisfaction for patients who are members of the digital generation."
Which social media outlets are Most Wired hospitals and health systems using?
- Blogs - 60%
- Facebook - 94%
- LinkedIn - 61%
- Mobile web app - 38%
- RSS feed - 37%
- Twitter - 80%
- YouTube - 80%
Creating a better patient experience through improved communication, to prevent complications and shorten wait times, has value. High-performing hospitals are hardwiring best practices to improve outcomes and quality of service. Access to real-time clinical information reduces errors and eliminates duplication. Checking drug interactions and drug allergies when medications are ordered is a major step in cutting medication errors; the Most Wired group has fully implemented this clinical decision support system. Nearly two-thirds of the Most Wired hospitals have implemented a compliance-driven alert system for government-required quality measures compared with slightly more than one-third of all responding hospitals.
CPOE utilization results in lower costs and improved quality of care. At Children's Medical Center Dallas, all medication, lab and radiology orders are entered utilizing the CPOE system for 100 percent of patients admitted to the hospital's inpatient and emergency departments. "This reduces duplicate orders and unnecessary tests, which reduces cost of care," says Pamela Arora, vice president and CIO. "The CPOE tests for common serious prescribing errors and automatically sends synchronized alerts to the physician, nurse and pharmacist workflow."
Most Wired hospitals are more prepared than their counterparts for security breaches and employ more advanced security tools to protect patient data. Ninety-three percent of Most Wired hospitals employ intrusion detection systems compared with 77 percent of the total respondents. "Half of risk mitigation is knowing what is going on in your enterprise," says Mac McMillan, CEO, CynergisTek Inc., and former chair of a Healthcare Information and Management Systems Society's security working group. "Most Wired hospitals are implementing more sophisticated IT security architectures and are better informed." Many organizations still do not perform risk analyses and penetration testing on a regular basis. "What it tells us is that we still have relatively immature risk management for the most part in the industry," McMillan says.
The systematic buildup of information security capabilities took five years at Atlantic Health System, Morristown, N.J. "Starting with a regular auditing and assessment program, we established a vulnerability baseline," says Linda Reed, vice president and CIO. "We layered upon that intrusion detection, device encryption, mobile media encryption, PHI detection, password and access parameters, cyber liability insurance, and annual staff education requirements. While tools are important, they only do half the job. The other half is people and instilling a sense of awareness, vigilance and importance in protecting personal health information."
Annual testing and risk assessments
Security measures hospitals use for authorized users
When physicians and nurses use technology to deliver patient care, real-time visibility into how well those systems are working is critical. "If physicians experience slow systems or unavailable networks, patient care can be jeopardized," says Pat Milostan, chief operating officer, CareTech Solutions, Troy, Mich., an IT services company for hospitals.
Seventy-five percent of Most Wired hospitals monitor the performance of their applications and infrastructure proactively to resolve IT issues before they negatively affect end-user experience compared with 58 percent of all responding hospitals. Milostan notes that this gap is a telltale sign of an IT environment that is very reactive, responding to many crises instead of proactively getting ahead of the issues. The percentage of Most Wired hospitals using executive dashboards to manage infrastructure performance was lower than expected at 67 percent.
Ninety percent of Most Wired hospitals and 73 percent of all surveyed hospitals use performance improvement scorecards to reduce inefficiencies. To safely provide the right level of care and optimize patient flow, 74 percent of Most Wired hospitals and 57 percent of all surveyed hospitals use automated patient flow systems. "The only way a health sytem will meet the Triple Aim [of better patient care, better population health and lower costs] is to have robust information technology solutions," says Heath Bell, CIO and vice president of revenue cycle, KishHealth System, DeKalb, Ill.
|Monitoring IT performance||2012 All||2012 Most Wired|
|Use tools to monitor if infrastructure components are up or down||96%||99%|
|Use tools to monitor the end-user experience||58||75|
|Use automated tools to escalate problems to highly skilled technicians (Level 2 or 3) based on category and type||72||86|
|Anaylyze issues to determine root-cause analysis as a means to put fixes in place to avoid reccurences||84||95|
|Use executive dashboard to manage infrastructure by exceptions/anomalies||51||67|
|Monitoring hospital/health system performance ||2012 All||2012 Most Wired|
|Patient logistics management includes patient status, orders pending, critical lab results and room availability||57%||74%|
|Workforce management tool (productivity and cost trends)||72||90|
|Performance improvement scorecards||73||90|
|Real-time, Web-based operational budget vs.expense monitoring, financial modeling and budget forecasting||53||72|
Source: Hospitals & Health Networks' Most Wired Survey, 2012
For the 14th year, H&HN has named the Most Wired Hospitals and Health Systems based on the Most Wired Survey. The 2012 survey results build on the analytic structure that was implemented in 2010 after two years of redesign. The methodology sets specific requirements in each of four focus areas. If any of these requirements are not met, the organization does not achieve the Most Wired designation. Thus, an organization may have many advanced capabilities, yet not achieve Most Wired status. The four focus areas are:
1 | Infrastructure
- Identity management, access controls and audit capabilities
- Data recovery plan testing and disaster recovery restoration capabilities within 72 hours
- Security technology safeguards, including encryption for laptops
- Regular risk analysis, security assessments and penetration testing
- Wireless networks for clinical applications, accessible by clinicians and staff
2 | Business and Administrative Management
- Expanded use of electronic payer transactions
- Automation of revenue-cycle processes
- Partially automated management systems for supply chain and use of bar code technology
- Patient flow automation
- Human resource management and training systems
- Enterprise decision support and business intelligence
3 | Clinical Quality and Safety (inpatient/outpatient hospital)
- Patient demographics, vital signs and status, and documentation recorded as structured data
- Routine use of electronic health record and clinical information systems by nurses, pharmacists and physicians
- Physician access to clinical pathways/order sets and medical image review across care settings
- Clinical decision support enabled for drug allergy alerts and drug interaction alerts
- Digital clinical imaging/PACS in hospital and clinic
- CPOE for medication orders
- Point-of-care medication administration systems and automated medication management
- Electronic recording of quality data
- Electronic recording of infection control data
4 | Clinical Integration (ambulatory/physician/patient/community)
- Physician-office EMR connectivity for clinical documentation and viewing results
- Physician office e-prescribing
- Online health information for patient education
- Interoperability of applications within hospital
This year, 662 hospitals and health systems completed the survey, representing 1,570 hospitals, roughly 27 percent of all U.S. hospitals. Even with additional requirements, the number of hospitals and health systems designated as Most Wired increased to 215 organizations. H&HN uses the same criteria to name the 25 Most Improved and the 25 Most Wired - Small and Rural.
From a set of separately submitted essays, a panel of hospital and information technology leaders identifies noteworthy IT projects and names the Innovator Award winners and finalists. IT projects are evaluated on achievement of business objective, creativity and uniqueness of concept, scope of solution and impact on the organization.
The 2012 Most Wired Survey was made possible by the generous support of McKesson, AT&T, CareTech Solutions and in cooperation with CHIME, the AHA and H&HN.
H&HN appreciates the efforts and support of the many individuals who contributed to the success of the Most Wired Survey and the research and analysis that go into the results article. The following is a partial list of the many individuals who contributed to the 2012 H&HN Most Wired Survey.<