Even as they speed ahead of the pack, top tech hospitals are shifting gears
Call it a contradiction. Or call it a requirement for success. No matter. The nation's top tech hospitals continue to speed ahead on the quest to improve quality and operations with information technology. At the same time, the fascination with whiz-bang tech has given way to a focus on the nitty-gritty work that comes part-and-parcel with successful IT projects. The result is that the nation's top tech hospitals are doing more--and doing it better--than other hospitals around the nation
For the sixth year, Hospitals & Health Networks has named the 100 Most Wired Hospitals and Health Systems (see foldout). This year, as a result of a tie, 101 hospitals are being recognized as the nation's Most Wired.
The list is based on the Most Wired Survey and Benchmarking Study, which is a joint project of H&HN, IDX Systems Corp. and the College of Healthcare Information Management Executives. H&HN has also recognized six organizations with Innovator Awards, which are a joint project of H&HN, IDX, Cisco Systems and CHIME. Other awards include: Most Improved, Most Wireless, Most Wired-Small and Rural (see sidebar, "About the survey"). This year H&HN received 482 surveys representing 1,298 hospitals, an increase of 19.3 percent in the response rate over the 2003 survey.
In the past year, the nation's top tech hospitals widened their technology advantage over other organizations. For example:
Of the 101 organizations named as one of the nation's Most Wired, 11 have been on the list all six years that the survey has been conducted and 19 winners have been on the list each of the past five years.
"If you look over the last year, we have seen consistent gains," says Larry Paulson, interim vice president, research and development for IDX, noting that there are 22 hospitals new to the list in 2004. He says clinical quality efforts remain among the top IT priorities. Hospitals are focused on improving safety at the point of care. "Any time you do knowledge-based work, you want to provide information to the decison-maker as soon as possible," he says.
Many of the Most Wired begin with the goal of improving the safety of the medication administration process, both by automating the ordering process and by matching medications electronically to patients at the time of administration. The idea is to get the order correct on the front end and administered correctly on the back end.
Physicians at the Most Wired hospitals and health systems are 10 times more likely to enter medication orders electronically than their counterparts at the least wired organizations. On average, nearly 27 percent of medication orders are electronically entered by physicians at the Most Wired organizations, compared with 2.7 percent at the least wired institutions.
The least wired are also more likely to have medications that are ordered manually, meaning that the medication never appears as an electronic order. A whopping 20 percent of medications at the least wired organizations are ordered manually. This compares with an average of 3.1 percent of medications ordered manually at the Most Wired.
Once the order is in the system, the correct drug must be dispensed. Nearly 35 percent of the Most Wired say that the lion's share of their medications--81 to 100 percent--are electronically matched to the patient and order at the time of administration. This compares with only 5 percent of the least wired. And 84 percent of least wired organizations do not electronically match any medications to the patient at the time of administration. (See figure 1.)
The medication administration system is wireless at Carilion Health System, Roanoke, Va. This year will mark the fourth appearance of Carilion on the Most Wired list. It has also been named one of the 2004 Most Wireless hospitals and health systems.
"Our medication administration system stops 500 mistakes per month," says Greg Walton, senior vice president and CIO, information services. "We are ready to pilot a system of smart IV pumps connected to our wireless network. These pumps will interact with our pharmacy system, our bar-coded patient armbands, IV bags and employee ID bracelets."
Nurses at Regional West Medical Center, Scottsbluff, Neb., use a unit dose bar code scanner to identify the patient. Nurses then verify the five rights of medication administration--the right patient, medication, dose, route and time. If something cannot be verified, the nurses must respond to queries on a warning screen before giving the medication to the patient.
"Most nurses have a 90 or 95 percent scan rate," says Susan Heider, vice president support services and CIO at Regional West, one of the 2004 Most Wired-Small and Rural. She says that PRN medications (medications given to a patient whenever necessary) and initial doses of new orders not yet entered into the computer are the most common exceptions to the medication matching system.
At NovantHealth, Charlotte, N.C., "each drug is bar coded at the dose level," says Toni Kourey, senior vice president and CIO. NovantHealth was named one of the 25 Most Improved organizations. "Nurses scan the drug and the patient bar-coded arm bracelet. The mobile cart with a laptop using the medication administration checker validates the five rights of administration and gives the nurses both visual and audio alerts."
Nursing confidence is key to nursing compliance, says Joe Butler, vice president and CIO of Hamot Medical Center, Erie, Pa., where wireless PCs with wireless bar code scanners are used to verify medications at the bedside. Hamot has been one on the 100 Most Wired list three times.
"The key challenge was the complete evaluation and re-engineering of the medication administration process," Butler says. Nurses are responsible for daily review of data on scanning, charting and alert overrides. "Nurse manager accountability was critical to our success. The verification process now has integrity. Nursing has confidence in their practice of medication administration."
Pharmacists play a central role at Crozer-Keystone Health System, which has been named to the Most Wired list four times over the past six years and has also earned a 2003 Innovator Award. "We are implementing hard-stop pharmacy rules to prevent the pharmacist from entering medication orders if critical patient information is not available," says Robert Wilson, vice president and CIO of the Springfield, Pa., system. Missing information might include patient weight and allergies.
Bar coding is one of the two key strategies currently used by hospitals to match medications to patients. Approximately half of the hospitals that have implemented electronic medication matching are using this technique, according to a follow-up question of Most Wired survey participants.
The Most Wired are planning projects that build on the success of their patient safety efforts. At Crozer-Keystone Health System, the IT staff is working with pharmacists to create a set of electronic rules to provide medication alerts for high-risk medications such as insulin, heparin, infusion therapies and anticoagulants. Carilion is exploring the use of a second bar code on the patient that will contain surgical information, such as type of procedure and site of surgery.
Education plays in integral part in the continuing efforts of the Most Wired to drive adoption--routine, active use of IT as part of the care process--by clinicians. They have a broader array of educational resources for employees.
According to survey results, more than 95 percent of the Most Wired have a nurse dedicated to IT training, compared with 41 percent of the least wired. More than 60 percent of the Most Wired have a physician dedicated to IT training, compared with 3 percent of the least wired. Eight percent of the least wired--roughly one in 12--do not provide any educational resources on IT whatsoever.
To promote use of the technology, Evanston (Ill.) Northwestern Healthcare is one of a small but growing set of hospitals offering continuing medical education as part of the training process. "Persuading the professional staff to make major changes in their behavior was the toughest sell," says Tom Smith, CIO of Evanston Northwestern Healthcare, which was named one of the 100 Most Wired for the first time this year. "To help in the transition, each professional received an average of 16 hours of training that also accrued as 16 hours of continuing medical education credits."
ENH worked to make sure that the education made a difference. The professionals needed to pass a proficiency test with a score of 85 percent or better before obtaining a password to the system. ENH's education initiative has been so successful that independent physicians who have privileges at the organization's hospitals also use the IT system.
Roughly 60 percent of the Most Wired offer continuing education credits to pharmacists and IT professionals who participate in technology training. This compares with 6 percent or less among the least wired. More than 75 percent of the Most Wired provide education credits to doctors and nurses, but only 31 percent of the least wired provide credits for physicians and 15 percent provide them for nurses.
"A key challenge is accommodating the diverse group of individuals that use these applications," says Tim Strauch, director of information services, Watertown (Wis.) Memorial Hospital, which was named one of the Most Wired-Small and Rural. "Physicians, as well as other caregivers, have different aptitudes when it comes to accessing and using electronic applications."
Marvin Meier, CIO of Altru Health System, Grand Forks, N.D., a Most Improved winner, agrees. "Process changes are the most difficult to implement. For many, using a computer in the care of patients is not as natural as using a pencil and paper. It takes a lot of time to learn to use this technology."
The robust set of IT educational tools employed by the Most Wired is one key to why they are motivating doctors and nurses to use clinical information technology. The Most Wired boast double, sometimes triple the adoption rates of the least wired. For example, regarding routine access to patient medical histories, 72 percent of Most Wired organizations say that their physicians have achieved the highest adoption rate measured on the survey: that 81 to 100 percent of their physicians routinely use IT to access medical histories. This compares with 29 percent of the least wired organizations responding that their physicians have achieved the highest adoption rate.
"The primary goal is always to ensure the highest possible use and acceptance of any technology by clinical caregivers," says Walter Fahey, chief technical officer and interim CIO, Maimonides Medical Center, Brooklyn, N.Y., a Most Wired and Most Wireless winner. "Technology implemented without the highest degree of clinician acceptance and support does not return adequate value."
The difference between the Most Wired and the least wired is even more dramatic when looking at tools they provide for improving clinical quality. More than half of the Most Wired, or 54 percent, report that they have achieved the highest level of adoption for physician use of drug interaction alerts--an 81 to 100 percent use rate--compared with 16 percent of the least wired. More than half of the Most Wired, 56 percent, report that they have achieved the highest level of adoption for nurse use of drug interaction alerts, compared with 17 percent of the least wired.
Drug interaction alerts also illustrate another key to higher adoption rates among the Most Wired hospitals: simply providing these services to clinicians. The Most Wired provide a broader set of clinical tools to caregivers than the least wired. And the Most Wired provide those tools from more locations.
More than 80 percent of the Most Wired provide bedside access to drug interaction alerts, compared with only 15 percent of the least wired. This huge difference between the Most Wired and least wired is consistent for all bedside clinical information functions throughout the survey. (See figure 3.) Another example, bedside pharmacy order entry: 79 percent of the Most Wired provide this service, compared with 19 percent of the least wired.
The number of services provided to doctors and nurses by the least wired improve when measuring access from both a nonbedside point of care (which includes exam rooms and affiliated physicians' offices) and remote location (anywhere outside the hospital, such as unaffiliated doctors' offices and physicians' homes). For nonbedside point of care pharmacy order entry, 94 percent of the Most Wired provide this service, compared with 51 percent of the least wired. More than double the Most Wired provide nonbedside point of care access to drug interaction alerts: 97 percent of the Most Wired provide this service, compared with 42 percent of the least wired.
For many of the Most Wired--and all of the 25 organizations named to this year's Most Wireless list--point of access is becoming moot. They are providing ubiquitous access throughout their organizations using wireless systems. Many organizations are beginning their initiatives by providing wireless access in clinical areas of their institutions.
"We are expanding our wireless infrastructure to include the whole campus," says Dennis Amadon, technical services coordinator for Southwestern Vermont Health Care, Bennington. This marks Southwestern Vermont's first appearance on the Most Wired-Small and Rural list. "Our goal is to provide access from anywhere."
Once again, there is a stark contrast between the accomplishments of the Most Wired and the least wired. More than 75 percent of the Most Wired provide wireless access to clinical information functions such as drug interaction alerts, pharmacy order entry and lab results review. The numbers flip-flop for the least wired. Only 13 percent of the least wired provide wireless access to drug alerts, 14 percent provide wireless pharmacy order entry and 24 percent provide wireless lab results review. Adoption rates among the least wired for wireless access to clinical information are minimal.
Another key distinction between the Most Wired and their least wired counterparts is a focus on assessing and documenting the value of technology. More than 90 percent of Most Wired hospitals and health systems conduct traditional return on investment analyses to justify IT expenditures. This compares with less than 60 percent of the least wired.
"Certainly the initial capital cost and ongoing operating expenses to absorb and still maintain a positive balance sheet is a key challenge," says Craig Hewitt, CIO, MeritCare Health System, Fargo, N.D., a six-time Most Wired winner.
An increasing number of executives also measure and document the effect of IT on their institutions. More than 90 percent of the Most Wired assess the impact of IT on quality, 89 percent assess the impact on safety and 95 percent conduct process improvement studies. This compares with 45 percent of the least wired that assess the impact of IT on quality, 48 percent that assess the impact on safety and 57 percent that conduct process improvement studies.
"There's no question that it takes the doctors longer to enter orders now, although that will improve as they become more used to working with the system," says ENH's Smith. "Some nurses, who used to wait to the end of each shift to do all patient charting, must do it as it happens at the point of care. Yet the benefits of complete, current patient records, available at the touch of a few keystrokes, make overall care easier, faster and better for both patients and providers."
In other words, the total benefit--to the organization, to the clinical staff and to the patients--comes back to the ability to train staff and drive use. "The effect on the workforce [who are] dealing with the pace of technological change has a tremendous impact on how well the true benefits are realized and how they improve the overall quality of patient care," Hewitt says.
Patients, clinicians and hospital executives have grand plans and high hopes for information technology. The challenge, say CIOs from the nation's Most Wired, is managing change.
"The pace of change and the extent of change are enormous challenges," says Cynthia Davis, vice president of information technology and CIO at DeKalb Regional Healthcare System, Decatur. Ga. "We are completely changing the way we do business, standardizing our care process, embarking on extensive training, engaging the medical staff and other clinical disciplines and moving on an aggressive timeline."
CIOs say that preparing the institution for change is at the core of success.
"There are three key challenges," says Dennis L'Heureux, vice president and CIO, Rockford (Ill.) Health System, which has been named to the 100 Most Wired for all six years of the survey. "The first is preparing the organization for change. Another is finding an IT solution that optimizes our investment, minimizes complications and fits into our overall strategic vision. Yet another is managing expectations across many stakeholders."
There is a fourth challenge, too: understanding that even as you're implementing the latest technology, new breakthroughs are on the horizon.
"Technology will continue to evolve," says John Prout, president and CEO of TriHealth Inc., Cincinnati. One example: RFID, or radio frequency identification. "The key will be to implement bar coding technology in the short term while planning a gradual migration to RFID over the long term. The clinical computing device will continue to evolve as well. The devices we use this year will be surpassed by technology in the years to come."
Expectations for IT are high, balanced by the fear of the unknown and concerns over just how dramatically technology will change the day in the life of doctors and nurses. The 2004 Most Wired clearly excel at doing the nitty-gritty work of health care IT.
ABOUT THE SURVEY
For the sixth year, Hospitals & Health Networks has named the Most Wired Hospitals and Health Systems. The list is based on the Most Wired Survey and Benchmarking Study, which is a joint project of H&HN, IDX Systems Corp. and the College of Healthcare Information Management Executives. The eight-page survey asks hospitals to report on their use of information technology to address five key goals: safety and quality, customer service, business processes, workforce, and public health and safety. This year, as a result of a tie, 101 organizations were named to the Most Wired list. Survey responses were scored using a methodology that emphasizes the use of IT to address safety and quality issues, as well as customer service. Responses from 40 organizations were verified with a follow-up survey and additional research into responses was conducted via e-mail. The results are the basis of several awards:
This year, 482 hospitals and health systems completed the survey, representing 1,298 hospitals. The hospitals represented in the survey tend to be larger and more urban than the national average, but the results make up a diverse sample. Each organization completing the survey receives a customized report comparing its responses with the Most Wired. For the 2004 survey, the editors of H&HN created a Most Wired Survey definitions board to assist in developing standard definitions for use by survey respondents. As the result of the inherent value judgment in any scoring system, H&HN does not publish the rankings as part of the Most Wired lists.
H&HN has also recognized six organizations with Innovator Awards, which are a joint project of H&HN, IDX, Cisco Systems and CHIME. Hospitals submit descriptions of innovative projects that are then evaluated by an expert panel. This year H&HN received 46 Innovator Award applications from which H&HN has named three Innovator award winners and three finalists. The 101 Most Wired and the Innovator Award winners will be recognized for their accomplishments at the 2004 Health Forum Summit July 25-27 in San Diego.
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