Cover 2007 Most Wired
One thing is certain: Technology is part of the process of improving care
The nation’s 100 Most Wired Hospitals and Health Systems have better outcomes than other hospitals on four key measures: mortality rates, the Agency for Healthcare Research and Quality’s patient safety measures, the Joint Commission’s Core Measures and average length of stay. This is the strongest evidence in the nine-year history of the survey of an association between the implementation and adoption of information technology and the quality and cost of patient care.
Although the analysis is compelling, chief information officers and researchers are quick to point out the limitations. The research shows that, in general, hospitals with good quality results are also dedicated to information technology. It does not show that IT caused those benefits.
“These initiatives are a combination of people, process and technology, not just technology alone,” says Mike Alverson, acting CIO, Texas Health Resources, Arlington, which makes its eighth appearance on the Most Wired list in 2007 and is an Innovator Award finalist. “Health care IT is a team sport.”
Analysts point out two general caveats to the outcomes research. First, information technology is one of many tools for achieving process improvements that lead to better outcomes. It must be used in conjunction with other tools and techniques to have an effect on care. Second, the analysis shows an association between IT adoption and key quality measures, but association is not causality. (See sidebar, “A Higher Standard”)
One thing is certain: like much of health care, CIOs and other senior executives at the nation’s Most Wired hospitals use technology as part of the process of improving care. They have measured the benefits of these changes. Disentangling the gains from using high-tech tools from the value of a skilled staff and better processes isn’t even of interest.
How are the Most Wired achieving their results? What are they doing to make technology part of their process improvement plans? Here are 10 lessons from this year’s benchmark group of top hospitals.
1. Improve patient flow The Most Wired have committed time and resources to improving patient flow, combining process improvement techniques with information technology. The University of Pennsylvania Hospital System, which appears on the Most Wired list for the seventh time, combined consulting assistance with technology and routine data reporting to address patient-flow issues. The Philadelphia-based system uses LCD monitors in a wide variety of locations—on patient care units, in the operating rooms, admissions, environmental services and patient transport—to display the most current information on each patient’s location, as well as specific details of pending patient movements.
“When a pending activity is delayed or overdue, the system displays an alert so that any issue may be resolved,” says Mike Restuccia, interim CIO. The process also provides automated paging for bed cleaning and transport. Staff review benchmarking reports at weekly meetings allowing them to address issues and learn from one another.
Internal analysis shows that, as a result of the project, one of the system’s hospitals, the Hospital of The University of Pennsylvania, has gained efficiencies equivalent to opening 17 additional beds. Bed turnaround time fell from 90 minutes to 45 minutes. Discharge prediction accuracy increased from 11 percent to 46 percent. The process has been implemented at two of the system’s hospitals, with plans to expand the project to a third.
“Patient-flow projects can be a powerful tool for reducing capacity constraints,” says Lewis Redd, managing partner, Accenture Health Provider Practice, Atlanta.
The Most Wired use electronic bed boards both in the emergency department and for inpatient bed management. There is a huge gap between the Most Wired and the least wired—the 100 hospitals that scored the lowest on the survey—in the use of bed management systems. The Most Wired are four-and-a-half times more likely to use inpatient electronic bed boards than the least wired and almost three times more likely to use bed boards in the emergency department (see figure 1).
“Patient-flow efficiency, workflow optimization and reduced LOS are being addressed through the deployment of automated bed tracking, the installation of inpatient scheduling and a [regional health information organization] initiative,” says Richard Rogers, vice president and CIO of Health First Inc., Rockledge, Fla., which appears on the Most Wired list for the third time. The RHIO project is intended to identify immediate bed opportunities for patients being transferred to rehab facilities, long-term care or mental health facilities.
“We do not believe that any system is going to overwhelmingly affect our patient flow in itself,” says Spencer Hamons, CIO, San Luis Valley Regional Medical Center, a 2007 Most Improved organization. “It must be paired with good management techniques, best practices from other hospitals, and a heavy dose of common sense.”
That’s a consistent theme among the nation’s Most Wired.
“There appears to be no overarching solution to this complex issue,” says Paul LoRusso, vice president and CIO, Wake Forest University Baptist Medical Center, Winston-Salem, N.C., which appears on the Most Wired list for the fifth time. “It is an area that needs to be addressed on many fronts with expectations geared to constant incremental improvements.”
2. Improve workflow “We use multidisciplinary teams to analyze and document workflow prior to implementation of automated systems,” says Frank Richards, CIO, Geisinger Health System. “When looking at existing practices, we follow a principle of first trying to eliminate, if not possible then automate, if not possible then delegate.” The Danville, Pa., system makes its fifth appearance on the Most Wired list in 2007.
The theme is consistent among Most Wired organizations. Eliminating waste and improving care is the goal for workflow redesign. IT is a facilitator.
“Anytime you can reduce a step in a process, it is one less opportunity for error,” says Michael Simpson, senior vice president and general manager with McKesson Provider Technologies, Alpharetta, Ga.
Analyzing workflow is key. “We’ve used workflow as a major part of our EMR install. Only after workflow analysis was done would IS begin the ‘build’ for that function. It was one way of getting user input into the EMR install process,” says Tom Smith, Evanston (Ill.) Northwestern Healthcare, which appears on the Most Wired list for the fourth time. Users developed 2,000 pairs of pre-EMR and post-EMR step-by-step workflow descriptions.
“Two major areas that have benefited from the introduction of electronic workflow are the nursing task lists and the physician inbox,” says Philip Loftus, vice president and CIO, Aurora Health Care, Milwaukee, a four-time Most Wired recipient. “In the case of the nursing task list, this brings together in one convenient place all of a nurse’s activities for an upcoming shift, including physician orders, reminders and nursing interventions.”
Nurses can check off tasks as they are completed, providing an easy way to monitor processes and to keep a formal record of completed activities. Similarly, the electronic physician inbox “brings together all of the physician tasks in one place, including patient schedules and historical data on the patients that they will be seeing,” Loftus adds.
Finding the key places where technology can and will be used to improve patient flow takes a collaboration between clinicians and technologists. “None of this can be effectively utilized unless those doing the work specify how the new structures can be incorporated in their day-to-day efforts,” says Penny Schaefer, director of clinical information systems, St. John Health System, Tulsa, Okla., a 2007 Most Improved organization. “Design takes into account many technologies, such as wireless access, handheld tools and complex integration. Perhaps the most important lesson to learn is that the job of addressing efficiency and effectiveness is never really done. You can only face the work remaining ahead by partnering with end-users, technical staff, vendors and colleagues.”
3. Process improvement is a discipline Hospital executives using information technology to improve clinical and operational results are finding that help is available in a variety of forms. Many have discovered the deep reserve of knowledge, talent, commitment and energy within their own organizations, harnessing that power by adding formal processes-improvement programs such as Six Sigma, Lean production principles, CQI or external consultants.
“We have very strong clinician representation when we utilize IT to improve workflows,” says Deane Morrison, CIO, Concord (N.H.) Hospital. The hospital has a chief medical information officer who leads a team of three additional physicians, a nurse informaticist who leads a team of four additional RNs and two pharmacists. The hospital makes its third appearance on the Most Wired list in 2007.
Sharp HealthCare, San Diego, uses “collaborative workflow design among key clinicians across our hospitals as we implement our new clinical systems,” says Bill Spooner, senior vice president and CIO. He says process changes are facilitated by staff trained in Six Sigma techniques. Sharp appears on the Most Wired list for the ninth time.
Six Sigma and Lean tools and methods have become more prevalent among Most Wired hospitals and health systems. For example:
This is ProMedica Health’s fourth appearance on the Most Wired list and the first for Denver Health. Eastern Maine is a 2007 Most Improved organization.
“We believe Lean is the perfect tool to take waste out of workflows and, in so doing, provide even greater levels of patient safety,” says J. Scott Joslyn, senior vice president and CIO, MemorialCare Medical Centers, Long Beach, Calif., which appears on the Most Wired list for the eighth time. The organization introduced Lean manufacturing principles with a major IT rollout. “So much opportunity remains,” he says.
4. Measure results One core principle of many process improvement systems is measurement: You can’t successfully improve or manage a process unless key results are measured and analyzed.
At San Luis Valley, staff determine appropriate metrics for success before launching a project, then monitor those measures throughout the project. “It’s of vast importance to determine what you want to accomplish in a technology project before you begin the process, otherwise you risk having the project goals driven by IT or by the vendor,” Hamons says.
A key measure at Denver Health is “time to care”—that is, the time between order placement and delivery of care. Using computerized provider order entry, the system reduced time between radiology orders and the availability of results by nearly 55 percent; the time between laboratory orders and the availability of results was reduced by nearly 61 percent; and the time between medication orders and the availability for the medication to be administered was reduced by more than 83 percent.
“You get what you inspect, not what you expect,” says McKesson’s Simpson.
Of the Most Wired hospitals and health systems, 80 percent conduct pre-project cost/benefit assessments and establish baseline metrics for their top five strategic IT projects, compared with 45 percent of the least wired (see figure 2, page 43). The Most Wired are also more apt to have a specific plan for when project metrics and original business case objectives will be measured and evaluated and conduct pre-project risk assessments.
Most Wired hospitals are keenly aware of qualitative feedback from clinicians, often seeking comments and concerns from medical personnel before simmering issues become full-blown problems. Qualitative feedback also provides a sense of how clinicians use and perceive the value of information technology.
Texas Health’s Alverson quotes an MD who said: “Tonight I was able to complete admission orders for a pediatric patient in the ER within 10 minutes after receiving the request. Within minutes of placing an order for an antibiotic, the pharmacist called me to suggest a different form of the medication. We worked together to discontinue the first drug, order the replacement and verify the order. This morning, I was able to complete my pediatric progress note on my patient in two minutes. I was able to spend less time ‘charting’ and more time with the child and his parents.”
5. Medication management drives quality to the bedside The Most Wired hospitals continue to lead the nation in electronic ordering and bedside medication matching to reduce the number of potential medication errors. This result has been consistent since these two medication management questions were added to the survey in 2005. The results have stayed fairly constant for the past three years (see figure 3, page 43 ,and figure 4, page 44).
Joe Butler, vice president and CIO, Hamot Medical Center, Erie, Pa., is among the IT execs who see bar-coded medication management as one of the leading technologies in the drive to improve safety.
“For four years, we have been collecting and evaluating data generated by our medication administration system,” Butler says. Each month, staff monitor and review 99 percent of the medications administered, including data on incorrect patient scans, patient overrides, incorrect product scans and product overrides.
“These metrics are routinely used to evaluate our processes, make improvements and measure again,” he says. “The data has created a conversation and focus around the factors that contribute to medication errors.”
The Most Wired are also finding ways to use IT to address the challenges of medication reconciliation. Among the Most Wired, 98 percent have an electronic system to develop a list of current medications, compared with 62 percent of the least wired; 89 percent of the Most Wired can compare current and prescribed medication lists electronically, compared with 48 percent of the least wired; and 91 percent of the Most Wired use IT to provide new medication lists targeted to caregivers and patients, compared with 59 percent of the least wired.
“Many hospitals, including ours, initially thought we’d be doing all of this by hand. A few IT clinicians knew we could do this easily electronically,” says Angela Nicholas, M.D., vice president and chief medical information officer, Susquehanna Health, Williamsport, Pa. “Most Wired hospitals are usually already capturing the information required. All they had to do was design a process around it.” Susquehanna Health makes its eighth appearance on the Most Wired list in 2007.
6. Smart alerts improve care Sharp HealthCare has implemented a real-time harm monitor that uses information in the clinical charting application to identify patients with potentially deteriorating conditions. This provides clinicians with the opportunity for early intervention. Sharp tracks and reports those interventions.
Hamot Medical Center uses technology in an effort to reduce patient falls. An automated system checks whether a fall-risk assessment is on file for each patient. If not, an instruction to conduct an assessment is automatically added to the work list for caregivers. Hamot appears on the Most Wired list for the fifth time.
The Most Wired are trailblazing the use of electronic surveillance systems tied to alert systems. Nearly 80 percent of the Most Wired hospitals have some form of electronic surveillance tied to alerts, compared with only 14 percent of the least wired (see figure 5). Much of this activity takes place in critical care units in the form of an electronic ICU.
Health First’s electronic ICU program is a remote critical care management system that has allowed the organization to use a limited number of critical care specialists across a three-hospital, 78-bed ICU system.
“We’ve observed up to a 35 percent reduction in ICU mortality, a 30 percent reduction in ICU cardiopulmonary arrests and significant reductions in time on the mechanical ventilator,” Rogers says. Health First has implemented a variety of ICU evidence-based care initiatives, including a set of protocols that have led to a 35 percent reduction in sepsis mortality.
The Most Wired also use information technology to ensure compliance with key indicators in the Centers for Medicare & Medicaid Services Hospital Compare database. According to 2007 survey results, 45 percent of the Most Wired use an automated review of Hospital Compare key quality indicators to provide caregivers with automated alerts, compared with 12 percent of the least wired (see figure 6).
“The availability of integrated alerts provides our clinicians with tools that are not available in the paper world,” says Randy Haskins, director of information services, Mercy Medical Center–North Iowa, a 2007 Most Wired–Small and Rural hospital.
7. Provide ubiquitous access to digital images The Most Wired are leading the way in providing digital images to a broad array of clinical service areas and a variety of patient settings. While nearly all of the Most Wired provide inpatient access to digital radiology images—as well as access in clinics, physician offices and other remote locations—more and more are providing the same breadth of access to images for cardiology, neurology, oncology and nuclear medicine (see figure 7). Ubiquitous access to pathology images lags behind the other services.
“Hospitals are driving toward clinical imaging as a quick win,” says McKesson’s Simpson. That win, he says, comes in the form of both storage and distribution of images.
This is a strategy that the least wired hospitals and health systems have also begun to adopt, but primarily on the inpatient side. The majority of least wired hospitals provide inpatient access to radiology and nuclear medicine images and a growing number provide inpatient access to cardiology, neurology, oncology and pathology images.
“Image capture through PACS has almost become the standard of care for hospitals. The return on investment for these systems includes the decrease or elimination of film costs,” says Susquehanna’s Nicholas. “The next step was to make these images available for image-intensive physicians such as orthopedics, pulmonary, cardiology and neurosurgery. And the increase in efficiency in patient care drove hospitals to figure out ways to provide images to physician offices.”
8. Don’t forget the operating room OR and anesthesia are among the last frontiers for electronic clinical documentation. Two issues typically arise: first, the documentation is not generally used by other departments, so the data have fewer uses organizationwide than other systems; second, anesthesiologists are resistant because of fears that the documentation might be used against them in liability lawsuits. Still, the Most Wired lead the way in implementing and adopting OR and anesthesia documentation. The Most Wired are 11 times more likely than the least wired to have full adoption of anesthesia documentation by physicians (see figure 8). Full adoption is defined as regular use by more than 60 percent of clinicians.
“Within the perioperative environment we have introduced a tracking solution that allows patients, family, friends and clinicians to track the status of the patient through the entire visit,” says Edward Martinez, vice president and CIO, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Fla., a second-time Most Wired organization. “This allows for a seamless transition through the process and consistent communication to all people involved.” Information is available to the patient, family, physicians, nurses, transporters, registrars, equipment supply clerks, and specimen procurement and laboratory specimen processing personnel.
Hospitals large and small see the OR as an area for automation and process redesign, and an area where IT can assist in improving safety and quality. Both the University of Illinois Medical Center at Chicago, a second-time Most Wired organization, and Massena (N.Y.) Memorial Hospital, a Most Wired–Small and Rural organization, say that operating room systems are among their top three capital priorities.
“We will begin deploying a paperless, fully integrated touch-screen OR system,” says Jana M. Grose, Massena’s MIS director. “This will provide patient tracking, operating room scheduling, equipment and resources scheduling and documentation of pre-op instructions and assessments.” The system will provide real-time perioperative documentation, inventory management, implant tracking and cost information. It will also generate surgeon preference cards.
9. Plan for the worst Disaster planning has become a subset of a broader issue facing hospitals: business continuity. Hospitals must have plans to address both natural and man-made events that effect technology and communications, as well as plans to ensure the effective daily use of IT, such as system response time, unplanned downtime, upgrades and maintenance.
Nearly one-third of the 2007 Most Wired say that in the event of a complete loss of their primary data center they could restore clinical information system operations within four hours. That compares with only 5 percent of the least wired. A total of 55 percent of the Most Wired would be up and running within a day, compared with 27 percent of the least wired (see figure 9).
Several Most Wired hospitals put business continuity and disaster recovery on their list of capital spending priorities for the year. Among them is Mountain States Health Alliance, Johnson City, Tenn., which makes its third appearance on the Most Wired list. “This project is high priority due to the need to ensure continuity of health care delivery with highly available systems,” says Stacie R. Fox, IT planning coordinator.
10. Infrastructure is key to the future To ensure business continuity—and make sure capacity is available for future IT investments—many of the Most Wired identify infrastructure investments as a major priority this year.
“Our infrastructure must be continually refreshed and maintained in order to support the ever-increasing requirements for bandwidth and sub-second performance,” says Fox.
Moffitt Cancer Center’s Martinez agrees. “We plan to invest heavily in furthering our storage infrastructure to provide physical and logical storage for all of the discrete data and images being collected at an ever-increasing rate,” he says.
More than half of the Most Wired say that they are planning infrastructure improvements in the coming year.
“Funding the infrastructure improvements necessary to support the numerous deployed systems is a challenge,” says Audrius Polikaitis, director of IS planning at the University of Illinois Medical Center at Chicago. “We are continually seeking to find the balance between capital investments for improving the underlying computing infrastructure and capital investments for deploying new functionality and further automating our clinical and business processes.”
That challenge may become more complex, says Accenture’s Redd. IT systems are holding more information and data and require more comprehensive support. Maintaining systems and supporting the infrastructure will take hard work and skilled staff while costing more money.
Redd cautions: “That’s a significant issue facing the industry down the road.”
This article first appeared in the July 2007 issue of H&HN magazine.