H&HN's 15th annual survey shows U.S. hospitals have made big strides in laying the foundation for robust clinical information systems. The next step: harnessing IT for the real work of improving care delivery.
Many of the nation's hospitals and health systems have made progress laying the building blocks for creating robust clinical information technology systems. Now comes the heavy lifting as they look to connect the care continuum, protect patient records in an increasingly mobile world and turn all of those bits and bytes of data they are collecting into actionable information.
As evidenced in Hospitals & Health Networks' 15th annual Health Care's Most Wired Survey, a good percentage of hospitals and health systems have deployed technologies that improve patient documentation, advance clinical decision support and evidence-based protocols, reduce the likelihood of medication errors, and rapidly restore access to data in the case of a disaster or outage.
That wasn't always the case, even as recently as 2007 when just 58 percent of Most Wired hospitals had systems capable of producing real-time alerts on drug-to-drug interactions. Fast forward six years and 100 percent of Most Wired hospitals now possess that capability, a major step in improving patient safety by reducing the likelihood of medication errors. Going back even further, in 2004, only 27 percent of physician medication orders at Most Wired hospitals were done electronically. That number is now up to 69 percent and climbing.
What's driving these improvements? Federal regulation for starters. The Health Information Technology for Economic and Clinical Health Act of 2009, more commonly referred to as HITECH, mandates that hospitals and physicians not just adopt health IT, but use it in a meaningful way.
"Meaningful use put technology in front of everyone," says Linda Reed, R.N., chief information officer and vice president of behavioral and integrative medicine at Atlantic Health System, Morristown, N.J. "But meaningful use is just the base."
Another key driver: delivery system transformation. Leaders at forward-thinking organizations know they can't make the leap to such things as population health management or accountable care without fully integrating their operational and IT strategies.
"IT plays a central and pivotal role in the successful transition to value-based payment models," says David Graham, M.D., senior vice president, CIO and chief medical information officer, Memorial Medical Center and Abraham Lincoln Memorial Hospital, Springfield, Ill. "IT is the infrastructure that enables all clinical and business units to translate data into information and to utilize that information as knowledge for improvement in the delivery of safe, high-quality patient care. IT provides the tools to collect and normalize data across owned affiliates and independent clinical partners."
To get to the next level of care delivery, clinicians, regardless of where they practice, need to be able to tap into systems that provide real-time and real-good information. Yet, significant hurdles remain.
Part of the challenge is resource capacity, says Chantal Worzala, director of policy at the American Hospital Association. A large segment of the field is still resource-challenged and can't move as quickly as it would like. There is also the lingering question of vendor readiness. The timeline between publication of federal rules governing what vendors must include in their products and when hospitals need to comply with meaningful use Stage 2 is tight and doesn't leave a lot of breathing room for anyone, she argues.
Those constraints don't minimize the need to push forward in many areas, not the least of which is connecting the care continuum. Meaningful use regulations increasingly call on hospitals and physicians to exchange health information electronically. Additionally, payment reforms focused on outcomes will necessitate better linkages between the disparate systems in use by hospitals and physicians. Yet, this is an area where the Most Wired Survey shows room for improvement. For instance, 81 percent of the Most Wired organizations report making clinical documentation available in employed physician offices, compared with 74 percent of all respondents. The problem is more severe when looking at independent practices, even for Most Wired hospitals. There, 51 percent of the Most Wired make clinical documentation available electronically compared with just 43 percent of all respondents. Now, consider medication lists and history. Just 40 percent of the Most Wired and 24 percent of all respondents can share that information electronically with nonaffiliated hospitals. Diagnostic images? Only 48 percent of the Most Wired and 31 percent of all respondents can get those to nonaffiliated hospitals electronically.
The long-sought Holy Grail of interoperability is one solution, but the industry has been moving slowly in that direction. Last March, five major IT vendors — Allscripts, Athenahealth, Cerner, McKesson and Greenway Medical Technologies — formed an alliance that promises greater data exchange. It will take time, however, for the CommonWell Health Alliance to get footing. And there's also the question of what happens to vendors, large and small, not involved in the alliance.
Health information exchanges often are touted as a utility that can better connect care settings. While there are some success stories, there also have been a lot of fits and starts. Sustainability has long been a problem for these types of organizations, dating back decades to community health information networks and regional health information organizations.
"The concept of health information exchange is absolutely correct," says Russell Branzell, president and CEO of the College of Healthcare Information Management Executives. But, he says, exchanges have been allowed to form without agreement on a national set of standards and data needs. Consider something as innocuous as the way patients enter their birth dates or phone numbers. Some systems use dashes, some don't.
"All of those things are needed to match you to the record, never mind the clinical data behind it, which hasn't been standardized," he says. "We need to standardize the entire process, which we've done in almost every other business sector."
Once exchange is mastered, something has to be done with the data. "Data are not the same as information," says Richard Schreiber, CMIO, Holy Spirit Hospital, Camp Hill, Pa. "Information depends on analysis and interpretation of measurements of the data. Without measurement, there can't be assessment of quality, risk, outcomes or value."
How hospitals and health systems are building support systems for clinical analytics is a new area of study for the Most Wired Survey, and one that seems to have a lot of traction. In research questions added this year, 92 percent of the Most Wired and 81 percent of all respondents said their organizations have an executive sponsor of clinical analytics projects. Eighty percent of the Most Wired have an enterprise-level governance structure in place for clinical analytics, compared with 67 percent of all respondents.
Still, Rose Higgins, vice president of strategic solutions at Relay Health, a business unit of McKesson Corp., a sponsor of the Most Wired Survey, believes there is a disconnect in the understanding of what data are going to be required as hospitals, insurers and others forge new partnerships.
"People have to rethink what they're investing in. They're not only going to need enterprisewide data, but also data from outside their four walls," she says. "As you peel the onion back, you realize that the investments are not where they need to be."
The AHA's Worzala adds that clinical analytics will be driven by the business needs of the organization; whether it is building an accountable care organization or taking on risk in another way. Those operational factors will vary from market to market, she says, and drive how clinical analytics is done.
Patient engagement is another bourgeoning area in health IT and one in which hospitals have some room to grow. According to this year's survey, 64 percent of Most Wired hospitals have either a pilot or fully rolled-out personal health record program. Additionally, a low percentage of hospitals — both Most Wired and all respondents — are able to provide patients with electronic copies of their discharge instructions or general health information through a patient portal. In both categories, the most common means of delivering the information electronically was via CD — 67 and 74 percent, respectively.
"The bottom line is that care must be connected and continue wherever the patient is — whether that's in the hospital or the doctor's office or in the home," says Geeta Nayyar, M.D., chief medical information officer at AT&T, a survey sponsor. "The health care industry has lagged behind other industries, such as banking and travel, in tapping technology that can engage the patient and connect the continuum. We are finally seeing real progress as an industry, but there is still more to do."
Atlantic Health's Reed agrees. To retain and capture new market share, hospitals have to engage patients on their terms, not the other way around. Beyond making records easily available to patients, Atlantic Health has embraced an ambitious social media strategy that includes everything from blogs, Twitter, Facebook and LinkedIn to a mobile app. Social media is used to deliver care management messages, conduct chats with physicians, and for crisis communications, among other things.
"The systems we are building aren't for the 85-year-olds of today," she says. "How are we going to attract patients of the future? It is through mobility and in the different ways we engage them."
Going beyond the four walls of the hospital
In the march to bring care to the patient, rather than the patient to the care, the Veterans Health Administration is leading the charge. With a diverse patient population that's dispersed from the coast of Guam to the mountains of Colorado to the Florida Panhandle, the VHA has embraced a digital health strategy that ambitiously uses telemedicine and is pushing the system to become a testing lab for other care innovations.
"We believe that our success — and future success — depends upon health information being available at the point of care," says Theresa Cullen, M.D., chief medical information officer at the nation's largest delivery system, with 152 medical centers and 1,400 outpatient clinics and other facilities. "As care moves beyond the four walls of the hospital, we need health IT systems that are connected in that full continuum."
Telehealth is a key component of that vision. The VHA has been using telehealth for more than a decade not only to extend its reach, but also to ensure that patients can get care as close to home as possible and, often, at home.
"The technology is designed with patients in mind," says Adam Darkins, M.D., the VHA's chief telehealth consultant. "We focus on people who are at risk of going to a nursing home and we look for ways to better engage them."
The telehealth program reaches patients in homes, hospitals and clinics. Last year, there were 119,000 home telehealth visits, largely focused on veterans with chronic conditions. The program enables patients to upload vital signs and extra information on any symptoms they may be experiencing to a care coordinator who then helps them with their treatment plans. Darkins says the home telehealth program has reduced bed days by 58 percent and admissions by 38 percent. Close to 76,000 veterans utilized telehealth services for 217,000 mental health consultations last year, as well. Overall, more than 500,000 patients were serviced by telehealth programs in 2012, according to Darkins.
Looking more broadly, the VHA is pursuing a digital health strategy that both Cullen and Darkins say is about better patient engagement. Cullen points to the Blue Button project as a prime example. Blue Button, which started in the Department of Veterans Affairs in 2010, enables patients to get easy electronic access to their health records. It often is held up as an example for the rest of health care to model.
"Access to data changes patients' lives. We've given patients control of their data," Cullen says.
Reaching the tipping point for info exchange
Atlantic Health System is the proud owner of eight different ambulatory electronic health record systems. With plans to affiliate with or acquire half a dozen more physician practices, that number surely will climb in the coming months. And that's on top of the McKesson Corp. EHR that runs throughout the three-hospital system.
Getting data and patient records to flow seamlessly between so many disparate systems is vexing. Indeed, it is a major challenge confronting nearly every hospital, health system and physician practice.
At Atlantic Health, though, physicians and neighboring hospitals are able to push and pull patient data through Jersey Health Connect, one of the country's more successful health information exchanges. Atlantic Health also allows physicians to tap into some EHR functionality via a portal.
As health care moves toward a more integrated model, the ability to exchange information quickly and easily will become paramount, says Linda Reed, R.N., chief information officer and vice president of behavioral and integrative medicine at the Morristown, N.J.-based system. As various parts of the country wrestle with how to effectively connect the continuum, providers in Jersey Health Connect are refining a system that Atlantic Health helped to launch a handful of years ago. What started with 13 health systems has grown to 27 organizations. More than 1,300 physicians are connected to the HIE, which contains nearly 2 million patient records.
Reed sees the HIE continually evolving. Atlantic Health is rolling out physician ordering via the exchange. It also has proved to be fertile ground for pulling data that are relevant to Atlantic Health's two accountable care organizations.
"There were some data that we couldn't find in our system, but when we went to the HIE, they were there," Reed says.
Still, there are challenges on the horizon, including long-term sustainability and connecting with other regional and state exchanges.
Information exchange isn't the only area in which Atlantic Health is pushing the envelope. The system has long embraced health IT as a critical part of its overall strategic plan.
"What we've noticed is any kind of efficiencies we are going to gain as an organization can't happen without IT," Reed says, who credits federal regulations with moving health IT to the front burner.
"Meaningful use — the good, the bad and the ugly — put IT in front of people," she says. "We are now at a tipping point because clinical integration and the need to exchange data are critical."
Texas Health Resources, arlington, Texas
It is "pretty easy" to head up information technology at Texas Health Resources, says Edward Marx. "We see IT as a strategic lever that enables us to achieve superior business and clinical outcomes. Our IT strategy is completely aligned with our overall strategy as an organization," says Marx, senior vice president and chief information officer of the Arlington-based health system. "Everything we are doing has a technology underpinning. If our organization is going to get to the next level, then we need all the levers to pull together. I'm right in the mix with all of our initiatives."
Technology has become such an essential element of Texas Health's overall strategy that the 25-hospital health system restructured its IT governance process just over a year ago. Marx now reports to the chief strategy officer and IT proposals must take an enterprisewide view, rather than a hospital or business unit view, to move forward.
"In the past, ideas floated up and maybe the IT services department was involved, maybe not," Marx explains. "Things got planned in silos. Now we are there from the beginning to say 'Yea' or 'Nay.' "
Under the new governance structure, the IT component of a project is identified and analyzed at the outset. This ensures that proposals incorporate an enterprisewide view. It also provides the opportunity for Marx's team to see if there are ways to leverage relationships with existing vendors. And, he says it makes it easier to halt projects earlier in the process.
"It is more difficult to hear 'No' when you've gone nine-tenths of the way through the process than when you've gone one-tenth of the way," Marx says.
Texas Health's hospitals are led by what the system refers to as triads — panels made up of the chief medical and nursing officers and president. Together, they filter ideas even before a proposal can make it into the official governance pipeline. Ultimately, projects that make it through the process are reviewed by clinical and operational leadership, along with members of the C-suite.
The criteria to get a project through, Marx says, "have gone to a new level in terms of the data that are now involved."
Marx says there have been considerable benefits, not the least of which is the true convergence of IT and strategy. "We are on the same trajectory," he says. The challenge? "Change is hard. Also, it is hard to say 'No,' " he says. "We have high ambitions at Texas Health. To achieve those, we have to be hyperfocused."
As providers look to improve clinical efficiencies and outcomes by tracking patient information across the continuum and exchanging data, they face the growing problem of how to keep data private and secure.
"Organizations are taking small steps in a big direction to be sure this is done with care and caution," says Keith Van Camp, vice president of information technology, St. Dominic–Jackson (Miss.) Memorial Hospital. "It is critical to understand how the processes work before taking these big leaps, so that is what we have tried to do as quickly but judiciously as possible."
Most of the hospitals surveyed have essential security controls such as access control, user identification, automatic logoff, mobile device passwords, encryption for laptops, secure disposal of electronic media that has stored ePHI and firewalls. "But there are other important security controls that still haven't been implemented," notes Pat Milostan, chief operating officer, CareTech Solutions, Troy, Mich. "Tape encryption is one that stands out. Backup tapes typically contain every patient record and all sensitive information in the organization. Some of the largest breaches that have occurred have been due to lost backup tapes. And yet, a significant percentage of organizations haven't encrypted them. Another control that should be at 100 percent is strong password requirements. Weak passwords are often the single most important factor in allowing hackers to access and steal data."
Technologies hospitals use to secure patient health information
|2013 All||2013 Most Wired|
|Access control (biometrics, key cards, smart cards, etc.)||86%||95%|
|Gather and trend data to mitigate potential issues before they occur||54%||72%|
|Log collection automation||69%||76%|
|Perform and escalate on system log exceptions/errors||61%||76%|
|Security incident event management||73%||87%|
|Strong password requirements||78%||81%|
|Use dashboards to manage infrastructure by exceptions/anomalies||72%||87%|
|Utilize pattern detection against automated login attempts||38%||48%|
Source: Hospitals & Health Networks' Most Wired Survey, 2013
Kootenai Health | Coeur d'Alene, Idaho | www.kootenaihealth.org
Program: Localization of IT services — A long-term strategy
Texas Children's Hospital | Houston | www.texaschildrens.org
Program: Rapid communication system
University of Utah Health Care | Salt Lake City | http://healthcare.utah.edu
Program: Value-driven outcomes costing
Carolinas HealthCare System | Charlotte, N.C. | www.carolinashealthcare.org
Program: Smartphone app to improve patient education and postoperative quality of life
Middlesex Hospital | Middletown, Conn. | www.midhosp.org
Program: Real-time location system to increase safety and reduce losses effectively
Peconic Bay Medical Center | Riverhead, N.Y. | www.pbmchealth.org
Program: Virtual power: Building an infrastructure to support our future
Additional coverage of the Most Wired Innovator Award recipients will appear in the August issue of H&HN
For the 15th year, H&HN has named the Most Wired Hospitals and Health Systems based on the Most Wired Survey. The survey focuses on four main areas. Organizations must meet the criteria in each section to achieve Most Wired status. This year, 659 hospitals and health systems completed the survey, representing 1,713 hospitals, roughly 30 percent of all U.S. hospitals. The number of hospitals and health system designated as Most Wired increased to 289. The 2013 Most Wired Survey was made possible by the generous support of AT&T, McKesson, CareTech Solutions and in cooperation with CHIME, the AHA and H&HN.
This article first appeared in the July 2013 issue of H&HN magazine.