Most Wired Innovator Award
IT pioneers use electronic whiteboards to track surgeries and smart phones to improve clinical efficiency and quality.
Innovative hospitals continue to adapt emerging computer and wireless technologies to improve the delivery and safety of health care. This year's Most Wired Innovator Award winners and finalists range from eEmergency services and clinical smart phones to digital pens and eWhiteboards for surgical tracking.
The eEmergency system installed by Avera, a 29-hospital system headquartered in Sioux Falls, S.D., connects minimally staffed rural clinics and emergency rooms to board-certified emergency physicians and specialists 24 hours a day. "Geography should not dictate the quality of care that you receive," says Don Kosiak, M.D., Avera's director of emergency medicine.
With the press of one button, rural health care providers in 57 communities across six upper-Midwestern states have immediate, two-way video access to emergency physicians staffing the system's hub in Sioux Falls.
"Medicine is a team sport," Kosiak says. "It was never meant to be practiced in isolation." With more than 14,000 coded diagnoses, 6,000 medications and 4,000 medical procedures, no one can know everything, every time. "Emergency physicians should have the ability to ask questions of colleagues," Kosiak says. eEmergency provides that capability.
The system uses several technologies, including high-definition videoconferencing supported by a dedicated broadband network. Throughout rural hospital EDs, 32-inch, high-definition, flat-panel monitors are mounted on walls. Ceiling microphones and the button — a Viking emergency speaker phone that automatically calls the hub — also stand at the ready. The hub launches a video connection within 20 seconds.
Hub physicians have access to electronic health records at each remote site, saving time in the event of transfers. Several PACS allow sharing of DICOM images, including X-ray, CT and MRI studies. Some remote sites have installed telehealth stethoscopes and examination cameras.
So far, the eEmergency system, installed in 2009, has provided assistance for more than 2,580 rural patients. The system gets triggered twice a day on average. The majority of cases are trauma (28 percent), cardiac events (26 percent), neurological issues (18 percent), respiratory distress (10 percent) and behavioral health (10 percent).
Timeliness is critical in most emergencies. In more than 600 cases, hub physicians were available an average of 14 minutes before local providers. "The system also has helped rural sites avoid 561 unnecessary transfers, saving patients' payers and providers an estimated $3 million in ground and air ambulance costs," says Jim Veline, Avera's senior vice president and chief information officer.
One key obstacle in eEmergency implementation, according to Veline, has been cost. The system has an annual budget of $3.5 million, with the majority of costs going toward salaries for hub physicians and staff. Also, each eEmergency remote site requires approximately $24,000 in videoconferencing equipment to implement the program. Broadband expenses are estimated at $6,000 per year per remote site.
"Funding the equipment need can be burdensome to small facilities with limited budgets," Veline says. He adds that Avera works with remote sites to secure federal funding and private grants to help offset fees.
At Cullman Regional Medical Center, inefficient communication in its surgery-anesthesia unit resulted in an estimated 200 telephone interruptions each day. There was a monotonous loop of calls among the one-day surgery unit, registration and anesthesia to determine if a patient had arrived and was prepped for a procedure. And that doesn't even take into account family members who were left in the waiting room wondering where the patient was and how he or she was doing.
To gain efficiency, Cullman formed a performance improvement team using Lean and Six Sigma and charged it with developing a homegrown system to communicate with registration, preadmission testing, surgery staff, surgeons and families. The solution was a network of eWhiteboards updated by the various departments as patient location and status changed.
"Initially, the tracking system focused on reducing phone calls to determine the whereabouts and status of surgery patients," says CRMC President Jim Weidner, "but the project mushroomed into much more of a comprehensive, visual communication tool that not only improved communication and efficiency, but improved family members' ability to track loved ones."
Using $9,916 of a $10,000 budget, Cullman purchased five eWhiteboards and Apple Mac minis to run them. The board in surgery required a touch screen overlay. Programming was done by Cullman's IT department using systems already in-house.
The eWhiteboards in registration and one-day surgery show a patient's expected and actual arrival times. The surgery board reflects medication alerts, anesthesia plan, status of surgeon site markings, pre-op medication, surgical suite occupancy and patient status.
There is also an eWhiteboard in the surgical lounge so surgeons can track patient prepping, and in the family waiting room so families no longer have to wonder while they worry.
As a result, there's been a 46 percent drop in phone calls among departments, with more decreases expected as the system becomes more robust.
"We put tight deadlines in place to complete the tracking board initiative," Weidner says. Completion was targeted for 90 days from concept to finished product, which gave the team an early win, while also minimizing invested capital.
Weidner's advice for team motivation and achieving such early success: Give the team the tools and resources necessary, insist on a sense of urgency and purpose for the team, and reward the team once it completes the project. Once the system went on the air, Cullman's performance improvement team was treated to a dinner at a local five-star restaurant. "It was worth every penny," Weidner says.
For all of its potential promise, computerized provider order entry also carries some heavy baggage, not the least of which are communication gaps between clinicians. The problem is that orders, including "stat" orders, can be entered from any device connected to the hospital EHR without any way to notify staff that an order has been placed. Nurses must check the computer continually to see whether an order has been entered into the EHR, interrupting bedside duties.
The University of Pittsburgh Medical Center addressed that problem with what is now a nearly ubiquitous tool — the smart phone. UPMC interfaced CPOE with BlackBerry smart phones to provide instant order notification.
"Nurses now receive alerts of new orders, improving the timeliness of order completion," says Debbie Balcik, director of clinical operational informatics. Balcik says nurse smart phones also receive alerts of arrhythmias or other life-threatening cardiac conditions. RNs acknowledge alerts directly on their smart phones, saving callbacks. The phone also is used to escalate alerts if they are not acknowledged in a specific time frame.
Balcik says the CPOE-BlackBerry system has improved communication throughout the campus. "Nurses and other caregivers can now be reached immediately, whereas before you had to call the nursing station, try to figure out which nurse was caring for which patient, and then send someone down the ward to find them," she says. UPMC also has seen an increase in productivity in nursing, nursing assistants, technicians and ancillary services.
While Balcik says the smart phones have been well-received by staff, there have been some bumps in the road. For instance, the small size of the screen and small keys were challenging for some nurses, but that was addressed by increasing font size and reducing the number of screen icons.
Another issue uncovered during the pilot was patient perception. Some patients and family members thought nurses were using their personal phones instead of attending to nursing duties. This was addressed by installing signs describing BlackBerry use to improve health care and also by a large label on the phones identifying them as nursing phones.
Costs included $149,700 for 300 BlackBerrys and $49,400 for a smart phone enterprise server, plus the monthly fees. UPMC used its existing wireless data infrastructure for all messaging and alerts. It contracts with a cellular carrier for voice-only services — $36.99 per month for each device.
"The smart phone is giving us the edge by providing a new technology to improve communication and decrease errors," Balcik says. "Strategically, the smart phone provides a platform that can be built upon to develop enhancements to support the clinical environment into the future."
Future enhancements include nurse call bell alerts and applications using the smart phone digital camera.
An EHR infrastructure of software, laptops and workstations is cumbersome to organize in a makeshift emergency care area, such as at a major NASCAR race venue. Give doctors digital pens though, and they can travel. Lehigh Valley Health Network, the official medical provider for NASCAR at Pocono Raceway in Long Pond, Pa., has a digital pen solution that allows clinicians to document patient encounters in medical tents on familiar forms, which are then synchronized to the EHR. "Rapid deployment of digital pens with emergency care paper templates allows us to bring emergency care and the EHR to the raceway," says Nadine Opstbaum, associate director, information systems, clinical systems. It didn't make sense to implement Lehigh's EHR network for race events a few times a year. Lehigh found the digital pen technology (DigitalShare, from Shareable Ink, Nashville, Tenn.), coupled with customized emergency medicine templates, to be a speedy, intuitive alternative to EHR deployment at Pocono, or at disaster sites. The digital pen solution also streamlined the process of submitting claim forms to the federal government for disaster relief reimbursement. "Our network has a comprehensive immunization program and the digital pen technology was utilized to document the thousands of people in the community who received flu shots," Opstbaum says.
Texas Health Resources earned finalist recognition for using collaborative and social media tools to incorporate best-practice protocols to help prevent catheter-associated urinary tract infections. By using Sharepoint, a collaboration tool that facilitates workflow and manages components of the EHR, and Yammer, a social media tool that allows rapid sharing of ideas and updates to stakeholders and caregivers, Texas Health Resources was able to quickly modify and test changes to 1,639 EHR order sets and deploy best practices to the organization within three weeks. Success soon was apparent in a more than 26 percent reduction in the length of catheter-line days within 60 days of protocol deployment. "Use of the EHR to help reduce catheter-associated urinary tract infection aligns with our efforts to achieve one of the goals of the federal Partnership for Patients — to reduce preventable all-cause harm rates, including hospital-acquired infections, in our hospitals by 40 percent by the end of 2013," says Ferdinand Velasco, M.D., chief medical information officer.
When different EHRs are used in an organization's ambulatory and inpatient settings, easy access to patient data can be difficult for clinicians. The University of Utah Hospitals & Clinics found a way to avoid separate sign-ons, patient selection and navigation paths using an EHR bridge, achieving Innovation Award finalist recognition in the process. "The bridge enables easy access to multiple EHRs from within the primary application used by the caregiver," says Travis Gregory, director of clinical transformation. He adds that now information is available with a single click and there is no need for additional sign-ons or patient selection. Gregory says they first investigated HL7-enabled tools to solve the problem, but quickly found limitations for their complex deployment. They also tried to build a single-view using federated data sources, but this became cost-prohibitive and potentially expensive to maintain. In the end, the bridge solution was found in Web capabilities that already existed in the two EHRs. "Many EHR vendors provide Web access tools within the application," Gregory says. "These tools can be leveraged for creative solutions with much less complexity and cost."
The Most Wired Innovator Awards honor hospitals that apply technology in innovative ways, finding creative solutions to serve their patients, staff and communities. A panel of CIOs and others evaluate submissions on a variety of criteria, including universality and achievement of business objectives, creativity and uniqueness of concept, impact on the organization, scope of the solution, stage of implementation, and technical creativity. Visit www.hhnmostwired.com.
Each month, H&HN will provide continuing coverage of the annual Most Wired Survey and Benchmarking Study and other IT issues. The survey is made possible through a partnership among H&HN, the American Hospital Association, the College of Healthcare Information Management Executives and McKesson Corp. AT&T and CareTech Solutions provide additional support.