Cover Story -- 2008 Most Wired

Are Patients Happier at Most Wired Hospitals?

Our 10th annual IT survey: Data, insights and the top 100 hospitals and health systems

cover Team Coverage by Alden Solovy, Suzanna Hoppszallern, Sarah B. Brown

Patients favor hospitals with advanced information technology. An analysis of data from the 2008 Most Wired Survey and Benchmarking Study finds that patients at top technology hospitals have a better overall assessment of their stay and specifically are more satisfied with the admissions process and the manner in which tests and treatments are handled.

In a separate analysis, the nation’s 100 Most Wired Hospitals and Health Systems have better outcomes on a variety of quality measures, including risk-adjusted mortality rates.

Taken together, the patient satisfaction and quality indicator analyses provide the strongest evidence in the 10-year history of the Most Wired Survey and Benchmarking Study that information technology makes a difference in both the patient experience and the quality of care.

Yet, an irony emerges from the data. While analyses show that top tech hospitals excel in providing quality, patient-centric care, industrywide progress in adopting clinical IT remains elusive. Overall gains in the use of information technology appear remarkably slow.

The quality and satisfaction results are compelling. This is the fifth consecutive year that an analysis shows that the Most Wired have better outcomes on a variety of quality measures. It is the first year in which H&HN closely examined the potential link between use of information technology and patient satisfaction. H&HN worked with Press Ganey Associates Inc. for the satisfaction analysis and with Thomson Reuters for the quality analysis.

“Facilities that are more progressive with regard to IT are also those that are more progressive with regard to changes that improve the processes of care,” says Dennis Kaldenberg, Press Ganey’s senior vice president of research, knowledge management and strategic planning.

“Health IT has shown incredible promise in helping us improve the quality and safety of the care hospitals deliver every day,” adds Rich Umbdenstock, president and CEO of the American Hospital Association. “The results of the Most Wired Survey confirm that today’s patient also understands the benefits of IT in improving care and improving the overall hospital experience.”

A growing body of evidence suggests that information technology is a key component of successful quality, safety and satisfaction initiatives. While these analyses show an association between IT and results, they do not show that adoption or use of IT caused those results.

“We may be measuring a commitment to quality,” says Press Ganey’s Suzanne Coshow, a research associate.

Lydon Neumann, senior executive at Accenture LLC, agrees that investment in information technology needs to be coupled with other efforts to drive exceptional results. “Most Wired is not the only thing at which these organizations excel. It’s characteristic of leadership that looks at all the elements they need in order to be high-performing organizations,” he says.

Neumann adds that the investment in information technology demonstrates the organizational commitment to patients, caregivers, physicians and clinicians, staff and administration. “It indicates a willingness to invest in areas that advance organizational effectiveness,” he says.

Hospital executives concur.

“The evolving relationship between quality and outcomes has always been at the heart of decisions regarding investment in technology solutions. Our focus continues to be supporting a quality patient care experience that delivers desired outcomes,” says Bonnie Sessa, interim CIO of Continuum Health Partners Inc., New York, a 2008 Most Wired and Most Wireless organization. This is Continuum’s first appearance on the Most Wired list.

“The role of IT in delivering exceptional outcomes through quality patient encounters is no longer questioned. It’s becoming essential to a health care organization’s ability to thrive,” Sessa says.

IT and Patient Satisfaction

Press Ganey evaluated patient satisfaction results from its client database; 268 Press Ganey hospitals data responded to the 2008 Most Wired Survey. Patients at Most Wired organizations are more satisfied than patients at other hospitals.

In the Press Ganey methodology, satisfaction is measured in a variety of categories, each with multiple questions. This top-line result, which is a composite of all the questions on the satisfaction survey, is statistically significant at the 95 percent confidence interval (see figure 1).

“As the consumer starts to shop more and more based on quality scores and pricing, how the consumer sees you in the marketplace will have an impact on what patients you get, what payer mix you maintain, lose or grow, and overall performance,” says Roger Neal, assistant vice president and CIO of Duncan (Okla.) Regional Hospital, a 2008 Most Wired–Small and Rural organization. “We will be implementing systems and changes to systems to help us report consumer-based information externally.”

Most Wired hospitals achieved higher patient satisfaction ratings, to different degrees of statistical significance, in eight of 10 categories. “Any action that an organization takes to improve communication, such as IT, is going to have an effect on patient perspectives,” says Press Ganey’s Kaldenberg.

The Most Wired have employed techniques ranging from patient portals to personal health records to foster strong customer relationships.

“Patients perceive this as technology protecting them,” says Merrie Wallace, R.N., vice president and solution line manager, McKesson Corp. “They feel the presence of that technology and they feel the safety.”

Press Ganey researchers found two aspects of the analysis particularly noteworthy. First, satisfaction with the discharge process did not produce a statistically significant association with information technology. Researchers expected patient satisfaction with three areas—admission, discharge and the handling of tests and treatments—to be strongly associated with information technology, in part because hospitals have been active in using IT to address these areas.

Second, researchers found a higher-than-expected association between IT and the overall patient rating of the hospital. In particular, the patient’s likelihood to recommend a hospital is significantly higher among the Most Wired than other organizations.

“I would speculate that the visible presence of technology in an organization improves its image as a progressive or cutting-edge delivery system,” Kaldenberg says. “Patients are most likely to recommend places with excellent service, display up-to-date technologies and provide their needed clinical outcomes.”

Hospitals’ goal is to produce the best clinical results and the best customer experience possible, says Kevin Burbules, CIO of Civista Medical Center, LaPlata, Md., a 2008 Most Improved organization. “We will continue to add components to our infrastructure whose function may solely be to provide context-appropriate information to our patients. We will add others to streamline our patient’s interactions with us, and still others that allow us to maintain long-term relationships with our patients.”

As part of the study, Press Ganey conducted separate analyses to control for other factors that might influence the results, such as bed size and status as a critical access hospital or members of the Council of Teaching Hospitals or a Magnet hospital as designated by the American Nurses Credentialing Center. Although specific results for a few patient satisfaction variables changed, the overall conclusion—that hospitals with greater investments in information technology have higher patient satisfaction—remained intact.

“In organizations that are more wired, patients perceive that clinicians are working together better,” Press Ganey’s Coshow says, adding that patients may associate the presence of information technology—such as workstations on wheels—with high quality care.

IT and Quality

Based on five years of analysis, the presence of information technology in a hospital is, indeed, associated with better outcomes.

Thomson Reuter’s analysis of the effect of IT on outcomes among the 2008 Most Wired includes four measures of quality and two measures of cost. The quality variables are: risk-adjusted mortality rates; risk-adjusted complication rates; and two composite indexes, one created from the Agency for Healthcare Research and Quality’s patient safety measures and one created from a subset of the Joint Commission’s Core Measures based on data reported on the Hospital Compare Web site. The cost variables are: severity-adjusted average length of stay and case-mix wage-adjusted expenses per adjusted discharge.

“Quality and satisfaction are tied to overall initiatives that hospitals take generally and embrace with technology,” says McKesson’s Wallace. “Those that are successful use this as part of an overall strategy and they achieve significant results. Those who just deploy technology for technology’s sake don’t see these types of results.”

The Thomson Reuters analysis was conducted twice, once comparing Most Wired hospitals with all other hospitals nationally—known as an out-of-sample analysis—and once comparing the Most Wired to all survey respondents, known as an in-sample analysis (see figure 2). The results were consistent between the in- and out-of-sample analyses:

•For the out-of-sample analysis, the 100 Most Wired had better results than all other hospitals nationally for four of the six measures: risk-adjusted mortality rates, core measures, patient safety and average length of stay. This is statistically significant at the 99 percent confidence interval.

•For the in-sample analysis, the 2008 Most Wired had better results than the other hospitals in the survey for the same four measures, with the difference for patient safety and average length of stay statistically significant at the 99 percent confidence interval and the difference for risk-adjusted mortality rates and core measures significant at the 95 percent confidence interval.

“By asking the question in two ways and getting the same results, it adds more evidence to support the hypothesis that these hospitals are different in terms of safety and quality,” says David Foster, chief scientist at Thomson Reuters’ Center for Healthcare Improvement.

Thomson has conducted the outcomes analysis for H&HN for the past four years.

The evidence of systemic gains in quality and satisfaction from investment in information technology among the Most Wired is strong. These top tech hospitals are employing IT in the pursuit of quality. Yet, the evidence of a slow slog toward widespread technology adoption and use among hospitals, in general, is equally as compelling.

Medication Management Challenge

Take medication safety, for example. Of the 556 hospitals and health systems that completed the survey, less than 5 percent, a total of 23 organizations, have effectively deployed technology at both ends of the medication administration process. The remaining 95 percent represent an adoption gap that jeopardizes patients and reduces efficiency (see figure 3).

This conclusion stems from two core questions on the safety and quality section of the survey. One question tracks the beginning of the process, examining how medications are ordered. The other question looks at the end of the process, determining if and how medication orders are matched to the drug and the patient.

Survey respondents were asked to estimate the percentage of medications electronically ordered by physicians, nurses, pharmacists and nonclinicians and the percentage that never become electronic orders. For this analysis, full adoption of electronic order entry is defined as at least 80 percent of orders entered electronically by physicians. Using that definition, 68 hospitals and health systems achieve full adoption of physician order entry.

In another question, respondents were asked to estimate the percentage of total medication doses administered that are electronically matched to the order, patient and nurse. Full adoption of medication matching is defined as at least 80 percent of doses administered matched to the order, the drug and the patient at the bedside using bar coding or RFID. With this definition, only 149 hospitals and health systems achieve full adoption of electronic bedside medication matching.

The results at the other end of the spectrum also are eye-opening. More than one-third of the participants—212 respondents—report that they have no activity on either front: no physician order entry and no bedside medication matching.

Electronic medication management is considered one of the fundamentals of using information technology to improve care. Yet, a large number of organizations do not have physicians ordering medications electronically nor use IT at the bedside to ensure safe administration.

The adoption gap for electronic medication order entry continues to widen. Since 2004, the number of medications ordered electronically by physicians rose from 27 percent of doses to 46 percent, compared with an increase from 12 percent to 19 percent among all hospitals participating in the survey. Among the least wired hospitals—the 100 respondents that scored lowest in the Most Wired Survey—the percentage of medications ordered electronically by physicians increased from 3 percent to 4 percent in the past five years (see figures 4 and 5).

“It requires a lot of clinical leadership to get physicians—when physicians have a choice—to move toward electing to use a safer tool for order entry. Institutions that can show incremental progress and incremental benefit to the physician community get through that last hurdle,” says McKesson’s Wallace. “When organizations don’t really embrace practice improvement as a business goal they stall at the hardest phase. That’s CPOE.”

This article 1st appeared in the July 2008 issue of HHN Magazine.

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