The 100 Most Wired
The nation's 100 Most Wired hospitals and health systems have, on average, risk-adjusted mortality rates that are 7.2 percent lower than other hospitals. The conclusion is valid at the 99 percent confidence level and remains valid even after controlling the data for the size of the hospital and teaching status.
The relationship between improved outcomes and information technology is documented in both the academic and practitioner research. But those studies typically examine the results of specific projects aimed at targeted safety improvements. This is the first analysis showing that hospitals with broad use of information technology across a variety of projects also have better outcomes. However, the analysis does not establish a causal relationship between IT and outcomes.
The results come amid an ongoing dialogue at the Agency for Healthcare Research and Quality on whether the most effective use of information technology targets specific safety projects or addresses more systemic issues of quality and outcomes. This analysis also comes on the heels of several widely publicized reports on the limitations of computerized physician order entry in reducing medication errors and its potential role in creating new forms of computer-related prescribing errors.
Each year since 1999, Hospitals & Health Networks has surveyed the nation's hospitals on their use of information technology to accomplish key goals, including safety and quality objectives. Based on a detailed scoring process, H&HN annually names the 100 Most Wired Hospitals and Health Systems. The 2005 Hospitals & Health Networks' Most Wired Survey and Benchmarking Study is a joint project of H&HN, IDX Systems Corp., Accenture and the College of Healthcare Information Management Executives. This year, 502 hospitals and health systems representing 1,255 hospitals participated in the survey.
For the last five years, the magazine has engaged outside analysts to determine if an association could be established between use of information technology and critical goals for that technology, such as better financial performance, higher credit ratings and differences in quality measures. Solucient conducted the 2005 mortality analysis for H&HN based on comparing risk-adjusted mortality results for the 100 Most Wired hospitals and health systems with those of the rest of the nation.
Behind the mortality analysis, the 2005 Most Wired data show three significant differences in how hospitals apply and use information technology to improve care:
The differences in the prevalence and use of IT among the Most Wired are consistent across all five sections of the eight-page survey. (See sidebar, "About the Survey.")
The 100 Most Wired have, on average, lower risk-adjusted mortality rates than other hospitals. It is critical to note that this analysis does not establish causality. (See sidebar, "The Search For Meaning: Does Information Technology Make A Difference?")
"The association is strongly suggestive, not causal, but it's an important piece of the research," says Carolyn Clancy, M.D., director of AHRQ.
This research starts with a benchmark group for hospital technology leadership--the 100 Most Wired--and asks if those hospitals have significant and discernable differences in outcomes. "It's not a random observation, even if it is not necessarily cause and effect," says Kaveh Safavi, M.D., Solucient's chief medical officer. Safavi and the editors of H&HN designed the mortality analysis, along with Dave Foster, Solucient's vice president of clinical consulting. Foster conducted the analysis.
"Thoughtful institutions that pay attention to quality are also interested in clinical information technology," says Graham Hughes, M.D., vice president of product strategy for IDX. "This adds increasing weight to the notion that careful implementation of clinical IT contributes to better care."
Most chief information officers and chief medical officers say that, to be effective, adoption of information technology must be combined with clinical process improvements and a culture of safety. "What we know from the studies we're supporting is that technology is only part of the drive to improve quality," Clancy says. "It clearly has to be linked with process improvement."
The difference in approach to IT and quality vary widely among hospitals. Information technology can play a supporting role, an organizing role or catalytic role in quality and safety efforts. Rarely, if ever, does it play the leading role in quality initiatives. In most cases, however, senior executives say that IT is one of the key ingredients necessary for improving outcomes generally and a core element of most individual safety efforts.
"IT is a contributor, but not an end unto itself. That's an important contribution of this work," says Carmela Coyle, senior vice president for policy at the American Hospital Association. "We are just beginning to understand the connection and contribution of IT to health care quality."
At AHRQ, researchers routinely discuss whether IT is best used as a catalyst for systemic quality improvement or as a tool applied to individual quality and safety efforts. "We have a lively debate at the agency going on daily, almost hourly, about what is the right wedge to drive change," Clancy says, noting that views are strongly held on both sides.
"What this survey and analysis suggests is something more holistic," says Lewis Redd, Accenture's partner-provider practice leader. He says that technology plays a role in both targeted safety efforts and systemic change. "There's no doubt in my mind that these tools lead to better processes and better outcomes."
Hospitals are attempting both approaches--use of IT to eliminate specific errors and the application of IT for general improvements in care--often simultaneously.
The promise of specific technologies, such as order entry and bar code medication matching, is to eliminate specific types of medical errors. The promise of a more systemic approach including decision support, electronic surveillance and ubiquitous access to information is to increase the use of evidence-based medicine, clinical protocols and adherence to best practices, thus decreasing errors of omission and increasing the use of best practices.
Although computerized order entry received early praise in both the academic and practitioner research as a tool for eliminating medication errors, recent studies have cast a shadow over those results. Earlier this year, the Journal of the American Medical Association, the Archives of Internal Medicine and the Journal of the American Medical Informatics Association released separate studies on limitations and potential unintended consequences of CPOE. The JAMA and Archives pieces were picked up in the popular media.
"There still seems to be a reasonable amount of concern about the recent reports that, despite the amazing amount of potential to reduce errors, there appears to be a small likelihood of introducing errors through the technology," IDX's Hughes says.
Those studies fueled a simmering debate in academic and policy circles about the potential for unintended consequences of clinical IT generally and, specifically, whether or not the cost of CPOE is the best use of resources for improving care.
"We need to better understand what it means, not just to have IT, but to really use it," says the AHA's Coyle, pointing out the need to know more about the drivers of adoption, successful implementation and use.
The literature suggests that reducing errors through CPOE hinges on a careful analysis of the effect of IT on clinical processes, as well as physician acceptance. The reports also indicate that CPOE is most effective when combined with clinical decision support. That mirrors the experience of the 100 Most Wired.
"For the benefits of CPOE to be realized, it must be part of a much broader strategy integrating clinical documentation, medication administration, clinical decision support, remote access and wireless strategies," says Richard Rogers, vice president and CIO, Health First, Rockledge, Fla. "Integrating, planning and executing these strategies simultaneously takes time, capital investment and resources."
There are two key comparisons of data in this analysis. First, we examined the average responses for the 100 Most Wired compared with those for all respondents and the average for the 100 respondents who scored lowest on the survey. The second comparison, which is new in 2005, examines use of IT by the top scorers in the survey's quality and safety section. The goal: Determine if the mortality results are backed by differences in behavior among hospitals.
For the second comparison, we created two new benchmark groups: the 50 top scorers in the quality and safety section of the survey and the 63 hospitals from the 100 Most Wired that did not score among the top 50 in the quality and safety section. (For definitions, see sidebar, "The Search For Meaning: Does Information Technology Make A Difference?")
The 100 Most Wired have greater use of CPOE by clinical staff, according to 2005 survey results. There have been many efforts to measure the use of CPOE in hospitals. Those estimates vary widely, often depending on both the definition of CPOE and the wording of the survey. Some surveys measure the prevalence of CPOE systems, focusing on the number of hospitals implementing the technology. Other surveys examine physician use of CPOE, looking for general estimates of the number of doctors using the technology.
The Most Wired Survey looks at key components of electronic medical information distribution on a detailed level, examining nurse, physician and pharmacist use of 14 functions in four general categories: basic patient information, decision support, order entry and results review. In general, the 100 Most Wired have higher adoption of all 14 functions among all groups, but the differences are significantly larger among physicians. For this analysis, "full adoption" of a technology by physicians, nurses or pharmacists is defined as use by at least 61 percent of those professionals.
The differences are staggering. Among the Most Wired, 41 percent say they have achieved full adoption of pharmaceutical order entry by physicians, more than five times the 8 percent full adoption rate among the Least Wired. (The Least Wired are the 100 respondents that scored the lowest on the survey.) But among the IT Quality Leaders--the 50 hospitals that scored the highest on the survey's safety and quality section--70 percent say they have achieved full adoption by physicians. The results are similar for lab and radiology order entry as well. The full adoption rate for clinical alerts ranges from 19 percent for the Least Wired to 65 percent among the Most Wired. Similarly, the difference in the full adoption rate for clinical guidelines ranges from 13 percent for the Least Wired to 59 percent among the Most Wired. (See figure 1.)
"We did not fully realize how difficult the battle would be to change physicians ordering practices," says Steve Pelton, CIO, Central Region, Ministry Health Care, Milwaukee. Still, he says the effort will continue. "As an industry, we are regrouping and learning from the experiences."
One factor that could affect adoption rates is the availability of order entry. The Most Wired provide clinicians with access to CPOE functions from more locations: At least 30 percent of respondents say they provide access from physician offices, ambulatory settings or other remote locations, compared with no more than 5 percent among the Least Wired. Again, the contrast with the IT Quality Leaders is stark: 94 percent say they provide CPOE access from physician offices, 86 percent provide access from ambulatory settings and 82 percent provide access from other remote locations. (See figure 2.)
"The impact on physician culture has been grossly underestimated, especially at organizations with voluntary medical staffs," says Ron Strachan, vice president and CIO, HealthEast Care System, St. Paul, Minn.
Adoption rates measure the percentage of clinicians who routinely use the technology, establishing a baseline for organizational comparison. But they do not distinguish between frequent and infrequent use of computerized order entry or whether top admitters have embraced IT. As a result, adoption rates are a relatively weak proxy for the volume of clinical level activity managed electronically.
At the clinical level, the Most Wired Survey asks respondents to estimate the percentage of medication orders that are entered electronically and who enters them. It also asks respondents to estimate the number of doses electronically matched to the patient.
The Most Wired excel at both ends of the medication delivery process. Among the 100 Most Wired, 28 percent of medication orders are entered electronically by physicians, more than twice that of all respondents and 14 times greater than the Least Wired, where less than 2 percent of medication orders are entered electronically by doctors. The difference is even more dramatic compared with the IT Quality Leaders, where physicians enter 42 percent of medication orders electronically. (See figure 3.)
The results are duplicated at the other end of the medication delivery process. Among the Most Wired, an average of 23 percent of medications are electronically matched to the patient and the order at the bedside, compared with 14 percent for all respondents and 1 percent among the Least Wired. The difference is even more dramatic for the IT Quality Leaders, where 41 percent of medications are electronically matched to the patient and the order at the bedside. The Most Wired and Tech Leaders (the 63 hospitals on the 100 Most Wired list that are not among the IT Quality Leaders) are more likely to support their use of bedside medication matching with automated medication dispensing devices away from the bedside. (See figure 4.)
Both provider and academic literature identify the use of decision support as key to the successful use of IT to improve care. Among the nation's IT Quality Leaders, there is pervasive use of electronic alerts by physicians, nurses and pharmacists, where the rates of full adoption range from 48 percent to 100 percent. That contrasts with the Least Wired, where clinicians are much less likely to use computer-driven alerts. Full adoption rates among the Least Wired range from 0 percent to 67 percent,
with duplicate order, drug-drug interaction, dose checking and allergy alerts being the most common. (See figure 5.)
Pharmacists are most likely to use decision support, but there is still a large gap between the nation's IT Quality Leaders and the Least Wired. The gap is even larger among nurses, but they are reaching full adoption rates for alerts and reminders faster than physicians.
"A successful project places as much or more emphasis on the impact to nursing and ancillary workflow as it does on building system intelligence that provides value to physicians," says Asif Ahmad, vice president and chief information officer, Duke University Health System and Medical Center, Durham, N.C.
The contrast in full adoption rates is most dramatic for physicians. Among the Least Wired, only 10 percent have achieved full adoption of allergy alerts by doctors compared with 76 percent among the IT Quality Leaders. For each of the seven other types of alerts surveyed, no more than 5 percent of the Least Wired have achieved full adoption among physicians. The nation's Most Wired also provide decision support more broadly to doctors via their physician portals. (See figure 6.)
The most technologically advanced hospitals have linked clinical alerting with electronic surveillance. The Most Wired are more likely to have an alert system tied to a surveillance system that monitors patient vital signs, lab test results and other clinical information designed to notify caregivers of deterioration in a patient's condition before an adverse event occurs. (See figure 7.)
"Technology is a tool to improve quality, but it is the people and the process of using technology that drives outcomes improvement," says C. Lynne Royer-Willoughby, a nurse and director of medical informatics at Community Health Network, Indianapolis. "IT is the means to the end, not the end."
Some CIOs say that the technologies, while promising, need to mature. Others say that the application of technology to changing hospital outcomes and, more broadly, improving population health, is a much steeper learning curve than ever anticipated.
"The holy grail is to deliver evidence-based medicine specific to the patient at the point of care to improve quality," says AHRQ's Clancy.
Among the 100 Most Wired, IT is in high gear across a broad range of goals: reducing errors, increasing use of evidence-based medicine, fixing processes and improving outcomes. But, CIOs say, the technology itself is beside the point.
"The most important role IT has in improving outcomes is its ability to provide the right information at the right time to the provider," says John Burke, CIO, Indianapolis VA Medical Center. "IT has become a critical tool in the care and treatment of patients at our facility. Without it, quality and timely care is not possible."
This article 1st appeared in the July 2005 issue of HHN Magazine.
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