Cover Story
2006 Most Wired Winners
Research and tabulations by Suzanna Hoppszallern
The nation’s 100 Most Wired Hospitals and Health Systems are pairing information technology with strategic plans in their efforts to improve quality, streamline processes and drive financial returns. The dominant role of financial assessments in evaluating IT plans has been replaced by a “balanced scorecard” approach, elevating nonfinancial measures—both quantitative and qualitative—as equal partners with the classic return-on-investment calculation.
The underpinning of this new and evolving discipline is measurement. The nation’s Most Wired are leading the way in applying business analytics to their IT projects. The goal is to deliver value through improvements in quality, satisfaction and patient care. Compared with other organizations, the Most Wired:
In addition, the 100 Most Wired are more likely to develop business continuity plans and to test them. They also have systems in place to more rapidly restore clinical information systems in the event that a disaster causes the complete loss of the primary data center. (“Double-Edged Disaster.”)
Each year since 1999, Hospitals & Health Networks has surveyed the nation’s hospitals on their use of information technology to accomplish key strategic and operational 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 2006 Hospitals & Health Networks’ Most Wired Survey and Benchmarking Study is a joint project of H&HN, Accenture, McKesson Corp. and the College of Healthcare Information Management Executives.
For the past six years, Hospitals & Health Networks has engaged outside analysts to determine if there’s an association between information technology and critical goals for that technology, such as improvements in safety and quality. Solucient conducted the 2006 mortality analysis using risk-adjusted mortality rates. (See “A Measure of Quality.”) This year, we also took a closer look at how federal hospitals fare on the survey. (See “Bringing Up the Curve”.)
The top tech hospitals continue to lead the nation in how technology is deployed and employed to improve care, including: using a wider array of IT tools to address quality and safety, physicians entering significantly larger percentages of orders themselves and the organization conducting a larger percentage of clinical transactions via information technology.
The differences in the prevalence and use of IT among the Most Wired are consistent across all five sections of the eight-page survey. This year, 541 surveys were submitted by hospitals and health systems representing 1,217 hospitals. (See “About the Survey”.)
The 100 Most Wired are more than twice as likely than the Least Wired, defined as the 100 organizations scoring lowest on the survey, to develop specific plans for when IT project results will be measured and when the original business case objectives will be evaluated for their top five strategic projects. (See figure 1.)
Park Nicollet Health Services, St. Louis Park, Minn., measures the value of IT projects using a total-cost-of-ownership model, defined as a five-year, cost-benefit analysis including costs of labor, software, hardware, maintenance and support. Costs are compared with projected clinical and financial benefits. Hospital executives are now combining this evaluation model with its lean production quality initiative.
Increasingly, Park Nicollet pays attention to cycle time and lead time reduction, says Francis Cheung, vice president and chief information officer. “We believe IT projects can have a positive impact on cycle time reduction,” Cheung says. “We are beginning to incorporate time measures into our total-cost-of-ownership model. A number of our recent projects focus on cycle time reduction for inpatient stays and urgent care visits to increase operating capacity.” Park Nicollet appears for the first time on the Most Wired list and is also one of this year’s Most Wireless.
Mercy Health Partners, Toledo, Ohio, another Most Wired first-timer, also evaluates the impact of information technology on clinical and operational processes.
“We look at every IT project as a process improvement project that utilizes information technology as an enabler,” says Jim Albin, the organization’s vice president and chief information officer. “The value of the project is the resulting improvement in the clinical or operational process. The improvements can be in the form of fewer tasks in the process, better information at decision points, fewer handoffs, quicker cycle times or better availability of information. They all translate into higher quality and more efficient patient care.”
Information is a key to value. “One of the main IT value producers is communication,” says Billie Waldo, R.N., vice president, McKesson Provider Technologies, Alpharetta, Ga. “When you think about the information that’s needed to ensure patient safety, you need to deliver it to the right people at the right time, in a workflow that they can accept and use.” She says that information technology allows physicians, nurses, pharmacists and other caregivers to see information tailored to their needs.
The 100 Most Wired Hospitals and Health Systems conduct a broad scope of analytics to determine the value of their top five strategic IT projects, such as: developing plans for when projects will be measured and when the original objectives will be evaluated; defining and setting targets for financial, quality, safety or patient satisfaction metrics; and establishing a baseline for each measure. The typical Most Wired organization conducts these activities for an average of 75 percent of its top projects.
“There is still some disparity as far as how value is achieved and measured,” says Lewis Redd, managing partner, Accenture Health Provider Practice, Atlanta. Some hospitals emphasize financial returns, while others look for quality and process improvements. “The priorities of hospitals vary. It’s just a question of which one is more important to you,” he says.
The difference is one of emphasis, Redd says, citing as an example two academic medical centers, each implementing the same system. “One is focused on making sure their financial returns exceed the outlay, even though they still want the quality improvements,” he says. “The other one is much more focused on making process changes and quality improvements, but they’ll certainly take any financial returns that come along the way.”
The two often go hand-in-hand. “You can get the quality and service benefits along with the efficiency and financial returns,” Redd says. “They are not mutually exclusive.”
Concord (N.H.) Hospital conducts project reviews six to 24 months after implementation. “We measure financial improvement, user satisfaction and qualitative improvements,” says Deane Morrison, chief information officer. The hospital makes its third appearance on the Most Wired–Small and Rural list and appeared twice on previous Most Wired lists. “For every IT project we undertake, we establish written business objectives with associated performance metrics,” Morrison says.
The Most Wired often tie their IT investments to specific strategies.
“Our IT projects are evaluated on a multifaceted pro-forma that takes into account quality, operational efficiencies, community support and financial goals,” says Nicholas Christiano, vice president and chief information officer, Health Quest, Poughkeepsie, N.Y., a 2006 Most Wired Innovator Award winner. “Through a portfolio management process, we strive to make a ‘balanced investment’ that provides enough financial benefit to support those projects that may not have a high ROI, but have intrinsic returns in quality and care.”
Improving quality is a prime motivator for IT investments, and the Most Wired organizations take extra care to evaluate the effects of technology projects on outcomes.
“IT investments allow us to provide more comprehensive patient data at the right time and in the right format, allowing our providers to make better decisions on the treatment of our patients,” says Ellen Predaina, chief information officer, Greene Memorial Hospital, Xenia, Ohio, which is one of the 2006 Most Improved. “It frees up our nursing staff so they can better focus on patient care and at the same time provides for good documentation of the patient’s visit.”
The Most Wired are applying analytical tools to determine the risks and benefits of clinical technologies, particularly those that influence process and workflow.
“We quantify the alignment with our overall strategic plan, the impact on patients, clinicians and staff, the return on investment and the impact on quality,” says John Halamka, M.D., CIO, Beth Israel Deaconess Medical Center, Boston, making its first appearance as a stand-alone hospital. CareGroup, its parent company, was on the Most Wired list in four previous years. Beth Israel Deaconess is also a Most Wireless hospital.
“We evaluate impact on workflow, errors and throughput. Our CPOE system has reduced medical errors by 50 percent,” Halamka says. “Our emergency department dashboard has reduced length of stay in the ED by 45 minutes.” The organization’s e-prescribing system is currently being evaluated.
The use of a broad set of value and quality measures is typical among the Most Wired. “We measure the success of our IT projects in many ways. One way is through the improvement in the quality of care. Another way is through reduction in paper,” says Marty Fattig, CEO, Nemaha County Hospital, Auburn, Neb. The hospital is one of this year’s Most Improved organizations.
The 100 Most Wired Hospitals and Health Systems are significantly further along in creating paperless records.
“Our information technology system has allowed us to store more and more information electronically, eliminating the need to store paper records,” Fattig says. “Our business office has actually removed most of the file cabinets from their department because they no longer need them.”
The survey asked hospitals to detail the composition of their medical record by estimating the percentage of their records in each of several categories: data that are available digitally via direct feeds from computerized systems, paper that is scanned into the record, data entered manually into the record, paper records never made part of the electronic record and other material not part of the electronic record.
The Most Wired estimate that 58 percent of their medical records come via direct feeds from electronic systems, 18 percent come from scanning paper documents and 16 percent of the data are entered manually. On average, the Most Wired estimate that less than 8 percent of their medical record is not available digitally or is in the form of other material, compared with the Least Wired that have a total estimated average of more than 39 percent of their medical record not available digitally. (See figure 2.)
The digital record opens a new world of quality and managerial analytics.
“We are able to more accurately document improvements with the clinical systems we have in place versus the prior paper world,” says Randy Haskins, information services director, Mercy Medical Center–North Iowa, Mason City, which is one of the 2006 Most Wired–Small and Rural. “We are tracking many patient quality factors and would be unable to easily do so without the EHR.”
Haskins says a significant area of improvement comes from using rules-based systems to improve the medication management process. The hospital has documented improved quality measures—such as severity-adjusted mortality and severity-adjusted length of stay—while improving nursing documentation, timeliness of treatments, timeliness of test results available to clinicians and reductions in variable drug costs.
The drive to go paperless goes hand-in-hand with the drive to go filmless. The survey asks hospitals to identify if they provide digital images for six clinical areas. All but one of the Most Wired provide digital radiology images in the hospital inpatient setting, compared with 72 percent of the Least Wired. The differences become even more dramatic for other clinical areas. For example, 92 percent of the Most Wired provide digital cardiology images in the hospital setting, compared with 40 percent of the Least Wired. (See figure 3.)
Combining data and images improves clinical decision-making, says McKesson’s Waldo, pointing to cardiology as a prime example. “In a paper world, you’ve got the image and the paper chart … somewhere. Then you hope there’s a medication administration record,” she says. “When you’re able to incorporate the image along with the relevant data, you can make a decision very quickly. The critical goal is to combine all the relevant information with the image.”
The Most Wired are also further along in providing digital images in other settings, such as clinics and physician offices. “Our system is designed so that providers, with proper security clearance, can view images on their patients via the Internet,” says Fattig. “By saving all diagnostic images in a digital format, they are available for all providers who may have need of them. This process reduces repeat examinations due to lost films or not having the films in the location where the patient is being seen.”
The digital reach of the Most Wired extends from medical records and digital imaging into telemedicine. Telemedicine links to other hospitals are the most common, with physician offices not far behind. Depending on the setting, the Most Wired are four to 10 times more likely to provide clinician consultations via telemedicine than are the Least Wired.
The Most Wired also provide a broad array of IT educational resources to staff, including physicians and nurses dedicated to training colleagues on IT. Roughly one in eight of the Least Wired report that they do not provide any IT educational resources to staff.
The Most Wired Survey takes a detailed look at both ends of the medication administration process: order entry and medication administration. Respondents are asked to estimate the percentage of medications ordered electronically and who enters them. They are also asked to estimate the number of doses electronically matched to the patient.
Bedside medication matching is a priority among the Most Wired, and they continue to lead other hospitals in the use of electronic medication matching. The Most Wired estimate that more than 31 percent of medications are matched to the patient and the order at the time of administration using bar coding or some other form of auto-ID. The lion’s share of these organizations also match the drug to the nurse. (See figure 4.)
The percentage of medications matched at the bedside is even larger among two groups: the 25 federal hospitals responding to the survey and the 50 top scorers in the survey’s quality and safety section, identified as IT Quality Leaders. That group includes 35 Most Wired hospitals and 15 hospitals that scored among the top 50 on the safety and quality section, but whose total score did not qualify their organizations for the 2006 Most Wired list.
The Most Wired also excel at using IT at the start of the medication administration process, with an average of 36 percent of medication orders entered electronically by physicians. That’s more than twice the average for all respondents and 18 times greater than the Least Wired, where 2 percent of medication orders are entered by the medical staff. (See figure 5.) As with bedside medication matching, federal hospitals and the IT Quality Leaders lead the way in provider order entry.
“The greatest opportunity for increase in quality will come with the increase in the percentage of physicians using these systems,” says Ron Margolis, chief information officer, University of New Mexico Hospitals, Albuquerque. The organization is making its fourth appearance on the Most Wired list.
Community hospitals with volunteer medical staffs have argued that hospitals with captive medical staffs—those with a large percentage of employed physicians and residents—have an advantage in gaining physician acceptance and use of information technology. That observation appears validated by the survey results.
On average, survey respondents reported that 16 percent of medications are ordered electronically by physicians. That number doubles when at least 40 percent of the physicians are on staff. (See figure 6.) The same result holds true when looking solely at the 100 Most Wired, although the effect isn’t quite as dramatic. The results suggest that most of the gain occurs when between 40 percent and 50 percent of physicians are on staff. Incremental gains in reported results are relatively small in organizations with more than 50 percent of physicians on staff.
Among the nation’s IT Quality Leaders there is pervasive use of electronic alerts by physicians, nurses and pharmacists, where full adoption rates range from 56 percent to 100 percent, depending on both the specific type of alert and the category of clinician. For purposes of this analysis, full adoption is defined as 61 percent or more of clinicians. Those rates are much lower for the Least Wired, for which full adoption rates range from 1 percent to 87 percent, with pharmacist use of drug-drug interaction alerts most common. (See figure 7.) Pharmacists are most likely to use clinical alerts and warnings.
Delivering value through information technology requires measurement and management. “We look to measure improvements in process and quality that are made possible by our IT systems. The systems themselves very rarely have a return on investment. It’s how you use them,” says George Brenckle, chief information officer, University of Pennsylvania Health System, Philadelphia, which is making its sixth appearance on the Most Wired list. “We constantly look for ways to leverage our existing IT systems to improve value.”
The process of measuring results has been formalized among many of the nation’s Most Wired. Senior executives at Hamot Medical Center, Erie, Pa., conduct a monthly review of clinical performance measures that includes the chief quality officer and other top executives.
“We are able to measure, prioritize and make changes that directly impact our patients and the care they receive,” says Joe Butler, vice president and chief information officer. “Specific IT investments that are routinely providing meaningful, actionable input include bedside medication administration, automated incident reporting systems and data mining and surveillance systems for infection control.” The medical center is making its fourth appearance on the Most Wired list.
“Process teams accept responsibility for analyzing data and trends, redesigning work and maintaining the focus on our patients,” Butler says, adding that “specific clinical performance measures are included in our strategic plan.”
When it comes to delivering value through information technology, the nation’s 100 Most Wired hospitals and health systems continue to focus on performance metrics and patient outcomes.
“Value and quality go hand-in-hand,” says Robert Theiss, CIO, Bloomsburg (Pa.) Hospital, one of the 2006 Most Improved. “In health care, our product is positive outcomes. If IT has a positive impact on quality, there is value. The greater the influence, the greater the value.”
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This article 1st appeared in the July 2006 issue of HHN Magazine.
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