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Like many hospitals nationwide, Peninsula Regional Medical Center has been on a seemingly never-ending information technology journey. The mission: to use high-tech systems to improve the quality and safety of patient care and to become more efficient. The hospital has been striving to become a meaningful user, if you will, since the mid-1990s when the first iteration of an electronic medical record was installed. Through the years, components have been added systematically. In 1998, the 362-bed medical center implemented point-of-care charting; in 2001, it installed automated medication storage and dispensing cabinets, followed by bedside scanning for patient medications in 2002. The next year, a medication-management system was added in the pharmacy. And in 2005, computerized provider order entry came online.
"We've been very methodical about how we implement information technology," says Raymond Adkins, chief information officer of the Salisbury, Md., hospital. "The last few years, CPOE has received a lot of focus. We've worked to increasingly leverage the decision support that you can have with CPOE."
The heightened attention to and education about CPOE has resulted in an 85 percent overall adoption rate among physicians. More impressive is what that has meant for patient care:
- A decrease in one year in the number of patients with elevated international normalized ratio for blood-clotting time from greater than 20 percent to 10 percent.
- A 19 percent reduction in adverse drug reactions with Dilaudid, a potentially dangerous narcotic medication.
- Increased compliance with heparin protocols by 60 percent.
"We implemented front-end knowledge support for physicians," says Chris Snyder, D.O., chief medical information officer at the hospital. "We're trying to stimulate them to think about what they are doing while they are doing it. Doctors realize this is a good tool."
And the safety improvements continue. A couple of years ago, a hospitalwide initiative targeting sepsis was launched. The clinical and IT teams built decision support and order sets into the EMR that have dramatically improved adherence to Institute for Healthcare Improvement guidelines. Between late 2009 and early 2011, the hospital cut its sepsis mortality rate by 37 percent, saving more than 77 lives.
"We hardwired the guidelines into our care process and heightened awareness," Snyder says. Adds Adkins, "We have all of this data directly populating the patient record and we can use the clinical analytics and protocols to real-time signal alerts."
Steady as IT Goes
Peninsula Regional shares a common strategy with many of the nation's leading IT hospitals: carefully building a clinical IT infrastructure with the intent of providing practitioners with the tools and information they need to improve patient safety and quality of care. Results from Hospitals & Health Networks' 13th Annual Most Wired Survey show that hospitals are indeed making steady progress deploying advanced systems, including CPOE, closed-loop medication, clinical-decision support, alerts and integrated digital images and dictation with EMRs.
CPOE, for instance, has been on an upward trajectory for a number of years. At hospitals on this year's Most Wired list, 59 percent of physician orders are entered electronically; that's up from 27 percent five years ago. Among all respondents, the number stands at 40 percent, compared with 12 percent in 2004. The emphasis on CPOE in federal meaningful use regulations has helped drive implementation, but the technology also is becoming the standard of care, says Andrew Mellin, M.D., vice president, predictive care at McKesson Corp., a sponsor of the survey. He adds that there's a level of expectation growing among physicians and physicians-in-training that hospitals have this technology in place.
"The Most Wired data reinforce the trend we've been seeing over the past few years of hospitals moving forward with technologies that are the most important for clinical care and patient safety," says Chantal Worzala, director of policy at the American Hospital Association. "We continue to see areas like medication safety and medication reconciliation take priority."
Looking at medication safety, 66 percent of Most Wired hospitals and 54 percent of all respondents use bar coding or RFID at the bedside to match the drug, the order, the patient and the nurse. That's up from 23 percent for Most Wired and 14 percent for all hospitals in 2005. Conversely, the percentage of Most Wired hospitals that don't do any sort of electronic medication matching plummeted from 19 percent in 2005 to a paltry 2 percent this year. The drop was even more dramatic for all respondents—from 42 percent down to 13 percent during the same six years.
But where hospitals—including the Most Wired—seem to be challenged is with data collection and some of the other meaningful use criteria, many of which were built into this year's survey.
Stage 1 of meaningful use, for instance, requires that hospitals record demographic information as structured data for more than 50 percent of patients seen in the emergency department or admitted. Hospitals are very good at tracking date of birth, gender, and race and ethnicity. In fact, 100 percent of the Most Wired record this data for 51 percent or more of patients; 97 percent of all respondents do so for date of birth and gender. The percentage falls to 93 percent for race and ethnicity. Hurdles arise when it comes to preferred language and mortality. Among all hospitals, 83 percent record preferred language and 68 percent mortality information. The Most Wired are slightly better—90 percent and 77 percent, respectively. Similarly, there are challenges recording an up-to-date problem list of a patient's current and active diagnosis. The Centers for Medicare & Medicaid Services requires this be done for 80 percent or more patients in the ED or admitted. Just 52 percent of all respondents have this capability compared with 70 percent of Most Wired.
The regulation also requires that hospitals be able to provide more than 50 percent of patients an electronic copy of their discharge instructions upon request. Here again, the Most Wired are outpacing the rest of the field with 74 percent being able to do so compared with 55 percent of all respondents. When it comes to providing an electronic version of a patient's health information—test results, problem lists, medication allergies and more—86 percent of Most Wired and 71 percent of all meet the requirement. But this is also an area in which hospital officials say that regulations need to take into account real-world practices.
"We offer any patient an electronic copy of their record and nobody wants it," says Marty Fattig, chief executive officer at Nemaha County Hospital in Auburn, Neb. "We can offer discharge instructions and they don't want those either. They want paper. I used to blame it on the fact that we are a rural and older population, but as I talk to people across the country, I hear the same things." Fattig sits on a Health & Human Services meaningful use work group, so he hears from a lot of officials at hospitals of all shapes and sizes.
One of the biggest challenges facing hospitals is getting real-time quality data to clinicians. Even among the Most Wired, 51 percent still manually enter CMS core measure data into an electronic file, which is barely better than the 54 percent in 2009. For all respondents, 64 percent are manually entering the data. When asked if they have an automated system to alert clinicians of compliance with core measures, 63 percent of Most Wired and 34 percent of all said yes.
Part of the explanation, says McKesson's Mellin, is that the IT systems are still evolving. Reporting wasn't necessarily a goal when the systems were installed initially. Then, it was more about automating processes and adding in decision support, he says, noting that most hospitals are retooling their systems to get the data up front and generate useful reports for clinicians.
Meaningful use will be a "burning platform" to automate this process, says David Muntz, senior vice president and CIO at Baylor Health Care System and chair of the advocacy committee at the College of Healthcare Information Management Executives, a survey sponsor. Currently, Baylor has automated data collection for 60 percent of quality measures. Muntz plans to be at 100 percent by early 2012. "We need to get there," he says. "It provides us with the ability to meet quality goals and do things more efficiently."
It also will become increasingly important as the payment system shifts from a volume-based model to one focused on quality and outcomes, says Daniel Barchi, CIO at Yale New Haven Health System.
Value-based purchasing, bundled payments and accountable care all require a greater reliance on data.
What is Meaningful?
Fattig offers a common refrain among officials from Most Wired hospitals: "Prior to meaningful use, we ran every new idea through the filter of 'Will it improve quality and will it improve patient safety?' When it improved one of those things and it made sense, that's the direction we went. Now comes meaningful use and you have to decide if you are going to chase the dollars or continue down the path you started."
That's not to say that the regulations deter hospitals from quality and safety initiatives. In fact, many of the requirements are aimed at improving patient care. What Fattig and others suggest is that priorities may have to shift in order to meet Stage 1 requirements. Fattig says Nemaha deployed a drug-formulary check ahead of plan. The application is one of the meaningful use rule's optional menu items for Stage 1, but likely will be required in Stage 2. At Peninsula Regional, Adkins says they had to slow implementation of a physician-documentation application slightly in order to accelerate in some areas of meaningful use.
But almost everyone agrees that meaningful use has put the field on a common course. "I don't think we were very focused in the past," Muntz says. "What meaningful use does is provide a scale by which we can all be measured." People can argue with the particulars of what's included in the rules, Muntz says, but adds, "They move us from data collection to decision support. They'll get us to real use of data and creating interface engines that take care delivery to a whole new level."
Some of the Most Wired hospitals already are well along the way of doing just that and more:
- Intelligent Design: Intermountain Healthcare is partnering with General Electric to develop an EMR that fully integrates clinical documentation, order sets, decision support, alerts and more. This is actually Intermountain's fourth attempt to build a clinical IT system from scratch. The idea is to give clinicians information on protocols and clinical pathways at the point of care, says Chris Wood, M.D., medical director for information services at the Salt Lake City-based health system. Standardized order sets and best practices—not just alerts—will prompt physicians as they are charting at the bedside. "The challenge for all of us in health care is to get quality data out of our systems to assess our care processes in a meaningful way," Wood says.
- Closing the Loop: When Detroit Medical Center set out to implement closed-loop medication administration, officials were undeterred by a big problem presented by the smallest patients. "We were going to deploy this hospitalwide," says Senior Vice President and CIO Michael LeRoy. That meant going beyond inpatient beds to the ED and even the neonatal intensive care unit. But how do you bar code with patients who may barely weigh 1 pound? Their wrists are far too small for standard wristbands. Clinical and IT staff teamed up to develop a wristband that would fit on the arms or legs of premature babies and could hold up under the special environmental setting of a NICU. The closed-loop system has been extended to the OR. "We tackled the process and made it happen," LeRoy says.
- Free-Flowing Information: Digitized physician documentation at Kane (Pa.) Community Hospital allows patient records to move seamlessly between outpatient and inpatient settings. "Medication reconciliation that brings together records from our outpatient clinics to the inpatient side, and e-prescribing, are valuable technologies for enhancing quality and safety," says J. Gary Rhodes, CEO of Kane Community.
- Safe Medications: Over the past three years, Columbia Memorial Hospital, Astoria, Ore., has greatly expanded technology in its pharmacy. "We have gone from three automated dispensing cabinets to 10," says Guy Rivers, CIO and chief financial officer of the critical access hospital. The automation is designed to reduce medication errors and already has resulted in fewer after-hour entries into the pharmacy department by nurse supervisors. The hospital also implemented an electronic system to monitor the temperature in pharmacy refrigerators. The system notifies pharmacists any time the temperature changes from the acceptable range and tracks the actions taken by pharmacy staff to resolve the issue.
Knowing that the pressure to improve outcomes is only getting more intense, not to mention the need to become more efficient and drive down costs, CIOs at Most Wired hospitals seem focused on the next building blocks of their IT systems: connecting with physicians and other providers. Building out this infrastructure will become more vital as provisions of health reform take hold, including the focus on reducing readmissions and the shift toward value-based purchasing. Hospitals will be held more accountable for the total care a patient receives, not just what happens inside their four walls.
Detroit Medical Center is experimenting with its physician-hospital organization to build these types of linkages. "When you go to the ED or are admitted, we push a message to your doctor saying, 'We are seeing your patient.' And at discharge, we push that information to the physician as well," says LeRoy, acknowledging that some of the information is faxed. "We have an air traffic controller who can see all of the PHO patient records to make sure that follow-up appointments are made and that medications are being filled." If those things haven't happened 30 days after the hospital visit, staff call the patient to find out what's going on.
Overall, hospitals are at varying stages of this effort, with the Most Wired doing slightly better than the rest of the field, but there's still a long way to go. Sixty-nine percent of the Most Wired can exchange a continuity of care document with other providers, compared with 43 percent for all respondents. Providing independent physicians with access to EMR functions? The situation is starker: 43 percent of Most Wired and 34 percent of all offer electronic clinical documentation. For CPOE and decision support, it's 41 percent among the Most Wired and 29 percent for all. And for viewing results—57 percent for the Most Wired, 47 percent for all. The numbers for each of these categories go up between 20 and 30 percentage points when looking at employed physician practices.
"This is the next area of opportunity for us," says Peninsula Regional's Adkins. "We are working with our employed and affiliated physicians to support their EMR implementations. That connectivity will allow us to get more information in a structured way and with that information we can better support the coordination of care for patients within our community."