Getting a healthcare institution to embrace meaningful clinical automation takes dedication, drive and deep knowledge of what clinicians need. For the past 10 years, the Association of Medical Directors of Information Systems has recognized outstanding achievement in applied medical informatics.
This year, the eight winners include two institutions, one team and five individuals. There were 43 nominees. The judges are: William Bria, M.D., AMDIS president and chief medical information officer at Shriners Hospital for Children system, Tampa, Fla.; Howard Landa, M.D., CMIO, Hawaii Permanente Medical Group, Honolulu; Harris Stutman, M.D., executive director of research, MemorialCare Medical Centers, Long Beach, Calif.; Blackford Middleton, M.D., director of clinical informatics research and development, Partners HealthCare System, Boston; Ray Aller, M.D., director, automated disease-surveillance systems for the Los Angeles County Health Department; Bill Childs, executive vice president, R3 Health Partners, Santa Ana, Calif.; John Glaser, chief information officer, Partners HealthCare; and Brian Malec, professor of health administration, health sciences department, California State University at Northridge.
The health information technology professionals most interested in Kaiser Permanente's enormous electronic health-record system tend to be from outside the U.S., says Andrew Wiesenthal, associate executive director of the Permanente Federation, the organization of the Permanente medical groups, and point man for KP HealthConnect.
Kaiser's patient base is bigger than the populations of many countries. “They're interested in what we're doing, and they think we look a lot like them,” he says.
But even much smaller healthcare institutions can take lessons from some of the organization's innovations, like a total joint replacement registry with data on 75,000 procedures that allows surgeons to compare the effectiveness of different implants and clinical practices. Kaiser Permanente Southern California uses KP HealthConnect, tied into electronic scheduling, to identify women overdue for mammograms and get them to schedule a screening. Kaiser Permanente Colorado used the data from the system, combined with practice guidelines, to reduce its coronary-artery-disease mortality rate by 76%.
Next up: standardized protocols for all adult malignancies, which, unlike childhood cancers, often don't have widely agreed-upon treatment strategies. “If we find out something good, we'll publish it, and others will be able to take advantage of it,” Wiesenthal says. “The real trick will be to make these guidelines machine-readable and importable, no matter which EHR software you have.”
The Fallon Clinic, Worcester, Mass., has managed to lick a problem that defeats many a clinical computing effort: getting disparate computer systems to talk with each other.
It's difficult enough for most organizations to do internally, but Fallon has also pulled in four area hospitals, a reference laboratory, an imaging center and a health plan. The elaborate array of system interfaces took 17 years to develop, using Fallon's in-house information technology team and collaborators from the outside organizations, but the result is elegant: a unified electronic health record with 15 years' worth of laboratory values, medication history, claims data and text documents that give clinicians a complete picture of a patient's care, regardless of origin.
Lawrence Garber, M.D., the clinic's medical director of informatics, says that the keys to success were making sure all the parties understood the value of what the IT department was trying to do, taking everything in small steps and designing interfaces that were inexpensive to maintain. “It's a challenge because you have to develop partnerships with your competitors,” he says. “But it's so great to sit in my office and know everything that's happened to my patient.”
University of Pittsburgh Medical Center's hospitals had a clinical computer system from one vendor that they really liked. More than half its physicians used a system from another vendor that they really liked. The two did not work together, which stymied the development of a unified electronic health record.
After exploring whether either party was willing to convert to the other's system (they weren't), the interoperability team came up with a bold solution. UPMC invested $35 million to buy 25% of Israeli software company dbMotion, move its U.S. headquarters from Atlanta to Pittsburgh and assign it the job of making the two systems swap critical information so seamlessly that neither side would be aware that there were two systems.
That was in 2006.
As of this past February, each side sees a unified patient record that has all the data from both systems. Chief Medical Information Officer G. Daniel Martich, M.D.,—who has the job of mapping data between systems (for example, so that a prescription for the diuretic Lasix from one system shows up as the same drug that the other system calls furosemide)—says it's too soon in the evolution of EHRs to prove a return on investment, but he knows it's there.
“You have to look at it as a cost of doing business, but you really do save money when you get everyone onboard and they interoperate.”
Adopting computerized physician order entry is like entering a pool of cold water—painful to do quickly, but so much more painful to do slowly.
OB/GYN Matt Sprunger, M.D., who doubles as CMIO, decided that the obstetrics unit at 122-bed Dupont Hospital, Fort Wayne, Ind.—which delivers about 2,400 babies a year—would be CPOE's first cold pool. Order communication was a mess of scrawled notes, faxes and other primitive paper strategies, and illegible handwriting delayed execution of up to half the orders. “If you start a CPOE project without the goal of eliminating handwritten orders, it makes it much worse,” he says.
After 10 months of planning, with involvement from representatives of all the potential user groups, the new system went live in May 2007 with a stated goal of no more handwritten orders. Though some doctors still want to write by hand, they're infrequent users anyway, and the vast majority of orders are now entered directly. The 127 physicians and midlevel practitioners on the unit enter about 38,000 orders a month on the system. Those illegibility delays have dropped to almost zero, and the time between physician order and medication administration has been cut in half. Dupont is now engaged in spreading CPOE throughout the hospital.
Of all the ways clinical computing can improve medical care, built-in practice guidelines are one of the most powerful, as a recent computerized physician order-entry project at Marietta, Ga.-based WellStar Health System made abundantly clear.
Under the direction of Jonathan Morris, M.D., the medical informatics officer/emergency medicine physician, 604-bed WellStar Kennestone Hospital added practice guidelines for the prevention and treatment of sepsis—one of the most stubborn and deadly diagnoses among hospital patients—to the new order-entry system in its emergency department.
The guidelines came from the Institute for Healthcare Improvement and were part of an international Surviving Sepsis Campaign. Two sepsis-related order sets, with standing antibiotic orders related to specific clinical presentations, made it easy to do the right thing and hard to do wrong ones. Before-and-after statistics show that following the guidelines saved 13 lives in 2008, reducing the mortality rate for sepsis in general by 14%, and for septic shock by 17%, according to its award entry information.
Most people agree that projects like electronic health records, physician order entry and the adoption of practice guidelines can't go anywhere in a healthcare organization without a physician champion to talk everyone into them and keep the momentum going.
Family physician Cynthia Herzog, M.D., played that vital role for MemorialCare Medical Centers, Long Beach, Calif., in its recent switch to a new clinical information system. Though she describes herself as “not very techie,” she chaired the physician informatics panel for 452-bed Long Beach (Calif.) Memorial Medical Center and 308-bed Miller Children's hospital, Long Beach, and was also a member of the informatics committee for MemorialCare's physician organization.
Herzog identified the 480 physicians (out of more than 1,200) who were responsible for 80% of the orders, and targeted them with strategies like special education sessions and a team of “clinical training specialists” who were versed in what the doctors needed to know about the system. (Herzog says that they served the same function for selling the system that pharmaceutical representatives do for drugs.)
Physician-entered orders are up to about 80% (vs. 10% with the former system), and the three hospitals that have fully implemented the system are now virtually paperless. Herzog refuses to take credit. “We had a huge team of very adept people,” she says.
Michael Dominguez, M.D., is one of those normally unsung heroes of computing: the very first user of a major new product.
“I didn't know that when I did it,” the physician says. It was the ambulatory-care component of the Sunrise Clinical Manager from Eclipsys Corp. He got involved when he was medical director for Community Medicine Associates, a group of health centers affiliated with University Health System in San Antonio. He implemented the product at seven sites with 40 to 50 providers. He became very involved in design issues, getting right down into the code to make it into what his organization needed. At that point, he realized that informatics was his niche, and he says he was happy to move to the health system as medical informatics officer in 2005.
More than 400 users at 30 clinics are now using the system. Dominguez still works on configuring it to be the right combination of free text (which doctors like) and structured data (which regulatory reporting requires). Dominguez sees patients one day a week to keep his hand in as both a physician and a system user. “If I make a mistake in how I programmed something, I suffer along with everyone else.”
Steve Margolis, M.D., a head and neck surgeon who was lured by the siren song of medical informatics and has been at Orlando (Fla.) Health since 2003, has an enviable track record: 85% computerized physician order entry in Orlando Health's emergency rooms (and close to 100% among residents), 80% CPOE in two of the eight hospitals (and steadily increasing in the others), a clinician portal for real-time access to clinical information from anywhere and standardized order sets systemwide.
The organization also has gadgets like robots that let physicians visit their hospital patients remotely. And perhaps most impressive of all, the chief medical informatics officer has an 80% approval rating from both the physicians and his administration, despite the demands and disruptions caused by all of these major IT projects.
“It's been an interesting journey because the technology is not mature,” Margolis says. “We want technology that looks like a 2010 Lexus, but today's EMR feels more like 1969.” He believes hospitals have to partner with their vendors to get what they need. “Unlike pharma, where they have to do trials to show that a product is error-free before we use it, we're evolving the technology to make it work in a live environment.”
Elizabeth Gardner, a former reporter at Modern Healthcare, Modern Physician's sister publication, and is a frequent contributor to the magazine. Reach her at gardnerem@sbcglobal.net.
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