The nine winners of this year's annual awards for outstanding achievement in applied medical informatics from the Association of Medical Directors of Information Systems share a common theme, according to AMDIS President William Bria—they know how to employ information technology to get the patient-care improvement job done.
The AMDIS competition previously yielded as winners many physician champions who led their organizations through the perilous waters of vendor selection and systems implementation.
Now the majority of the awards under the program, in its 11th year, are presented to individuals whose IT projects go beyond getting systems up and running—though there are a few of those, too—but rather, focus on using IT to drive process improvement and advance patient safety, says Bria, who is also chief medical information officer of the Shriners Hospitals for Children system, based in Tampa, Fla.
“The winners this year are men and women who have figured out how to take these tools and use them for what they're good at, to enable data collection and data reporting and process change,” Bria says.
“It's an old message about the promise of health IT,” Bria says. “It's not astounding. But it's the idea of the winners of saying, ‘What's the most important thing this tool can do?'—and then doing it. That's what the AMDIS award winners are showing now.”
The judges again this year were: Bria; Raymond Aller, director of automated disease-surveillance systems for the Los Angeles County Health Department; Bill Childs, vice president, Vitalize Consulting Solutions, Reading, Mass.; John Glaser, the outgoing vice president and chief information officer at Partners HealthCare System, Boston; Howard Landa, CMIO at Alameda County Medical Center, Oakland, Calif.; Brian Malec, professor of health administration and chairman of the health sciences department at California State University at Northridge; Blackford Middleton, corporate director of clinical informatics research and development at Partners HealthCare; and Harris Stutman, executive director of research at MemorialCare Medical Centers, Long Beach, Calif.
Russ Cucina is the medical director of information technology at UCSF Medical Center, San Francisco, an organization in IT transition.
When we caught up with him via telephone for an interview for this story, Cucina was in Verona, Wis., training at Epic Systems Corp., developer of the comprehensive electronic health record the hospital contracted to purchase in March.
At the 642-bed medical center, Cucina spearheaded development of its home-grown NoteWriter application, which started as a “user-oriented,” Web-based, “skunk works project” to improve clinical documentation.
“We began by stealing time, and we got a little bit more scope to have our own server,” says Cucina, a physician. “Over the course of three or four years, we've turned it into a pretty neat physician documentation tool that we thought was more feature-rich than we ever thought it would be.”
The application has a built-in, computer-aided correction system based on the Joint Commission's list of “do not use” abbreviations. Improper abbreviations appear in red and their suggested substitutions in green.
While the medical center eventually will replace NoteWriter with the new vendor-developed system, work on it may not be lost. The hospital is considering making the software available through an open-source license, Cucina says.
Cucina also managed development of a reconciliation tool for discharging patients that accounts for medications patients were taking before admission, during their hospital stays, and what are prescribed when they leave. The Web-based system, first deployed in December 2007, is being rolled out throughout the hospital and remains a work in progress.
The application helps guide physician decisionmaking and records those decisions in the EHR as well as on a single, printed prescription form. It also creates a patient-friendly version listing medications the patient is to keep taking at home at their previous dose, medications the patient is to keep taking at home at a different dose, new medications, and medications the patient was taking at home that they should stop taking after discharge.
“We're continuing to develop it even now,” Cucina says. “We've scaled back because we know Epic is coming in.” The medication reconciliation software also will be made available via an open-source license, Cucina says.
The Cleveland Clinic has an electronic health-record system called MyPractice for its clinicians and a tethered personal health record, MyChart, for its patients. So why did it want to partner with Microsoft Corp. on a pilot home health project using the software giant's HealthVault PHR platform?
In a word, interfacing.
By using HealthVault, Cleveland Clinic could focus on what it does best, patient care, while the clinic could leverage Microsoft's gravity as the biggest planet in the software universe to solve the problem of interfacing with multiple home health devices, according to award-winner C. Martin Harris, a physician and the clinic's chief information officer. The partnership with Microsoft let the Cleveland Clinic build just one interface, between its system and the HealthVault platform to monitor patients' blood glucose meters, blood-pressure cuffs, weight scales and pulse oximeters.
Under the six-month pilot, about 250 patients entered data from their home health devices via a home computer into HealthVault, where the information moved directly into the clinic's EHR.
“That allows us to apply rules against that information and, depending on where the results are, we can push the information to the nurse practitioner that might be working with the physician, and if it's outside of the scope of their practice, it was pushed to the physician,” Harris says. “It allowed us to leverage the technology to get the right information to the right person at the right time.”
“It's really a great partnership in that if HealthVault weren't there, I could do that, but I'd have to do each connection directly into my EHR,” Harris says. “This way, I make one connection into HealthVault” and the blood glucose and all the other metrics pour in automatically. “So it makes my efforts easier. HealthVault has those relations with the device manufacturers. I really don't want to be in that.”
“We actually saw a drop in the number of office visits that occurred for patients who had diabetes or hypertension while maintaining their (blood sugar) for diabetics or blood pressure for hypertensives,” Harris says. “The end point either stayed the same or got better.”
Harris says the number of office visits for heart patients went up, not down, “which might be a good thing, because when these patients get sick, they end up in the emergency room.”
“So, that's a very promising model,” Harris says, particularly with the more than 75 million baby boomers aging and not enough healthcare professionals available to care for them using traditional means.
Ted Kremer is the executive director of the Greater Rochester (N.Y.) Regional Health Information Organization, which is providing health information exchange services to a 10-county area in western New York.
Kremer is the only AMDIS award recipient this year who isn't a physician.
“It's a little intimidating, but I'm honored,” Kremer says.
Rochester RHIO, as it is less formally known, was founded in 2006—with Kremer hired as its first and thus far only executive director. It used $4.4 million in state grants and $1.9 million in support from hospitals, health insurers and local businesses to get launched. It has received another $12.8 million in subsequent state grants and began offering IT services in 2008 with 26 physicians in five practices.
“We've had significant grants to stand up and build out our service,” Kremer says. “But we have an operating model where the payers have been funding our ongoing operations” using a claims-based surcharge. Payers see clinical improvements from health information exchange as the business case for supporting the RHIO, Kremer says. “We don't exchange claims data, so, absolutely, it's the delivery side of healthcare, the efficiencies there.”
The RHIO now offers 1,700 healthcare providers, including 500 physicians, a range of services, including electronic prescribing, patient medication histories, electronic health-record support and clinical messaging, including medication, laboratory and radiology reports from member labs, hospitals and radiology centers. Recently, it began offering emergency physicians in six hospital emergency departments access to patient information through the exchange.
In New York, patients must consent to the use of their protected health information, even for treatment, payment and other healthcare operations. To accommodate New York law, the state has developed a privacy guideline that state-funded RHIOs must use. According to Kremer, more than 350,000 patients have signed consent forms thus far. But even patients who have withheld consent can have their records accessed if they are involved “in a life-threatening emergency,” unless the patient has specifically declined consent to a particular provider, according to the organization.
Kremer holds a master's degree in public health from Yale University and is the former chief technology officer of Oxford Health Plans, Trumball, Conn., now part of UnitedHealth Group.
Integration is the future for Michael Oppenheim, vice president and chief medical information officer at North Shore-Long Island Jewish Health System based in Great Neck, N.Y., where since 2002 he has led both the implementation and the customization of electronic health-record systems for the 10-hospital organization.
A major accomplishment during Oppenheim's tenure thus far has been the implementation of an inpatient EHR at North Shore-LIJ. “We're expecting to have all of the hospitals and health systems on all of the core elements of the EMR by 2013,” says Oppenheim, a physician.
But he has also helped develop an EHR strategy to assist 7,000 affiliated physicians in the service area of the organization to purchase and deploy EHRs in their office-based practices.
Fortune smiled on North Shore-LIJ in early June with Allscripts-Misys Healthcare Solutions' announced acquisition of Eclipsys Corp. North Shore-LIJ uses Eclipsys products for its inpatient EHR and selected Allscripts for its ambulatory EHR vendor. “We're very happy in retrospect with the choices we've made.”
“What's incredibly exciting about what we're doing at the health system is the belief the future depends on its ability to integrate care across all components,” Oppenheim says, not just the hospital or doctor's office, but also home care, long-term-care facilities and hospice. Getting all of these providers and care settings wired up and interconnected “is necessary to set us up for any kind of bundled-payment, quality-based payment system. We believe they're all coming.
“This transcends not only all of the North Shore-Long Island Jewish facilities, but all of the providers in the geographical area,” Oppenheim says.
“We started enrolling toward the end of 2009,” Oppenheim says, adding that he expects a “surge” of signups and rollouts by affiliated physicians through 2011, which includes much of the first “payment year” under the Medicare portion of the federal EHR subsidy program of the American Recovery and Reinvestment Act of 2009. Faculty practices should be all up and running by 2012, he adds.
Affiliated physicians will be offered two “tiers” of financial support from the hospital for EHR installations, which will avail itself of the 2006 Stark and anti-kickback law exemptions, Oppenheim says. The hospital will pay a 50% EHR subsidy for affiliated physicians interested in sharing clinical data on specific patients for clinical use, he says.
North Shore-LIJ will subsidize the maximum under federal waivers, 85% of an EHR's cost if a physician will share data on all patients—“to pull quality metrics across the region,” Oppenheim says.
Todd Rowland is both a physician and the executive director of HealthLINC, a regional health information organization based in Bloomington, Ind.
In 2003, only about 3% of medical practices had electronic health-record systems in HealthLINC's key southern Indiana service area, prosperous and bustling Monroe County, home to Indiana University, and largely rural Orange County, gateway to the Hoosier National Forest.
A year later, Rowland helped found HealthLINC and by 2009, more than half of physician practices in Monroe County and 76% in Orange County have functional EHRs, progress “directly facilitated by HealthLINC activities,” according to AMDIS.
Rowland has had some pioneering RHIOs as models in the vicinity: Cincinnati-based HealthBridge, whose turf now extends into far southeastern Indiana, and the Indianapolis-based Indiana Health Information Exchange, which grew out of the work by the Indiana University-based Regenstrief Institute. The three have teamed up to create a multi-RHIO health information network.
At HealthLINC “We're moving lab data in a structured way,” Rowland says. “We don't have all the labs yet. Nobody ever does. Even HealthBridge that's been up for 13 years, they don't have all the labs onboard.
“We get all the radiology reports and the medical records from two hospitals,” Rowland says. HealthLINC also has developed interfaces with two vendors' EHRs to push Web-based clinical messages directly into physicians' EHRs.
As with most RHIOs, “Sustainability is a problem,” Rowland says. “As long as hospitals look as this as a cost beyond normal operating business costs, it will be a problem, and they will still continue to look at it that way. Our goal is by the end of 2011 to be financially sustainable,” Rowland says.
“I think what's changed for us is meaningful use and all the grant funding,” he says, referring to requirement in the 2009 stimulus law that in order to receive a slice of the billions in federal subsidies available for the purchase of an EHR, providers must demonstrate they can meaningfully use the systems, including exchanging information to improve patient care.
Chris Snyder, chief medical information officer for 366-bed Peninsula Regional Medical Center in Salisbury, Md., has a lot of the top-end, clinical information technology toys to play with—closed-loop medication management; computerized physician order entry; medication scanning and storage; diagnostic results reporting; and a comprehensive longitudinal data repository.
Snyder, a hospitalist, played a hands-on role in seeing these systems implemented, particularly CPOE. With a medical staff of 400 composed largely of affiliated physicians not employed by the hospital, simply installing CPOE and then mandating its use wouldn't work as a rollout strategy. That meant Snyder had to do a lot of one-on-one proselytizing and training to get to where the hospital is now, with 85% of orders generated through CPOE.
“Being a community-based regional medical center, we don't have a lot of resources,” Snyder says. “It's me, myself and a couple of nurses.”
Snyder's strategy in 2005 was to introduce CPOE first in orthopedic surgery, then to general surgery, urology and the eight employed hospitalists, then deploy it slowly across the hospital.
The orthopedic surgeons showed some initial interest, but from an implementation basis, they were chosen to go first on CPOE “because they're on such a protocol-based practice” and would be an easier group to convert, Snyder says. “They have standard order sets and have a lot of midlevels to help adopt CPOE.”
Still, Snyder recalls standing in the operating room, talking to a surgeon and anesthesiologist saying, “By the way, why aren't you using orders?”
Snyder says he could get away with such hectoring for two reasons, “I'm a practicing CMIO, so I think they still have some respect for me.” But the main selling point Snyder says he preached was patient safety.
In 2009, with CPOE adoption well on its way, the hospital finally mandated its use via a directive from the medical staff executive committee. But even then, full physician adoption wasn't a sure thing.
“When we suggested we were going to mandate using CPOE, I had a cardiologist challenge me: ‘Is it safer? Prove it to me.' ”
Snyder says he spent some time thinking of the best demonstration he could implement locally. He says he recalled a study conducted by a hospitalist staffing firm on the effects of dosing Dilaudid, a narcotic painkiller.
“I started looking at the data to see if we had a problem, and we did, just as every other hospital,” Snyder says. But Snyder knew that CPOE could guide physicians to computer-generated forms to limit what could be ordered and prompt the ordering physician if they picked too much or too little. Since the prompt was introduced, the hospital has achieved a 19% reduction in adverse drug reactions with Dilaudid, according to Snyder.
Jonathan Sykes, the chief medical information officer and director of clinical information systems at 391-bed Allegiance Health, has seen both the Scylla and Charybdis of clinical quality improvement and led the fight to tame both.
On the one side, to satisfy an increasingly safety- and quality-conscious public, including employer healthcare groups, providers must push health information technology to measure and drive improvements. On the other side, push too hard on providers with miscalibrated IT tools and the providers will push back.
A key area of contention is in the use and adjustment of computerized clinical decision-support systems.
Sykes says many of the employers in and around Allegiance's home town of Jackson, Mich., are suppliers to the auto industry in Detroit, which is roughly 80 miles east on Interstate 94.
Not surprising, the quality, cost and patient-safety initiative of the Leapfrog Group, which publishes hospital patient-safety measures and includes a push for effective use of computerized physician order-entry systems. General Motors Corp. and Chrysler Corp. are members of the Leapfrog coalition.
Allegiance set a goal to reduce medication-linked drug errors, so Sykes led a program to add medication alerts to the existing hospital CPOE system. The tricky part, Sykes knew, is to have sufficient alerts firing to flag errors and improve safety, but not so many as to overwhelm clinicians, promote “alert fatigue” and run the risk of vital alerts being ignored.
In the first month when the alerts were turned on full blast, the CPOE system fired off an average of 115 alerts a day, which Sykes, a physician, realized could quickly become a nuisance and risk CPOE use overall.
The data was analyzed and a group of clinicians, including physicians and pharmacists, was recruited to come up with a list of recommendations to block the reporting of certain alerts to clinicians, even though the system quietly recorded each, reported and unreported. The panel also vetted any provider complaints.
By suppressing selected alerts, the total number displayed by the CPOE system was cut nearly in half, to 64 to 68 a day. Physician use of CPOE was maintained, while “reported” drug prescribing errors fell from an average of 0.62 per 1,000 orders between January and August 2009 to 0.50 per 1,000 orders between September and December 2009, according to Allegiance.
Marilou Terpenning is the managing partner of the four-physician, Santa Monica (Calif.) Hematology-Oncology Consultants, and also the health information technology superuser and guiding light into her group's deployment and customization of two, interfaced electronic health-record systems.
She is the only physician from a medical group practice among this year's AMDIS award winners.
Terpenning says that the group wanted the security of a name-brand, multispecialty EHR that could be certified for use in primary record-keeping. But the group also wanted an oncology-specific software system to handle the intricacies of support for the specialty. So, in 2006, it bought both—first, General Electric Co.'s Centricity EHR as a primary system; then, a few months later, IntrinsiQ's IntelliDose, as the oncology niche product.
While there was an existing relationship between the two companies, and a degree of basic interoperability between their two systems, “We had to do a lot of the development of the interfaces,” Terpenning says.
The practice extended computerized physician order entry in Centricity into IntelliDose, as well as built links to laboratories and to the group's practice management system, she says. Terpenning's practice is a beta site for the practice management interface.
So far, despite the additional effort, “We've been very happy with the separate programs.”
In oncology, according to Terpenning's AMDIS awards brief, “treatment planning, order writing, dose calculation and safety checks are critical to safe patient care.” The oncology system supports clinicians with specialty-specific automated safety checks.
Terpenning's practice, meanwhile, “leveraged customization capabilities to build treatment plans supporting patient type, cancer stage, lines of therapy and their oncologist-tested best practices,” according to her summary. “The patient-care protocols streamline workflow for staff as they treat patients and smooth the check-in and assessment process for patients as they proceed through infusion administration. The oncologists select and review treatment plans and can modify them on the fly based on current patient assessments.”
Order sets developed by the practice for chemotherapy have smoothed workflow and accelerated the pre-authorization process. Terpenning says that integrating the charge-capture functions of the oncology system with the practice management system has enabled the practice to achieve 95% accuracy on charges and lowered billing time in accounts receivable by as much as two days.
The practice also has a Web portal for patients, which allows for patient communication.
“Patients love the portal,” Terpenning says. “They know it is the way of the future. They feel grateful we're putting the time and effort into improving patient care.”
Sidna Tulledge-Scheitel is a practicing primary-care physician and medical director for global products and services at the Mayo Clinic, which, despite its international reputation for medical specialists, also provides primary-care services to 140,000 residents in the Rochester, Minn., area, including its own employees and their dependents.
As such, Tulledge-Scheitel is helping lead Mayo to promote better chronic-care management and improve care coordination for its primary-care patients, particularly through its Mayo Clinic Health Manager. Launched in 2007, the online tool combines a personal health record and a library where patients can access Mayo-created health content as well as receive alerts and reminders for various conditions. Mayo is working in partnership with Microsoft Corp., using its HealthVault personal health-record platform.
Tulledge-Scheitel says a rules engine in the system can trigger health recommendations, such as for immunizations, cholesterol checks, colon cancer screening and Pap smears.
“If you had high blood pressure on your list, it would recommend a goal for you based on what it knows about you,” Tulledge-Scheitel says. “The system will recognize that and then there are trackers in the system.”
Health Manager uses the Microsoft connections center in HealthVault, Tulledge-Scheitel says. “They're masters of interoperability. It's nice to be agnostic to the device.”
Health Manager “knows what your goals should be, and if it's trending out of range, it notifies the user. That's our connected health vision. We believe that the first alert should go to the readers. ‘Did you take your medication?' ‘Are you on a low-salt diet?' ”
For now, Health Manager, which is not tethered to Mayo's electronic health-record system, is more of an “information therapy site,” Tulledge-Scheitel says. But it is “a very iterative application. We are constantly changing it, iterating it—it's not in its final form.”
For example, adaptations for asthma and diabetes patients as well as pregnancy are coming out this month, she says.
Tulledge-Scheitel also serves as an assistant professor in the Mayo Clinic College of Medicine and is a member of the board of directors of the Institute for Clinical Systems Improvement, Bloomington, Minn., created in 1993 by Mayo, along with HealthPartners and Park Nicollet Health Services, two Minneapolis-area health systems whose aim is “to promote better outcomes, better chronic-care management and more coordinated care,” according to the Mayo organization.