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Passionate about care

AMDIS winners use computers to improve medical quality

By Joseph Conn
Posted: July 12, 2004 - 12:01 am ET

From an academic researcher in computer technology recruited to medicine to an angry trauma surgeon who pressed his hospital to do better after a patient's life was threatened by a computer glitch, all 10 winners of the 2004 AMDIS Awards for achievement in applied medical informatics have one thing in common: They are people or organizations with a passion for improving the quality of care through computer applications.

The Association of Medical Directors of Information Systems has named four physician leaders, a fifth individual and five institutions as recipients of its fifth annual awards.

The winners were chosen from a field of 67 nominations, "a little bit more than normal, but the quality of them is a lot better," says Rich Rydell, executive director of AMDIS, a not-for-profit organization of 1,200 physician information-technology leaders based in Keene, N.H.

"Clearly what this illustrates to us is this explosion, this kickup into high gear, of IT successes," he says. "That's why we're giving out 10 awards."

The winners will be honored at the 13th annual AMDIS Physician Computer Connection Symposium, set for July 14-16 at the Rancho Bernardo Inn near San Diego.

Entrants were judged by a panel of AMDIS members on their application of IT to improve patient care, support a medical practice, improve workflow, and enable efficiencies and/or contain costs.

Individual winners

Charles Frazier, M.D.
, is a family practitioner and director of medical informatics at Riverside Health System, a five-hospital integrated system headquartered in Newport News, Va. Frazier developed a secure Web-based connection called Health-E-Link for Riverside Physician Associates, the system-owned, 170-physician multispecialty group.

The interface lets patients schedule and review appointments, renew prescriptions, check referrals and send messages to group physicians, Frazier says.

The Web portal interfaces directly with the group's Logician electronic medical records, or EMR, system, from GE Medical Systems Information Technologies. The interface also flags physicians logged into the EMR, telling them they have incoming mail and allowing them to conveniently check and respond to e-mails that have been triaged by a nurse.

Frazier says he built the system because the other portals he saw on the market dumped e-mails into a folder that could be opened by physicians only by closing down the applications they were working in and launching another e-mail application.

"We talked to a couple of (portal system vendors)," Frazier says. "All of those (portal) guys who talk about interfacing (with EMRs) say they're talking to vendors, it was all in the future," Frazier says. "They offload your data.

"The docs I work with and I just feel that we've got too doggone many mailboxes to deal with already," he says. "If you're in a medical record all day, every day, why would you want to flip over to something else?"

With Frazier's system, practice members are "seeing the messages through the thing they're seeing all the time (their EMR)," he says. "It just seemed to make sense to do it the way we set it up. Our challenge right now is to market it both internally and externally to our patients."

There are about 1,200 patients now using the portal, Frazier says. That leaves considerable room for growth throughout the Riverside system.

"We've got 136,000 active patients that we're tracking with medical records," Frazier says. "Not all of them have Internet access, but there's a substantial percentage that could use this as another avenue of communication.

"We're working on the functionality to push the (lab results) back out to the patients," he says. "We don't have that yet."

Kenneth Fath, M.D., a cardiologist and medical director of performance improvement and medical informatics at Burlington, N.C.-based Alamance Regional Medical Center, champions IT at the 238-bed community hospital. His efforts include rolling out a computerized physician order-entry, or CPOE, system from Eclipsys Corp.

Fath proudly notes that the Alamance implementation began in 1998, before the Leapfrog Group, a business healthcare coalition, gave CPOE a national buzz.

"I'm thrilled that I work in a hospital that's forward-thinking and started on this before Leapfrog and that push," Fath says.

The CPOE rollout was completed in early 2000. "We have about 75% of all orders put in on a purely voluntary basis," he says. He is working with hospital management to develop a method to mandate the use of the system across the organization. Fath also is helping the hospital piece together an electronic medical record.

Currently, paper charts remain the documents of record, but all physicians affiliated with Alamance have access to the hospital's available electronic medical records via the Internet.

The hospital has electronic-prescribing and discharge instructions configured on a knowledge tree based on a list of the top 10 diagnoses.

They are working on developing structured progress notes. Fath receives a stipend for his work on a hospital performance improvement committee but otherwise is unpaid for his IT efforts.

"There are some things that could have been done more quickly without me working a call schedule," Fath says, adding, "It is possible to do this without a full-time person."

Thomas Hughes, M.D., an OB/GYN, waded into clinical IT eight years ago when his seven-physician practice, Medical Center for Women, based in Fullerton, Calif., started using an EMR. The group switched to Logician EMR by GE Medical Systems Information Technologies three years ago.

"We're real happy with it," Hughes says.

Hughes won an AMDIS award by drawing on that experience to go big time, serving as physician champion of Care ReDesign, a 2-year-old IT initiative, including deploying the Medical Information Technology CPOE and EMR systems at St. Jude Medical Center in Fullerton. The system, pioneered at 293-bed St. Jude, will be rolled out through the entire 14-hospital St. Joseph Health System, which is based in Orange, Calif.

Hughes served as chief of staff at the hospital and currently is a board member and chairman of the medical-staff informatics committee. Clinicians are currently at work developing order sets for the clinical information system.

"We started off with a committee of 40 doctors representing all of the specialty fields," Hughes says. "We've made over 100 order sets. It's still ongoing.

"The ideal situation would be for each patient to have one chart that each physician uses," Hughes says. "I hope some day we'll get to that point." But for now, Hughes says, "Our plan is not to rush this. We're taking it a step at a time."

For example, Hughes says it is still faster for him to use dictation to prepare a patient's history of present illness, but he now works off a pick list in the EMR when doing physical exams.

Hughes warns physician leaders looking to spearhead a clinical system to have patience, take the hype in stride and grow a thick skin.

"They always sell this by saying it's going to be so much faster," he says. "It's not faster in the beginning when you put the data in, but it's so much faster retrieving it."

"I feel like I've had a few wounds," he says. "But overall, it's gone along well."

Reid Coleman, M.D., the physician leader implementing a CPOE system at Lifespan, a multihospital system in Providence, R.I., won an AMDIS award for spear-heading CPOE rollouts at three hospitals.

Starting in September 2001, "We piloted it at each hospital in rapid succession, then went back and rolled it out," Coleman says. "We let each of the affiliates pick when they wanted to start."

Today, 80% of physician orders are computerized at the system's flagship, 559-bed Rhode Island Hospital.

The CPOE system from Siemens is expected to be running this summer in all units of the 208-bed Miriam Hospital, Providence, where 30% of orders are entered on the new system, while the rollout is 40% complete at the 148-bed Newport (R.I.) Hospital, with just 7% usage. The Newport installation should be completed by September, Coleman says.

Each hospital has its own physician champion working with Coleman: Mitchell Levy, M.D., at Rhode Island; A. Gerson Greenburg, M.D., at Miriam; and Terrence McWilliams, M.D., at Newport.

They would have been done sooner, Coleman says, maybe 18 months from start to finish, except "We backed off to install a new pharmacy system to ensure we had perfect orders to pharmacy. That slowed us down about nine months."

To facilitate the rollout, Coleman designed an e-mail feedback system to help IT staff work with clinicians to design order sets and report back on how they work. Coleman also started an innovative IT department rotation in which 10 residents have completed one-month tours of service within the system's IT department rather than in clinical service.

Coleman's roots in IT go back to Brown University, where he enrolled as a freshman in 1968 and began working out lab results from a physiology class on an IBM 360 mainframe donated by Brown alumnus and former IBM CEO Thomas Watson Jr.

"To have a computer to do that then was phenomenal, because in those days we were all still using slide rules," Coleman says. "Ever since then, I've been a geek."

His involvement in healthcare IT, patient safety and quality improvement began when he helped develop care protocols in the 1980s.

"I have 25 years as a practicing internist and, just as everybody else in medicine, I was internally screaming there has to be a better way than this," Coleman says.

He went on to work as medical director of Lifespan's capitated 50,000-member managed-care organization, tracking patient care using Health Plan Employer Data and Information Set (HEDIS) measures. Capitation died in Rhode Island about 18 months ago, Coleman says.

"We had a really successful failure," he says. "We drove about 14% of the cost out of the system with our program. We just didn't drive the cost down fast enough. Capitation was an idea that was starting to fade."

Coleman attributes Lifespan's success with information systems to his chief executive officer, George Vecchione--winner of the 2003 CEO IT Achievement Award, sponsored by Modern Healthcare and the Healthcare Information and Management Systems Society, and a leader who Coleman says "really believes in patient quality and sees where IT belongs in the process"--and to Carole Cotter, "a great CIO."

"She understands physicians want to do a good job, but they need better tools, and she's flat-out dedicated to giving them the tools to provide better care," Coleman says.

Coleman has a few pointers for physicians leading their own IT projects.

First, "If you don't have support from the top down, the board and the CEO, don't try it."

Second, "The value (of IT) to physicians is the information you give them at the point of decision-making. That's huge."

Third, learn to speak your colleagues' languages. "You have to understand physician and be able to translate from physician to pharmacy and nursing vocabularies. You have to be able to get the information from an order into the syntax that's understood by pharmacy and nursing."

And finally, "We made sure it works before we turned it on. If you're looking for key points, that's one."

Dario Guise, associate director of the Informatics Center at Vanderbilt University Medical Center in Nashville, won an AMDIS award for his work in designing and implementing Vanderbilt's StarChart EMR system and its StarPanel workflow management system.

Guise earned a degree in engineering in his native Italy and a master's degree in pure and applied mathematical logic from Carnegie Mellon University, where he worked as a researcher before he was recruited to come to Vanderbilt in 1994 along with his wife, Nunzia Guise, M.D., a medical informaticist.

He created the Web-based front end of the Vanderbilt IT system in 1997 that is still in use today, developed the StarChart EMR from the ground up in 1999 and began working on StarPanel in the summer of 2001. It went live in November of that year, and its systemwide rollout was completed in June 2003.

StarPanel links physicians at more than 90 Vanderbilt outpatient sites via electronic messages and provides access to inpatient and outpatient schedules, results reporting and all StarChart information. The medical center estimates the twin systems have enabled the organization to trim 75 positions.

Guise hosted President Bush on a recent tour to view the technology. "It was really, really exciting to have him and David Brailer, M.D., (Bush's top healthcare IT adviser) talking about what this means," Guise says.

However, the associate director of the informatics center at Vanderbilt says he found pleasure, too, from his colleagues as the systems built for them were developed and deployed.

"It was a lot of satisfaction and a lot of fun, along with all the impediments you might expect," Guise says. "What we discovered, of course, was some of the people who absolutely knew they were going to hate the system, some of them came to me saying, 'I love it.' "

Guise says he takes satisfaction not only in knowing his systems allow physicians to provide better care, but also that they give physicians who use them something very precious--time.

"I was always happiest when I got to do something that changed people's lives and made their work better," he says. "If you give them an hour and a half each day to spend with their families, that's really tremendous."

Organizational winners

The Nevada Army National Guard's Air Ambulance Unit, which recently was deployed in Afghanistan (and previously in Kosovo), was honored by AMDIS for its use of hand-held palmOne personal digital assistants.

Onboard medics use the PDAs loaded with Med-Media software to record vital patient information in-flight, including initial diagnosis and medications administered, look up information such as drug interactions, pediatric drug applications and medical protocols, and download that information in seconds to hospital computers.

In Afghanistan during eight months ending last September, the 45-member Black Hawk air ambulance unit flew 127 combat missions to save the lives of more than 150 people, more than one-third of them children.

They also included one U.S. Special Forces soldier wounded during an ambush by pro-Taliban forces. The unit's unarmed ambulance was accompanied by an Apache gunship and another Black Hawk loaded with a Special Forces quick reaction team.

"We never got hit," says the unit commander, Capt. Rich Ferguson, adding, "We tried very, very hard to be evasive."

Ferguson, a full-time officer, doubles as branch chief for information technology for the Nevada National Guard. His air ambulance unit, based near Reno, also runs search-and-rescue and fire-fighting missions in Nevada and eastern California.

Ferguson says the PDAs solve a problem he first observed in a war zone.

"I noticed in Kosovo we were losing a lot of information between the doctor and the person in the field," he says, particularly if the air crew was rushed to return to the battlefront or if the patient was critically injured and there was no time to lose before treatment.

The PDAs, which have infrared communications ports, could communicate almost instantly with a laser printer or a PC at the surgical field hospital.

Now, he adds, "We'd hand them the Palm or download. That saved us a lot of time and miscommunication."

Massachusetts Institute of Technology Medical, the medical services provider for the MIT community based in Cambridge, Mass., won for its deployment of a TouchWorks EMR from Allscripts Healthcare Solutions married to the existing Flowcast practice management system from IDX Systems Corp. IDX owns a 20% interest in Allscripts.

The EMR is used by 45 full-time and 30 part-time community-based specialists employed by MIT Medical, which serves 23,000 patients per year, including student and faculty.

Tom Goodwin, clinical information systems coordinator at MIT Medical, says IT deployment began in 1999 with a clinical repository for labs and X-rays, and they began adding EMR components in March 2003 with a task management module. Since then, they have added the labs and X-rays to the new system and deployed a prescription-writing tool to write 1,300 scripts a month. The complete system is about three-fourths implemented, Goodwin estimates. A 13-member health information systems committee is working on templates to facilitate more direct note-taking to reduce dictation expenses, he says. Adding a charge-capture module lies ahead, too.

Goodwin figures the system saved MIT Medical $180,000 in its first year, in part through the elimination of 2.5 full-time equivalent employees due to fewer chart pulls.

"We'd like to be fully electronic by January 2006," he says, adding that IT-savvy internist David Shein, M.D., was recruited from Beth Israel Deaconess Medical Center to serve as MIT's physician champion. "It's been fantastic."

Central Utah Multi-Specialty Clinic, a 59-physician multispecialty group practice based in Provo, Utah, won for its deployment of the TouchWorks EMR from Allscripts Healthcare Solutions. Initial implementation began in April 2002 and was completed in October of 2002.

The group, in an article published in the Journal of Healthcare Information Management, estimates the system had a $952,000 positive impact in its first year, including savings from staff and space reductions from eliminating paper charts.

The practice reports that it saved $380,000 by lowering transcription costs by 35%. Physicians have the convenience of logging into the system anywhere there is Internet access.

Jeffrey Johnson, M.D., an internist and head of the clinic's information technology committee, works closely with Jamie Steck, originally the group's accountant who became its IT director.

"You've got to know when to push and when not to push," Steck says. "Doctors know they've got to do it, but getting adoption is critical. If you can start with things that don't change their practice patterns and yet give them a good result, you'll see rapid adoption."

Johnson says the group uses their accounting system instead of mandates to coax physicians into using the EMR's templated documentation tool instead of dictation. With his own patients, he says he eased into using the EMR by documenting only half his patient encounters with the computer until he was up to speed with the new system.

"You've got to learn where stuff is, so it probably takes you a couple of weeks," Johnson says. During the learning period, when he fell behind, he reverted to his old method of paper and dictation to catch up.

The group allocates to each physician their transcription costs, which are deducted from their income each quarter, Johnson says.

"When I quit dictating, that money went into my pocket. It was quite a motivation for me."

Memorial Health, a healthcare system with facilities in southeast Georgia and southern South Carolina, including 485-bed Memorial Health University Medical Center in Savannah, Ga., won for its WebOne Portal affording physician access to clinical information as well as other in-house IT systems.

Frank Davis, M.D., a trauma surgeon, remembers vividly how he was called to his current position as an IT leader. It was a bad pelvic fracture in the emergency room in 1998.

"The patient was trying to bleed to death on me," Davis says, but the new patient-registration software that had been installed with little if any physician involvement malfunctioned.

"Because the patient wasn't in the system, they couldn't release blood products. They did get it fixed, and the patient did survive," but Davis says he "raised Cain" and insisted on physicians being involved in IT decision-making. Davis became the embodiment of the warning, "Be careful what you ask for."

He now heads the Memorial Health physician IT committee.

The hospital launched its WebOne Portal from McKesson Corp. in 2000 to give all clinicians access to existing electronic medical information.

"That thing went up in about six or seven months," Davis says. "Part of the key was to have a lot of nurses in the IT department who really know how to take care of patients."

The hospital is a product-development site for McKesson's Horizon Expert Orders physician order-entry system, a commercialized version of the CPOE system developed at Vanderbilt University. Again, physicians were bypassed in the first round of CPOE training.

"We actually started with the nurses," Davis says. "We wanted the nurses and the secretaries to use the same system as the physicians. They could help teach the physicians when they started using it. It's a little bit of a role reversal, but I think the physicians are on board with it."

About 500 nurses and ward secretaries are now trained on the CPOE system that is accessible in all of the hospital units, while physicians still use paper to write orders and prescriptions, Davis says.

"It's taken us about a year and a half to get where we are with the nurses," Davis says. "Probably about 75% of the orders are entered now by the secretaries, but the nurses are helping out."

Meanwhile, physicians are being held back and won't be trained on the CPOE system until a new prescription-writing module is complete.

"We're anticipating rollout in the fourth quarter," he says. "Once we have the pharmacy piece mapped, the physicians will pick it up and start doing the orders themselves. The nurses will become our super-users and will be there at the elbows of our physicians."

Davis says Memorial is also lucky in that it has 70 people in its IT department.

"For a 500-bed hospital, that's a pretty aggressive number."

Columbia Basin Health Association, a three-clinic not-for-profit community health center based in Othello, Wash., won an AMDIS award for its various electronic applications, including an OnBase document imaging system, HealthPro practice management system and ChartLogic EMR.

Since January 2000, the clinic has moved deliberately toward a completely paperless office. Today, an electronic dental-records system is all that remains to be done and it is being deployed this year.

The rest of the clinic records are 100% electronic, with the main office completing its EMR rollout in October 2003.

"We've really embraced the IT part," says Greg Brandenburg, CEO at the clinic since 1998.

"We wanted to improve patient care, and to do that we knew we had to have data integrity where we captured 100% of the information all of the time."

Misbah Keen, M.D., clinical IT leader at the CBHA, says the wall-to-wall IT system allows physicians to track patient care in ways that would be impossible with paper.

For example, many clinic patients are eligible for subsidized prescription drugs. The clinic's electronic prescription-writing tool built into the EMR automatically sends prescription orders to the clinic pharmacy, where most of the scripts are filled.

"When we send them a script, they'll go ahead and fill it and keep it ready," Keen says. "You give them the prescription, they assume it's expensive. This way, they go to the pharmacy to at least find out how much it is. Plus it's good patient service."

If a prescription is not picked up at the end of the day, the pharmacist notifies the prescribing physician, who decides what to do--perhaps call or take a more aggressive action.

"We've even sent people out to find them if the provider thinks it's necessary," Keen says.

The convenience drives compliance. Today, about 90% of clinic scripts are filled. Prior to the EMR, it was 70%, Brandenburg says, while the average days in accounts receivable has dropped from more than 100 to less than 40. Dictation costs, which averaged $1,000 per provider per month, have been cut enough to pay for the cost of the system in one year, he says.

"I know the efficiency it's brought to our system has been tremendous," Brandenburg says.

Keen, who is working on a master's degree in informatics through Oregon Health & Science University, monitors the care of nearly 500 diabetics against 20 metrics.

"We have data to show, once we implemented this system, we've had HBA1C go down, and our screenings for foot checks have gone up."

The system helps Keen check on internal physician performance as well--for example, their percentages of electronic charts signed and closed within the goal of 95% completed within 48 hours of the patient encounter.

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