The computerization of patient information is being championed as a necessity, not merely a plus, in the healthcare system of the future.
As health networks form and multispecialty medical practices get larger, information technology is being viewed as the unifying force enabling huge amounts of data to be entered, transferred, stored and retrieved in the name of medical efficiency and economics (Oct. 11, 1993, p. 39).
But information system vendors and experts in system integration are making one big assumption in their computerization plan.
The central premise is to lure clinicians to computers parked in convenient places throughout the hospital, the outpatient clinic, the medical support areas and back in the physician office. That's where they enter orders, receive results and begin to tap into comprehensive databases of information leading to better and more cost-effective medicine.
Some leading-edge hospitals are documenting payback for their efforts to guide the ordering process via computer. At Brigham and Women's Hospital in Boston, for example, a single change in ordering behavior brought about by physician interaction with computers is saving $600,000 in charges a year for one drug, said John Glaser, the hospital's chief information officer.
Those savings depend on establishing effortless clinician contact with the computer system at the right time. "We've got to touch them at the point before the work begins," said Bruce Bearden, director of product management and requirements for First Data Corp.'s Health Systems Group, one of many healthcare software vendors working to make computers easy for clinicians to use (Feb. 28, p. 52).
"Until you have physicians ordering, there's no way to provide support at the point of decisionmaking," said Erica Drazen, a healthcare consultant and vice president at Arthur D. Little, a Cambridge, Mass.-based consulting firm.
The expense of providing enough computer workstations, as they're called, for a typical 300-bed hospital is estimated to be $350,000 minimum to as much as $1 million, including network connections and basic software (See related story, p. 42).
That's based on an estimate of $1,800 to $5,000 per workstation, but it doesn't include the multimillion-dollar expense of buying sophisticated information system software that guides the operation of each computer in the network.
Clinician acceptance determines whether the expense pays off. Make that computer a magnet for clinicians and it will set up the rest of the information system for success, experts say. Make it a time-consuming or vexing task and it will squander the system's investment and potential.
Physician uprising.The University of Virginia Medical Center, a 700-bed teaching hospital in Charlottesville, established a routine of direct order entry by medical residents, but not before learning some hard lessons.
A system for placing pharmacy orders was roundly opposed by residents when it was implemented in July 1989. Opposition eventually resulted in a June 1990 work action in which residents abandoned the step-by-step ordering procedure and opted to type their orders in, said Thomas Massaro, M.D., director of medical affairs.
Typed-in "free text" orders took more time to process and put a strain on pharmacists. At one point during the month, 250 such orders were placed in one day, compared with the usual 10 to 20, Dr. Massaro said.
But the physicians could type the orders faster than waiting for screen after screen of computer prompts to appear, said Ms. Drazen.
High expectations by the hospital and a lack of physician direction at the outset were more of a problem than the actual operation of the computer system, said Dr. Massaro, who narrated the experience in the January 1993 issue of Academic Medicine. Physician opposition receded when a new class of residents were given thorough orientation.
"You have to be more patient than we probably were at the beginning," he said. Computer ordering time also must be put in the context of the total work saved, not just the time it takes to process an order on a computer instead of writing it out on a chart.
For example, he said, computer ordering may take longer, but a physician hunting down a chart before writing an order takes more total time. Time savings made possible by computer convenience and access should be measured and explained before the computer system is implemented, he said.
No time for waiting.Waiting time can be the most important variable determining physician acceptance, said Ms. Drazen. Two main factors contribute to the wait: the procedure for searching for and calling up information, and network delays influenced by the way software and databases are managed, she said.
At the Rehabilitation Institute of Chicago, the information system automatically measures the average response time every half hour, and the system's support staff looks at a week's worth of averages once a month, said John Schreier, director of information systems.
The aim is to keep the system's response time at "a second or less," Mr. Schreier said. "It's a matter of fine-tuning your system."
At some point, the fine-tuning can't keep up, and computer processing capacity may have to be upgraded. Two years ago, the rehabilitation hospital spent $45,000 on a secondhand IBM mainframe to replace the one installed with the system in 1986. Mr. Schreier said the move bought some time and extra processing power in the push to sustain a responsive system, but he added that another upgrade will be necessary "within a few years."
The premium on speed and response time for clinicians also calls for buying the fastest processors available, consultants said.
In addition to the main processing units, workstations any slower than the current standard-the Intel 486 microprocessor-could disappoint physicians accustomed to that speed now, and also may be hard pressed to handle the next wave of software innovation, said Colleen Wells, an Arlington, Texas-based consultant with Superior Consultant Co.
At Bethesda Hospital in Cincinnati, response time is being kept to less than a second from screen view to screen view without having to spend much money because hardware was purchased with sufficient capacity, said Larry Collins, senior vice president.
Speedy response is a critical requirement, Mr. Collins said. "If it's an order entry procedure, to be accepted it has to be nearly as fast as you could write it down," he said.
And acceptance makes speed even more important. "People who use the system become so familiar with the system that they're ready to point on the next screen before it comes up," Mr. Collins said.
Besides getting access quickly to the system itself, the user must be able to get quickly to the data or task at hand once in the system, said Darryl Sutorius, M.D., co-director of thoracic and cardiovascular surgery at Bethesda. "Doctors don't want to go through 18 screens to order a unit of blood," Dr. Sutorius said.
Computer-prompted savings.Feedback from physicians indicates they're not being pulled into the computer age reluctantly. They just need reasons why it's better than what they're doing now (March 1, 1993, p. 35).
Up to now, acceptance has revolved around ease of use and value of information to clinical practice. But growing business imperatives, such as the movement toward capitation and the influence of insurance eligibility on the use of hospital services, could make physicians seek out the workstation for guidance, Ms. Drazen said.
"The prime motivator is putting physicians at risk for cost," she said. "Once that happens, they'll insist on having information to keep costs andduplication down."
At Brigham and Women's, 14,000 inpatient orders are processed each day, said Mr. Glaser. In an average day, the hospital has to cancel a medication order 87 times because it was already ordered by someone else. Three times a day, an order is stopped because the patient is allergic to the medication.
Just one reaction to medication "costs us $6,000 in additional care to undo the damage created by an adverse and preventable medication error," Mr. Glaser said.
The hospital's information systems division last year instituted a clinical order entry and monitoring system to cut down on those and other costs. A series of prompts and information infusions guide ordering and create system preferences on dosages and frequency of dose based on recent medical knowledge, he said.
For example, an anti-nausea drug commonly given to chemotherapy patients was typically being ordered every four hours, while research has shown it can be given every eight hours. Just by changing the dosage that registers by "default" if no dose is specifically entered, 94% of orders went to the new frequency, saving $600,000 in charges a year, Mr. Glaser said.
In another case, computer-screen questions about the use of human growth hormone helped reduce the charge volume to $50,000 a year from $750,000, he said.
Brigham and Women's is now working on ways to get physicians to question the frequency of some commonly ordered tests as well as the continued ordering of tests after results reach a normal reading. Research shows that 62% of tests stay normal after the first normal reading, Mr. Glaser said, and the workstation reminds the ordering physician that a certain number of previous tests were normal.
Giving vs. receiving.Whatever the appeal of workstation potential, not all physicians can be persuaded to use it fully, or sometimes at all.
The clinical information system at Bethesda was installed 10 years ago by Atlanta-based TDS, but 20% of the 1,200-member physician staff still dictates to an order clerk, Mr. Collins said. Of the 80% who use the system, there are "varying degrees of use"-some will use it for retrieval of results and other useful data but not for orders, he said.
In his article in Academic Medicine, Dr. Massaro said physicians "understand the need for data in making clinical decisions. As a result, the retrieval process was less of an issue" among residents at the University of Virginia Medical Center.
"Most of the debate centered on the ordering component, but there are no physician role models for point-of-care order entry," he said. "Residents were forced to absorb duties previously performed by clerical staff, and they resented it."
Custom order sets.To ease the burden, some information systems allow physicians to make up their own customized order sets, reducing the time spent at the workstation.
Bethesda's Dr. Sutorius said he found he was going through the same ordering motions after every cardiac procedure he performed.
Using tools for creating physician-specific series of orders, he came up with a custom shortcut. Now that he has a personal order set, "a few clicks of the light pen and I'm off doing something else."
John McGuire, M.D., an attending physician at the Rehabilitation Institute, said his personal order set is especially handy for rehab demands, involving a lot of equipment and therapy. "Some of this stuff is pretty repetitious, so it lends itself well to the computer," he said.
Dr. Massaro said the introduction of departmental and personal order sets was well received, and by June 1992-two years after the pharmacy-order protest-273 residents had generated 2,684 such sets. In fact, an oversight committee of residents took a look at the custom files and reduced the total to 545 to weed out duplication, he said.
Slant by specialty.To make an impact
on physicians, information system vendors also are working on providing different sets of information for a spectrum of providers, from primary care to subspecialties, said Scott Belmont, director of clinical services at Electronic Data Systems, a Dallas-based healthcare information technology integrator that's developing order entry and results applications.
Primary-care physicians need a broader range of information to diagnose from a wide range of possibilities. Subspecialists generally get patients after their ills are narrowed down and they need more complex clinical questions answered, Mr. Belmont said.
Generalists also need a more administrative slant to their information because they typically perform patient management functions for their practice or health network, he said.
Getting to the chart.Access to information now contained in a patient chart is another benefit that must be sold to physicians, said Kim Stried, a healthcare consultant with Coopers & Lybrand. A paper chart can only be in one place, she said-in the medical records department or under the arm of one physician somewhere in the building.
If physicians can be moved to use computerized data retrieval, it creates "a foundation for more of a decentralized approach to accessing information and reporting the information," Ms. Stried said.
Instead of having to pass the record around, or spend time trying to locate it, the data can be instantly available to any number of clinicians at the same time, she said.