Deep inside the laboratory information system at Eastern Maine Medical Center are nuggets of knowledge just waiting to be unearthed.
The process of digging them out is under way, and the prospects for payoff are promising: The few nuggets already discovered have been appraised at hundreds of thousands of dollars in salvaged revenue from tests that had gone unbilled by the 347-bed Bangor hospital.
That's barely scratching the surface compared with the potential to pick up on patient problems before they get worse, avoiding millions of dollars in treatment costs.
These are not new opportunities, though. They are old opportunities that were never exploited until now.
Healthcare organizations need all the opportunities they can get to wrest value out of expensive investments in information technology. Mounting financial pressures, combined with maturing appreciation for clinical cost control, are changing expectations for healthcare information systems, observers say.
"That thrill of investing in technology for technology's sake is a dead-end street," says Dev Culver, chief information officer of Eastern Maine Healthcare. The Bangor-based network includes Eastern Maine Medical Center and three other hospitals.
The laboratory information system at the medical center has been around for more than a decade, doing workhorse chores for the lab and spitting out results for doctors and clinicians. But only recently did the hospital harness the system's innate ability to analyze results and forecast trouble long before any alarm bells sounded.
By applying rules to certain tests--if this is so, then that must be the case--the hospital found it could greatly improve monitoring of powerful medications, feeding results back to doctors and giving them time to take corrective action before the levels became critical, Culver says.
In addition to improving care and conserving resources, introducing rules into billing routines can prevent certain tests from slipping through the cracks. The provider already has found tests worth $250,000 that were being overlooked and not billed.
That doesn't seem like much for a medical center that had more than $230 million in total revenue last year. But it's just one of potentially hundreds of small, focused initiatives that collectively can save millions of dollars annually. And all by doing "absolutely nothing but using the technology in place," Culver says.
Most healthcare organizations have plenty of technology in place, despite criticism that the industry is undercomputerized and does not spend enough on computer advances.
"There's unused power in almost every kind of system that's ever been installed," says Luther Nussbaum, chairman and chief executive officer of First Consulting Group, a Long Beach, Calif.-based healthcare information technology consulting firm.
They need it now. Tapping into that power is becoming a priority for providers and vendors alike.
For provider organizations, the expense side of healthcare management is becoming the only hope for balancing the operations budget as the reality of revenue stagnation sinks in.
For vendors, providers' budget pressures translate into customers' decreased ability to buy expensive computer applications. That is prompting healthcare software companies to devise consulting services and add Internet-technology features designed to draw value out of the systems they have already sold.
"Managing the knowledge is the industry they're in, and the software is a means to it," Culver says. That recent realization contrasts with vendors' longstanding approach of "installing the software and heading for the hills," he says.
For years, the whiz-bang potential of jazzy features and elaborate functions might have sold providers on technology and differentiated one vendor's big-ticket system from another's. But the new focus is on getting clearly defined and maximum value from information systems.
That means a provider organization is likely to investigate and reap the full benefit of a 5-year-old information system before spending more on new software applications, says Janet Gordon Kennedy, principal shareholder and chairwoman of the Kennedy Group, a Chicago-based provider of strategic services in healthcare information technology.
Not all older computer systems have the power and installed features to serve newer priorities in healthcare operations, such as comprehensive clinical information exchange with physicians. But organizations no longer have to buy a new set of costly and sophisticated computer applications for their unmet needs, says Kennedy.
Instead, new computer tools deploying Internet technology can supplement and fill gaps in existing systems--"new technology concepts that make old technology work better," she says.
The shift toward demanding near-term value is borne out in recent surveys asking healthcare managers to rank their top priorities for information technology development in 2000.
In a survey of 35 top healthcare CEOs, released in June, initiatives involving the Internet and e-commerce headed the list, followed by the need to prepare for information management provisions of the Health Insurance Portability and Accountability Act of 1996.
Third-highest in priority was improving the use of current computer applications, and it was comfortably ahead of plans to purchase new applications (See chart, p. 52). The survey was conducted by Infohealth Management Corp., Chicago, which provides information technology management to healthcare organizations.
Results of that survey mirror an earlier poll of information systems professionals during the Microsoft Healthcare Users Group conference last fall (Nov. 29, 1999, p. 62).
Behind the interest in information systems productivity is an urgent need to tame costly processes of care, areas where management practices haven't made much of an impact.
"Healthcare is clearly challenged financially," says Don Ragan, CIO of Detroit Medical Center. "Before, everything was reimbursed. Now we have to work for a living."
That work includes overhauling both the technology and the processes of healthcare operations, Ragan says (See related story, p. 52).
Automation mismatch. During the past decade, as reimbursement for services shifted to prenegotiated payments instead of open-ended fees, hospitals and other care venues responded by consolidating into networks to gain benefits of scale and better coordination of care.
For the network premise to have any chance of containing costs, information and operations have to be meshed in ways that foster efficiency. But although multiple hospitals and clinics ostensibly are part of the same organization, the structure of networks can be wildly complex and scattered, with a clutter of inherited information technology and disjointed operations.
The mismatch between existing information systems and care-delivery needs takes many forms:
* Systems for the wrong processes. The traditional role of a hospital information system was to deliver a clean bill for payment, assembling the documentation to support charges before sending the bills out, Ragan says. But these days the goal is complicated by contractual terms that have to be met correctly during care, such as limits on what is and isn't reimbursed. No amount of billing automation can prevent denial of payment for services that aren't covered. That calls for billing systems and new processes focused on changing "the way we practice, knowing that the bills are being rejected," Ragan says.
* A lack of systems for the right processes. Executives are awakening to their organizations' deficiencies in computerizing the clinical process, says Daren Marhula, a healthcare analyst with U.S. Bancorp Piper Jaffray Equity Research. "Now more than ever, healthcare managers need to understand what the actual cost of treatment is in the care setting," he says in a recent research report. "Only by understanding costs will (healthcare organizations) be able to return to profitability. This is what clinical systems enable."
* Too many existing systems, confounding cost-effective integration. Even when an institution has the right systems in place, the situation changes when many independent institutions are combined. Each software application may do its original job well and contribute great functional ability to a department, but the success of a network depends on information integration, says John Halamka, M.D., chief medical information officer of Boston-based CareGroup Health System. The six-hospital network was trying to integrate more than 100 information systems when Halamka joined CareGroup in December 1998. He standardized systems to a core of 15, then used Internet technology to organize and distribute information (See related story, p. 56).
* Systems with untapped potential. Like the lab system at Eastern Maine, many computer applications can do much more for physicians and patients than automate routine chores--but only if organizations are aware of what they should be doing to support clinical decisions better.
Risk reduction. Through a consulting arrangement with its clinical systems vendor, Eastern Maine Healthcare has become aware of steps it can take to identify interventions early in the stages of conditions that otherwise could worsen in the hospital.
A six-month study of about 8,000 patient discharges isolated 180 patients on digoxin, a heart-regulating medication. They clearly had a problem with elevated levels of the drug three to five days before their readings indicated alarm, Culver says. One problem with monitoring digoxin is that it's often being taken by patients hospitalized with other problems, allowing the medication risk to fester in the background while doctors focus on more-acute situations.
When physicians saw the findings of the six-month study, they identified 40 cases in which they would have taken different action had they known earlier what was going on.
"They would have changed dosing at that moment," Culver says. The medical center is in the final stages of determining the estimated savings of those interventions.
A similar opportunity for action is materializing as a second study gets under way. By monitoring a substance called creatinine, this one looks at how clustering lab results can reveal how well or poorly patients' kidneys are clearing toxins after medical procedures.
A range of drugs, which can be expensive as well as dangerous in high doses, often is administered early in treating serious conditions but can be tapered as soon as kidney-function results issue an all-clear sign. Early recognition of those signs offers an opportunity to scale back on dosing, which is better for the patient and less expensive for the hospital.
Culver says a trigger for greater scrutiny programmed into the reporting software is "now firing 30 to 40 times a day," indicating another source of clinical risk to reduce.
The initiatives are in collaboration with Cerner Corp., a Kansas City, Mo.-based information systems company that has supplied clinically oriented applications to Eastern Maine for more than a decade.
Now the vendor is supplying clinically oriented personnel. Teams of experts in care management look at established activities in the healthcare network, decide on ways to change or enhance an activity and then tap the capabilities of the installed software to help do things differently.
Eastern Maine is paying Cerner an hourly rate to defray costs of assigning four to five process-change consultants, five to six applications specialists and an executive team, all bringing expertise on-site.
The "nontraditional relationship" with Cerner centers on initiatives with clinical-improvement objectives and intended results, Culver says. During the next seven years, the series of initiatives is projected to accumulate avoided expenses and resulting savings of at least $40 million. Cerner will get an undisclosed percentage of those savings, he says.
The healthcare network also is thinking ahead to clinical demands on its labor force. With shortages in skilled medical personnel a fact of life, Eastern Maine wants to make better use of them as inpatient acuity gets higher and access to qualified nurses becomes increasingly difficult.
"We know just how inefficient we are in many of the routine processes that make up a normal day of patient-care delivery," Culver says.
"Clinical documentation is one example where our manual processes have skilled staff like nurses putting the same information in four or five locations on forms." A closer look at operations provides "the opportunity to make significant gains in efficiency and effectiveness as a result of redesigning these documentation processes around a fully automated structure," he says.
Insisting on value. The consulting arrangement helped patch up a relationship gone sour. Less than two years ago, Eastern Maine was "decidedly unhappy" with its vendor relationship and the value of its installed applications, Culver says.
By that time it had invested about $7 million in broad categories of information technology. "We had all this software running, and we felt abandoned and ignored," he says.
The health organization told Cerner so in November 1998. As it happens, the vendor had been developing an internal consulting business for about two years, and Eastern Maine became an early customer. That led to the current collaborative efforts to get more out of those millions of dollars invested in software.
Healthcare information systems companies have noticed the swing away from financial and patient-accounting approaches and toward provider cost control. They're scrambling to highlight their ability to instill clinical and decision-enhancing value.
Companies with a clinical information emphasis are displaying what they can do immediately for providers as well as what their wares can accomplish eventually when matched to a customer's operation.
Without much re-engineering of work processes, providers can reduce the turnaround time of lab results, says Randy Thomas, director of corporate strategy and marketing with Delray Beach, Fla.-based Eclipsys Corp.
Getting orders to the lab faster gets the results reported and entered into patient charts faster. Also, receiving test results quicker eliminates the need for doctors to reorder the same tests, she says.
A 62% decrease in the time to turn around lab results figured into a lower rate of resource utilization at Sarasota (Fla.) Memorial Hospital, says James Turnbull, CIO of the 529-bed facility. Other factors included computerized order sets, the checking of duplicate orders and decision support based on clinical rules entered into the system.
In Sarasota Memorial's study of 2,200 patient cases, physicians who regularly used order-entry, results-retrieval and other functions of a clinical system that Eclipsys installed reduced their resource usage 8% and decreased the length of patient stays 7%. Doctors who rarely used the system had increases of about 1% in resources used and length of stay.
Longstanding leaders in financial and administrative applications are also emphasizing the service side of their business as they add clinical and decisionmaking functions.
"Customers absolutely do need to get more value out of their current systems," says Janet Dillione, who heads the clinical systems division of Shared Medical Systems, based in Malvern, Pa. The division is working to add features to existing systems that concentrate on increasing patient safety and reducing medical errors.
When customers talk with McKesson HBOC, "there's much more acute attention to the solving of the business problem" rather than the accumulation of computer functions for broad purposes, says Dan LaBenne, vice president of strategic planning for the company's Atlanta-based information technology business.
Whose responsibility? LaBenne characterizes the shift to demonstrated value as "an evolution and some business reality that should have been there all along."
The information systems unit of McKesson HBOC is getting a dose of that reality in sales of smaller, more targeted applications and "less emphasis on the feature/function war," he says.
Providers have their hands full trying to grasp the features of software already installed, he adds. "We've sold a lot of product that's still not fully implemented. The process of re-engineering--where they're going to get the returns--has yet to occur."
To some observers, though, untapped computer capabilities amount to evidence that information systems companies didn't do their part in advising customers how to best use the products they purchased. "The vendors have done a pretty poor job of customer service over the past several years," says Michael Davis, research director with the healthcare division of GartnerGroup, a Stamford, Conn.-based information technology analysis and consulting company.
If healthcare software companies now intend to plumb the service end of information systems management, they have to do better at driving home the productive capabilities of software at the outset, he says. "If they're using this as a way of doing the type of installation they should have done in the first place, I have a problem with that."
Some healthcare organizations have written ongoing consulting services into their contracts with information systems vendors, says Michael Kreitzer, an independent healthcare information systems consultant. But if those services weren't included at the beginning, healthcare organizations can't expect to get them from vendors years later without paying for the services, he says.
One approach is to formalize an annual meeting between healthcare executives and senior vendor executives to plan for the coming year, Kreitzer says. The high-level meeting is supplemented by a more nuts-and-bolts visit by a vendor implementation team, he says.
Normally members of such a team tour the facility after the installed application is first put in operation, giving advice on how to capture its full capabilities. But in this case, those "walk-throughs" continue for years afterward as users gradually get accustomed to the applications or encounter problems. The vendor team "looks for those functions not being used properly or not well enough--if at all," Kreitzer says.
Establishing the post-implementation meetings is an easy way to get free advice and to huddle with clinical leaders who are likely to be making the same rounds, he says.
The give and take of clinical problems and technological know-how in such encounters creates the potential for unearthing computer-assisted solutions just by observing how people are doing their jobs. "Quite often the change can be done right there."