Physicians at Sarasota (Fla.) Memorial Health System were ordering too many complete blood counts in situations when a less complete count would do, at half the cost. The difference in cost to the facility was only $3, but it added up quickly.
A message displayed on a computer screen during a CBC order advised when it was all right to order a hemogram instead. "That one little educational tool" reduced CBC orders 15% in the first six weeks and is projected to save $120,000 a year, some of which will be passed on to patients in lower charges, says Colleen O'Connell, director of clinical systems.
At the University of Illinois at Chicago Medical Center, referrals for consultations now come directly to the electronic in-box of physicians, replacing paper forms that often were signed illegibly by the referring physician and thus made it difficult to figure out whom to consult with, says Daniel Hier, M.D., head of the neurology department. "It took literally days for consultations to get back," Hier says, the result of "a very cumbersome system that did not work well."
The doctor-to-doctor communication feature of the medical center's clinical information system helps prevent delays in care, and it eliminates miscommunication on important details such as patient medications that doctors have to get straight when teaming up on the care of one patient, Hier says. "Collaborative care has been revolutionized at this institution," he says.
Information system designers at Montefiore Medical Center are finding other ways to help busy physicians expedite care. For example, 60% of critical blood transfusions were being held up because doctors did not authorize a blood-type and cross-match test when ordering a transfusion, says Dorrie Napoleone, director of clinical information systems for the New York teaching institution.
To end the chasing after doctors to order the test, a prompt was programmed into the computer system used by physicians to enter orders. The percentage of noncompliant orders for transfusions dropped to 2%.
The clinical information systems behind these operational improvements cost millions of dollars, took years to implement and forced significant change on thousands of workers at each institution. An electronic medical record "has a radical impact and changes the organization like nothing else," says Bruce Berg, M.D., Sarasota Memorial's associate chief medical officer.
But now that much of the upfront pain is behind them, early adopters of information automation in care delivery are trimming steps out of once-Byzantine routines and making coordination of care automatic instead of iffy. At the core of each improvement project is a concerted effort to identify and include all the essential sources of information, bring them together in an electronic format and make clinical details available on demand to physicians and caregivers.
In the process, providers are finally merging the priorities of cost containment and safe, effective care. Some healthcare organizations are seeing the first signs of lower cost per discharge and reduced length of stay by using computer assists to expedite treatment. "Everybody benefits when you do something to help a patient and get their hospital stay decreased," says Roger Hecker, M.D., an internist at Our Lady of the Lake Regional Medical Center in Baton Rouge, La.
Hospitals report efficiency gains in a number of areas:
* Physicians are spending less time looking for charts and gathering diagnostic details. That allows them to make informed decisions faster, and duplicate tests are ordered less often because computers are storing and tracking what's already done. Besides saving money, eliminating duplication also saves doctors unnecessary waiting and helps them get a patient to the next stage of treatment faster.
* Automation of pharmacy and nursing paperwork has freed up time for skilled professionals to do more of what they're trained to do (See related article, p. 32).
* With patient histories computerized and the computer able to analyze patient status for potential problems, hospitals are bringing a systematic approach to avoiding not only medication errors but also patient falls, bedsores, infections and other scourges that can add days to stays and endanger patients.
Bringing it all together
Healthcare organizations have been installing multimillion-dollar information systems for more than 10 years, but those purchases have been piecemeal without a vision for patient care, says Wayne Freeberg, an engagement manager with the healthcare group of Computer Sciences Corp., an El Segundo, Calif.-based information systems and services company.
Separate computer applications for laboratory, pharmacy, radiology and registration have contributed to the collection of patient histories, orders and reports, "but it doesn't come together as a tool to assist in the caregiving," Freeberg says.
Patient data that did come together usually consisted of printouts jammed into a paper record, not computerized parts of a whole picture that could be drawn to order for whatever challenge a clinician faced. Or parts of the picture were available by computer but not others, leaving gaps in medication history or pertinent observations that could influence future conclusions by clinicians.
"The biggest problem we faced five years ago was access to the information we needed to make safe and intelligent decisions on patient care," Hier says.
If someone was rushed to the emergency department, for example, there was no way to know if the person had been seen in UIC Medical Center's outpatient clinic the day before and had been treated for a problem that would immediately shed light on the nature of the emergency, he says.
The traditional paper chart was "largely illegible, largely unavailable and disorganized," Hier says. Often a doctor couldn't tell who wrote the charted information, and pieces of the chart frequently were missing.
The hospital had an order-entry and clinical documentation system, but it did not support outpatient activities. Data-gathering in outpatient departments was all on paper and separated from inpatient operations.
Radiology results were "disastrous," with neither reports nor films available much of the time, Hier says. When they were available, they were stored separately-films in a storage room and reports in the patient's chart. When the chart was missing, a doctor had to find the film and have a radiologist re-interpret it, he says.
That's all changed. X-rays and radiology reports are now available online, as are data on a patient's medications, medical history, previous encounters with UIC physicians and other information entering into decisions. "It's one-stop shopping for the physician," Hier says.
Beginning in August 1997, UIC introduced computerized information retrieval to physicians at eight satellite clinics in the Chicago area and gradually throughout its outpatient operations, including a new 245,000-square-foot outpatient center adjacent to the hospital. Inpatient conversion to computerized information began in November 1999 and is about 65% complete, making it necessary to support both computerized and paper-based records during the transition.
In addition to the clinical benefits, the system has generated estimated financial value totaling $3.6 million so far. (See related article, p. 36).
At Our Lady of the Lake, a 15-year history of computerization put the hospital at the leading edge of automated patient-data documentation, says Gary Jump, vice president for information systems. "Our people know how to chart online and deal with the elements of a computer record," Jump says. "We think in an automated fashion in this organization."
Most doctors had someone else enter orders for them, though there was "a loyal group of about 20 to 30 physicians" putting their own orders in, he says.
But the Baton Rouge facility hit a technology wall several years back, at a time when doctors were asking for better ability to manage their patients across inpatient and outpatient settings. A pharmacy information system was not Y2K- compliant, the laboratory system was "falling apart" and the order entry and nursing documentation system was showing its technological age, he says. Physicians were unhappy with separate computer systems that did not coordinate information, especially how medication was ordered and administered to patients, Jump says.
Information professionals at Our Lady of the Lake had prided themselves on an ability to connect disparate computer systems together. "We could interface anything, anytime, anyplace, and we were good at it," he says.
But this time they could not get the ingredients to interact with each other to provide the comprehensive and analytical picture the way physicians wanted it. That included resolving the fragmented medication delivery process among physicians, nurses and pharmacists.
"Our decision was to back off and do it right," Jump says. "Before we bring the orders back up, we were going to solve the meds problem."
The medical center began testing the integration of its automated medication administration record last month, more than two years after launching a wholesale replacement of its core systems with an integrated set of new applications developed by Cerner Corp.
Additional features are scheduled for installation through 2002, and the total cost of software licenses and implementation will be about $4.3 million, Jump says. That includes a break on the cost of system replacement as an initial customer of Cerner's new technology, he adds.
Moving care along
A joint study conducted last October by UIC and Cerner's Benefits Realization Practice reported that physicians spend 30% less time looking for charts, averaging 30 minutes saved per day. That percentage should escalate as the remaining elements of the inpatient chart are converted to electronic form, Keeler says.
Patient visits are more productive because a complete medical record is available online 100% of the time in outpatient areas, and all the inpatient information computerized so far is also universally available. Before the electronic record took over at UIC, the patient record was not available 40% of the time, and it was seldom available in the emergency room.
New information is added to online patient charts as soon as it's created, which also helps move the treatment process along, says Terri Sterling, vice president for patient care services at Our Lady of the Lake. When a physician can get an X-ray or lab test result in an hour instead of after late rounds, it expedites a decision that can accelerate progress for a patient as well as ultimately reduce the length of a hospital stay, she says.
Sometimes doctors are waiting for confirmation that a patient's condition has improved enough to warrant discharge, Hecker says. If a confirming X-ray is taken at 11 a.m. but the results aren't in front of the authorizing physician until late in the evening, "a patient is not going to be discharged at 2 in the morning," he says.
"Outcome and length of stay depend a lot on timeliness (of information)," Jump says. Computerized care processes eliminate sets of hands that add delay and increase the risk of error, he says.
As information systems departments accumulate the sources of information to enable quicker decisionmaking, some gaps become more noticeable and require extra effort to resolve.
At Montefiore Medical Center, information professionals took a break from their unit-by-unit implementation of computerized physician order entry in February and March to automate documentation of vital signs, says Napoleone, the information services director. In addition, they decided to computerize readings on patient fluid intake and output, an important consideration in managing congestive heart failure and monitoring kidney function, she says.
That basic information, shared by many caregivers, was necessary for doctors to write orders online. But they had to search for it in paper records, negating some of the benefits of computerized order entry.
"As we bring up some things electronically, it helps to bring others electronically as well, or it makes doctors work in (both) the electronic and paper worlds," Napoleone says. Montefiore is mandating computerized entry in the interests of patient safety. But in exchange, doctors are encouraged to identify "what information would be of value to have at their fingertips. And that's what we're concentrating on," she says.
Sarasota Memorial studied the impact of its order entry system and found that when physicians used it themselves, their patients' cost per discharge and length of stay both decreased.
Two doctor groups were studied in 1999, one contingent that used the system and one that didn't, says O'Connell, the clinical systems director. After monitoring the stays of more than 2,000 patients, doctors entering their own orders and retrieving results online experienced an 8.6% decrease in their resource-utilization costs and a 6.8% reduction in length of say, O'Connell says. They also received lab results 62% faster.
Computerization is instrumental in getting abnormal lab results to physicians more quickly at Our Lady of the Lake, says Donna Hoglen, a laboratory systems specialist. "Error is not only doing something wrong but failing to do something," especially when communication of results is paramount, she says.
Typically a lab technologist had to recognize critical test values from sticky notes and other reference material, then interrupt work to alert the appropriate physician. Now a computer is programmed with logic that automatically recognizes critical test values and immediately sends an alert to a queue monitored by someone whose job it is to make sure the doctor is called.
That removes the delays and downtime in the lab that result when a busy technologist has responsibility to make the call, Hoglen says. And with a trained person operating under a protocol, documentation of the calls is standardized, she says.
Computer-aided messages among physicians also can eliminate delays and assure accuracy of information, says Hier, the UIC neurologist. The online physician inbox capability is widely used by conferring physicians to share information on medication interactions, prevent duplication of tests and effort, and guard against "plain old ignorance" of a patient's total medical situation, he says.
The traditional model of communicating those details is by using the patient as the intermediary between two doctors, Hier says. That substitutes by default for the inability of practitioners to reach each other by phone.
With the doctor-to-doctor option and the online medical record, colleagues share notes, gain access to patient chart entries and correspond with each other in memos that are conclusively identified instead of signed in illegible scrawl. "All the need to pick up the phone goes away," he says. "You can say it's not a big deal to pick up the phone and call someone. But it is a big deal."
Automating amid complexity
Physician actions dictate the activity of healthcare, but behind the scenes a complex supporting force of nurses, respiratory therapists, infection control specialists, discharge planners and many other professionals must work collaboratively in a fast-changing work environment. It can be a challenge just to know which patients and situations need their attention.
For example, a nurse responding to evidence of a hospital-acquired infection should alert infection control in addition to recording the situation on a patient's chart, Hoglen says. That expedites checking of possible causes such as contaminated intravenous tubing and could head off a spread to other patients, says Nancy Luttrell, director of nursing informatics and patient-care services at Our Lady of the Lake.
The medical center's information system automatically notifies infection control of such events the instant they're recorded, mobilizing a response without the need for a harried caregiver to remember it and pick up a phone, Hoglen says.
At Alamance Regional Medical Center, Burlington, N.C., the infection control office sends out an automatic alert to a nursing station when a patient with an infectious disease is admitted, reminding the nurse to make sure the room's ventilation is set for negative pressure, in which air is drawn in so the infection risk to others is reduced, says Terri Andrews, manager of clinical applications.
"We weren't doing a good job with that," Andrews says. But with the reminder, the record of compliance is close to 100%, she says.
Prevention of patient falls and pressure ulcers-two top safety concerns after medication errors and hospital-acquired infections-can be managed with the aid of computerized management protocols and alerts to the appropriate caregivers, Luttrell says. The process begins at admission, which can identify a patient with a history of balance problems or a predisposition for pressure ulcers based on a standard test, she says.
The management of such conditions is time-intensive and involves knowing the range of pertinent professionals to contact and making sure they're notified, Luttrell says. Instead of leaving it to chance, Our Lady of the Lake adds special duties automatically to the clinical system's computerized nursing task list, prompting caregivers at certain time periods.
For example, nurses are alerted to order special skin-care products and turn the patient every two hours, duties that once might have fallen through the cracks on busy shifts. "They were authorized to do it, but they weren't led," Luttrell says.
Management of such risks become a problem partly because of the number of tasks to manage concurrently, Jump says. The computer helps to guide caregivers from the order through the care process, sometimes eliminating parts of the process.
"The opportunity is tremendous," he says. "We haven't even scratched the surface."
A sampling of other computer-assisted improvements includes:
* Automatic paging of cardiopulmonary technologists for urgent treatment at Alamance. With only two technologists in the hospital, they usually are out working when new orders come in on their computer. Now the orders trigger a page that includes the patient's name, the treatment ordered and the condition it addresses. The two professionals can go right from one assignment to the next without going back to the office or taking a nurse away from other duties to track them down, Andrews says.
* A hearing test for a newborn infant with a possible hearing problem automatically triggers an audiologist consultation at Alamance.
* A computer at Our Lake of the Lake knows the difference between respiratory treatment for a toddler and a teenager. Entering the age ensures that the right treatment scale pops up.
* When a physician orders a pump for patient-controlled administration of pain medication at Sarasota Memorial, a computer pre-empts the order if it's contraindicated by the patient's age or a recent creatinine-level test showing impaired kidney function.
Whether it's a small, targeted program or a wide-ranging sweep for drug interactions, the capability of their clinical systems to alert, coordinate and remind clinicians has executives excited about the potential.
"It's much easier now that we have physicians online," Napoleone says. "We can turn on a rule in a very short time and start affecting something in a very short time."
"It's limited only by our imagination," she says. "We can do a lot of good things now."