Once a comprehensive clinical information system is there to use, it gets people thinking.
Managers at Sarasota (Fla.) Memorial Health System have had some time to get their minds going, and they're piling up initiatives to expedite care and improve efficiency in ways not possible or even considered before.
They've used computer assists to quicken and reliably execute entire processes, such as patient transfers to rehabilitation units.
They've used the system's analysis ability to investigate the source and extent of care-delivery problems in the time it once took to pull the first of many paper charts.
And they've programmed increasing depth of feedback on patient conditions, alerting clinicians to dangers that before could not have been routinely highlighted.
"You can individualize the care in ways it (formerly) would be unmanageable to do," says Colleen O'Connell, director of clinical systems.
The healthcare system has been a proving ground for the physician order entry, clinical documentation and decision support applications engineered by Eclipsys Corp., says Denis Baker, Sarasota's chief information officer.
Access to clinical information from physician homes and offices is in such demand that 150 doctors were on a waiting list for remote access three years ago-it was held up until February 1999 by a temporary HCFA ban on sending identifiable patient data over the Internet, Baker says. Use of the system is being fueled by that remote access option, which generates 350 sign-ons a day, he says.
Though doctors are not required to enter orders, 30% of them do. Within the healthcare system's 845-bed hospital, a network to support wireless communication to and from the information system is in place, with 150 laptop computers rolling around on carts for doctors and nurses. Baker says more devices probably will be needed.
Computerized alerts at the point of decision include the emerging first wave of duplicate orders, drug interactions, readings of kidney function and warning signs for digoxin toxicity and other adverse drug events. But Sarasota's clinical and computer professionals are thinking up others, such as warnings about nutritional deficits in recovering patients, O'Connell says.
A lab test that checks levels of albumen in the blood can signal possible malnutrition if the level is falling, which could interfere with recovery and healing. But in a facility without computerized monitoring, it's not practical for the dietary department to respond to the threats, she says. "Short of a dietician coming up and looking at every chart in the organization, that just doesn't happen."
At Sarasota Memorial, a computer sifts through test results as they're added to the lab system and flags potential health problems. If a patient's albumen level is low, it alerts a dietician to respond immediately, O'Connell says.
The computer system's organizational abilities have brought reliability to key procedural activities that once had suffered from inefficiency and caused delays in care arrangements.
Nurses for the system's home healthcare agency were not responding in a timely way to doctors' requests for assessments, the first step in arranging for continuing care in the home after discharge, O'Connell says. The orders would lie on the desk of a unit secretary for awhile, then the secretary would call the home-care office and usually leave a message because the nurses were elsewhere in the hospital at work. If the secretary didn't see the order by 4 p.m., the call would be delayed until the next morning. Meanwhile, nurses would check messages twice a day. Case managers often had to spring into action looking for the nurses.
As a result, nurses doing assessments weren't able to see 75% of patients scheduled for home care before discharge, she says, adding that some patients were held in the hospital as long as three days because they could not care for themselves.
Now an order for home care is placed online and activates a pager that alerts the nurses wherever they are. That eliminates both the unit secretary and case managers as intermediaries and ends delays in communication, allowing nurses to go directly to the next patient. The percentage of missed visits before discharge has dropped to 7% or lower, O'Connell says.
A new project involves automating summaries pulled together by caregivers when a patient is transferred to another setting of care such as rehabilitation, she says. Usually someone has to fill out a form and spend about 20 minutes searching a chart for information to pass on to the next unit. The new caregivers often don't get the full complement of details, and that puts two nurses on the phone for 10 minutes to complete the picture. Now when a patient is transferred to a skilled nursing facility, the information for the summary report is drawn into an electronic form, she says.
The clinical system's database is "extraordinary" for supporting investigation of quality problems, says Bruce Berg, M.D., associate chief medical officer. For example, he was able to complete research in 10 minutes on anecdotal observations that patients were getting the wrong concentrations of pain medication in self-administered pumps. Normally, the response to stories floating around the hospital would include forming a committee and taking three to six months to investigate, Baker says. What's more, in this case the computer could only detect problems with 1% of the cases, which would have been a waste of time to uncover. "Bruce's safety officer has bigger fish to fry than a 1% problem," he says.
The computer database is there for all manner of such on-the-spot probes as questions come up. Recently four patients fell out of bed during a weekend. A manager could quickly call up all medications from those patients to see how medicated they were and whether that was contributing to the problem, he says.
Medical managers can go looking for things they can't possibly pick up in chart review, uncovering problems that are "so blindingly obvious once it's exposed," says Baker.
"Organizations are so complex that there's so much to fix," Berg says. With computerized analysis, "things pop out at you."