Forty-three victims of Rhode Island's disastrous February nightclub fire were admitted to Rhode Island Hospital in Providence, the flagship facility of Lifespan, the state's largest health system. Any hospital easily could have been overwhelmed, but Rhode Island Hospital rose to the task and information technology played a significant role.
Many of the victims received their care in the only paperless intensive-care unit in the Northeast, with an electronic medical record system that gave physicians their complete information at a glance, updated itself in real time whenever a caregiver added a note and registered new laboratory results the moment the analysis was completed. Each patient room had a workstation, and caregivers also used wireless devices, from tablet PCs to personal digital assistants, to transmit and receive information.
All 43 patients pulled through and the last one went home in May. The hospital's caregivers credit the computer system with giving them the information they needed to make the best medical decisions-for these patients and for all others.
And they credit Lifespan President and Chief Executive Officer George Vecchione with the foresight and drive that made the unusually advanced clinical information system-called Lifelinks-a reality.
Vecchione was named a winner of Modern Healthcare's and the Healthcare Information and Management Systems Society's CEO IT Achievement Award because under his leadership Lifespan has embarked on 150 cutting-edge information technology projects that make the four-hospital system one of the most "wired" around.
"They are clearly one of the most progressive organizations in their use of IT and that has happened because of the vision and leadership from Mr. Vecchione," says Dennis Barry, president and CEO of Moses Cone Health System in Greensboro, N.C., and one of the award judges.
Lifespan has been recognized by multiple organizations for its commitment to information technology and was included in CIO magazine's CIO-100 awards last year. Lifespan was the only healthcare provider so honored, and it joined such savvy IT users as Amazon.com, IBM Corp. and Wal-Mart.
The whole enterprise is based on a single wide-area network, wired and wireless, that ties together its four diverse facilities, as well as more than 500 physician offices. Its information technology plan represents an expenditure of $60 million over six years.
In addition to Lifelinks, Lifespan has a picture archiving and communications system fully installed at 148-bed Newport (R.I.) Hospital, its smallest acute-care facility, and is rolling it out to 568-bed Rhode Island Hospital and its pediatric unit, Hasbro Children's Hospital, and 209-bed Miriam Hospital, its teaching hospitals in Providence. When the installation is complete, physicians at all the facilities will be able to look at all of a patient's radiology images-X-rays, CAT and MRI scans, ultrasounds-through the Lifelinks system from any computer connected to the network, even from home.
At 60-bed Emma Pendleton Bradley Hospital, a children's psychiatric facility in East Providence, the staff is working with a vendor on developing its own automated mental health record system. At Miriam Hospital, Lifespan has a $1.45 million robotic laboratory system that can process up to 4,000 blood tests a day with nearly no human intervention, and it pipes the results directly to the clinical information system. It serves all the Lifespan affiliates and can compete for outside business as well.
Computerized physician order entry is being used in the ICUs at Rhode Island and Miriam hospitals and is gradually being extended to other units. One in four physician orders is now entered directly at the two hospitals, including 90% of medication orders in the ICUs. Physicians also can sign off on patient charts with an electronic signature.
"We're zealot missionaries about this stuff," says Mitchell Levy, director of critical-care services at Rhode Island Hospital. "We think it makes care better. We can read each other's notes and communicate better. Our mortality and infection rates are down. George has focused on the right things-not just on technology, but on the right applications for the right reasons."
Leadership and commitment
Unanimously, Vecchione's associates say he "gets it" when it comes to computers.
"We love George-he lets us do what we want with our computer toys," says Joe Amaral, CEO of Rhode Island Hospital and a dedicated technophile. "He creates an enabling environment for things to happen." Just after making this comment, Amaral stops David Hemendinger, Lifespan's chief technology officer, to inquire about obtaining a BlackBerry, a wireless device that will let him check and answer his e-mail on the run. Hemendinger says he'll take care of it.
"We would not be able to afford the kind of state-of-the-art technology that's out there without Lifespan's support," says Dan Wall, president and CEO of Bradley Hospital, which provides psychiatric services through its inpatient and outpatient facilities and three schools. "Under George's leadership, we've been able to make investments as a system and have been able to get connected in a lot of different ways. He's been committed from the beginning."
For Bradley, those investments included IT staff support to dramatically customize an off-the-shelf mental health record system for the unique needs of a pediatric facility and an unexpectedly large expenditure for hardware. "We found that in order to get people to do the documentation, they need laptops and wireless devices, which were not in the budget origi-nally," says Henry Sachs, president of Bradley's medical staff. "Lifespan gave us the dollars to do it. They told us, `If we're going to make it work, we really have to make it practical to use.' "
Though Vecchione is no geek himself (he describes his own computer skills as "average at best"), he knows how to give the geeks freedom to get the job done, while keeping them from roaming too far afield from the core mission.
And he readily absorbs what he needs to know, says Reid Coleman, Lifespan's medical director of information systems and a key internal and external evangelist for the Lifelinks system and the physician order-entry component. Vecchione only had to hear Coleman's spiel once and he had it down pat.
"The second time he heard me give my talk, I skipped a step, and he jumped in and said, `What Reid meant to say here was that the system helps prevent slips of the tongue and slips of the pen.' "
Nancy Barrett, director of systems integration and development, concurs. "George felt it was important for everyone to understand what we were doing, so he insisted that we demo each system at every opportunity, even if it wasn't quite done yet," she says. "At this point, he could probably do all the demos himself."
Coming from a background in public accounting, Vecchione first moved into healthcare management with a job at New York's Mount Sinai Hospital. When he arrived at Life-span in 1998 from New York-Presbyterian Hospital there was already an ambitious IT plan in the planning stages that included an electronic medical record and computerized physician order entry. Though he kept to the basic plan, one of his first moves was to reorganize Life-span's management so that the chief information officer stopped reporting to the chief financial officer but instead reported directly to him. "We needed to give focus to the fact that IT was part of the solution and was a strategic investment, not just a cost center," he says.
The next step was to reformulate the planning body responsible for information systems. Lifespan's information systems Strategy and Steering Council includes all the top executives from each affiliate, Lifespan's CIO, and representatives from nursing, finance, human resources and strategic planning, as well as the heads of information systems planning councils at the affiliates. All decisions apply systemwide whenever possible-a critical move for getting efficient implementation and economies of scale. Affiliates are allowed to have their own specific applications only if they can justify them to the information systems council.
Developing software internally, a common strategy among large institutions with advanced clinical systems, was deemed too expensive and time-consuming. "Our strategy is to use off-the-shelf products as much as we can," says Lifespan CIO Carole Cotter. "We can't afford to spend 12 years getting this done."
When Vecchione arrived, Lifespan was operating at a loss-typical for the state, whose aggregate hospital profit margin was -1.2% in 2001. Several IT initiatives have helped the system break even recently.
One of Vecchione's first requests was better decision support for himself and his executives. "In one of the first meetings, he asked all the CEOs to talk about their census," Cotter says. "They said, `We don't have census reports.' Well, they had them, but they were just printouts" and useless for analysis.
That encounter led to the creation of the "management dashboard," an application that takes information from all administrative systems and lets managers see their status at a glance for all key performance indicators.
In 1999, Lifespan's laboratories were processing 250,000 tests annually. By 2002, the new centralized robotic lab at Miriam Hospital had increased that number to 850,000, and the overall profitability of the lab had jumped from $400,000 to $3.5 million.
Even simple projects have yielded big dividends. A contract management module, installed to help determine whether payers were reimbursing Lifespan in accordance with the provisions of their contracts, has paid for itself many times over: It's identified $41 million in underpayments.
Also, a recent negotiation with Blue Cross and Blue Shield of Rhode Island, the state's largest payer, yielded higher rates to help cover Lifespan's IT investment. "They said they were pleased to participate in the funding of these initiatives," Vecchione says.
As for quality of care, Coleman says that in common with most healthcare providers, Life-span didn't have a clear "before" picture on medical errors, and therefore can't measure whether they've actually been reduced. "But we know residents aren't being paged as often by nurses who can't read their writing, and the number of times docs have to go down to medical records to hunt down a chart is rapidly diminishing."
Outreach in the industry
Vecchione was instrumental in starting the Rhode Island Quality Institute, a consortium of payers, insurers, government representatives and providers dedicated to making Rhode Island a laboratory for testing ways to improve the quality of care.
Under his leadership, the institute is about to embark on testing a statewide electronic prescribing system that would allow physicians to send prescriptions directly to any pharmacy. Vecchione negotiated with the vendor, SureScripts, to make Rhode Island the test site for the system and has been busy persuading competing hospitals, physicians and pharmacies to participate.
"Through Lifespan, George has direct contact with 25% of the physicians in the state," says Quality Institute President and CEO Laura Adams. "He's created a critical mass right there."
Another initiative, the electronic intensive-care unit, or e-ICU, would allow a group of intensivists to work for all participating hospitals simultaneously, with electronic monitoring of ICU patients at a remote site. Again, the project would require cooperation from hospitals that normally compete, but studies have shown the e-ICU can reduce mortality by 30%.
"He knows when something is the right thing to do," Adams says. "George could gain a competitive edge (with an e-ICU) by just having Lifespan do it and not involving other hospitals, but he's leading the charge to allow all the players to link in if they want to."
Vecchione says feedback from caregivers gives him his greatest sense of accomplishment. "It's quite startling to be stopped by doctors and nurses when they relate the impact of having the right information to make the call that saved someone's life," he says. "You get a great feeling."