The big electrical blackout of 2003 found Port Huron, Mich., in the dark -- except for the soft glow of hundreds of computer screens at Mercy Hospital, where a backup generator had kicked in to support the new clinical order-entry system. A photo of a nurse working by the light of the screen made the local front page and put the 119-bed hospital's cutting-edge information technology in the public spotlight for the first time -- quite a change for an institution that had no clinical automation of any sort just two years earlier.
A recent Mercy ad in Port Huron's Times-Herald focused on the new computer system, featuring a laudatory letter from the director of healthcare initiatives at General Motors Corp. He cited the hospital's compliance with the recommendations of the Leapfrog Group, a consortium of large employers (including GM) that backs greater use of IT in healthcare to reduce errors and cut costs. The ad's tagline: "Safer. Smarter. Digital."
The day the computer system made its debut in 2003, physicians entered 23% of their orders themselves. "The excitement was like Christmas Eve," recalls Cindy Nicholson, director of clinical integration. "They were fighting over who would enter the first order." A year later, almost half of physicians' inpatient orders are placed online -- excellent progress in the type of community hospital setting where most clinical order-entry systems average closer to 30%.
Urologist Thomas Coury, chief of the medical staff, says Mercy's doctors have a long way to go toward full acceptance of the system -- especially internists and family physicians, whose orders tend to be more intricate and varied than those of surgeons and specialists. "A lot of them are still unhappy with the change," he says. "But the hospital administration has been great -- absolute superstars. Their support, energy and effort have been outstanding, and they've done a great thing."
Mercy is the guinea pig (or as its administration likes to think of it, the pioneer) for a $200 million investment in computerized order entry and electronic health records that will see similar systems installed at 16 more member organizations of Trinity Health, Novi, Mich. Computer screens literally line Mercy's hallways -- one outside each patient room, (tucked into fold-out boxes that resemble those formerly used for paper charts) plus several at each nursing station. Each unit also has a few computers on rolling carts, and wireless laptops are available to be "checked out" by clinicians who prefer to carry their order-entry device with them. Hardware alone has cost the hospital $500,000, but Nicholson says it's worth every penny. "If you're going to go with it, go big," she advises. "You can't skimp on devices. I never want a physician to have to wait to enter an order. And I want them to do it the way they want to."
The colossal effort -- called Project Genesis -- will take until 2008 to complete and will alter the work habits of every physician and nurse in the Trinity system, not to mention those of most other employees, right down to the housekeeping staff. It will be a major legacy of Trinity Chief Executive Officer Judith Pelham, who has championed the initiative and several others, large and small, that leverage the information of each member organization for the benefit of all. For these innovations, she is a winner of the second annual Modern Healthcare/HIMSS CEO IT Achievement Award. (Pelham, 58, has announced that she will be stepping down as Trinity CEO sometime after June 30.)
Trinity has 24 hospital systems in seven states, with clusters in Iowa and Michigan and other facilities as far apart as Silver Spring, Md., and Fresno, Calif. Formed in 2000 from a merger of two Catholic systems, the organization faced the challenge of unifying a diverse and scattered collection of institutions.
Pelham, Trinity's first CEO, saw IT as key to that effort. One of her first actions was to convene the system's leadership -- board members, clinicians and executives -- to formulate a strategic plan with a major focus on creating common clinical, financial and enterprise information systems.
Striking a chord
"Judy and her colleagues got Project Genesis on the board's agenda about four years ago primarily as an opportunity to knit our far-flung holdings together," says Trinity board Vice Chairman Patrick Hays, a clinical professor at the University of Southern California's School of Policy, Planning and Development. "They quickly followed up by pointing out the issue of preventable medical errors, which struck a chord with us because of the (Institute of Medicine) report." A highly publicized 1999 report from the IOM estimated that tens of thousands of patient deaths resulted annually from easily prevented medical errors.
Award judge George Vecchione, CEO of Lifespan, Providence, R.I., and one of last year's award winners, says Pelham's persuasive powers with her board were a key factor in her receiving this year's honors. "The level of board support was just what we were looking for, and she demonstrated to me that she was doing a great job of educating them," he says. "She also paid attention to putting a structure in place among the executive team to guide IT development. The application depicted a solid strategy that was being executed flawlessly."
Pelham regards Project Genesis as Trinity's opportunity to help healthcare IT overall, as well as to transform her own organization. "There haven't been the tools until recently to do electronic medical records, and vendors need a critical mass to make it worthwhile to develop them," she says. "We are big enough to provide it, and we're a good lab because we have community hospitals, rather than university hospitals." She meets regularly with the top management of the primary clinical system vendor, Cerner Corp., and Trinity's experiences are helping to shape the commercial product.
For the order-entry system installation at Mercy, Pelham gave the staff freedom to do whatever it took to make the project a success with the clinicians who would be using it. All of the institution's 190 physicians were in private practice and under no obligation to use the new system, but without them it would quickly become a white elephant. Nicholson developed individual plans for as many of them as she could, concentrating on those whose participation was key.
"The busiest surgeon in Port Huron didn't want to do it, but we needed to have him on board," says Mary Trimmer, senior vice president of Project Genesis operations, who at the time was CEO of Mercy. "Cindy said, ?If we can get a minute of his time a day, we will train him a minute at a time.' The first day, she showed him how to sign on but wouldn't show him anything else even though he asked her to. He was immediately intrigued. Now he is one of the biggest users of our system." Trimmer left the CEO's job earlier this year to take the Project Genesis post.
Mercy's average length of stay is down 10% to 20%, a change that current CEO Peter Karadjoff attributes to the computerized order-entry system. "We don't have a study, but it's the only thing we've been doing differently," he says. "The speed with which things get ordered and executed has clearly increased."
For Pelham, a primary goal of good IT is to get good information -- and then share it among those who could benefit. Under her leadership, several initiatives have fundamentally and measurably changed the way Trinity's clinicians look at drug orders, clinical quality indicators and error reporting.
The adverse-drug-event alerting system was a relatively inexpensive way to start taking advantage of clinical systems integration, even before the physician order-entry system and electronic health record were deployed. A simple interface got Trinity's lab information system and its pharmacy system talking regularly, and in 16 of its member organizations, an alert will print out in the hospital pharmacy whenever a medication order clashes with a lab result. Systemwide, 15,000 alerts fire every month, and they lead to changes in care about 1,300 times per month -- changes that wouldn't have happened without the alerts. A study conducted at the pilot site, Mercy General Health Partners in Muskegon, Mich., estimated potential savings of $27,000 to $160,000 per month from the averted errors (Feb. 24, 2003, p. 32).
"After we got the initial results, it made me scared about what goes on in hospitals that don't have one of these systems," Hays says.
Through a systemwide intranet, Trinity's member organizations can access "integrated information shared services," called I2S2, which shows data regarding each member's performance on the clinical indicators tracked by the Joint Commission on Accreditation of Healthcare Organizations. "It came about under the radar because we were getting a lot of requests to share information," says Paul Conlon, Trinity's vice president of clinical quality. "We said, ?Why couldn't we create a little Web site?' Then it just blossomed." It's not fancy; off-the-shelf software lets people access a hodgepodge of spreadsheets, word-processing files and PDF documents. And they do, almost 2,000 times a month. The system helps each hospital borrow best practices from others that have figured out good solutions to given problems, and improve their performance on key clinical indicators.
Error reporting is a touchy subject everywhere, and nowhere more so than in a healthcare organization, where life-and-death decisions are made daily. Pelham instituted the Potential Event/Error Reporting System, or PEERS, modeled on systems used in the airline industry. It's anonymous, voluntary, nonpunitive, and available through a simple Web interface to any employee or physician who wants to alert management to a problem -- medication errors, patient falls, inappropriate behavior, or any procedures or problems that put patients at risk.
"Judy had to walk the talk on this one," Conlon says. If employees didn't have complete trust in their ability to report errors without negative repercussions, PEERS would have been a bust. But it worked.
"People were hungry to talk about things not going right," Pelham says. "Over half of them give their names, and often it's their error. They've responded very enthusiastically."
In 2003, PEERS reporting led to 72 facility improvements, 29 new policies or procedures, 36 revisions of existing procedures and 179 revisions of existing processes. For example, PEERS reporting flagged a cluster of complaints in one hospital that physicians weren't responding to their pages. Analysis showed that all the guilty physicians were in one area of the hospital that turned out to be a "dead zone" for their pagers. The installation of an extra antenna solved the problem immediately, Conlon says.
Outreach in the industry
Trinity and Mercy regularly host visits from other healthcare institutions wanting to get a good look at the kind of comprehensive clinical computing that's likely to become a new industry standard over the next several years. Pelham and her management team meet regularly with all of Trinity's major software vendors to influence product development.
Pelham also promotes information technology in a number of venues. She's an adviser to a Rand Health study examining the potential impact of IT on patient care and healthcare costs, and also works with the Healthcare Research and Development Institute. She addressed the HRDI's 2001 conference about computerized physician order entry and the PEERS system. She also has given a presentation to the Greater Detroit Area Health Council about Trinity's IT implementation plans, and she covers the topic frequently for Trinity's own clinical conferences. At one event, CIO Jim Elert recalls hearing her speak for almost an hour on Trinity's future -- and at least half of the speech concerned Project Genesis. "Afterwards, a bunch of other CIOs came up to me and said, ?Can we steal your CEO?' " Elert says. "It's really all about the leadership -- not the fancy tools but giving people what they want and need to do their job right."
Elizabeth Gardner is a freelance writer in Riverside, Ill. She can be reached at[email protected]
Trinity Health at a glance
Headquarters: Novi, Mich.
Data for fiscal 2003 ended June 30
Number of hospitals: 45 (29 owned and 16 managed)
Annual total revenue: $5 billion
Annual operating income: $116 million
Annual information technology operating budget: $186 million
Total employees in information technology department: 953
Annual discharges: 320,228
Staffed acute-care beds: 6,078