It's the beginning of a new era for clinical care at Bronson Methodist Hospital. During the next few months, the 343-bed facility in downtown Kalamazoo, Mich., will contract for a system that lets physicians, nurses and other professionals interact with a smart computer system that can advise them on the best way to practice medicine according to well-established medical evidence and offers deep detail on individual patients.
But it's anything but the beginning for Bronson's foray into clinical information technology. The sophistication of the feedback soon to be presented to doctors when they enter orders and treatment information would not be possible without years of IT groundwork, patiently phased in and gradually built up according to a plan that yielded benefits along the way while always looking ahead to the endgame that's about to get started, says Mac McClurkan, vice president and chief information officer of Bronson Healthcare Group.
Nearly five years after the Institute of Medicine hurled the healthcare industry's record on medical errors into the public eye, leaders of the industry and the federal government are coming to appreciate clinical IT as an essential factor in improving patient safety and defusing the error issue. The growing public and press preoccupation with electronic health records, computerized alerts about medical dangers and evidence-based support for treatment decisions has providers scrambling for an understanding of what's involved in bringing facilities into the computer era.
But hospitals and physician groups new to the notion of clinical computing may have dozens of IT projects to plan for and implement before they can achieve the level of medical and financial benefits that advocates of computerized care are fond of reciting, experts say.
Before taking on those initiatives and their multimillion-dollar price tags, healthcare organizations also would do well to decide what they're trying to change, be able to explain why and then prepare their workforces, says Karen Knecht, vice president of advisory services with Healthlink, a healthcare information consulting firm.
"You're imposing on how people are going to do work," Knecht says. "They're used to a very certain way of doing that work, and you're going to begin to wobble their world around a whole lot. So you need a very deliberate, a very focused approach around process."
Bronson's own three-step work plan began before the millennium when decisions were made to progressively capture all pertinent test and treatment data in digital form. Once all the laboratory tests, medications, X-rays and medical reports were computerized, IT pros and managers worked to aggregate the data for presentation in productive ways to clinicians, without making them wait or sending them on searches for accessible computers.
Executives at Bronson had to make hundreds of decisions during that time, and some lessons were learned the hard way--for example, that a million dollars or more for elaborate backup and recovery of clinical data was money well spent. But at least that ground has been covered, McClurkan says. "What concerns me is that a lot of hospitals have yet to even tackle the first step," he says.
Through the deployment of a cutting-edge analytical system for use by physicians, projected to be rolled out in early 2006, the third step in the Bronson plan will enable it to harvest all the data already captured as well as information continually coming in on hospitalized patients. A computer program then will merge the information with evidenced-based standards of care, help doctors size up the patient's situation and suggest options for what to do next in arriving at a diagnosis or deciding on treatment.
That includes creating electronic orders automatically at the conclusion of the evaluation process that resulted from a physician's interaction with the computer. Instead of telling the computer what he wants to order, the doctor tells it what the problem is and what he plans to do about it. The decision-support system weighs the facts, fills the doctor in on things he might not have considered, hashes out a safe and sound course of action and finally presents a set of ordering options to confirm or de-select.
Pulling it all together
That level of sophisticated interaction is the goal of today's clinical IT journey, McClurkan says. More than just presenting data to doctors and other clinicians, the clinical system draws inferences from the results of tests based on the results of other tests as well as treatment histories--and on what the smartest people in a particular discipline of care say should be done if patient data line up a certain way.
Valuable information such as lab tests, medications, X-ray interpretations and vital signs come together in a "logical coherence" rather than merely showing up side by side on the same computer screen with no clue as to how they affect each other, McClurkan says.
The decision-support potential of such computer applications hinges on the electronic availability of all the medical details necessary to evaluate a patient condition thoroughly and accurately, Knecht says.
"Clinical computing is only as good as the content that's in there," she says. Managing that clinical content is a challenge unto itself, calling for a carefully established process within a provider organization to refresh and update both the patient detail and the industry knowledge that underpins evidence-based decisions.
But that's a problem only for providers enjoying the luxury of already having built the array of feeder systems that fuel the decision-support engine. Most organizations have gaps if not yawning chasms in their lineup of prerequisite computer applications necessary to capture clinical details for making decisions and to compile a comprehensive electronic health record, says Frank Cavanaugh, a principal with Cardinal Consulting.
For example, physicians relying on a computer-based record will have to see radiology images and electrocardiograms. But a lot of radiology is neither in digital form nor easily accessed, and EKG results often can't be sent to doctors except in paper strips, Cavanaugh says.
Take an inventory
A first step for providers brain-storming a plan for clinical IT is to inventory what feeder systems they have and don't have, says Randy Thomas, vice president of advisory services with Healthlink. That includes such mainstays as systems to report lab data, medication lists, allergy information and alerts about chronic conditions, she says.
To make clinical IT a force for efficiency and cost-savings as well as care improvement, computer systems for billing, collections and registration and discharge processes also need to be scrutinized for their ability to be integrated into the network for medical care, says Skip Lemon, vice president of implementation services with First Consulting Group. Those systems inject essential financial oversight and keep track of patients in the hospital, he says.
The registration system is the hub for a range of activities, from managing the revenue cycle to providing the digital intake point for hospitalized patients, Lemon says. It's the vehicle for scheduling treatments, ordering tests, transferring patients from one department to another and gathering data at discharge.
Bronson officials decided in the mid-1990s to build a new facility to replace six aging buildings, a $181 million project that culminated in the opening of Bronson Methodist in late 2000. The push to digitize all feeder systems was built into the planning for the replacement hospital, but it started in the early 1990s when nurse charting and documentation were computerized, McClurkan says.
The healthcare system introduced basic computerized order entry, with clerks keying in the data instead of clinicians. Requisitions for supplies also were made electronically.
In 2000, the hospital installed a digital radiology-image storage and transfer capability, added an automated drug-dispensing system and installed a new pharmacy information system. It's currently implementing a bedside bar-code scanning system to manage medication administration. Other paper-based information not captured by the lineup of feeder systems was scanned into a document-imaging system so clinicians and workers could at least call it up on a computer instead of searching for a paper copy.
"By 2000 we were all done with major portions of the first phase," McClurkan says.
Making it accessible
The next phase--and the precursor to pushing decision-support data to doctors in a system for computerized physician order entry, or CPOE--is a plan to aggregate the data captured in digital form and make it accessible to doctors and other clinicians, he says.
Once captured, the clinical details still tend to be fragmented just as they were in a paper chart. Using Web technology and the Internet, Bronson was able to bring it all together securely and conveniently for clinicians according to their specialty needs and their rights to gain access to certain data.
The hospital's 450 physicians were accessing parts of the electronic medical record, mainly by signing in and out of separate systems housing different data. A Web-based physician portal, acquired from McKesson Corp., enabled data from several sources to be viewed on the same screen, allowing doctors to sign in just once and get the range of detail they sought in a single computer session.
"Web-enablement is probably the most critical factor in that second phase of access," McClurkan says.
The sequence in which different types of data are introduced to doctors can help justify the cost of IT and provide clinical benefits that will make physicians ready for more, says William Stead, director of the informatics center at Vanderbilt University Medical Center and principal architect of the Nashville-based teaching hospital's clinical information network.
"The basic idea is to do as many things as you can to increase information to the physicians," he says.
The initial step of feeding good data to physicians without asking for much in return also can be a good tactic for getting them to feel comfortable with computers instead of threatened by them, Cavanaugh says. "Giving physicians access to information more easily than they had is better than having them change their techniques for ordering," he says.
Vanderbilt has one of the leading physician order-entry and decision-support information systems among academic medical centers, presenting a mix of patient data, medication facts, best-practice discoveries and hospital rules to doctors when they order tests and treatments (April 22, 2002, p. 32). McKesson liked it enough to purchase the design and functions of the orders application and commercialize it--the incoming Bronson decision-support and order-entry effort is based on the Vanderbilt-McKesson product.
But the Vanderbilt effort to put electronic data in front of the physician staff started small and very basic in late 1995 with an electronic chart of information gathered through a Web browser--only a year after the technology became available. "It's very inexpensive to do that, and it has a high payback," Stead says. The implementation took less than six months and cost less than $500,000.
After several years of developing the CPOE-driven system for the inpatient setting, work turned to computerizing the outpatient side but again the development emphasized the simple changes that made a difference. Instead of plunging into physician-office order-writing and electronic prescription-writing, the rollout focused totally on the communication handoffs and inter-staff interaction that drive the routine of medical practice, Stead says.
Elements of that first round included:
* Notification of new test results or other documentation involving only a physician's panel of patients, whether the doctor ordered it or someone else did. Also included were phone messages and notices of prescriptions to renew.
* Message handling--taking a note from someone and putting it in someone else's electronic inbox.
* Simple note-taking tools using templates of often-expressed phrases strung together, allowing computerized recording of physician observations and patient reports while reducing dictation and transcribing.
* Scanning paper documents to pick up any important medical data not in database form.
"We saved 50% more than it cost us for that set of things alone," he says. For example, transcription costs in physician practices were reduced by 20% in the first year. The medical center had saved one full-time-equivalent clerical employee for every 10,000 patients seen, or about 80 FTEs for the 800,000 patient visits typically logged annually, he says.
In all, the first phase of the outpatient project cost $3.3 million and saved $5 million during the 18-month rollout. Of that savings, $2.9 million came in reduction of transcription costs, Stead says.
In succeeding years, Vanderbilt has introduced physician order entry in the outpatient setting, a separate project because the order workflow in physician offices was so different; added automatic capturing of charges associated with medical services; and launched electronic prescription-writing. The phased approach made it more palatable to doctors and easier to implement, Stead says. "Most people try to lump all that together" in the same IT initiative, he says.
It's nothing without accessibility
Success in getting clinicians to use computers is the seed of a new problem. Hospital leaders at Bronson soon were getting complaints that there were not enough PCs at nursing stations during physician rounds and other peak periods.
"You create a huge dependency and that's why in phase two, access is so important," McClurkan says. "It's something organizations learn the hard way. They create the demand and there's not enough computers to go around."
"To use today's modern technology you need a good network," Stead says. "It needs both tethered and wireless capability."
Bronson spent $1 million to increase the number of PCs in clinical areas as well as add portable devices such as personal digital assistants and laptop computers.
It also installed a wireless computer network to send and receive data from the portable devices, running up an additional expense of nearly $1 million so far, McClurkan says.
The wireless network will create increasing benefits as new technologies are added. For one thing, it will allow the incoming bedside bar-coding system to electronically update the computerized medication administration record as nurses do their work.
Looking ahead, "That's a key input for CPOE," he says. Besides the benefits of preventing medication errors, it's "one more thing we're making accessible" for diagnosis and treatment decisions later on.
The need for a good backup
Unless, of course, the computer system goes dark. Looming over the conversion to electronic records is the threat of total inaccessibility, says Lemon of First Consulting. "When you're rolling out clinical systems, these can't go down," he says. "You need a way to immediately switch to a backup system" because patients' lives depend on it.
Clinicians at Bronson suffered through a series of serious computer-system outages during the introduction of computer systems in 2000 and 2001, which required lengthy crisis measures to recover data and made the physicians and other clinicians on staff dissatisfied with the way things were going, McClurkan says.
The problem helped focus the attention of the board on the need for a good backup and recovery option, he says, and a disaster-recovery data center was installed with two duplicate and geographically separated storage databases at a cost of $1.5 million. The experience also identified the need for a CIO, an executive position the healthcare system hadn't considered until then. That's how McClurkan came to his current position.
The CPOE and decision-support system made possible by the prerequisites of digital data and easy, reliable access will save the healthcare system $6 million to $8 million annually once it's rolled out, according to a study by First Consulting on the costs and benefits. The implementation is scheduled to begin in January, and a fully built but offline system will be available for doctors and other clinicians to get to know and experiment with by the fall of 2005, prior to the rollout in early 2006.
The study is projecting a five-year payback on the investment, with a net gain in benefits over costs of 32% during a 10-year period. About 90% of the savings will derive from better clinical care--reducing adverse drug events and reducing medical practice variation by getting physicians to follow recommended practice protocols. Reducing variation not only increases adherence to the latest medical evidence of what works and what doesn't but also cuts down on utilization of drugs and other resources that don't add medical value, McClurkan says.
Two other measured areas of impact showed only minor benefit from CPOE. Labor reductions would save only a few hundred thousand dollars a year, and reductions in claims denials from payers--normally a fruitful area for benefits--would only represent nominal savings.
With 100% of physicians signing in to the electronic medical record through the physician portal, the CPOE pinnacle is an add-on rather than a stark new change for doctors to assimilate, McClurkan says. Along with the hospital IT project, the first pilot for a wireless medical-record system in physician offices began May 5. The system eventually will be expanded to all 80 physicians employed by Bronson.
The payback projected for the next decade is a welcome culmination of all the IT development up to this point, but Bronson did not have to wait until now to see benefits. "Each piece of the process has a benefit associated with it," McClurkan says. "With a stepped approach you're getting benefits and you're also reducing risks."
Billing gets faster
For instance, the process of converting documents into computer images helped re-engineer the whole information management routine around revenue collection. The access to billing and medical-care documentation made it easier to handle questions from payers, enabling bills to go out faster and much cleaner. The system also gave physicians a way to accelerate claims submission by signing their charts electronically from home.
The hospital's average number of days in accounts receivable had been right at 100 days, but the computer-assisted business changes lowered that to 45 days while cutting claims denials in half.
That could explain the minor impact of CPOE on the claims process--a simpler IT system earlier in the phased timeline already had taken care of that problem.
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