Where IT really matters

Nearly three years into a federal incentive program to get providers to adopt electronic health records, hospital executives on the leading edge of that push see it turning a corner.

Some of the leading clinical informaticists, who combine patient-care knowledge, technical expertise and change-management skills, say their facilities have moved from struggling to adopt digital record-keeping systems to modifying them for greater effectiveness.

It's a basic but crucial step, they say, to keep moving a lagging healthcare industry into the information age.

“The idea of really starting to engage with it is still ahead of us and to the degree that there are exemplars now of people who have gone well beyond the requirements, that is a good thing,” says Dr. William Bria, president of the Association of Medical Directors of Information Systems and formerly chief medical information officer for the Shriners Hospitals for Children system, Tampa, Fla. Modern Healthcare is recognizing such exemplary professionals through its third annual list of Top 25 Clinical Informaticists, a distinction that honors leaders for both using data-driven improvement strategies and helping newer members of the profession.

The federal government's electronic health-record incentive program has already doled out $7.1 billion of the $27 billion it is expected to provide as payments to providers who meet its adoption and “meaningful use” compliance requirements. More than 3,700 hospitals have received such payments and many more are installing the systems required to eventually qualify for those federal funds.

Such progress comes amid increasing federal scrutiny of whether providers are using EHR systems to artificially boost their reimbursements from public and private payers, as well as Republicans in Congress calling the program a waste of taxpayer dollars.

Against the contentious financial and political backdrop, clinical informaticists are keeping their heads down and continuing to wrestle with the practical problems and opportunities presented as such systems move past the threshold of basic use at their facilities.

“Now it is time for us to get to the next level, not just to say these tools can help us get better at doing what we've always done but how do these new information tools help us to do things we've never been able to do before,” Bria says.

Many providers have gotten to the point where they have many examples of how their systems have moved beyond the original basic design.

For instance, Dr. Colin Banas, chief medical information officer at 744-bed Virginia Commonwealth University Health System, Richmond, helped create a dashboard to embed in its commercial EHR system that monitors the status of vulnerable patients and gives clinicians an early warning of major problems.

“We see the rapid response team walking around with iPads looking at this dashboard we made, hitting refresh and figuring out who to see next rather than waiting for the call,” Banas says.

The health system recently finished the program's pilot phase and concluded that it reduced code blues in the intensive-care unit.

Another tweak to an existing commercial EHR was the addition of care templates for certain conditions to the standard messaging function of the electronic record system used by 854-bed Northwestern Memorial Hospital, Chicago, says Dr. Lyle Berkowitz, the hospital's associate chief medical officer for innovation.

The templates provide several standardized checklists of actions that are needed whenever a specific condition is identified. For example, when hematuria (the presence of red blood cells in the urine) is found, the template will call for actions including a CAT scan and urology visit and specify the order and time frames in which they should occur. The required care is coordinated by a dedicated clerical support team, which makes the necessary appointments for patients and follows up within a month to check if they occurred.

“The innovation here is not some special technology, it's just a concept of using the messaging functionality in a certain way, in a certain time that you can send the message to our team and we take care of that for you,” Berkowitz says.

He says the template can be used with any EHR system's standard messaging functions, and the hospital is working to spread it among the various physician groups on its campus, some of whom use different health IT systems.

Other informaticists highlight ways they have found to use their EHR systems to realize their promise of both improving patient care and boosting provider revenue. Dr. David Kaelber, chief medical informatics officer for 559-bed MetroHealth System, Cleveland, used the organization's EHR system to boost clinically necessary referral appointments that its patients were not otherwise keeping.

Kaelber first identified the problem of patients not getting necessary follow-up when he was director of MetroHealth's pediatric weight-management program. He noticed that few overweight children receiving care elsewhere on the hospital campus ever made it to the weight-management clinic.

An analysis using MetroHealth's EHR showed that fewer than 50% of patients there either scheduled an appointment or kept it within one month of receiving a written referral.

“That was upsetting as a physician,” Kaelber says.

A daily tracking and outreach program launched in February has since been credited with 30,000 new appointments over the past six months and an estimated $1 million per month in new net revenue.

Moving beyond the initial stages of EHR selection and installation also has given informaticists insight into how facilities can gird for the steepest challenges in adoption.

Liz Johnson, vice president of applied clinical informatics at Tenet Healthcare Corp., Dallas, says rural hospitals can face challenges over access to professionals and technology.

Johnson credits the ability of her 51-hospital system to fully install EHR systems in 26 of those facilities in 22 months to having a clinical informaticist and a “physician champion” in every hospital and the creation of standardized learning and ongoing training tools.

“Putting the system in place is only the first step; now is our opportunity to be inventive and innovative and take the power of that implementation and improve patient care,” she says.

Johnson says that when smaller and more rural hospitals lack such assistance as part of a larger system, they should seek EHR implementation models that have worked at other similarly sized facilities and use the expertise of their vendors to ensure the system and training are right.

Other challenges clinical informaticists are grappling with as EHR adoption progresses beyond the initial stages include problems with health information exchanges. The clinical data-sharing hubs have progressed to different degrees in different states.

For example, after having trouble integrating with a Virginia health information exchange, VCU Health System “repurposed” its EHR system's Web tool to create a referring provider portal that allows physicians outside that health system to access their patients' clinical data. More than 600 such physicians have created accounts to log in to its system, so far, Banas says.

“So it's a nice intermediate step before we get perfectly integrated with a health information exchange,” he says.

Similarly, Dr. David Milov, chief of clinical informatics at Nemours health system, which has children's hospitals in Delaware and Florida, says a “fragmented” health information exchange approach has left its facilities in Florida uncertain about how to proceed. That led Nemours to begin trading information directly with other health systems using a tool within its EHR systems.

The health system has had more success with health information exchanges in other states where they are well-established, such as Delaware, he says. However, participating in those exchanges can carry costs of $1 million-plus for hospitals and result in hospitals sending out nine times as much patient data as they receive from other providers.

“It's hard to rationalize a six- or seven-figure commitment to a state information network, but we've bitten the bullet and done that to be good citizens, and things are working well,” he says.

Dr. Gregory Ator, chief medical informatics officer at the 606-bed University of Kansas Hospital, Kansas City, says his facility is moving from the installation to the problem-solving phase of EHR adoption. Specific challenges include the need to reduce hospital-acquired conditions and better describe patients upon admission.

Ator says his facility had the benefit of having only staff physicians onboard during the installation and training phase of EHR adoption.

“Right now we have the good fortune to have a closed medical staff and the ability to pass a policy that says, 'You have to use electronic records to document patient care, and you have to place your orders using that system,' ” he says. “So we have several hooks that are not available to the community hospital.”

Broadening adoption of EHR systems has increased the likelihood of hospitals participating in other “second wave” digital health data initiatives, such as a blood donor clinical data-sharing system, says Dr. Kevin Land, senior medical director of field operations at Blood Systems, Scottsdale, Ariz.

More than 100 hospitals have added Knowledge Based Systems software, which Land helped to develop using HHS funding. The system provides a comprehensive approach to capturing and analyzing donor-related data.

“As a general rule, the hospitals that have more advanced implementation of this system also have the more advanced EHR systems or computerized physician order entry,” Land says.