The Landscape: CIOs are realizing that everything they and their fellow executive and clinician leaders want to accomplish in hospital-based organizations - improving patient safety and care quality; enhancing efficiency and clinician workflow; delivering evidence-based patient care; creating outcomes transparency for purchasers, payers, and consumers; and participating in value-based purchasing initiatives, not to mention snagging federal funding under the ARRA-HITECH legislation passed last year - will require robust data infrastructures. And as pioneers are learning, creating those infrastructures is challenging and complex, but immensely critical.
The Future: Experts say the need for robust data infrastructures to support performance improvement and transparency will only intensify. The time is now to put the needed technologies into place.
No one needs to explain to Marianne James, senior vice president and CIO at Cincinnati Children's Hospital Medical Center, or Uma Kotagal, M.D., senior vice president for quality and transformation, the importance of a robust data infrastructure to the pursuit of performance improvement. Cincinnati Children's, a leader in the development of evidence-based guidelines for inpatient pediatric care, has been zooming ahead with patient safety and quality improvement progress for the past few years.
Some of the many positives, says Kotagal, have included increased compliance with guidelines for the administration of antibiotics to avert surgical-site infection, from 56 percent a few years ago to 98 percent; and a greater than 70 percent reduction in opiate over-sedation of patients. “We've been using a rapid-cycle process involving daily and weekly failure reports to clinicians to examine care delivery practices and improve them,” she reports. “Physicians very much respond to data, but the data has to be timely, actionable, and reliable.”
The secret to such rapid advances? A robust, enterprise-wide data infrastructure that can produce such reports day in and day out. And that has been job number one for James and her colleagues in IT. “In the past,” she says, “the success we had had with evidence-based care and quality improvement had required us to go through some heroic efforts in IT to make sure things have happened, as we've had to pull together all the disparate data. Now that the data sits together in one place, with common data definitions, it should further empower our clinical informaticists to work even more fully with our clinicians.”
Like their colleagues nationwide, James and Kotagal recognize that the ability to pursue the new, evidence-driven healthcare depends strongly on the strength of the organization's core data backbone. And that means having EMR, CPOE, eMAR, and advanced pharmacy applications implemented, along with an advanced data warehouse, and sophisticated reporting capabilities. Chief Technology Officer Tony Johnston and the rest of the Cincinnati Children's team are working to upgrade and implement the systems needed to support such clinical transformation.
A confluence of factors
What the IT team at Cincinnati Children's is doing mirrors efforts nationwide to upgrade the core computing infrastructures as organizations push ahead into the emerging operating environment. Industry experts see tremendous challenges and opportunities alike in the current landscape.
“For years, we've been talking about the need for robust data warehouses as a fundamental element in hospital IT plans, but there always seemed to have been more urgent things to take care of,” says Jane Metzger, principal researcher in the Waltham, Mass.-based Emerging Practices group at CSC (Falls Church, Va.). “But several things have happened,” she says, “and the performance management challenges for hospitals and their business and operating environment have radically changed.” In addition to the push from organizations like the Joint Commission that have been demanding documentation of quality improvement, Metzger says pay-for-performance programs, the potential for broader value-based purchasing, and the push for greater safety have all awakened CIOs to the need for stronger data structures. On top of all that, the drive to fulfill the meaningful-use requirements under ARRA-HITECH in order to obtain federal stimulus funds has really jump-started the discussion around data infrastructure.
Indeed, a strong awareness of the need for robust infrastructure has been top of mind among the CIOs of those hospital organizations that are pioneering the most dramatic innovations in patient safety, care quality, evidence-based care, and clinical transformation. At 20-hospital University of Pittsburgh Medical Center, Senior Vice President and CIO Daniel Drawbaugh says, “As you move in the direction of an integrated electronic health record, what occurs on the reporting side is that the requirement and demand for reporting for clinical analytics and financial analytics just skyrocket.” As a result, he notes that 91 data marts - subcomponents of the health system's broader data warehouse - have burst forth, up from 55 just a few years ago. And, as UPMC's clinicians pursue more and more patient safety and care quality improvements, the demand for data and reports will only continue to intensify, he says. Presently, there are already 25,000 clinical reports of all types available for the appropriate clinicians and managers to use.
Similarly, at the 44-hospital Trinity Health system in Novi, Mich., Vice President and CMIO J. Michael Kramer, M.D., says, “By having a unified data warehouse, we can put critical data into the hands of our executives, our financial leaders, our clinician leaders, and our doctors. And we couldn't do that if we didn't have a single standardized architecture.” Kramer and his team have created more than 300 evidence-based clinical order sets, which are used across the majority of its facilities as part of its core EMR/CPOE system. Kramer says he believes Trinity Health has moved further than any community hospital-based, multi-hospital system in the country in such work. And without the core foundation of EMR, CPOE, eMAR, advanced pharmacy, and a robust data warehouse, such advances would not be possible, he emphasizes.
For Aurelia Boyer, R.N., senior vice president and CIO at the five-site New York-Presbyterian Hospital in Manhattan, moving forward to unify and integrate her organization's data infrastructure is a constantly moving target, particularly given its ongoing acquisitions of facilities in the New York City area. She and her colleagues are all live on EMR, CPOE, eMAR, and nursing documentation, and will soon be live with physician documentation. Still, a diversity of products and technologies remains a challenge. As a result, her organization is using the Amalga product from the Redmond, Wash.-based Microsoft to perform data analysis enterprise-wide. The use of such tools, she notes, is propelling organizations like hers forward, even as they continue to work toward more unified data platforms.
Other CIOs are following similar paths. Catherine Szenczy, senior vice president and CIO at the nine-hospital MedStar Health system in Columbia, Md., has also turned to the Amalga product, even as it is a commercialized version of a program first developed in-house (and then called Azyxxi) at MedStar. “We are moving towards greater consolidation, but that is obviously a long-term project,” Szenczy says, adding that Amalga will continue to help her and her colleagues improve clinical performance as they build a stronger core data infrastructure. “It's becoming more and more critical for hospitals to move toward robust infrastructures, especially as we aim toward meaningful use,” she reflects. “It's not enough just to use systems, it's necessary to demonstrate that you've improved the quality and safety of care. And without data, how do you accomplish that?”
Accelerating the future
Deborah Gash, vice president and CIO of Saint Luke's Health System in Kansas City, Mo., says, “There is a lot of work industry-wide that still has to be done to get the needed data into electronic form in a discrete way, in order to perform effective analytics. So in the next one to two years, there will be a lot of focus on putting that infrastructure in place. And after that happens, things will move forward very quickly.”
Adds Keith Figlioli, senior vice president of health care informatics at the Charlotte-based Premier Inc. alliance, “We're still very early in terms of robust data infrastructures in individual provider organizations, let alone across communities. In fact, we're still basically putting in a lot of what I would call proprietary, transactional warehouses right now. But vendors will inevitably have to move towards more open data platforms, as hospital organizations go through mergers, connect disparate systems, and become involved in HIE initiatives,” he says.
Greg Walton, CIO at the 542-bed El Camino (Calif.) Hospital, says that infrastructure challenges will inevitably persist as hospital organizations evolve toward clinical IS tools, and their performance improvement initiatives. “Some vendors and some CIOs believe that you can design a data model that's complete or almost complete. I don't believe that's possible,” says Walton. “My entire career, the data model has continued to grow broader, because the technology has continuously expanded what is possible, and medicine has moved forward.”
The bottom line is simple: the future is already here. And as healthcare accelerates toward a new environment of continuous quality improvement, value-based purchasing, and demands for patient safety and quality documentation, the pressure to implement the most robust possible data infrastructures will only intensify. Those CIOs and their colleagues who heed the call will find themselves on the right side of history - not to mention reimbursement. And those who don't, need to rethink their concept of ‘future.’
Healthcare Informatics 2010 February;27(2):12-14