CHRISTUS Health’s Electronic Health Record Performance Transformation

With 44 hospitals and hundreds of additional facilities and services located across the southern U.S. and Mexico, Irving, Texas-based CHRISTUS Health is committed to using IT innovations to support the quality of care of its patients. Its 7,000 physicians expect its electronic health record (EHR) system to be fast, reliable and easy to use. Yet with so many users spread across so many locations and a large base of applications, the task of ensuring a consistent and uniformly high level of application performance excellence is challenging. There's a tremendous amount of technology that sits between that end-user device and the data center to deliver applications services to the end user—everything from networks, infrastructure, the cloud, and the applications to the back-end databases.

Problems can and do arise anywhere in this complex application delivery chain, and they can be extremely hard to pinpoint. CHRISTUS Health has implemented application performance management (APM) to enable it to proactively in identify and fix performance problems.

The ‘Google Effect’ in Healthcare IT

Like most consumers of IT, the physicians have come to expect an extremely high level of application performance, also known as the “Google Effect.” That is, they expect all the applications and services they interact with to be as fast and reliable as Google.

For an organization like CHRISTUS Health, the ability to deliver Google-like application performance can have a direct impact on our physician recruitment and retention, but more importantly it can impact the care given to our patients. As a voluntary healthcare system, physicians with credentials to practice at CHRISTUS Health facilities can also practice in other hospitals. If our applications begin to slip, there’s the threat that physicians may move patients from one of our hospitals to another hospital. Things like an insufficient applications portfolio, slow log-ins, poor responsiveness, and waiting for transactions to process can have material impacts on both the care delivery process as well as our organization.

The Evolution from Paper-Based Records to EHRs

For hundreds of years, our health system has run on paper. Physicians were required to study on paper and manage patients on paper. In the last few years, the healthcare industry has undergone a staggering transformation to move to electronic health record technology with the goals of improving patient care and safety, while containing ballooning healthcare costs. Recently, the government provided billions of dollars in the effort to get healthcare systems to use EHRs as a component of the American Recovery and Reinvestment Act of 2009 (ARRA) that has been successful in helping to rejuvenate our still-ailing economy.

Yet as of 2011, only about 57 percent of office-based physicians used EHRs, according to the U.S. Department of Health and Human Services (HHS). Why the slow uptake? Could it be that doctors as a whole are simply technology-averse and resistant to change? A recent study from Manhattan Research suggests otherwise. Specifically, this study found that about 62 percent of physicians have adopted tablets—mostly iPad—for professional purposes, nearly doubling since last year. Nearly half of tablet-owning physicians have used their device when caring for patients.

So the blame doesn’t lie with physicians. The simple fact is that many EHRs were not designed with physician ease-of-use in mind. This is a by-product of their evolution from administrative and billing applications, to adding increasing automation for efficiency-purposes (e.g., in labs and radiology departments), and to now adding clinical care and documentation capabilities. They can, as a result, be slow, inefficient and cumbersome, and often appear to fail to make physicians more productive. However, if you look at productivity and quality of the entire healthcare system, studies have shown that more efficient and effective care is supported by these systems. To state the obvious: physicians are crucial to the healthcare system, so optimizing service to them will even further increase the benefits that EHRs have been shown to have.

Mobility Adds to the Complexity

At the same time that they demand higher levels of application performance, physicians are also growing increasingly mobile in their jobs. Healthcare is among the top three industries adopting iPad technology for business use, according to recent market data. This is indicative of the work, of course, that physicians do. They deliver care in multiple settings, have to deliver it wherever the patient is, and have to access information about the patient wherever they are. Add to that the importance of physicians being able to easily access the body of medical research, treatment and best practice information, as well as use the communications capabilities of these devices to “call a friend” (a consultant), the picture becomes very dense. The wide array of browsers and devices in use today only adds to the complexity of our picture; we need to deliver consistently high application performance across all of them.

APM: A Remedy for CHRISTUS Health

For CHRISTUS Health, operational strength, physician productivity—and most importantly, human lives—literally depend on strong application performance. Application performance management (supplied by Compuware Corp., Detroit) enables us to be proactive in identifying, isolating and fixing the widest possible range of performance problems, wherever they may lie in the application delivery chain.

A true understanding of the physician experience is at the heart of our APM strategy, which consists of five key steps:

We start by encouraging groups within CHRISTUS Health to work on defining acceptable performance. Physician expectations are high; therefore it helps to develop specific goals and objectives relative to what's acceptable for the physician community. At the same time, physicians are frugal; they understand the need to be as efficient as you can be, but to also control costs as well.
Second, we actually measure the end user experience across a wide range of browsers and devices. In the past, some healthcare organizations were forced to send IT personnel out to facilities with stopwatches to actually measure the performance of applications because they had received complaints from end users. In contrast, APM gives us a bird’s eye view into the physician experience in real-time, helping us understand how end users are really experiencing the technology and how systems are performing in production.
Third, we monitor the entire application delivery chain. Only by understanding the true physician experience at the end of the chain can we recognize, pinpoint and diagnose problems in applications as they extend from the data center, through the cloud and major Internet service providers, across a variety of third-party cloud services and local service providers, and ultimately to our facilities.
Fourth, we use all relevant data. We identify trends over time to understand where additional infrastructure or services may be warranted, all in the spirit of optimizing application performance over time.
Finally, and perhaps most importantly, we inform the physician community, proactively communicating how solutions are performing.

A Decision Tool for Physicians

At CHRISTUS Health, it’s not enough to just deploy applications. We must deploy them in a way that brings information together quickly to the point of service, so that physicians can make the best decisions possible. This means providing the right information at the right time to the point of service, with high speed and solid reliability.

Our APM approach enables us to meet this challenge across our enterprise. We gain additional benefits, including allowing physicians to use whatever device they prefer, versus dictating what kind of device they need to use. We plan to extend our APM capabilities to our ambulatory environments, so that we can manage all of the components of our growing, clinically integrated network. Finally, we are planning to extend these capabilities to our patient portal, empowering patients with the same level of application performance that physicians experience. This will allow patients to actively participate in their own care management in a fast, reliable and easy manner.

George Conklin is senior vice president and chief information officer at CHRISTUS Health.