By every measure—intensifying reimbursement changes, legislative and regulatory mandates, and media coverage—the demand on the part of purchasers and payers for a fundamental transformation in healthcare quality and patient safety will be agenda item number one for hospital organizations in the years to come. And, increasingly, C-suite executives and boards are realizing that clinical transformation is not truly possible without IT.
That puts CIOs in a position which is both enviable and daunting. More and more, they are becoming vital strategists in their organizations' clinical transformations. Put simply, those paying the bills for healthcare are putting a collective foot down and demanding that patient care be of far more consistent clinical quality going forward, while at the same time less expensive. CIOs not up to the task might as well go elsewhere, because experts say this trend is only going to accelerate.
What's at stake? Survival. The Baltimore-based Centers for Medicare and Medicaid Services (CMS), through the Medicare program and a host of private insurers, is already pushing more aggressively on pay-for-performance programs, and demanding documentation of quality-of-care outcomes. And, looked at from an industrial-model perspective, many agree it will be impossible for hospitals to become more cost-effective without tackling care delivery issues. And once again, IT, strategically deployed, will be a key facilitator.At the 20-hospital, 4,200-bed UPMC Health System in Pittsburgh, Senior Vice President and CIO Dan Drawbaugh and Chief Medical Information Officer Dan Martich, M.D. agree that clinical transformation is among the top goals of their organization.
What's more, in the current economic climate, Drawbaugh says, “It's become extremely important to ensure in any clinical transformation initiative that we can track the return on investment and can validate the return on investment. From an operational and clinical perspective, the physician leadership and operational leadership take complete ownership for the investment and the return that we're seeking on that initiative.”
Adds Martich, “Clinical transformation is, in large, predicated on bringing to the doctor or nurse the technologies that will enable transformation. Those technologies include wireless capabilities, access from home, complete access to the electronic record, and complete redundancy and backup. And all those things are predicated on being able to finance them.”
So, like senior executives at hospital organizations across the United States, Drawbaugh, Martich, and their colleagues are pursuing care quality, safety, and workflow transformation in the context of an increasingly economically challenging environment.
The solutionFor organizations leading the charge towards clinical transformation, there are numerous paths forward. At UPMC, Drawbaugh and Martich are emphasizing their push towards CPOE as an effort that encapsulates all the clinical IT changes. At UPMC, among the hospitals that have implemented CPOE so far, 85 to 90 percent of physician orders are now created electronically. As a result, those hospitals have seen a 20 percent increase in the prescribing of generic drugs, while the implementation of clinical decision support rules has increased blood pressure control among patients treated in the ambulatory setting by 32 percent.
Naturally, CIOs in such innovative organizations are assuming ever-higher profiles as they become change agents as well as technology experts. “It's important that the CIO feel ownership and true partnership with the operating organization in terms of transforming quality and safety,” Zoph says.
At Geisinger Health—the Danville, Pa.-based integrated health system that serves 2.5 million people in 40 counties across central Pennsylvania—Ronald Paulus, M.D., the organization's chief technology and innovation officer, cites the concept of “paired responsibility” as a critical success factor in his organization's clinical transformation efforts. The pairing of IT and clinical and executive leaders has helped make Geisinger's groundbreaking ProvenCare program effective, he says. The program has established innovative clinical pathways and guaranteed prices for a range of procedures, beginning with coronary artery bypass graft surgery.
In the program, each service line is led by a pair of clinical and executive leaders, each mutually accountable for the budget, clinical outcomes, and patient and employee satisfaction in their area. And, Paulus adds, in addition to the implementation of the paired-responsibility concept, the creation of a culture of innovation, which is making intensive use of IT analytical tools, has been the other most important success factor in Geisinger's clinical transformation breakthroughs.
The ROI factorWith regard to return on investment, those in the trenches of clinical transformation say the question really should be turned on its head: What happens to those organizations that choose not to work to transform themselves? The end result could be extinction, many say. More immediately, one big ROI element is differential pay under the pay-for-performance programs mushrooming across healthcare.
“The increase in pay-for-performance is a key driver out there. It's something we're seeing a lot of,” says Sue Schade, vice president and CIO at Brigham and Women's Hospital in Boston. Schade emphasizes that, for Brigham and Women's, a core piece of mission and vision is the reworking of patient care for optimized quality and outcomes, regardless of external influences.
As a result, the hospital moved to the tip of the spear nine years ago when it created its Center for Clinical Excellence to drive clinical quality change. Schade says IT has a symbiotic relationship to process change. In fact, says Eric Poon, M.D., M.P.H., IS director of clinical informatics at the hospital, clinicians there have come to expect, and even demand, the best clinical IT tools in order to optimize care delivery.
Schade says one lesson learned at organizations like Brigham and Women's is that it's critical for CIOs to be grounded in the clinical operations of their organizations. “They're not a doctor or nurse or other clinician,” she says, “but they really need to understand what the day-to-day lives of caregivers are like, and how information systems need to support them.”
As a result, Schade participates at least once a month in the weekly multidisciplinary ground rounds that clinician leaders and senior executives conduct, interacting freely with clinicians on the floors about their day-to-day challenges.
Richard Bankowitz, M.D., vice president and medical director at the Charlotte, N.C.-based Premier Inc., cites executive leadership, the development of a culture of quality, systemic thinking, and the agreement to be data-driven and to focus on measurement, as key success factors. Those are the common elements shared by hospitals that have significantly improved their clinical outcomes as part of their participation in the CMS/Premier Hospital Quality Incentive Demonstration (HQID) project, which CMS and Premier have been jointly sponsoring.
Naturally, says Bankowitz, “IT is a very, very important facilitator” in such work. One key sub-element with regard to IT, he adds, is that a system must be put in place at successful organizations “to obtain data, analyze it, and feed it back to people.”
Importantly, says Erica Drazen, Sc.D., a partner in the Lexington, Mass.-based Emerging Practices division at the Falls Church, Va.-based CSC Corporation, “You really have to figure out what to do first” around clinical transformation. “Then,” she says, “Select a system that will take you there, and then implement them at the same time. But if you put in the IT and then try to change things, people get stuck in the system-use process.”
Policy moves will push everything along, says David Nash, M.D., dean of the Jefferson School of population Health at Thomas Jefferson University in Philadelphia. “CMS is going to be a principal driver for change.” He attributes this to the agency's unfolding ‘never events’ policy. “You can have never ‘never events,’ because they're direct, immediate economic consequences,” Nash says.
Still, Nash, who has been in the industry for decades, says the horizon looks bright, “I'm very optimistic because of the spectrum of people who are now much more engaged in the quality and safety conversation; so I'm very optimistic that we really will make some progress here,” he says. “And I'm even more optimistic that the Obama administration will strengthen the incentives” for performance improvement in healthcare.
Payer and purchaser pressure, in the form of P4P initiatives and public outcomes reporting, is pushing clinical transformation from the outside, while internal efforts to make care more efficient and cost-effective are also having an effect.
Strategically implemented IT is emerging as a critical facilitator of clinical transformation. Those organizations making the most dramatic progress in clinical transformation are also leaders in strategic IT implementation in clinical care.
Strategizing on clinical care improvement goals, selecting the right information systems, then implementing both process and IT changes at the same time, will be important to success.
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Healthcare Informatics 2009 February;25(14):24-26