Two large end-user organizations deploy two robust clinical information systems and prove that great expectations, coupled with great preparations, can lead to exactly the desired results.
Hospital administrators who have abandoned the realm of paper for the digital world have given their clinicians greater access to information, improved diagnostics and safer procedures. But to maximize the benefits of any clinical information system, organizations must have a well-planned implementation strategy. This is especially true for hospitals that have taken a best-of-breed approach where interfaces with other hospital information systems are crucial.
Two large end-user organizations deploy two robust clinical information systems and prove that great expectations, coupled with great preparations, can lead to exactly the desired results.
The healthcare industry is awash with stories of physicians balking at the idea of giving up paper-based charts and orders. But once they realize the benefits they can gain–from more face-to-face time with patients to being able to remotely access patient data 24/7–they don’t want to return to a paper-based world, says Robert Dolan, chief executive officer of Saint Francis Heart Hospital in Tulsa, Okla. Yet Dolan warns, “Physicians cannot be dragged into IT kicking and screaming. They have to be stakeholders from the beginning.”
As acceptance among the staff grows to the point of dependency, the systems themselves must be dependable, points out Gary Davidson, vice president and chief information officer at the Hospital of Saint Raphael in New Haven, Conn. “Once you start using these systems, you need the redundancy so they stay up 99.99 percent of the time,” he says. “If your billing system goes down for a couple of hours, your organization can still function. But with clinical information systems, a physician needs clinical results immediately to treat a patient, so you need the system to be up continuously.”
Both Dolan and Davidson have had recent successes in rolling out completely different systems. Dolan’s brand new hospital did a complete install in 2004 of the Centricity Clinical Information System from GE Healthcare, a unit of General Electric Co. that is headquartered in the United Kingdom. Also installed was GE’s Cardiac Cath Lab suite. Davidson’s hospital continued to implement systems from Raleigh, N.C.-based Misys Healthcare Systems, rolling out the Misys CPOE (computerized physician order entry) in 2002.
The Heart of the Matter
Oklahoma has the distinction of having the second highest rate of heart disease in the nation, says Michael Spain, M.D., a cardiologist and board member of Saint Francis Heart Hospital.
Even though Saint Francis Hospital–a 900-bed, not-for-profit Catholic hospital in Tulsa–had its own cardiovascular department and transplant program, there was a growing need for a regional hospital that specialized only in problems of the heart. Rather than build a wing on an existing hospital, the decision was made to build a separate specialty hospital that could be “a hospital of the future,” Spain says. For legal reasons, a partnership was forged between Saint Francis Hospital and 34 area heart specialists, Spain adds, which allows physicians to practice in their own hospitals as well as in Saint Francis Heart Hospital.
Partnering with physicians early on proved beneficial. “We wanted physicians to be very involved from the start,” says Spain. Dolan adds, “Our physician partners were involved at every step, even in the design of the hospital and its staffing.” Truly a hospital of the future in both technology and patient care, Saint Francis Heart Hospital contains two surgical suites dedicated to open-heart procedures and surgical vascular procedures, four cardiac catheterization labs including electrophysiology and peripheral vascular capabilities, and a full-service emergency room.
Patient-centric Design
The facility was designed with 52 private, inpatient beds on the second floor and 16 day-patient beds on the first floor, Dolan says. While the 16 beds were licensed as part of the hospital’s total complement of 68 beds, they are still being used as day-patient beds, he explains.
In addition to being a wireless hospital, each room features a built-in workstation. “We wanted a terminal to be available wherever a clinician needs it,” Dolan says. Physicians also use these workstations to share with their patients recent test results, like video of their angiograms, as a way to better engage patients in their own healthcare and to encourage them to be more involved in making decisions.
All-digital Environment
Building a hospital from the ground up gave the founders of Saint Francis Heart Hospital the opportunity to put in place an all-digital infrastructure, so the hospital could open as a completely paperless, wireless and filmless facility. “It was a ‘greenfield’ project, so we engaged our IT partners in all the minute details,” says Dolan. “But we didn’t want our IT systems driving us.”
Dolan also credits Spain with helping to pave the way into an all-digital environment.
Spain’s practice, Cardiology of Tulsa, had been using a practice management system from Provo, Utah-based PCIS Gold, a division of DHI Computing, as well as an electronic medical record system from Horsham, Pa.-based NextGen Healthcare Information Systems Inc., and was now completely paperless. “It’s so incredibly important to have a physician champion, someone engaged on the user level,” Dolan says. “They know what to expect.”
Even so, Dolan and Spain say that in choosing GE Healthcare, they found a partner who was able to build an information system backbone from the ground up and have all systems operational within the nine-month time frame. The total project also came in under budget, Dolan says.
Efficient Interface
At the heart of this all-digital venture is GE’s Centricity Clinical Information System, which integrates patient information from every care area and procedure, including cardiology, perioperative, pharmacy and laboratory, into a comprehensive electronic medical record. The installed system also included GE’s CPOE system with future capability to administer medications at the bedside using bar-code technology.
In addition, GE Healthcare supplied the hospital with its Cardiac Cath Lab suite of technology, including the Innova 2000 and Innova 4100 and Mac-Lab hemodynamic monitoring system. Plus, all diagnostic images, physiological signs and structured clinical data also are held within the Centricity Enterprise Picture Archiving and Communications System (PACS).
But GE Healthcare also recommended and installed compatible systems and applications to ensure a seamless delivery of healthcare across the entire enterprise. “Accountability was a big feature for us,” says Spain. “If there was a gap, it was their responsibility to fill that gap.” As a result, Saint Francis Heart Hospital uses a series of interfaces that Dolan says has the feel of true integration. This has allowed the hospital to use an HIS (hospital information system) from Chesterfield, Mo.-based Stockell Healthcare Systems and documentation software from Silver Spring, Md.-based SoftMed Systems Inc.
To save time and facilitate the interfacing, GE Healthcare implemented a Quovadx engine on the front end, Dolan says. “The Quovadx engine allowed us to meet the nine-month target date,” he adds. Saving time also has been one of the biggest benefits of working in an all-digital hospital, Dolan notes. The staff has been able to reduce the admissions process to 10 minutes versus an industry average of closer to 30 minutes.
Clinical staff has immediate and simultaneous access to the patient record, which allows more time for hands-on patient care. Also, physicians have found that they are now spending almost 40 percent less time looking for charts and collecting data, he says. Patient satisfaction has improved as well. Dolan says his hospital continues to post a 98 percent patient satisfaction rate, well above the national average of 90 percent.
Furthering Patient Safety
Staying current with digital technology solutions has made the Hospital of Saint Raphael in New Haven, Conn. one of the most recognized in the nation. Affiliated with Yale University School of Medicine, this 511-bed hospital has been recognized as one of the Top 100 Hospitals in the United States by Solucient Leadership Institute (a national, independent healthcare information company) for overall services, cardiovascular care, intensive care, stroke care, orthopedic services and cardiac bypass surgery.
U.S. News & World Report also has listed Saint Raphael as one of 50 of “America’s Best Hospitals” for cardiac care; ear, nose and throat care; hormonal disorders; neurology and neurosurgery; and respiratory disorders. Plus, AARP has named the hospital one of the top 50 in the nation based on adult medical services, adult surgical services and overall services for people 65 and older.
Regionally, the hospital has been recognized for being one of the first to use state-of-the-art diagnostic and treatment devices including intensity modulated radiation therapy for prostate cancer; stereotactic radiosurgery for brain and head tumors; and bedside monitor-defibrillators for cardiac patients. So, when the Institute of Medicine and the Leapfrog Group began advocating for greater oversight in the ordering, distributing and administering of medications in very public statements and reports, the Hospital of Saint Raphael made patient safety a priority, says Davidson.
But much of the groundwork had already been laid, he notes. In 1992, the hospital rolled out a clinical information solution from Misys Healthcare Systems. To ensure that clinicians have real-time assess to comprehensive patient information at all points of care, the Misys CPR (computerized patient record) was integrated with key clinical information system applications. Included in this suite were registration, clinical documentation, order entry, laboratory, radiology and pharmacy information system modules.
Easier Said Than Done
In May 2002 the Hospital of Saint Raphael rolled out the Misys CPOE. “We had their pharmacy order entry system, so our pharmacists were already entering orders into the Misys pharmacy system,” says Davidson. “But we built the order sets to link the orders and streamline physician order entry as much as possible.” Today, physicians are responsible for entering orders while pharmacists review them.
Davidson does agree that “paper is fast,” but he justifies the extra time as a necessary part of the verification process. “It takes longer because it forces you to acknowledge all of the alerts and dosing questions up front,” he says. Training clinicians on a new CPOE also takes time, so Davidson put into motion an extensive training strategy over a four-week period. “We developed our own quick reference guides for physicians and did the training ourselves. The key is to train physicians as close as possible to when the system goes live,” he says.
Still, with 500 active physicians, training schedules were prioritized. “We made sure we had trained the top 100 physicians who are responsible for the most admissions before we activated the system. Then, we trained as many of the remaining physicians as possible, based upon available resources and schedules,” Davidson says. “We were extremely flexible, even meeting them at their offices if necessary so they would know how to use it.”
Avoiding Workflow-based Errors
The go-live activation was broad-based, he says. “I didn’t do a one-unit pilot. I did it by service–medicine first, then surgery–which have seven units in each.” To facilitate the training, in-house support staff wearing distinguishable red coats and called, simply, “Red Coats,” were in the units 24/7 for the first two to three weeks after the go-live. If, during the training period, an IT problem arose or the system needed to be tweaked, members of the development team, not the trainers, were called to fix the problem, says Davidson.
Tweaking the system also means taking into account the differences between paper-based order entry and computer order entry. “Computers and people think differently, and computers are only as good as the user,” Davidson notes. He adds that changes in workflow and even improvement in efficiency can lead to computer-user errors that are much less likely to occur in paper systems.
For example, physicians will often order medications for more than one patient at a time. In a paper-based environment, they are used to physically thumbing through the pages of a patient’s charts and then writing the order in an individual chart. Ordering via a CPOE system allows the physician to call up on the screen information for more than one patient. Having several windows open at the same time can be problematic. “If you pull up Patient A and pull up Patient B, it’s not hard to make a mistake and order for Patient B while you’re still on Patient A,” Davidson explains.
High Capacity Networks
While the potential for this type of error usually is resolved through training and oversight, other problems more closely related to information technology also can occur during the early stages of deployment. To mitigate major problems, Davidson stresses that the system needs to be tested extensively before going live. “You can’t make major changes once the system is up because, since clinical systems are used to treat patients, they need to function correctly and be available, especially at peak times.”
As an example, Davidson says that at peak usage, there are usually between 350 and 400 people using the Misys system concurrently. “Every physician is on and every nurse is on,” he says, “and that stresses your entire network.” To prevent network failure, Davidson says the organization not only must build in server redundancy, but also must be sure that its network has the capacity to support CPOE performance requirements before a go live. “We were gearing up for PACS in addition to CPOE, so we had already upgraded the capacity of our network to support PACS. Consequently, I knew we had the capacity to support order entry,” he explains.
As part of its medication/patient safety initiative, the Hospital of Saint Raphael also deployed in all nursing units mobile, computerized and wireless medication carts in addition to wireless mobile carts for accessing the computerized record. It has not yet, though, installed bar-coding technology at the bedside. “I didn’t get as far as I wanted,” Davidson says. “But in 2002, the industry wasn’t ready. There still isn’t one bar-coding standard for all manufacturers.”
Nevertheless, rolling out the Misys CPOE has reduced the chances that a medication error will occur on the front end, as well as continuing the hospital’s tradition of being both a high-tech and high-touch healthcare provider.
For more information about Misys CPR/CPOE from Misys Healthcare Systems,
www.rsleads.com/602ht-220
For more information about the Centricity Clinical Information System and cardiology products from GE Healthcare,
www.rsleads.com/602ht-219
Richard R. Rogoski is a free-lance writer and contributing editor to HMT. Contact him at [email protected]
© 2006 Nelson Publishing, Inc
