One-on-One with Virginia Commonwealth University Health System CMIO Alistair Erskine, M.D., Part III

June 24, 2011
Virginia Commonwealth University Health System (VCUHS) is an academic medical center that has served the Richmond, Va. area for more than160 years.

Virginia Commonwealth University Health System (VCUHS) is an academic medical center that has served the Richmond, Va. area for more than160 years. The VCU Health System’s academic mission supports and is directly linked to Virginia Commonwealth University. As the clinical delivery component of the VCU Medical Center, VCUHS is a regional referral center for the state. MCV Hospitals is the teaching hospital component of the VCU Health System, which also includes several outpatient clinics and MCV Physicians, a 600-physician, faculty group practice. Also included in the system is the 779-bed Medical College of Virginia Hospitals (MCVH) and VCU’s Massey Cancer Center, a National Cancer Institute designated facility. The VCUHS treats more than 80,000 patients annually in its emergency department, which is the region’s only Level I Trauma Center. Recently, HCI Associate Editor Kate Huvane Gamble spoke with Alistair Erskine, M.D., who serves as CMIO and Internal Medicine Hospitalist at VCUHS, about his role with the organization, his thoughts on pushing forward during tough economic times, and how his organization is leveraging technology to improve the safety and quality of care.

Part I

Part II

KG: So with this particular application, there wasn’t any co-development required. But VCU has collaborated with PatientKeeper in the past.

AE: Yes. We’re one of two of their development partners, which means we actually have three domains: a production domain, a testing domain and a development domain. And they have full access to our development domain to take alpha-beta tech software and put it in that development domain and test it against our real production database with all our patients. So it’s a much more robust test for them, to be able to take this software and break it and kick the tires on it in a real productive environment. And it’s information that they’re pulling from — and not placing into — the environment.

We’re a contract signed development partner with PatientKeeper, and frankly, the way we benefit from that is whatever software comes out from PatientKeeper, from this point on, we don’t pay for it.

KG: Going back to the hand-offs, how big of a role does improving safety play in automating the process? Were you finding a great deal of errors with the paper-based system?

AE: I can tell you that I’m horrified when I pick up one of those pieces of paper as an attendant in the wards. You may have about 15 patients that you’re taking care of that have a slew of medical problems, and even things like their room number, or their medical record number, or if they’re allergic to something or not, or the spelling of their name, or the problems that they have on that list — it’s just filled with inaccurate information. And I think the accountability obviously goes to the residents, but you know that the sign-out process is the last thing they do at the end of the day, so that’s probably the time that they’re most exhausted and most anxious to go home, so they’re attention to detail at that time is probably at its weakest.

Can I quantify the number of errors or the degree and weight of those kinds of errors? We haven’t gone through that exercise, albeit that would be a good exercise to go through, to be able to show quantifiable differences in the accuracy of document before and after the PatientKeeper Sign-out. And as we roll that out more, we are thinking about ways to do that; taking a small sample of previous paper-type document and being able to find out how accurate they are, and then give the sign-out a score, and then do the same thing post-PatientKeeper to show that the document is actually more accurate.

Other ways we’re looking at — and again, we don’t have results — the impact of an electronic sign-out process is looking at things like length of stay and mortality numbers and complication rates, and objective measures like that, to be able to say that patients who have electronic sign-out end up with a half-day decrease in length of stay as a result of having a better, interfaced communication tool.

We’re trying to find additional metrics, like the number of times that a resident who is signed out and at home ends up getting a page about something that was not clear in their sign-out, compared to when it’s an electronic process, and how that communication occurs. Things like, do we see a number of pages decrease in the middle of the night from the person who has signed out, that the primary care team and the overnight medical team are communicating better using the electronic process.

KG: It seems like an obvious case where technology can work to cancel out human error. At the end of a long shift, there is more likely to be errors made in documentation.

AE: Six Sigma would be horrified if residents were spending time at the end of the day typing in a patient’s name and location and medical record number. They should be thinking and spending time on one of the actions overnight, like what are the things to look out for, not very routine ADT information, which is what they spend a lot of time doing, and just seems like a waste of time.

KG: It’s a really interesting project. Do you have other projects coming down the pike? I know there isn’t much capital out there.

AE: The sun never sets on the universe of activities in any clinical IT shop, whether the money is there or not.

One way to look at it is, okay, so the capital dollars dried out because of issues with investments and other things. Well, that’s a great time to optimize your system. So you may not have the implementation, but there are plenty of optimization opportunities that are ripe for the taking for all the people that remain employed. It’s also a great time to look back at processes that were put in. Sometimes, as applications are installed and as a practice is transformed, it’s not fully optimized post-implementation. So you go back and you make sure that what you were intending to do actually works, and you go through the process of cleaning up the database and cleaning up processes, and trying to identify workarounds and trying to improve upon them.

That activity will go on an infinitum; potentially more so when there are fewer new projects to implement. That being said, we still have every intention of completing the nursing documentation project that we had already started, so putting in final inputs and outputs and not just having admission assessments done by nurses, which are electronic now, but also the daily carriers and the way the flow sheet ends up being interactive. Those things we plan on going live this fall, and we’re in the process of building that right now.

The second major project that we have underway is rolling out to our ambulatory clinics full use of the EHR, more so than what they have now, which they use primarily for data retrieval purposes, and have the clerks put in the orders. Only a quarter of the notes are electronically typed in the system; the remainder of them are either on paper or being dictated.

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