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It seems that everyone has a horror story about the care they received in the hospital. Is it because we providers deserve our patient's criticism or have they become more suspicious and alert to the risks? Maybe it has just become fashionable to knock the quality of the American healthcare delivery system?
I have had two recent personal experiences as a patient in the operating room. One was perfect. Obviously, this is about the other.
The facts are simple: I have a potentially life-threatening reaction to certain types of anesthesia and I am allergic to Ancef, an antibiotic. Furthermore, you must take into account that I am a consultant making a living by promoting and implementing mechanisms for safer healthcare delivery.
Being a physician, one could argue that the odds would be in my favor. I am more knowledgeable about medical care and I might get special treatment from my colleagues. I know how to be a good patient. I called in to the anesthesiologist a week before my surgery to review the safest route of anesthesia and I brought a printed and detailed medical history with me on the day of surgery. The surgery center's only electronic capability was for billing (it worked perfectly).
The fiasco began when I was told that the anesthesiologist with whom I had discussed my procedure a week before was not there due to a schedule change. I was assured, however that it had been discussed with his colleague that would be putting me to sleep. It hadn't. There was no record of our discussion. My nurse, a “traveler” (an agency nurse hired to work during our busy snowbird season) checked my armband and the label on my pre-op antibiotic before hanging it. I asked to see the bag of medication before I allowed it to run in. Despite my red armband, it was Ancef. She was apologetic. She returned with clindamycin, an alternative antibiotic, and having learned her lesson from the Ancef offered me the IV bag to examine. Yes, it was clindamycin, but why was I getting an antibiotic in the first place? I asked to see the physician order sheet. My physician had faxed in a standard pre-printed order set. There was a large X by both antibiotics. To my doctor the X meant no. To my nurse it meant yes.
A doctor in scrubs approached my stretcher syringe in hand. He introduced himself as my anesthesiologist (the other was on break) while simultaneously reaching for my IV line to inject “happy juice.” I stopped him abruptly. He too was uninformed of my anesthesia sensitivity.
So what went wrong? What lesson can be learned from this horror story? Would an electronic medical record have provided some protection? Yes, an EMR with CPOE would have caught my allergy to Ancef and an appropriately implemented medication administration system would have blocked administration. Yes, CPOE would have made my physician's orders clear and unequivocal. No, there is no protection against poor communication, incompetent hand-offs, or bad policy and procedure. We need to get our house in order.
True interactivity is not about clicking on icons or downloading files, it's about encouraging communication.
Got kiosks? The emerging environment of patient care is going to be not just about using automation to improve clinicians' ability to provide higher-quality, safer care in a more efficient way, but also about enhancing the patient experience.
As executives at more and more patient care organizations are learning, today's patients are becoming more demanding health care consumers. And why shouldn't they be? If consumers can check in at airports and hotels conveniently, why shouldn't they expect the same when they arrive for non-emergent care in hospitals? Yet most hospital care experiences remain behind the curve with regard to the kinds of experiences consumers have in other service industries, including the transportation and hospitality industries, retailing, and others.
Among the expectations patients bring to their hospital stays are control of their environment; ability to communicate with staff; frequent contact with their own doctors; quick response to needs; diversions; good meals and food choices; contact with family; simple check-in; and prompt service, according to a new white paper from the Waltham, Mass.-based Emerging Practices Group at the CSC Corporation. Among the technologies hospital leaders should consider, the report's authors suggestions, include kiosks, digital signage and wayfinding, online portals, the provision of e-mail with providers, online scheduling, and online bill-paying.
From my perspective, the need to improve and enhance the patient experience in hospitals is a no-brainer. What's more, as intra-market competition intensifies in communities and regions across the country, it is improvement in the direct patient experience that will be the first thing noticed by patients/consumers as they consider where to go—or go back—for patient care. I continue to be fervent in my advocacy of improvement in quality of care and patient safety. But at the same time, I believe that hospital and health system leaders need not only to improve the core of their patient care quality and safety; they have to do it while enhancing their patients', and patients' families', experiences of care.
Obviously, the “enhanced patient experience” mandate adds yet another item to the long list of mandates facing CIOs. After all, they are the ones who will supervise the purchase of self-service kiosks, patient entertainment systems, and automated systems that will allow patients to do such things as custom-order meals or access video-based translator/interpreter services. But CIOs also have a distinct opportunity to be “heroes” in this area, as the relatively easy wins (certainly compared to rolling out CPOE and closed-loop medication management systems, for example) in this area can lead to real gains in market competitiveness. Wouldn't it be best if you got those gains before your local competitors did?
And then, of course, there's that human element. Who wouldn't want to see more smiles on the faces of patients in their hospital?
“Patient-Centeredness: Using IT to Support the Shift to Patient-Centered Care” can be accessed at: http://www.csc.com/industries/healthservices/knowledgelibrary/4795.shtml.
The primary justification for the enormous cost and risk of EHR implementation is a belief by hospital executives and Board members that they will gain a competitive advantage from its use. Clearly an EHR is differentiated from other IT investments in this regard, as illustrated by the results of a recent HIMSS survey:
“Which technology would most increase a hospital's competitive advantage?”
Electronic health records (58%)
Clinical documentation (12%)
Computerized MD Order Entry (11%)
Radiology PACS (8%)
Electronic prescribing (7%)
Source: HIMSS survey, October, 2007
A hospital's competitive position in its local market is defined by the following Key Success Factors:
Deliver high-quality (safe and effective) care
Provide an attractive provider network to meet the needs of patients, payors and employers
Provide an attractive care environment for patients
Provide an attractive work environment
Generate sufficient funds to cover ongoing operations and required capital investments
Meet regulatory/legal requirements
Source: Based on HSC Issue Brief No. 97, August, 2005
An EHR can have the greatest potential impact on the first and fifth of these KSFs, as shown in the following summary of published EHR benefit studies.Greatest Quantitative Evidence of EHR Benefit
Reduced ADE incidence
Reduced medication error incidence
Reduced order turnaround time
Increased use of preventive care
Reduced redundant testing
Reduced drug use and costs
Reduced lengths of stay
Nursing staff time savings
Some Quantitative Evidence of EHR Benefit
HIM workload, staff reductions
Pharmacist time savings
Decreased cost of paper forms
Decreased transcription costs
Improved documentation quality
Reduced payment denials
Improved quality of coding
Improved charge capture
Source: Thompson, Classen, and Haug, EMRs in the fourth stage, JHIM, Summer 2007
Clearly the purchase and implementation of an EHR is a strategic issue, given its potential value, its high cost, and the high risk of failure associated with EHR implementations. As such, these decisions and activities demand the direct involvement and participation of the Board of Directors, not to mention senior hospital executives.