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Performance Improvement Special Report: Part I. The Landscape

May 2, 2007
by Mark Hagland
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Performance Improvement: EMR Nirvana

Part I: The Landscape

With the backdrop of an environment that's becoming more demanding and intense every day, pioneering hospitals, medical groups and health systems are making performance breakthroughs that even a few years ago were thought impossible. They are making clear advances in improving patient care quality and safety, redesigning clinical workflow, making their clinicians and staff more efficient than ever, and reaching out to connect data and information across sites, physicians, and communities. The key enabler? The electronic medical record (or electronic health record), say industry experts and leaders at pioneering healthcare organizations.

In fact, industry insiders say, it is becoming increasingly clear that EMRs (along with other related clinical information systems) will be essential. They will be non-negotiable tools for achieving rubber-meets-the-road performance improvement in quality, efficiency, and connectivity. What's more, those in the vanguard of EMR development are learning that their work is literally never done, and it's never over. Instead, the path ahead is a one of continuous work, adjustments, and improvement, leading to a revised and revolutionized care delivery system. It is in the ongoing enhancements, improvements, and iterations to these systems where the "value-added" comes in, many agree.

"The value in these systems is not just in getting the initial adoption, but coupling implementation with process improvement and getting real change," says Tim Zoph, vice president and CIO of the 744-bed Northwestern Memorial Hospital in downtown Chicago. "We've trained 98 percent of our employees on GE's DMAIC methodology —‘define, measure, analyze, improve, and control,' Zorph says. "So in parallel with our electronic health record infrastructure going in, we embraced process improvement. Having this EHR infrastructure has given us the opportunity to improve care." Since 2004, the hospital has completed more than 125 process improvement projects, primarily in clinical areas. And over half those have used data or information technology. Leveraging IT to enable change and measurement, the hospital has seen a 57 percent reduction in avoidable harm through process improvement, he says.
Tim Zoph

Among the areas that hospitals, medical groups, and integrated health systems are focusing as they move from the just-implemented phase of EMR adoption to more mature phases, are:

  • Intensive, iterative revision of physician ordering and clinical decision support programs, following first implementation of computerized provider order entry (CPOE) systems, in order to achieve improved care quality and more efficient clinician workflow.

  • Detailed work on electronic medication administration record (eMAR) and full closed-loop medication administration systems, to reduce medication errors and improve medical management processes for all clinicians.

  • Improvement of clinical documentation systems, for both physicians and nurses.

  • Expansion and enhancement of physician and community connectivity to health systems' clinical information systems.

  • Electronic connectivity with patients across the continuum of care, for enhanced patient education, medication compliance, and other benefits.

Glenn Galloway
Every area in which pioneering organizations are moving forward, their leaders say, will help them build upon initial EMR/ advanced clinical systems infrastructures. Over time, they say, patient care organizations will make the leaps in quality, efficiency, and connectivity that all the stakeholder groups (purchasers, payers, regulators, consumers) are demanding.

When the real work begins

John Glaser
Above all, many say, understanding that the initial EMR implementation is only the first step is essential to leveraging EMRs' performance improvement power. "Often, people will say, 'Let's implement, and we'll get it in, and we'll declare victory,’” says John Glaser, Ph.D., senior vice president and CIO of Partners HealthCare system in Boston. "And I say, it's hard work, and you have to keep redesigning. But the biggest thing learned is that you'll never be done; and what you've done so far, by going live, is to put in a tool that will help you improve care and processes. So be aware that implementation never ends, and that processes must be put into place to constantly make the data better and more useable. The real work actually begins after the point at which we define implementation as being over."

Among the many clinical care improvement projects that have been initiated at Partners hospitals have been initiatives to improve hemoglobin a1c level management in diabetic patients, and improving smoking cessation rates, while in the clinical workflow area, speeding the process of laboratory test results to patients has been a focus.