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Performance Improvement Special Report: Part II. The Improvements

May 1, 2007
by Mark Hagland
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Hospitals Take Action to Help Patients

Part II: The Improvements

When executives at Memorial Sloan-Kettering Cancer Center decided in the late 1990s to expand their clinical operations beyond the organization's core 432-bed inpatient hospital facility on Manhattan's Upper East Side, they realized that automation would be required. Creating six satellite clinics across the New York metropolitan area (including Westchester County to the north, New Jersey to the west, and Long Island to the east), the renowned cancer center's leaders wanted to enhance the availability of their services to patients across the metro area.
Patricia Skarulis and David Artz, M.D.

Faced with the potential for a medical records and clinical decision support nightmare, Memorial Sloan-Kettering's leaders decided to forge ahead with a comprehensive automation plan, implementing a system-wide electronic medical record (EMR), including a picture archiving and communications system (PACS).

"We decided we wanted to become broader; but we realized quickly that we couldn't have an efficient operation while moving paper records and diagnostic images around," explains Patricia Skarulis, Memorial Sloan-Kettering's vice president and CIO. "So we imaged our paper records, installed our core EMR and PACS system, and got rid of all our films, and did this while we opened the new facility in Midtown."

Skarulis describes the synchronicity of the expansion and the need to move forward into automation as "fortuitous." Now, not only are all of the organization's 600 staff physicians and its nurse practitioners entering orders through its CPOE system, the organization's clinicians have been working collaboratively with its EMR vendor (Atlanta-based Eclipsys) to customize and optimize oncology order sets, confirms David Artz, M.D., Memorial Sloan-Kettering's medical director of information systems.

The work has been complex and time-consuming, but the results have been very positive, Artz says. To take just one example, he cites the situation around blood clots, something to which many patients are post-surgically disposed. Depending on the type of surgery, most patients (but definitely not all) should receive low-molecular-weight heparin, an injectable drug. At Memorial Sloan-Kettering, for patients with a predisposition to blood clots in their legs, the order for low-molecular-weight heparin is now forced, meaning that any physician who wishes not to order heparin under designated conditions must consciously and specifically choose not to do so. "Preventing blood clots in cancer patients' legs is one of the hot-button topics in cancer care," Artz explains. And this particular innovation helps to avert a common oversight in that area.

Such innovations speak to the core of what information technology can offer physicians in complex clinical areas such as cancer care, Skarulis adds. "If you didn't have that particular order set," she says, "you'd have to be trying to educate everyone, and checking on whether they did it. This way, it forces them to act, and we also can do analysis," to determine what is happening with individual patients and with the organization's patients collectively.

Meanwhile, in terms of clinician efficiency, Memorial Sloan-Kettering has self-developed an application built into the Eclipsys EMR, one that gives a broad view of any patient's illness at a glance, with fields pre-populated in the system that show medication history and current meds, patient demographic data, and current physician notes. The application, Skarulis and Artz note, is especially helpful for residents, as they do handoffs of daily patient oversight. In fact, its implementation dovetails with the publicly expressed desire on the part of the Oakbrook Terrace, Ill.-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that hospital organizations do a better job of patient supervision handoffs, a widely observed point of medical error.

Optimizing order entry

The experience at the 744-bed Northwestern Memorial Hospital in Chicago is illustrative of one of the biggest challenges — and opportunities — in the automation of clinical processes. That's because off-the-shelf software programs inevitably must be custom-tailored and optimized for the use of clinicians in particular organizations, says David Liebovitz, M.D., the organization's medical director for clinical information systems. In fact, Liebovitz reports that, contrary to the typical approach taken to developing order sets for CPOE use, at Northwestern, "We did not build many order sets based on medical diagnoses, but rather, we built them based on surgical procedures. The reason for that is that the average patient in an academic medical center has so many complex situations —multiple myeloma, COPD (chronic obstructive pulmonary disease), while happening to have community-acquired pneumonia, for example, coming in. So building order sets based on medical decisions seemed inappropriate," he says. As a result, Liebovitz and his colleagues spent months building academic medical center-appropriate order sets for their physicians.

In addition, Northwestern clinicians and IT professionals completely reworked the medication order alerts in their vendor's CPOE system. As Liebovitz explains it, "The standard vendor alerts built into applications are too jumpy. It's in the literature that 90 percent of the alerts are ignored or turned off. So we turned them off entirely," painstakingly creating their own alerts in order to adjust the proportion of times when a physician entering a medication order would receive an alert "ding."