For the physicians and nurses at Children's Hospital of Pittsburgh, a member of the 20-hospital University of Pittsburgh Medical Center health system, the logic behind going totally paperless as the clinicians and staff prepared to move into the hospital's new replacement facility in 2009 was inescapable. Already live for several years with its EMR and CPOE, the hospital's move to its brand-new facility was to be accompanied by the elimination of nearly all of its remaining paper-based processes.

And because the hospital's IT staff, led by vice president and CIO Jacqueline Dailey and CMIO James Levin, M.D., Ph.D., had long been collaborating closely with clinician leaders, the organization was well-positioned to reap all the benefits of automation in preparation for the move, which took place in June of 2009.

There was just one big wrinkle, insofar as clinicians in the hospital's three intensive care units (its general ICU, cardiac ICU, and neonatal ICU) were concerned. While the organization's core EMR/CPOE system (based on the Cerner Millennium suite, from the Kansas City, Mo.-based Cerner Corporation) supported a host of innovations to patient care delivery, intensivists working in the ICUs found themselves struggling with one automation element.

In the past, they had worked with what to outsiders might seem like clumsy and indecipherable paper-based patient flowsheets. Yet as unwieldy as those flowsheets might have appeared to anyone else, the intensivists in the ICUs read them with ease. But the first iteration of the automation of those flowsheets had left the intensivists confused by the way in which key patient data was being presented. What's more, a complication with another innovation was creating intensivist pushback. On the one hand, every patient room at Children's had been equipped with a computer workstation. But it often took a full two minutes to log into the system, a frustrating length of time for physicians in the fast-moving practice context of the ICU.

The solution? Dailey, Levin, and the clinical informaticist team went to the vendor and proposed developing a new solution for the ICU, which came to be called iAware (a Cerner spokesperson confirms that iAware had, as of press time, gone live in six other hospitals across the country, and is being customized for a variety of clinical departments).

“I think part of our success in this area came from the fact that we never left this to go onto the next project, until we could make sure our clinicians were comfortable …”

With regard to the two-minute log-in issue, the computers were re-engineered so that a quick jiggle of the mouse would open up the computer screen to show all the key patient data immediately. And more broadly, Dailey, Levin, and their colleagues, in concert with Cerner developers, created with iAware a broad new capability based on the clinical dashboard concept. Now, intensivists and nurses, as they open the iAware dashboard, instantly access the most important patient data for immediate decision-making: hemodynamic data including heart rate, blood pressure, and respiratory rate; lab data including hemoglobin levels, blood gases, lactic acid levels, and creatinine levels, and the patient's current medications.

One early challenge in the development of iAware was the recognition among clinicians and clinical informaticists at Children's that there was a physical limitation to the amount of “real estate” available on the screen. So the hospital's intensivists sat down together to determine which data elements were most important, with the elements mentioned above making the cut. Fortunately, says Constantinos Chrysostomou, M.D., one of the cardiac intensivists, “It didn't take us long to agree on which data elements should be on the dashboard.”

Part of the reason for the success of the alpha-site implementation, says Dailey, was the very rapid cycling of development on the new tool. In fact, it simultaneously both kept clinicians engaged in the process of development (side by side with the hospital's clinical informaticists and with its vendor's developers), and promised a quick return on investment for the time clinicians invested in the development process.

“I think part of our success in this area came from the fact that we never left this to go onto the next project, until we could make sure our clinicians were comfortable with their new e-record,” says Dailey. What's more, she says, “They weren't difficult clients at all. But I think they were as confused as we were at the beginning; so we really had to listen carefully to them and to address their critical care needs.”

At the nub of the development challenge, she says, is that the intensivists at first could not easily articulate what the problems with the new form of data presentation in the system were. So clinical informaticists, including Levin, sat down with intensivists and nurses and painstakingly uncovered and worked through the issues involved.

An underlying challenge in critical care informatics, notes clinical informatics nurse Karen Bondi, R.N., is “the volume of data constantly being entered into the charts” in the ICU. “I think people didn't actually appreciate that until we actually started charting on IView.” In fact, she says, “The amount of data charted is overwhelming. And the status of patients continually changes. So you have all this data, and you have to make sense of it some way and very quickly, because the patient is going to change very quickly, especially in a pediatric setting.” The fast pace of the ICU environment, and the limited real estate available on the iAware screen, are the elements that led, necessarily, to the intensivists needing to select the key data elements to appear on the screen. Still, the flexibility of the technology has allowed for slight customizations among the three ICUs - general, CICU and NICU - in terms of the data points presented.

Virtualization to Boost Server Utilization

WHO: Children's Hospital of Pittsburgh, a member of the 20-hospital University of Pittsburgh Medical center health system.

WHAT: Alpha site co-development of a readily available clinical dashboard for use in decision-making and charting by intensivists and nurses in the hospital's three ICUs.

WHEN: February-July 2008

RESULTS: Improved patient safety, clinician workflow, physician-nurse communications.

THEMES: Workflow and patient safety innovation, clinician/IT collaboration, and co-development with vendor.

SECRETS OF THEIR SUCCESS: A culture of innovation, collaboration, and patient safety at Children's Hospital; strong prior experience with EMR/CPOE; intensive clinician-IT team-based work on the solution; a collaborative partnership with the hospital's clinical IT vendor.

“Technically, there were certain things we asked for that we couldn't pull into the dashboard easily; so we had to cut certain practical corners,” says pediatric intensivist Shekhar Venkataraman, M.D. “But though we got a dashboard that wasn't everything we wanted, it provided most of the key elements we needed.” Satisfaction increased with each of about “three or four iterations” of rearrangement of the data elements to be included inside the window views, he adds.

“You have all this data, and you have to make sense of it … very quickly, because the patient is going to change very quickly, especially in a pediatric setting.”

In addition, says Beverly Brozanski, M.D., the hospital's NICU director, it can provide data in the smallest patients. “The other good thing about the dashboard is that, when children are in intensive care, they tend to be very sedated, and tend to be on major fluids, so we can really monitor their intake and output, and that's very helpful, because it can give us an idea of fluid-electrolyte balances,” she says.

Seeds planted in fertile ground

Many hospitals have helped to co-develop clinical IT solutions, and many more have automated or at least partly automated their ICUs. So what sets Children's Hospital of Pittsburgh apart? Four factors in particular seem to have played a role in the success of the iAware initiative. They are: several years' experience operating in a live EMR/CPOE environment prior to the start of this initiative; a strong, collaborative partnership with the organization's core clinical IT vendor; intensive collaboration among all stakeholder groups, including physicians, nurses, clinical informaticists, and IT; and above all, a culture focused on continuous improvement in patient safety and care quality, something that Children's Hospital and indeed all of the University of Pittsburgh Medical Center organization are both known for.

With regard to the vendor interaction, CMIO Levin says, “We pushed Cerner in a way that was not their typical current approach, asking their developers to come onsite here to work; and in addition, the whole process was very rapid from beginning to end.” He adds that for any kind of co-development like this one to succeed, a deep mutual commitment between customer organization and vendor is an absolute prerequisite.

Then there is the level of collaboration that has evolved between and among clinicians, clinician leaders, clinical informaticists, and IT executives and managers at Children's. That spirit of collaboration, says Sue Park, R.N., the hospital's director of clinical and operational informatics, certainly infused the iAware initiative. “From the clinical perspective,” Park observes, “the clinicians obviously want to be providing the best care they can provide. So they've always worked well with other disciplines. And in moving forward on online documentation, they wanted to make it the best they could, pulling the data out and getting a better view of their child's condition.”

More broadly, CIO Dailey says, “I think that we do have a culture whereby everyone feels an accountability to the bedside as strongly as do the clinicians at the bedside. We've decentralized the informatics nurses, and the IT staff, so they're both making rounds and interacting with the clinicians every day. And whether you're a desk analyst or a nurse or an intensivist or a CIO, your role is the same, you're taking care of that child in that bed.” In short, she says, “We have a confidence in one another that no one is going to walk away and abandon someone else at the bedside.” Still, she quickly adds, “It was not that way when I started here 10 years ago.” When she first arrived at Children's a decade ago, she says, there was still a lot of territoriality going on. But the need to move forward collaboratively in order to implement EMR, CPOE, and other core clinical information systems, and a hospital-wide (and indeed, at the UPMC level, system-wide) commitment to a culture of continuous patient safety and quality improvement, have transformed the working environment at the hospital. “And this e-record initiative,” she adds, “has really been the biggest change agent here in the past several years.”

Takeaways

• Children's Hospital of Pittsburgh clinicians, clinical informaticists and IT executives were able to co-develop with their vendor an innovative new tool for immediate patient data visualization, and for charting, in the hospital's three ICUs.

• Several years' experience with EMR and CPOE prior to the co-development laid the groundwork for a collaborative culture and for experience that emerged during the development of the new solution.

• Development of the solution helped complete the hospital's transition to nearly paperless patient care.

Not surprisingly, Children's Hospital of Pittsburgh is receiving recognition from a number of organizations for its advances, both in clinical IT, and in patient safety. In December, HIMSS Analytics, a division of the Chicago-based Healthcare Information and Management Systems Society (HIMSS), recognized Children's as the first pediatric facility in the U.S. to receive its “Stage 7 Award,” which means the hospital has reached HIMSS Analytics' highest level of clinical IT advancement. And in October 2008, the Washington, D.C.-based Leapfrog Group named Children's of Pittsburgh one of only seven children's hospitals in the U.S. designated as “2008 Top Hospitals” for, among other things, achieving high levels of performance with seven complex, high-risk procedures; staffing its ICUs with qualified intensivists; and implementing CPOE, which Leapfrog considers a key patient safety tool.

Don't worry that the folks at Children's Hospital of Pittsburgh are going to get lazy or rest on their laurels anytime soon. They're too focused on the future, particularly on using IT to help facilitate continuous improvement in patient safety and care quality. Nor will they forget the core importance of end-user input and buy-in to the success of any clinical IT implementation. “Keep in mind,” Levin says, “Our challenge earlier on was not that the ICU physicians didn't like technology or want to move into the new hospital; in fact, everyone was excited about moving to our new digital hospital. But they were right about the existing screens in our vendor's CPOE not working in terms of viewing data with enough immediacy; and that had to be fixed. For me,” he concludes, “there are two lessons here. One is, listen to your users; and the other is, your users are right.”

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Healthcare Informatics 2010 March;27(3):20-28