The Washington-based Government Accountability Office (GAO), an independent, nonpartisan agency that keeps an eye on Congress's spending, recently released a report, ‘Healthcare Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections,’ outlining how hospitals, which rely heavily on IT are able to prevent infections and save money in the process. No big surprise there for healthcare CIOs. What state and hospital association officials told the GAO, however, highlights the real issue CIOs often face in the hospital-acquired infection (HAI) arena: most hospitals face challenges with implementing and funding HAI technology — and that can limit the scope of systems and the timing of implementations.
“I believe as more and more imperatives come for infection control, (health) systems like mine are going to say ‘I only have so much money, I have all these things I'm supposed to be doing, and I need to have a thoughtful and relatively objective strategy for looking at where am I going to11 get the best bang for my buck,” says Mark Wheeler, director of clinical informatics at PeaceHealth, a nine-hospital system headquartered in Bellevue, Wash.
So when it comes to the IT solutions that can address the Oct. 1, 2008 reimbursement changes from the Centers for Medicare and Medicaid stipulating that it will no longer pay hospitals for treating HAIs, CIOs may need to be more creative than ever.
The Centers for Disease Control and Prevention (CDC, Atlanta) estimates that HAIs affect more than 2 million patients a year, and cost the nation more than $4.5 billion annually. In addition to the serious safety issues for patients, the cost of treating HAIs exceeds most payer reimbursement, resulting in hospital net loss. Since the CMS reimbursement changes were first announced, hospitals have been scrambling to implement solutions.
Ensuring compliance for HAI regulations is high on every CIO's to-do list. But should CIOs wait for their infection or quality control departments to drive the solution? “The CIO has to have an HAI strategy that is in alliance with the enterprise strategy because it's not simply a one-topic issue,” says Lynn Eckendorf, a consultant at Falls Church, Va.-based Noblis Center for Health Innovation. “HAI is a great example of using technology to enable strategies to reduce infection.”
As exposure to multi-drug resistant organisms, or ‘superbugs,’ becomes more common, one of the most common resulting infections in hospitals is MRSA (methicillin-resistant Staphylococcus aureus). For Tom Smith, CIO of Evanston Northwestern Healthcare, a three-hospital system in Evanston, Ill. (that recently changed its name to NorthShore University HealthSystem — NSUH), MRSA screening was part of the enterprise strategy. “MRSA is the way we decided we want to practice medicine,” Smith says, in regard to screening.
NSUH was one of two health systems the GAO visited in preparing its study (the other was the University of Pittsburgh Medical Center). NSUH, which is on an Epic (Verona, Wis.) EMR, added an orange banner on the medical record screen that highlighted any patient who had yet to undergo a MRSA test. “You need some kind of clinical-record keeping at point of care, otherwise you're putting something into a piece of paper and looking at it,” Smith says. “You can do that if you have enough people — but it takes a lot of people.”
Another MRSA initiative is currently going on at PeaceHealth, and Wheeler says the system is performing a cost benefit analysis of MRSA screening. “When you look at infections, there are many strategies you can take,” he says. “What you really need to do is ask what is the cost and benefit of any intervention.”
To determine numbers for MRSA, Wheeler says he plans to use his enterprise data warehouse from U.K.-based GE Centricity for a multiple regression analysis to pick the best predictors for any patient being a MRSA carrier. “You can screen everybody, but it depends on the MRSA carrier rate,” he says. “It's all locally driven.”
Wheeler says if hospitals have a carrier rate of five percent, it doesn't make sense to screen everybody — particularly when keeping the budget in mind. “If we can screen a third of our patients, that's a big change in the cost,” he says. “We'll miss some, but if there's competition for that money for other things like hand-washing, the combination might turn out to be a more efficacious strategy.”
Saving staff for other important functions around HAI is cited by many as one of the big benefits of automating. “If you are reducing the need to put resources in one area, you can deploy them in other areas,” Eckendorf says. That includes monitoring and reporting any infection patterns to the CDC.
At BayCare Health System, a Tampa, Fla.-based nine-hospital system, CIO Lindsey Jarrell was using two infection control systems. They were interfaced into his Kansas City, Mo.-based Cerner EMR and automatically monitored clinical data to alert the hospital of any types of infection patterns within the hospital. He says his quality officer began taking a look at HAIs about 18 months ago. “Knowing what was coming, and knowing that we needed to get better in the management of HAI, we said ‘this is not going to do.’”
BayCare just kicked off an implementation of infection control tracker TheraDoc (Salt Lake City) to monitor patients in-house. “We're taking a much more in-depth approach to this system,” says Jarrell, who previously was using MedMined from Cardinal Health (Dublin, Ohio.) “The business case around HAIs is that it's got a lot of visibility in the organization.”
Jarrell has been building alerts and prompts into his EMR to do reporting. “If the user acknowledges the alert, we have the ability to report on that.”
According to Eckendorf, one of the most important tools during an EMR implementation is setting up the prompts for clinical actions that help prevent infection, like specific elapsed time for a catheter. “You can't assume that's already going to be set up by the vendor because you may have a more stringent timeframe than that recommended by standards bodies,” she says. “That's where your clinicians are going to be essential in establishing those guidelines. They may say, ‘There are 10 different prompts, let's trim it down to two.’”
Alerts and prompts around HAI have to balance between too many and not enough, most agree. “Writing a good alert is not a simple task,” says Smith, who works with a physician advisory committee to keep alerts and prompts on track. “If you want to get very sophisticated with an alert, you have to take into account two or three or four different criteria, lab results, maybe an age, a sex,” he says. “In the case of MRSA, it's just yes or no.”
At NSUH, the MRSA prompt exists in the Epic EMR, within the nursing documentation screen. There are only two options available, either ‘yes, the screening was done’ or ‘no, the patient refused.’ If it's not filled in, there's an alert that sounds at least once in an eight-hour period to remind the nurse to complete it. “It's a relatively simple step, but it removed the idea of the nurse and doctor having to remember to do it,” Smith says. “Obviously MRSA is important to us and we made an important commitment to it in terms of patient care perspective. The tool was a way to implement the policy that the physicians and administration set.”
So just where do CIOs fit in with the HAI policy — are they heading up the IT charge, or following the lead of the clinicians? “The role of the CIO is really to provide the infrastructure and base application,” Smith says. “You can do a lot of these kinds of things with paper charts — it's just much harder. IT puts that policy in front of the nurse, and that's a pretty powerful tool.”
Eckendorf says part of the CIO's role should be a facilitator whose job is to assemble workgroups around the HAI issue. “Because IT crosses so many functions, they're really well positioned to get a group like this going.”
And as with so many other hospital projects, most agree with the role of CIO is as facilitator when it comes to HAI projects. “I think the key thing is that somehow administration has to set the expectation that operations and physicians will use the tool the way that we've provided,” Smith says. “It can't be something that I'm pushing onto physicians or nursing staff — they have to come to me.”