The CIOs and CMIOs from Trinity Health System, Beth Israel Deaconess, Summa Health System, and Children's Hospital of Pittsburgh share their experiences toward meaningful use and offer tips for navigating the long road ahead.
Meaningful use comes in all shapes and sizes; the healthcare leaders at Trinity Health System, Beth Israel Deaconess, Summa Health System, and Children's Hospital of Pittsburgh can attest to that. An underlying theme rippling through the campuses of these meaningful use front-runners is the fact that healthcare IT innovation is deeply embedded in the culture of the organization. For starters, these healthcare organizations implemented many of their clinical information systems years ago to improve patient care, long before the July 13 announcement of the meaningful use final rule. Another key factor of their success is the strong collaboration between the IT staff and clinicians to create effective, and in some cases transformative, information systems.
BEGIN AT THE BEGINNING
Trinity Health System's meaningful use story began literally 10 years ago with the launch of its $300 million IT overhaul, dubbed the “Genesis” project. Prior to that, the Novi, Mich.-based health system looked like a “nursery school rag carpet,” with its lack of common clinical information systems, according to J. Michael Kramer, M.D., Trinity Health's vice president and chief medical information officer (CMIO).
“When we learned that something worked really well clinically in one part of Trinity, we wanted to have the ability to have all of our hospitals have access to that best practice.” That led to a technology strategy in which all of the hospitals implement the same system in the same way, rather than each hospital implementing its own system, explains Paul Browne, senior vice president and CIO at Trinity Health.
Currently, 27 of Trinity's 47 facilities, or 63 percent of the system's staffed beds, have been woven into this less-crazy patchwork quilt. Browne makes sure that features and functions that worked well in the facility's old clinical systems are implemented in their new information system. (The Kansas City-based Cerner Corp. is the health system's core clinical IT vendor.) “We're not always successful with that, but a lot of times we are. So that has really helped push ourselves and Cerner to make the product better,” says Browne.
The Genesis project was rolled out in two phases. The first phase, from 2001 to 2004, implemented a system-wide adverse drug event alert system that uses an algorithm based on select criteria when a drug is ordered, to make sure that the medication is appropriate for the patient. Since 2001 about 90,000 alerts have been sent that have led to changes in medication. “We don't know how many times of that 90,000 someone would have been actually harmed, but what we do know is that the physician felt that what the computer had to offer was compelling enough that they should change the medication order,” says Browne.
The second phase of Genesis implemented computerized physician order entry (CPOE) and brought 20 modules, including emergency department, pharmacy, and radiology systems, online. The first hospital to go live with this new strategy was the relatively small 119-bed St. Joseph Mercy Port Huron in Michigan, in May 2003.
Trinity's leaders plan to complete their system-wide technology roll-out in September 2012-an ambitious goal for a health system of any size. Trinity's strategy leverages many factors like the complexity, size, and a hospital's readiness for change. The Mount Carmel Health System, which is comprised of four facilities in Columbus, Westerville, and New Albany, Ohio, will be the last group to be brought into the fold; its clinical systems were already quite advanced, which made integration into the Trinity system more complex.
What helps set up each of Trinity's hospitals for a successful integration is an intensive activation period before going live on the main system. A year before the go-live weekend, Kramer meets with the heads of all the specialties to engage them to create a motivation for change within the organization. Three teams are formed to facilitate readiness in finance, operations, physician, nursing, pharmacy, and ancillary services. Kramer appoints a CMIO in each facility to lead the engagement. The team then goes through a project management starter set with close to 3,000 tasks and a central repository of 230 best practice clinical workflows. “During the readiness phase process we transfer the knowledge from our now 27 facilities to the next facility,” says Kramer.
This high level of standardization within the Trinity system has led to many quality improvements in patient care. Last spring's H1N1 outbreak, for example, led Trinity to develop a detailed, system-wide dashboard that showed clinicians how many patients exhibited influenza-like symptoms, were getting prescriptions for the flu medication Tamiflu, and were on ventilators; as well as whether the hospital or the ICU was full. In that system, an emergency room nurse hit a button on the electronic admission intake form, which populated the dashboard with information. The form was rolled out within a week to all facilities, and a system-wide status report could be run.
“Once you get over the hurdle of implementation like Trinity has, these sorts of benefits will accrue, but it requires a high level of skill to manage the complexity and begin to realize the opportunities, and I think that is the story of meaningful use that hasn't been told,” says Kramer.
When CIO John Halamka, M.D., couldn't find a system to manage the core clinical systems of the Boston-based Beth Israel Deaconess Medical Center (BIDMC), he and the team that came before him built their own. While implementing BIDMC's CPOE system in 2004, Dr. Halamka decided it had to be Web-based. “If you want CPOE on any device including an iPad, you want it on the Web, with any browser, any operating system, anywhere, and you want it fully integrated into every other system that you have,” says Halamka. “There wasn't a vendor product that did that.”
It took a year to complete the CPOE roll-out, but since it has been in place, BIDMC has been reaping core clinical benefits. Adverse drug events decreased 50 percent between 2004 and 2007, and the hospital is on track to achieve zero-percent adverse drug events by 2012, says Halamka.
Before instituting CPOE, the hospital was an early pioneer of the electronic health record (EHR), building its own ambulatory EHR in 1977. By 1985, the hospital had reached 100 percent physician adoption. BIDMC has gotten so sophisticated that it already fulfills many of the higher-level meaningful use requirements, such as sending an inpatient or outpatient summary upon patient discharge to the next provider of care. BIDMC, a member of the New England Healthcare Exchange Network (NEHEN), has been sharing insurance eligibility with other NEHEN members and submitting claims electronically since 1997, and it recently added e-prescribing and clinical summary exchange. BIDMC has also been working with the Massachusetts eHealth Collaborative to build a state-wide quality data center to act as a registry capable of storing all of the meaningful use quality measures.
According to Halamka, meaningful use is not about the product; it is about people. “No vendor can guarantee meaningful use; if they say it, they're lying,” he says. “So the hard part is how you ensure that a clinician e-prescribes, how you ensure that a clinician updates a problem list.”
One way BIDMC solved this problem was by changing its medical staff bylaws in 2007 to require doctors to use its clinical information systems as a condition for keeping staff privileges at BIDMC. To enforce the bylaws, random quarterly audits are performed, and have shown a compliance rate of upwards of 96 percent.
“There's been a culture for 30 years at Beth Israel Deaconess of clinicians being directly involved in the design of systems,” Halamka says. “Since there is such tight clinician involvement with IT, we have done quite a lot of work over the years that prepared us for meaningful use. We didn't have too big of a gap to fill when the proposed regs came out.”
MEANINGFUL USE MICROCOSM
Summa Health System unknowingly got its start toward meaningful use adoption six years ago when it instituted its CPOE system in its two flagship hospitals: Summa Akron City and Summa St. Thomas, both in Akron, Ohio. The hospitals had both been on electronic medical records (EMRs) since 2006. It was the summer of 2009, after the American Recovery and Reinvestment Act and Health Information Technology for Economic and Clinical Health (ARRA/HITECH) Act legislation was released, when Summa System CIO and vice president Greg Kall and CMIO Charles Ross, M.D., came together to start brainstorming a master plan to link up the entire Summa System.
As Dr. Ross tells it, Summa has followed a different path toward meaningful use than other health systems that are now building a single integrated system for their clinical information systems. Summa had to build upon systems they had in place seven years ago and link up additional systems as they came.
In the fall of 2009, Summa's leaders built out their CPOE, a single enterprise version of the core EMR product from the Westborough, Mass.-based eClinicalWorks, at Summa Barberton in Barberton, Ohio and Summa Wadsworth Rittman in Wadsworth, Ohio, as well as their employed physician group Summa Physicians. The team also began making enhancements to the Computer Programs and Systems Inc. information system at Summa Wadsworth Rittman Hospital, which included the addition of CPOE functionality. Summa Barberton Hospital, which was already using QuadraMed's Revenue Cycle System, began implementation of the QuadraMed QCPR EMR system in the fall as well.
Since the Summa Western Reserve Hospital in Cuyahoga Falls, Ohio was acquired in early 2009 and the Summa Physician group opened in 2005, a need to connect those institutions to the others was imperative.
“To some extent, Summa Health System is a microcosm of the issue across the country of having different levels of functionality and different computer systems in place,” Kall says. “The problem that the government is trying to solve in terms of interoperability in the movement of clinical information from place to place is the same type of problem our organization faces. The cost of replacing all our systems with the same system is too much of a hurdle for our system to overcome.”
As an alternative, Summa made the important decision to link the hospitals’ disparate systems by an enterprise master person index (EMPI) from eClinicalWorks Electronic Health eXchange, making it easier for clinicians to use the Web to access patient information across the health system. About 300 providers currently access lab and radiology results with the EMPI, which Kall feels is like a great grassroots start toward a health information exchange. He hopes to eventually link the EMPI to the Ohio Health Information Partnership (OHIP), which received $50 million from the state's budget and HITECH provisions in ARRA.
“We have a head start; we began this process a long time ago by implementing clinical IT systems. So we don't have the challenges of physician adoption or the resistance of change to clinical processes as much as some other organizations might have if they're just beginning this journey,” says Kall. “These types of changes take a long time to embed themselves in the culture of an organization.”
MU COMES IN ALL SIZES
Children's Hospital of Pittsburgh (CHP) vice president and CIO Jacqueline Dailey and CMIO James Levin, M.D., Ph.D., agree that improving patient care has always been their goal for implementing clinical information systems, rather than the promise of federal dollars.
“We got meaningful use from the system at that very point of that first implementation [of CPOE] because we provided physicians with guidance in terms of ordering their pediatric orders, order sets and protocols, and weight-based dosing,” says Dailey.
In 2002, CHP decided to implement CPOE to eliminate transcription errors for patient orders, even before rolling out its complete EHR. Before 2002, health unit coordinators and nurses had transcribed paper orders from physicians, a practice that sometimes resulted in errors in translating the orders. In pediatric care settings, a simple slip of a decimal point in medication dosing could be life-threatening. Taking out that extra step in the order process and having doctors directly input their own orders was a huge step forward for the organization.
Another leap forward toward meaningful use was when CHP moved to its new completely paperless campus in June 2009. In preparation, the hospital fully implemented its e-record. Because of the young age of its patients, the CHP IT team had to personalize its EHR accordingly, says Dailey. Pediatric clinicians have to document different criteria compared to an adult while taking a child's history, so behavioral selections like crying and sleepiness were given within patient assessments.
Dr. Levin says CHP's patient population poses challenges with privacy issues on the road toward meaningful use. “It's very challenging to do a personal health record for children because it's their parents who are accessing the record,” he says. “And in every state, adolescents have the right for some of that information not to be shared with their parents.”
Levin and Dailey say the keys to their success are constant IT rounds to get bedside clinician feedback and their extremely mobile IT staff. “It really has evolved to not [giving] specific training on using the EMR-it's training for doing your job, because there's really no clinician who can do his job without using the e-record,” Levin says. Dailey's proactive IT staff of 12 doesn't wait for clinicians to report problems; it makes rounds doing short tests on all clinical workstations. Even CHP's C-level executives make patient safety rounds to get feedback on clinical workflows, and as Dailey attests, the clinicians are not shy with providing their comments.
“We pay very close attention to the workflow by the nurses and other clinicians by doing a lot of rounding, having a lot of design meetings with bedside clinicians to make sure we get the system implemented in a way that is useful for them,” says Dailey.
Healthcare Informatics 2010 September;27(9):14-19