A few months ago, New York City-based Memorial Sloan Kettering Cancer Center’s (MSK) Josie Robertson Surgery Center (JRSC) opened to patients as an outpatient cancer surgery facility specially designed for those who need to stay for only a short time and do not require inpatient hospitalization. Officials at MSK attest that the facility was specifically designed around the patients’ needs, with features allowing them to leave the hospital sooner and recuperate in the comfort of their own homes.
At the core of this infrastructure are new technologies that MSK officials say make the new 16-story building housing 12 operating rooms on the borough of Manhattan’s Upper East Side a “smart” one. The informatics motivation came down to finding ways to keep patients at the center of their care and advance the ability to incorporate patient-generated data, provide new forms of cognitive support, and support team care coordination around the patient, says Pete Stetson, M.D., chief health informatics officer for Memorial Sloan Kettering. “So we did that with a smart building, smart patient, and smart team approach, rather than the standard deployment of an electronic health record (EHR) and a portal,” he says. “We wanted to re-envision the way we would deploy those systems and push them as far as we could all the way to the edge to wrap around the patient as opposed to having the patient do whatever we need them to do. And to do that, you need to have the building itself as an agent in the care of the patient.”
As chief health informatics officer, Stetson is responsible for the division of health informatics and health information management at MSK, a job he has had for about a year. He says that there are four main levels of innovation at the new facility—cognitive support, communication support, patient-reported outcomes, and data about where patients and care team members are in the building. “We are incorporating patient-generated data for the first time at MSK through a way of collecting patient-reported outcomes and getting those into clinical workflows and clinical systems. We are also finally wiring up the building with a real-time location system [RTLS],” he explains.
Pete Stetson, M.D.
Much of this innovative work was part of a year-long process prior to opening Josie. Stetson says they are now hooking together systems “which are not hooking up anywhere else in the country.” We have Epic OpTime which is our OR [operating room] system connected to Versus, which is an RTLS system with bi-directional interfaces. We have connected Versus and Allscript’s Sunrise clinical Manager, and we have new connections from Epic OpTime with our EHR from Allscripts. We have applied a bunch of rules to make the [systems] communicate and talk to each other, and be as smart as possible,” Stetson says.
Alongside Stetson at JRSC is Dan Stein, M.D., Ph.D., director of preoperative informatics and innovation at the center. Stein points out some of the non-IT-focused elements of the center, such as the look and feel of it, the furnishing, and the amenities for the patient and his or her family. “The goal is that the patient gets up and out of bed, due to this being an ambulatory cancer surgery center. The whole layout was designed to make it as convenient as possible for the patient, given that it’s a cancer center,” says Stein, who even slept in a hotel room across the street during the go-live period to make sure he was available in a pinch if necessary.
Dan Stein, M.D., Ph.D.
But key to the enhanced patient experience is indeed the technology, Stein acknowledges. At a basic level, the interfaces between the real-time location system and some of the facility’s clinical information systems allow for the automation of time stamps that otherwise would have been done manually, such as when the patient arrives in the OR, or when he or she leaves the OR, Stein says. “OR utilization or turnover are things that are usually done manually and subject to human error. Automatically populating information is something that’s really beneficial when thinking about analytics and ways to optimize the system,” Stein says.
Other technology advancements are inside patients’ rooms, as they have TVs and “infotainment” systems with educational materials and entertainment mixed. Stein says. Also, there is integration with that and the RTLS systems so when a member of the staff, be it a nurse, physician, or assistant comes into the room, because the room is smart and knows who is walking in, the system can display the name of that person and his or her role on the TV in the patient’s room. “Oftentimes patients can be disoriented given the situation they are in, so this makes for a little better of an experience. They know who is coming in or out,” Stein says.
Further, the facility has a display board in the area where the patient’s family is waiting, where there is a coded identifier for the patient who is having the surgery, and the family members can watch as these time points progress, so they can see when the patient is in the OR, when he or she is out, and when he or she is ready to be seen. This way, it’s not just the staff who is knowing what the progress is, but also the family members, Stein notes.
To this end, Stetson says that the JRSC informatics team integrated care pathways order sets in its EHR, which trigger a set of activities on nursing flow sheets. The nursing flow sheet documentation is assembled by a set of medical logic modules, or MLMs, a standard in informatics around alerts, Stetson explains. “What we did was take the documentation from the nursing flow sheets and aggregate that into different statuses for the patient. And we use that to determine whether the patient is progressing along the domain-specific pathway on his or her way to a safe discharge in a timely fashion,” he says. “Because this is an ambulatory surgery center, these are mostly same-day procedures, and we want to know which patients are at risk of not ambulating fully, or not getting discharge instructions done, and these are shown on status boards in our EHR that the nurses have access to on a population level. So it is basically population health management in real time across the building,” Stetson says.
What’s more, Judy Hagerty-Pagilia, vice president of health informatics at MSK, says that the team internally developed a patient portal, allowing the push of information to the patient for educational purposes in advance of scheduled procedures. The next step, Hagerty-Pagilia says, is to collect clinical information upfront that would be typically collected during the first encounter. As Stetson notes, “This allows us to extend T-minus 10 days before the surgery all the way out to T-plus 30 days after the surgery to get input from the patients on how they are doing. “We collect patient-reported outcomes before the surgery and we will be sending them symptom scores through the portal for structured data collection on their outcomes after the surgery so that we can inform the surgical teams how the patients are doing based on these self-reported outcomes,” Stetson says.
On a quiet day, JRSC might have just shy of 20 cases, with the busy days having up to 38 cases. The facility doesn’t expect to be at this full capacity for quite some time though, its informatics leaders say; for the first year they will get about 8,000 cases in sum, while in future years, as feedback gets collected and refinements made, that number might be doubled. “One of the core strategic objectives for this facility was to deploy it as a learning health system,” Stetson says. “We want the data we get back from our systems to inform the future design of those systems. We are collecting data on the people, processes, and tools, and how they’re used in order to better understand how we can better take care of patients. It’s about using the data we gather from before, during and after the surgery to decide which patients are best for same-day operations, as opposed to going to the main ORs and being inpatients for a few days. And we’re using predictive analytics to determine that,” he says.
Another key success factor for the deployment of JRSC was that the project was led by clinical leadership. The director, Brett Simon, M.D., is an anesthesiologist, and a lot of this was his vision for change in the way surgical care is provided for patients, Stetson notes. “We enlisted key team members from the surgical teams and we had extremely strong nurse leadership in the design of the systems. There is a nursing informatics group at MSK that took a lot of the lead in puzzling through the workflow that nurses would need to do to use these new systems,” he says. “The way we did it and got through the change management aspects was having it be a clinically-led project. Our objectives, goals and metrics are derived from the clinical leaders.”