Children’s Hospital Boston is a 396-bed pediatric medical center that treats more than 527,500 patients annually and is the primary pediatric teaching hospital of Harvard Medical School. Children’s is a certified Magnet hospital for nursing excellence, and was ranked first in five specialties in the 2009 edition of America’s Best Children’s Hospitals as featured in U.S. News and World Report. Recently, HCI Associate Editor Kate Huvane Gamble spoke with Senior VP and CIO Daniel Nigrin, M.D., and CMO Eileen Sporing about the importance of involving nurses when selecting and implementing IT systems, the issues they’re looking to solve in rolling out technologies, and the fundamental differences in caring for pediatric patients.
KG: You’ve both been at Children’s for quite some time. As CIO and CMO, how often are you in communication?
DN: We meet at least on a weekly basis as part of our clinical systems implementation. To be clear, the “project” is essentially over; we’ve implemented the original project that we intended to do, but we recognize that we’re far from done. We continue to have new needs and need to improve upon the things that we’ve already deployed. We meet as part of a team at a minimum of every week, if not more than that.
ES: I would say that our work collaboration is continuous. I think there are very few weeks that go by that one of us isn’t in the other one’s office a couple of times asking for advice or giving information or looking at how we can provide leadership around these solutions together. I would say that it’s a really important collaboration for me, and probably one of my most important ones. I think there’s very little that I can independent of my relationship with Dan to ensure that we’re created the right infrastructure to enable our clinicians to provide safe care.
KG: What is your IT philosophy — would you consider Children’s to be cutting-edge?
DN: I think we are, at least we consider ourselves to be at the leading edge if not the bleeding edge as we sometimes say. I think we recognize that the technology definitely gives us an opportunity to improve upon the care that we deliver and to make our clinicians’ lives easier. So we try and implement technology when we believe it can do those things.
ES: That being said, though, there are challenges in pediatrics related to the state of vendor capability to support pediatric care. For example, in the world of academic medical centers, our implementation of our clinical electronic medical record was more recent than in many adult-oriented academic medical centers just because of the challenges in pediatrics.
But I do think we are on the leading edge of development for solutions to those challenges.
KG: I want to talk about some of the IT challenges relating to pediatrics, but before we get there, can you tell me about your process for selecting technologies? Who is involved in the discussion?
DN: One thing I think we recognized early on is that any IT project, whether it’s clinical or nonclinical, is dead in the water if you don’t involve your stakeholders throughout the entire process. That’s obviously very true on the clinical side, so with respect to wireless technologies specifically as they relate to nursing, we try to engage our clinicians and clinical leaders from the nursing side of the organization right from the get-go, from the initial idea to RFP process, to vendor selection, to site visits, and then all the way through the implementation process.
ES: Dan and I have been the executive leaders of our clinical information solutions since we started thinking about those clinical information solutions. It’s always been a partnership, and that gets modeled everywhere else within the organization. So there are physicians, nurses, and pharmacists involved in every step, from the decision about what needs to be done, all the way to vendor selection, to the development of the solution to meet our needs.
KG: How critical is it that nursing is well-represented in this process?
ES: Very critical. We’ve had, since we began to implement a clinical system, nurses involved from almost every practice in the hospital. We’re a very specialized pediatric organization, and solutions that work for nurses in the physicians in the ICUs don’t always work in the non-ICUs, and so we’ve just used the same strategies for staff involvement that we use for everything else.
We’ve had a shared leadership model in nursing for well over 20 years, and so our nursing staff is very capable of stepping forward when leadership is required in any area. This is not unusual for us.
DN: Another important thing is there are paid physicians on our implementation team now that are staffed by nurses who have found an interest in medical informatics and IT solutions in general, and are now working on these initiatives, in some instances full-time.
KG: I’m sure it makes a difference when it comes to adopting technologies if the nurses have been able to provide input on which solutions are chosen.
DN: When you hear about EMR systems implementation, the focus is always on the physician. For example, the physician is the one who has to do CPOE. As a physician, I feel comfortable saying that while that’s important and it’s obviously a big impact on the workflow of physicians, I think many institutions don’t recognize the impact it has on nursing workflows and nursing processes, and it’s absolutely critical that you involve the nursing organization when you do these things if you’re hoping for success. And I think it’s a mistake that a lot of organizations make; they concentrate so much on the physicians and the political battles that they forget about involving the nurses as much as they ought to.
ES: I think the real emphasis on that point has to do with workflow. Physicians and nurses have different workflows, and unless both clinical perspectives are at the table, you’re doomed to failure, either with the physician adoption and integration of the technology, or with the nursing acceptance and driving to solution.
KG: In terms of your IT goals at Children’s, what are the biggest issues you’re trying to solve? Is improving communication a priority?
ES: I think that workflow and patient safety are the biggest issues we’re trying to solve. I think we have pretty robust communication across and within clinical disciplines in this institution, and we’ve implemented technology to support that all along — well before we implemented our EMR. The communication devices we’ve used include PDAs, BlackBerry devices, and telephone technology to support real-time communications. If you were to ask our clinical staff if they’re burdened by not being able to access their colleagues, I think they would say no.
On the other hand, the challenges in implementing electronic medical records for nursing are real because most EMR solutions call for linear processing and that’s not the nursing workflow for the most part. Nurses are managing a panel of patients at any one point in time and are multitasking around all of those patients, and the technology doesn’t really support that kind of work as we wish it all did. So we’re constantly trying to solve that problem.
KG: Do you have a patient flow or bed management system in place at Children’s?
ES: We do. We’ve implemented a bed management system, and some of the nurses and other staff in support services are very accustomed to working with that technology. And I do believe that has improved a lot of our patient care processes. But again, we did that in collaboration with our medical staff colleagues as well, so there’s very little that we do where a partnership is not involved.
KG: Have you found that it has helped improve efficiency among the staff?
ES: Absolutely; we’ve taken a lot of time wasters out of the process, and were able to feed back data to people so that we know exactly how long it takes to identify where capacity is and how we can get patients moved as quickly as possible. So I think there’s a high level of satisfaction, and that the system is an enabler of improved process.
KG: When did the system go live — was it recent?
ES: Yes, it was in the last year. We took a lot of manual process away, from the nurse having to make five phone calls and wait and not know when, for example, the housekeeper would be available to clean a bed. Or getting calls from the ED for a patient needing to move or from the recovery room for a patient needing to move. So we’ve eliminated all of those processes and that’s been enormously satisfying.
We have not implemented all of the capacity in our patient management system, so we’re looking forward to continuing to look at how to leverage that technology to support workflow as well.
Part II coming soon