Point of Care Series: Part 1
The following story is the first installment of our three-part series on point-of-care issues. In this piece, we look at the broad trend toward improving patient safety through IT adoption. In part two, coming in September, we will study the vital area of medication safety. October will feature part three — an examination of devices that have shown to improve safety by allowing clinicians to move order entry to the point of care.
HEADLINE: Split-Screen Sensation
DECK: Patient safety moves forward in some hospitals — but, seven years after "Quality Chasm," progress is still spotty
by Mark Hagland
It really is one of those classic "glass-half-full-or-glass-half-empty" questions. Is patient safety improvement making progress in the nation's hospitals? Or do most U.S. hospitals remain mired in the old culture of reactive correction? The answer depends on where one looks and whom one asks.
The picture is mixed. On the one hand, says Carolyn Clancy, M.D., director of the Rockville, Md.-based federal Agency for Healthcare Research and Quality (AHRQ), "We've seen some impressive momentum, where over half of the nation's hospitals are participating in the 100,000 lives campaign" of the Boston-based Institute for Healthcare Improvement (focusing on a nationwide effort to save lives through safety improvement efforts).
"And we get letters every day from hospital leaders asking us to help them improve patient safety. So awareness is way up, and certainly some early steps of activity have been made. Adoption has been slow for CPOE" (computer-based provider order entry), she acknowledges; "but what people are realizing is that the key is not just IT, but IT embedded into a culture that focuses on averting harm in every step of patient care. And that realization is becoming less unusual."
On the other hand, Paul Ehrlich, M.D., a vice president in the clinical consulting practice at Long Beach, Calif.-based First Consulting Group (FCG), says, "I don't think it's become clear to everyone yet that hospitals need to become proactive about patient safety improvement."
In fact, West Orange, N.J.-based Ehrlich, who practiced 14 years as an obstetrician/gynecologist, says, "Most hospitals are still reacting to patient safety issues as opposed to being proactive. They're reacting to activity on the part of the JCAHO (the Oakbrook Terrace, Ill.-based Joint Commission on Accreditation of Healthcare Organizations) and various external and internal incidents, including sentinel events they're having, as opposed to determining how to be proactive in making their organizations safer."
A senior executive at JCAHO says it's important to put all this into perspective. Paul Schyve, M.D., senior vice president, says of the long journey towards improved health system patient safety, "I think we're at an interesting beginning, actually. There is pretty much a recognition now that patient safety is something that we need to focus on. If you went back before the first IOM report, that wasn't true," he says, referring to the federal Institute of Medicine's famous "Crossing the Quality Chasm" report released in November 1999. "The IOM report woke everyone up."
Now, the health care system is moving into the "hard work" of actually putting in place all the tools, including facilitative IT tools, to improve patient safety at individual hospitals and health systems.
Pioneers moving forward
There's no question, those interviewed agree, that many hospitals have either not yet begun serious patient safety improvement efforts, or are just setting onto the path. A variety of theories have been advanced for this relative slowness, including a lack of resources and conflicting organizational priorities. But a number of pioneering organizations are showing that serious gains can be made, with strong IT facilitation, in communities as far-flung as San Diego, St. Louis, and Spartanburg, S.C.
For example, at Missouri Baptist Medical Center in St. Louis, patient safety officer Nancy Kimmel, Pharm.D. can cite an impressive list of accomplishments, particularly with regard to adverse drug errors (ADEs) — one of the most important and worked-on patient safety improvement areas nationwide.
Using a variety of tools, including core electronic medical record (EMR), laboratory, and pharmacy systems from San Francisco-based McKesson Corporation, as well as a self-developed BJC medication alerts-based system called the Pharmacy Expert System, Kimmel and her colleagues have created significant advances. Those clinical information systems are, in fact, universalized across 13-hospital, St. Louis-based BJC system of which Missouri Baptist is a member.
When the Pharmacy Expert System went live in early 2001, Missouri Baptist was recording 3.0 ADEs per 1,000 doses; soon after the new system implementation, that figure dropped to 1.0. Using a paper-based trigger tool that alerted clinicians to intervene when patients appeared to be at increased clinical risk, Missouri Baptist clinicians drew the figure down to 0.6/1,000; and, since the tool was automated in 2004, the average has fallen to 0.14 ADEs per 1,000 doses — in other words, 1/20th the number of such incidents as when the program began.
Meanwhile, at Novi, Mich.-based Trinity Health — a 45-hospital system spread across Michigan — a broad-based program called CareExperience, the implementation of an EMR across 24 of the organization's facilities, is also being used to improve patient safety system-wide.
Trinity's Narendra Kini, M.D., executive vice president, clinical operations improvement, reports that a core element of the program — the organization's confidential medical error reporting system, implemented four years ago at every Trinity Health hospital — has amassed 45,000 entries: one of the largest databases of its kind in the United States.
"It's a great area for us to analyze and innovate from," says Kini, who is also leading the vast EMR implementation. "We've made substantial policy, procedure, and clinical workflow changes" using data collected from the reporting system to improve patient safety. (Trinity Health uses Kansas City, Mo.-based Cerner Corporation's EMR as its core clinical system.)
Among the key results of the system-wide patient safety initiative: annual drug costs have been reduced by $18 million across Trinity Health; 25,000 physician orders have been changed because of alerts and interventions coming from the system; and core clinical indicators across a wide spectrum of areas have improved. This includes timely administration of antibiotics, and increased volume of discharge instructions and of smoking cessation counseling, Kini says.
At San Diego's Sharp HealthCare system, senior vice president and CIO Bill Spooner reports that the 1,800-bed system (with four acute-care hospitals and three specialty hospitals) has a number of initiatives ongoing, including the use of a computerized intravenous pumps/medication safety system.
In fact, Sharp was one of the two pilot organizations implementing the system (from Dublin, Ohio-based Cardinal Health) in a wireless context, Spooner notes. Sharp has also implemented what its leaders call the "harm monitor" to provide alerts and detect emergent conditions in inpatients, using technology from San Diego-based Clinicomp, Intl.
Nancy Pratt, R.N., M.S.N., Sharp's senior vice president of clinical effectiveness, says with regard to the computerized IV pumps with automated dosing alerts, she found through analysis that within a two-month period at one system hospital 13 situations occurred in which alerts required nurses to reprogram the pumps, therefore shielding patients from potential harm.
Why such a strong initial focus on intravenous drugs? "We know that of the five groups of very powerful drugs, three — anticoagulants, narcotics, and insulin — are all given regularly by continuous infusion."
IT a key
Of course, IT is a facilitator in all this, most agree. In fact, in a number of areas — data collection and analysis, clinical decision support, and bedside technology — significant improvement is impossible without IT. The key, says Sharp's Spooner, is that the results come from "technology effectively applied, not just technology. We've adopted some of the processes that our quality people have used for some time, such as failure mode effects analysis — a technique for quantifying and managing risk around any process. We've applied those to critical interfaces to the workflow and design around our CPOE pilots" and in other areas, he says.
Ray Shingler, CIO of two-hospital Spartanburg (S.C.) Health System, agrees that the key is to develop a patient safety strategy and create and implement tools around that strategy. He and his colleagues have developed a non-punitive reporting system for events, and have also invested in a smart pump system from Cardinal, much like Sharp.
Among lessons learned was the importance of user-friendliness, Shingler notes. When only two-thirds of nurses initially used the new pumps, the organization did a reassessment and a reeducation program. As a result, the acceptance rate soared to 96 percent of nurses, and 1,423 potentially harmful events were averted within a year.
Broad health system barriers remain to universalization of patient safety improvement efforts. Among these, says FCG's Ehrlich, are funding issues, a deeply embedded culture of silence and individual blame in the Unites States. Nor does Ehrlich believe that the emergence of federal Patient Safety Organizations under the Medicare program (created by the Patient Safety and Quality Improvement Act of 2005) will provide a definitive push for hospitals.
Instead, experts agree, the same pressures forcing increased efficiency, cost-effectiveness, and accountability onto the healthcare system also argue for the inevitability, after much struggle, of patient safety improvement. Critically important is physician involvement.
"You must first involve physicians," says Trinity's Kini. "Second, there needs to be a set of core applications in order to enable intelligence." Some level of EMR implementation is crucial for decision support, though even simple decision support can translate into substantial gains in safety and quality. "It's a challenging journey," says Kini. "But in the end, I'm optimistic."