Few hospital organizations have taken the idea of transforming patient care quality as far as Boston's Brigham and Women's Hospital. In 2000, leaders at the 747-bed academic medical center, which is one component in the vast Partners HealthCare system, created a special Center for Clinical Excellence (CCE), with a full-time staff of clinicians, and a mandate to improve patient safety across the Brigham organization.
Among many elements of the work being spearheaded by the CCE — led by Michael Gustafson, M.D., vice president for clinical excellence and executive director of quality and safety, and Tejal Gandhi, M.D., executive director of quality and safety — has been the initiation of so-called Patient Safety Leadership “WalkRounds.” These involve multidisciplinary executive and clinician leader rounds in various clinical departments; the creation of an integrated patient safety team; and the ongoing development of a consistent, data-intensive process for patient safety event analysis by CCE leaders and analysts.
As part of this ongoing umbrella initiative, every patient safety incident is not only reported, but analyzed; and clinician leaders and executives hear weekly from frontline clinical staff about their patient safety concerns during the WalkRounds process. With constant quality improvement as their charge, CCE clinician leaders are seeing continuous improvement in care quality and patient safety, Gustafson reports. As a result, the hospital has won a slew of national healthcare quality awards, and become a model for other patient care organizations.
At the core of the operational challenge for innovators like Gustafson is the nexus where data meets people, he stresses. “You can't really start having effective relationships with physicians, nurses, and others, if you don't have good integrity of data,” says Gustafson, who practiced as a general surgeon for many years. “You've got to have very clean sources and definitions of data and good integrity of data in order to get basic buy-in from physicians. That integrity is a part of our reputation.” And, he adds, IS departments on their own often produce data and reports that aren't genuinely helpful to clinician leaders like himself. But he credits close collaboration with vice president and CIO Sue Schade and her team as bringing about the IT support he and his team have needed.
In 2010, when clinical documentation is rolled out, the hospital will have a constellation of systems to support the organization's ongoing clinical improvement work, Gustafson and Schade agree.
The challenges are many, but so are the opportunities, Schade emphasizes. “I think everybody can and should do this, and they can do it with different degrees of investment.” Very importantly, she says, CIOs need to think about the strategic implications of their clinical IS rollouts, even if their organization is not actively planning for intensive analytics work.
Indeed, Schade speaks from experience. “If you're focusing only on getting some core clinical systems rolled out, but not also planning for what the back-end reporting and analytics need to look like, you're selling yourself short,” she says. “We rolled out the eMAR (Electronic Medication Administration Record) for most of our inpatients, but we didn't account for the back-end reporting tool for that, so now we're trying to juggle the resources for that back-end reporting system.”
For organizations like Brigham and Women's, which have a commitment to improving patient care quality and safety, she says, the right IT setup is critical.
Nationwide, a slew of initiatives
Nationwide, a number of hospitals and health systems are moving to harness information systems in order to provide analytic data that can help clinicians improve patient care quality and safety. Among them:
At the 606-bed Maine Medical Center in Portland, clinician and executive leaders have been developing a broad range of improvement initiatives using data analytics tools (like the folks at Brigham and Women's Hospital, the Maine Medical Center is using tools from Cary, N.C.-based SAS). “We use the business intelligence tool as an analytic tool, but also as the mechanism by which we try to keep the physicians and staff abreast of our priorities and our progress on achieving those priorities,” explains Doug Salvador, M.D., patient safety officer and associate chief medical officer at the hospital. “So we've worked with more and more physicians in groups on new key process indicators, and then found forums within those groups to regularly review those sets of data.” Among the many initiatives at Maine Medical Center has been one around the use of blood transfusion in cardiac surgeries. Following up on national clinical studies that found blood transfusion was done too often in cardiac surgeries, Salvador and his colleagues have reduced blood transfusion rates for those surgeries from 60 to under 20 percent, while saving at least $300,000 in the past two years on the cost of acquiring blood products.
At Gaston Memorial Hospital in Gastonia, a suburb of Charlotte, N.C., clinicians have developed an innovative program that is providing them with real-time alerts for handling cases of MRSA (Methicillin-resistant Staphylococcus aureus) and Clostridium difficile bacterial infections. Using the Safety Surveillor product from Charlotte, N.C.-based Premier Inc., as well as the Soarian products from Malvern, Pa.-based Siemens Medical Systems, clinicians at Gaston Memorial have been making significant progress in managing and minimizing bacterial infections in inpatients, reports Jan Mathews, R.N., director of clinical performance improvement at the 435-bed regional community hospital.
At the nine-hospital, Omaha-based Alegent Health, vice president and chief quality officer Mark Kestner, M.D., and his colleagues have been initiating a series of care quality improvement projects, using data derived from the organization's clinical information systems, under an umbrella process called Quality Accelerator. “We're using the diffusion theory with regard to designing new processes, testing them in a controlled environment, undergoing rapid-cycle change, and then diffusing completed, vetted processes across the organization,” says Kestner. Among the numerous projects initiated so far are a reengineered, automated medication-reconciliation process that has increased the percentage of time nurses spend on patient care each day; and the development of a program that has automated nurses' verbal reports to each other at the time of shift handoff.
At the 500-bed VA North Texas Health Care System in Dallas, William Yarbrough, M.D., a staff physician, and his colleagues have used continuously fed clinical IS data to dramatically reduce catheter-related bloodstream infections in the hospital's medical and surgical ICUs. Automation of the infection monitoring process has been essential to its success, Yarbrough emphasizes. A previous paper-based version of the program failed for a variety of physical and process reasons, he says.
CIOs: It's about clinician-IT collaboration
Two things are becoming clear in the industry, say executives, clinician leaders, and experts. First, the drive towards using data derived from clinical information systems is accelerating and intensifying, with leader organizations demonstrating the many ways such processes can drive care quality and patient safety improvement. Second, making these initiatives work — and even possible — means close collaboration between CIOs and clinician leaders across the entire patient care organization.
Judy Klickstein, senior vice president of information technology and strategic planning at the three-hospital Cambridge Health Alliance based in Cambridge, Mass., says, “We learned early on that the concept of, ‘If you build it, they will come,’ does not work universally. This is incredibly interesting stuff to do, and the performance improvement people love this stuff. But when you start to engage at the line level with floor nurses and nurse managers, it's a little more challenging. So we've learned more about how to engage people — nurses, physicians, line staff and unit coordinators — around this.”
There's no magic solution in that regard, says Klickstein, but she and her team work closely with the quality and performance improvement groups at their health system, which has led to progress in a number of clinical areas, she notes. Among those areas is pediatrics, where there has been improvement in asthma care and the development of a generic disease registry platform for multiple disease states.
John Glaser, Ph.D., vice president and CIO of the Partners HealthCare system, emphasizes, “Fundamentally, this is a clinically led undertaking. The clinical leaders know what measures to look at, and have to fundamentally lead it. If the organization is uninterested, the CIO can't lead this.”
But with clinician enthusiasm for data-driven quality improvement work, major progress is very possible, he adds. The challenge then for CIOs is complex. “We've got to work on two parallel tracks here,” Glaser explains. “One is the analytical process, setting up tools. The second track is all these transactional systems that have to be put in place, all the alerts and clinical decision support and such. And the decision as to whether CPOE comes before or after clinical documentation. There are lots of reasons to choose one over the other; but one factor might be data gaps for analysis.”
Glaser has the advantage of a large staff, including clinical data analysis specialists. One of these is Jonathan Einbinder, M.D., corporate manager for quality data management for the entire Partners system. Einbinder confirms Glaser's perceptions of the path forward. “It's a long journey,” he says. “We've created some of the infrastructure to date, and we've identified opportunities; but to create change is a much bigger challenge.”
The next frontier is creating actionable data on whole populations, something Einbinder and his colleagues are actively pursuing. The goal is to identify patient issues across large groups, such as diabetics, or those who might need clinical interventions across a range of dimensions, and then empowering the right people (dedicated case managers, for example) to do those interventions in real time. What CIOs can do on a strategic thinking level, he says, is to “take a lesson from non-healthcare companies, which generally treat their data and information as a very valuable asset, and to use information to generate competitive advantage, if you will, on quality and efficiency. Healthcare organizations typically don't do that.”
Fran Turisco, research principal in the Lexington, Mass.-based Emerging Practices group at the Falls Church, Va.-based CSC Corporation, says progress will be powered by external and internal pressures. Indeed, she says, the industry has already gone through a series of phases, from voluntary reporting mechanisms to mandatory reporting ones, to full-blown pay-for-performance programs, and now to non-pay for poor performance (such as the recent never-events mandate from the Medicare program).
At the same time, she says, “Reimbursement in general, including from private payers, is going down, and now, providers are starting not to be paid for such events as patient falls. So there are very compelling external factors that are really making hospital leaders sit up and say, ‘What can we do to manage our efficiency and our patient safety issues?’”
Prodded by such developments, hospital and health systems are now moving quickly to implement EMR, CPOE, eMAR, and clinical documentation systems that will help to improve care quality, patient safety, clinician workflow, and efficiency, she says. However, it's unclear whether the tools CIOs need are available on the market. Turisco says vendor products are still not mature enough to power analytics for patient care transformation.
Rick Ingraham, global healthcare strategist for SAS, an analytics vendor, disagrees. “In my mind, the technology already exists, and the emphasis is already there among the payers.” In addition, leader organizations like Maine Medical Center and Brigham and Women's are showing the way forward for their peers, he says. Ingraham's prediction: “At the major urban hospitals, the volume of publicly reported metrics will triple within five years, and you'll see robust analytic systems in every major urban hospital.”
Stephanie Alexander, senior vice president for healthcare informatics at Premier Inc., says, “As hospitals in the nation begin to come to consensus around performance measures, we've made tremendous progress in improving quality outcomes at better value, while at the same time automating those processes and implementing electronic medical records.” A majority of the processes involved in the P4P work that the 260 hospitals participating in the CMS/Premier HQID (Hospital Quality Incentive Demonstration) project remain paper-based, she concedes, but believes that situation will change in the next few years.
Editor’s note: In the print edition of this article, Judy Klickstein, senior vice president of information technology and strategic planning at Cambridge Health Alliance, was incorrectly identified as an M.D. We apologize for the error.