Swift, optimum clinical decision-making depends on healthcare systems delivering the right information at the right time to the right caregiver. Model systems across the country are exploiting a host of technologies such as computerized physician order entry (CPOE), clinical decision support (CDS) and electronic medical records (EMRs), to ensure this better than anyone else while increasing quality, disseminating best practices and decreasing costs. To create comprehensive, intuitive systems, several of the country's most proactive health systems have formed extensive partnerships with health IT vendors to benefit from the vendor's connectivity and software system development knowledge base.
The benefits of clinical IT are phenomenal. Consider:
- A typical 300-bed hospital can save more than $10 million by deploying a today's standard EMR, says Marc Probst, CIO of Intermountain Healthcare in Salt Lake City. The estimate swells to an impressive $14.7 million with a Stage 4 EMR. The Stage 4 EMR is a concept that includes knowledge sharing and advanced decision-support capabilities.*
- University of Pittsburgh Medical Center Presbyterian Hospital (UPMC of Pittsburgh) decreased its rate of medication errors by 55 percent since deploying a positive patient identification (PPID) system to match patients to their medications.
- Duke University Health System in Durham, N.C., reports that its physicians order the appropriate initial tests for 98 percent of patients as part of the initial presentation since it deployed CPOE several years ago. Such solutions are a tall order, even for health IT giants. IT changes, and improves, healthcare across the board; and genuine change in the practice of medicine is seldom easy. "The goal isn't simply to get physicians to use computers; it's to provide them with easy-to-use technology that supports the way they think, automates routine processes and helps them deliver better, more efficient care. That's how you build a system that physicians embrace," shares Michael Russell, MD, associate CIO at Duke University Health System.
- Results at Partners HealthCare in Boston of a decade-long EMR rollout to 3,200 physicians and CPOE deployment at all 11 hospitals include a 55 percent reduction in serious medication errors on the inpatient side and identification of 120 critical and 600 subcritical results requiring follow-up in the average outpatient month.
*Note: Intermountain Healthcare uses its own EMR adoption stage model, not a HIMSS Analytics model.
Patient Data: By the numbers
University of Pittsburgh Medical Center
- UMPC deployed CPOE at four of its 20 hospitals. The system averages 1.4 million orders monthly
- UPMC has invested more than $1 billion in IT over the last five years to improve the quality, safety and efficiency of patient care
- IT staff includes more than 1,100 computing and technology specialists and 200 biomedical engineers
- UPMC supports 200 clinical applications from more than 120 vendors
- IT system includes more than 35,000 computing devices and more than 550 Terabytes of data
UPMC: On the eRecord
UPMC is a health IT giant. Comprised of 20 hospitals, UPMC employs 2,500 physicians, with another 2,500 physicians affiliated with the enterprise. In the last five years, UPMC has invested more than $1 billion in health IT, including a $402 million deal with IBM to overhaul its IT infrastructure. "UPMC has more beds in HIMSS Analytics than anyone else," says CMIO G. Daniel Martich, MD. In fact, two UPMC hospitals have attained Stage 6 HIMSS ranking of EHR progress.
UPMC has staged a multi-front EHR project with CPOE and decision support incorporated as separate modules in the eRecord. "Every component-ER, ICU, OR-is necessary, so we're attacking all areas simultaneously, targeting the most critical needs first. For example, UPMC first deployed CPOE in Children's Hospital of Pittsburgh and expanded from there. CPOE adoption hovers near 90 percent in the four hospitals where its been deployed, says Martich. The CMIO attributes the project's successful adoption rate to physician involvement and leadership in the decision on which vendor or home-grown solution to select, as well as in development, training, implementation and post go-live support. The focus and message of why CPOE is being deployed-quality, safety and patient care-can be translated much more easily when physicians are involved from start to finish in the process, says Martich.
eRecord focuses on providing on-time information at the point of care or what UMPC dubs "automating perfection." The before and after differences in patient care are fairly dramatic. Consider for example patients with catheterized bladders, whose risk of infection increases the longer the catheter remains in place. Prior to the decision-support implementation, a patient might remain catheterized until a physician or nurse remembered to remove it. Now, an automated alert pops up 48 hours after insertion to remind caregivers about the risk of catheter-associated infection. eRecord sites report a 60 percent reduction in catheter-associated urinary tract infections. Other alerts focus on cumulative acetaminophen doses as it becomes toxic to the liver when a patient takes more than 4 grams daily. Because acetaminophen is a component of many medications, patients often receive more than 4 grams daily. With CPOE, an alert prompts the clinician to discontinue certain drugs or order others to avoid exceeding the 4 gram mark. The hospitals have realized a tremendous drop in the number of patients exceeding the 4 gram dose.
The other half of the UPMC environment consists of 500 ambulatory care sites. The national ambulatory EMR adoption rate hovers at 4 to 17 percent, but UPMC has achieved a 60 percent adoption rate and expects to roll out Epic Systems Corporation's EpicCare Ambulatory EMR software to all sites within 18 to 24 months. Universal adoption, however, is just one step in the journey.
UPMC aims to unite the inpatient and outpatient records to provide a standard patient view. Currently, physicians access the ambulatory record regardless of locale, but inpatient use is restricted by geographic zones.
The enterprise record is a tall order for a health system that uses 200 clinical applications. UPMC supports 650 interfaces, but the reality is that not every system can be interfaced to every other system. "It would be unscalable among 200 applications," explains Martich. So, UPMC's scalable solution rests on its interoperability or aggregator platform. UPMC's chosen aggregator is dbMotion. According to Martich, dbMotion has shown it can interoperate with multiple different vendor products. The initial plan taps into dbMotion to pull essential clinical data from both the major inpatient and outpatient applications of the enterprise to present physicians with a core set of patient data that includes medications, allergies, labs and immunizations. The capability drives improvement in the transfer of care between inpatient and outpatient settings, says Martich. For patients, it should produce such benefits as reducing unnecessary tests-like being re-stuck for bloodwork performed in separate venues.
Patient data: The next stage
The U.S. will continue to evolve in the next decade with early and mid-tier adopters reaping benefits from pioneers' projects. Take for example Duke University Health System. As the academic powerhouse collaborates with McKesson, the vendor makes the content available to its other customers. UPMC and IBM created a joint-venture fund aimed at commercializing solutions that may benefit health providers beyond UPMC. "Several concepts are in the development pipeline," confirms Martich.
At Intermountain Health, Probst continues to think big, envisioning an eventual global transformation of healthcare enabled by Stage 4 EMRs. "The difference between current Stage 3 EMRs and Stage 4 systems centers on advanced decision support and data sharing," states Probst. Stage 4 records will provide the ability to share knowledge and protocols among institutions. For example, a Chinese hospital could digitally disseminate SARS best practices to educate and inform providers around the world.
Next-generation clinical decision-making
Harnessing IT to disseminate patient data and best practices and improve clinical decision-making is a healthcare essential. "The process is relatively well understood. Success requires organizational leadership, workflow changes and good tech choices. But that doesn't mean it's easy. It's a long journey," advises Partners' Glaser. Benefits accrue and accelerate along the way, and they come in all forms-improved patient care, financial savings and greater efficiency. It is the medicine healthcare needs.
The above is an abridged version. The complete article is available on-line at CMIO.