Healthcare IT at a Crossroads
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Automation Angst
This infusion of cash and automation is heightening tensions around IT, though, and the strains are beginning to show:
In a handful of recent surveys, nurses say many benefits of technology are outweighed by clumsy user interfaces and time-draining sign-on procedures that are impractical in the crush of daily work.
Risk managers worry about the rush to automate without adequate planning and training. “One of things that concerns me is the speed at which we are trying to implement new technology and processes. Too often, a tech solution is slapped on top of a manual process without a thorough review of the process itself, and the impact it might have on related processes,” says Douglas J. Borg, director of insurance for the Duke University Health System, Durham, N.C.
Hospital executives are scrambling to figure out the legal implications of relying on digital records as new “e-discovery” laws require hospitals to quickly deliver every electronic document requested for legal proceedings.
Government and private payers contribute their own challenges with pay-for-performance rules that pressure hospitals to spend money on statistical systems for analyzing outcomes and reimbursements.
In the middle of it all are CIOs, who must bridge the old and the new, often learning their evolving role on the fly. “[CIOs] are much more engaged in the fabric of the actual day-to-day operations,” Lawonn says. “We’re using IT at the point of care, and we’re interacting in real-time with nurses, physicians, physical therapists. Our interactions today are within the workflow of how you provide patient care.”
All of which leaves hospitals with IT growing pains. “The reality,” says Vi Shaffer, research vice president for Gartner, “is that having more information more accessible changes the rules for everyone.”
Fault Lines Appear
To many people’s surprise-and relief — healthcare is starting to outpace certain other industries when it comes to technology adoption. For example, while a study published in December 2007 by Diamond Management and Technology Consultants found only a third of CEOs across American industries championed technology and included CIOs in strategic planning, almost 70 percent of healthcare respondents say the senior business leader is an active IT proponent. By similar percentages, healthcare organizations say the CIO and the person in charge of business strategy were both “very involved” in the integration of business and IT.
However, a study by Spyglass Consulting Group found that 64 percent of nurses consider wireless infrastructure too unreliable to support point-of-care applications, a prime component in bedside documentation for EMRs. So-called wireless “dead zones” make network access impossible or drop established connections. As a result, most acute care nurses say they keep PC carts in hallways and out of patient rooms, instead preferring to use them like fixed-location terminals.
The Spyglass study also reported that point-of-care applications typically don’t integrate well with nurses’ work practices. For example, to use a bar-code reader prior to administering a medication, a nurse must find a mobile cart, wheel it into the room, log in to the system, find the patients record, and then finally scan the medication. “It just takes phenomenally longer than what nurses are used to doing,” says Gregg Malkary, Spyglass managing director.
So how do nurses respond? “In some organizations, nurses are cutting off all the patients’ wristbands and wanding them all at the nurses’ station. The idea is, ‘If I can do everything at once, I can save myself a lot of time and a lot of steps,’” Malkary says.
Other problems for nurses arise because clinical applications may not be able to share data even if each is designed to support industry-wide data standards, warns Jan Wilson, R.N., manager for nursing information systems at Lehigh Valley Hospital, in Allentown, Pa. For example, when a patient moves from the emergency department to the med-surg floor, nurses often need to consult two different applications for vital signs rather than seeing a combined summary. “So, nurses either have to learn multiple software programs or they defeat the purpose [of electronic systems] and print out reports so they can review information from another system. We have a long way to go before we’ll see data across the continuum.”
Hospitals are circumventing workarounds with almost obsessive up-front planning and lengthy rollout schedules. Methodist Hospital of Southern California in Arcadia has been planning for almost two years to fully turn its new electronic charting system into a full-blown EMR. Over the next year, nurses will electronically input only initial assessment data and the patients’ belongings list until the entire staff becomes comfortable with the technology.
“We’re taking baby steps and are going very slowly,” says Steve Owens, R.N., director of nursing administration and transitional services. “We overdid [the slow pace], but that was good. Its made us successful.”
Methodist also ran a 24-hour “command center” for seven days after the program’s go live to connect nurses with staff “super users,” a consultant, or the nurse informatics officer if problems arose.
A survey of nurses by healthcare researcher KLAS also points to other factors leading to uneasy relationships among clinicians and clinical IT. The frustrations aren’t caused by “a genetic trait of clinical people” prone to dismissing technology, stresses Kent Gale, KLAS president. On the contrary, nurses who regularly operate high-tech diagnostic equipment and CT scanners would readily accept clinical programs that enhance productivity and patient care. KLAS found low adoption rates by nurses for applications designed to automate core activities like patient discharging because the programs were too cumbersome. “There’s a lot of redundancy — you have to enter things two or three different times in two or three different places,” Gale says. Nurses “basically say that the vendors stopped before they finished” perfecting the design of their software.
Ironically, CIOs and nurses find common ground in the battle against applications that don’t work as advertised. A decade ago, hospitals followed an IT-centric approach to clinical systems, Wilson says. “Now I don’t think an IT analyst makes any decisions without talking to clinical users. From the way systems are designed to how they’re upgraded, it’s a lot more clinically driven and much more collaborative,” she says.
In the KLAS survey, IT managers also complained that “the care and feeding [of some nursing applications] was more than they would like to see,” says Gale. “IT departments are saying, ‘Vendors need to do a better job testing their own software before they give it to us.’ ”
Increased Risks
The frustrations highlighted in these surveys don’t point only to personnel issues; they also have wide-ranging legal implications, CIOs and consultants say. When clinicians enter data multiple times in the same or different applications, they increase the chance for errors, Malkary says.
Dead zones in wireless networks may prompt a nurse to administer a bedside medication without the bar-code safety check, Gale cautions. System errors that result in lost or inadvertently altered medical data are another concern. “When we think about the reliance on technology for direct patient care, do we have the appropriate kinds of [liability] coverage for an event where we might have a system outage?” Alegen’s Lawonn asks. “We have been having conversations with the folks in risk management about new kinds of coverage that we may need, given the fact that we have these electronic media for capture, storage or retrieval.”
Rules for legal discovery — the request for relevant information from a hospital for research in litigation — were expanded in 2007 to more broadly cover electronic data.
The new regulations are causing hospitals to review their processes for the disclosure of information, as well as data retention and destruction policies, says Duke’s Borg. “It will be important for hospitals to work closely with their counsel to determine what policy additions and changes might be necessary. We’ve only [seen] the tip of the iceberg on this issue,” he says.
“Everything is discoverable now, including e-mails and [instant messages],” explains Tom Weakland, managing partner in Diamond Managemen’s healthcare practice. “Managing all that technology is much more complex, especially in a large organization where you have lots of physicians all communicating and collaborating together.”
A lot of companies discourage or even prohibit IM use, Weakland says, “because they haven’t figured out how to track it and make it discoverable. Others have pretty strict standards around what you can and can’t e-mail.”
Another potential risk comes because some core hospital systems still run on decades-old applications with outdated capabilities, such as the inability to create long, harder-to-hack passwords. CIOs know these programs don’t meet today’s best practices, but IT managers must accept them for the time being. “You just run up against a brick wall because you can’t do what you can’t do,” says Joel Wagner, vice president of global delivery at Eclipsys Corp., a health IT software vendor. In addition, more resources must now be spent for behind-the-scenes technologies designed to avoid downtime and data loss. “Business continuity used to be more of an option for a community-based hospital. Now it isn’t,” he adds.
For Alegent’s Lawonn, continuity and recovery strategies mean spending more for alternate power sources and system-wide redundancies. Still, the biggest availability threats remain regular maintenance downtime. “If you’ve got to make a change to the application you’ve got to bring it down,” he says. He works with vendors and systems integrators to keep the disruptions as short as possible by having revisions and patches ready for uploading. “And then we keep talking to our provider about zero downtime. We’ve just got to get there,” he says.
Borg says that all of these new potential risks hasn’t led Duke to expand its liability coverage, although other hospitals are considering so-called “cyber-liability” insurance to mitigate the loss or misuse of electronic data. Instead, Duke is opting for prudence based on careful front-end planning to examine and document new technology-based processes before they’re implemented. “We pilot everything to work out issues and problems before [an application] is released for broader usage,” he explains. “It takes a group with both clinical and technical skills to manage [the evaluation process] successfully.”
Increased Scrutiny
CIOs face pressures to add another genre of applications that isn’t directly related to patient care but one that’s increasingly vital to hospital operations — analytical software to address the rise in pay-for-performance plans.
First, hospitals need internal analyses to understand how well they’re meeting industry quality measures, such as the Joint Commission’s Core Measurement rankings. In addition to moving hospitals toward better patient outcomes, the analyses should tell organizations how profitable their procedures are for treating various illnesses. “Looking at how we treat pneumonia patients is an organizational question,” Gartner’s Shaffer says. “How do we treat them, how do we get paid for them, and are we going to make money on them?”
Second, hospitals need comprehensive outcome information to see how they’re complying with evolving reimbursement rules from federal agencies and private insurance companies. For example, the Centers for Medicare %26amp; Medicaid Services says it will change how it pays for healthcare-associated infections and clinical mistakes. The challenge for hospitals is how to collect data to show they are receiving all the money they’re due under those new rules, Shaffer says.
Fish Memorial’s Scorecards
To help with CMS core measures reporting, Florida Hospital Fish Memorial in Orange City added electronic scorecards to its operations to summarize clinical performance, such as whether patients diagnosed with pneumonia received the proper antibiotics within the four-hour timeline set by CMS. The hospital worked with its EMR vendor, Cerner, to develop the scorecard module and now sees some measurements within a minute of the activities.
“Based on this technology, we continuously adjust our processes,” says Evie Lowe, R.N., chief operating officer. “We have a team for evidence-based practice that looks at our current data and what we need to do to improve certain areas. The results are also rolled up to the corporate level where they review the system-wide results on a quarterly basis.”
Fish Memorial used the performance summaries to improve treatment of influenza and pneumonia patients. “We found we were right where we wanted to be, so we created a multidiscipline team to work out a process,” says Karl Jacob, R.N., quality manager. “We’ve had at least a 50 percent improvement in our results in one year.” Actions included programs to vaccinate more of the high-risk members of the community, he adds.
The answer could be a greater reliance on business intelligence applications, a category of software that will likely be one of the biggest growth areas in the next year, according to analysts. Diamond Management says data mining and analysis programs were cited by hospital executives most often as tools to transform the businesses. “They realize that not only are you strategically dependent upon technology to do your day’s business, but you are also starting to become more and more dependent upon technology’s ability to help you analyze all of the different information you have available to you as an organization,” Weakland says.
In addition, with the push for greater insights into internal operations, pay-for-performance programs will increase reliance on business intelligence for external reports, which will also require CIOs to develop new working relationships. “The CIO is having to both work more closely with the clinical staff and to better understand how information that comes out of IT is framing the way that the institution is perceived by the outside world,” says Jeff Luck, director at SG2, a healthcare consultant.
Lke other sophisticated technologies, a new business intelligence application may not immediately deliver on its full potential, says William Woodson, vice president at SG2.
“It’s proving to be quite cumbersome, even for places that have reasonably good EMR systems,” he says. The problem is that much of the data from ambulatory operations is still captured with pen and paper. Melding it with electronic information into an analytical program requires someone to manually pull data from charts and enter it into digital systems — a time-ccrisuming process.
“We expect to see more metrics coming into the world that are combined inpatient/outpatient [information],” Woodson says. “There’s going to be some heavy lifting for most of the industry for a while.”
New Job Descriptions
Pressures for greater clinical buy-in to technology, new legal risks, and a growing requirement for more detailed performance measurements are redefining what it means to be a CIO.
It puts some CIOs at a career crossroads. Some top IT managers must work to maintain their newfound influence by immersing themselves in the needs of clinicians and business managers, Shaffer says. “If CIOs devolve into saying, Those are other people’s problems — I keep phones working and the e-mail running,’ then they are essentially demoting themselves and relying on others to determine their fate,” she says.
