The Problems

Current Priorities Concerning Technology

The Children's Memorial Medical Center Strategic Plan, "Achieving the Vision of CMMC" was approved in February 2003. In the assessment, comparisons were made to top tier competitors' endowments, grant support and clinical volume. CMMC aspires to compete in this league and outlined aggressive increases in activities to achieve this vision. Amoung the goals were: There is no mention of information technology in this document and this is viewed by the PTTF as a significant shortcoming. Information technology is essential to each of the items selected above from the Strategy Plan.

The Patient Relations Annual Data Report for FY03 (published Nov 26, 2003) tracks 8 categories and information problems are significant issues in 6 categories. Complaints have risen linearly in the last 48 months.

There are very compelling business reasons, discussed elsewhere (The Business Case for Informatics), which should encourage a reevaluation of priorities and greater attention to and investment in information technology.

Current Perceptions of and Experience with CMH Technology

The PTTF conducted surveys of division chiefs, clinical practice directors (CPDs), and faculty. The former two were performed with paper forms filled out during meetings with the respondants. The faculty survey was conducted electronically. An email was sent to the faculty directing them to a web form where responses were entered and submitted. There was a 75% response rate to this survey.

Email: Communicating through a single channel does not work.
SELECTED COMMENTS FROM THE SURVEYS

I cannot make any informed comment about most of these specific areas. In general IT at CMH is lacking. I recognize the lack of resources is a significant problem. However, the rigid technical requirements are not helpful as is the arcane ordering system. How will CMIER, CMH, NWU and NMH be linked to one another across the NWU website? This has a significant impact on CMIER or CMH based researchers exposure to grad students and postdocs Can the system requirements at CMH be expanded (from PC only) - most CMIER labs are mac-based. Why does the hospital support 2 libraries - Brenneman and CMIER? Why not consolidate them? Most journals and many medical texts are available online. What will be the policy on faculty members establishing their own website within the CMH-CMIER umbrella ? Can this be used to recruit patients in clinical trials?
We need an electronic medical record [that is seamless with in-patient and out-patient] at CMH today, not next year or in 2010.
A completely integrated electronic medical chart that includes progress, nursing, operative, consult notes in addition to labs, path reports, pharmacy orders should be the highest priority. A wireless network with text messaging pagers that include a keyboard would diminish the need for numeric pagers that require a telephone or the current web-based pagers that require locating a terminal and logging in. Nextel type cell phones with walkie-talkie and text messaging might be useful.
the current state of our information management is archaic. we will be under increasing pressure to see more patients quicker and provide better care at lower cost. we need to invest immediately in a comprehensive and robust system to provide state of the art i.t. applications to our patient care activities. we need a system with integrated scheduling, referral, registration, medical record, adverse event, pharmacy, laboratory, imaging, billing, and physician communication capabilities. it will be expensive and painful. it will improve our service, our care, our quality, our safety, and our patient satisfaction. it would also be a very powerful clinical research tool. our patients deserve it and we deserve it.
I think the priority is to make systems compatible accross depts. so that I can read cardiology dictaions, radiolgoy reprots, EEG reports, lab tests (including send out), all on one easy to use system.
The highest priority for me would be the implementation of an electronic medical record so that physicians would have access to all information in a patient's chart at all times. Available information on recent visits is abyssmal in the current system, and access to this information would significantly improve patient care in the ED and elsewhere in the hospital. In addition, it would expedite any retrospective research endeavors within the division, and would have the potential to significantly improve our abilities to do ongoing patient identification for prospective studies as well.
Although, I do understand that the task force can only straddle one hurdle at a time, please also keep in mind that the mission of the task force also relates to research. Perhaps a future survey might address research-related issues of concern that need to be evaluated. Thanks very much for your time and willingness to work on these areas for the faculty.
Prior to adoption of electronic record system, one needs efficient and fast access to computers and to the internet. Our IT department needs to be improved.
Our practice and its needs are distinctly different than other PFF practices. What we do need is a patient tracking system and a comprehensive electronic medical record
importance for what????? this is meaningless and unanswerable -- try again! and this is copyrighted -- amazing! A group made suggestions for an electronic medical record several years ago. What happened to that recommendation????
many resources but not consolidated. A lack of a database wastes time and hinders all attempts at clinical research; patient data acquisition should be as easy as surfing the web.
We should institute web-based billing to avoid the paper and increase efficiency. According to reliable sources, 90% of outpatients (including procedures) in my specialty can have insurance billed before leaving the office.
- Electronic billing may improve efficiency and save man power resources - Communication of radiology reports has improved. - Need system that flags the provider when lab results are ready and available
My previous institution (________) migrated into electronic medical records more than 2 years ago, including both inpatient and outpaitent services, order entry, prescription with system for drug interaction and allergy checking, letters and school forms, patient education handouts, all lab reports, discharge summary/transcription. At the beginning, it required many works including hardware and software installation, customerization for each department/division,and provider/staff training. Once this was accomplished, the system improved patient care, efficiency, and billing. The weaknesses of ___ system include (1) different software programs for inpatient, outpatient, and transcription. It would be more efficient to have all the information together under one entity for a given patient; (2) The current system is not built in a way that the database can be easily used for research purpose. In my opinion, electronic medical record is the trend for the future, many hospitals in the country have already developed such system. It would be a new feature if the system could combine patient care and pediatric research. This could be potentially a huge resources with "free" data collection. We can propose the hospital to try this idea out in a few clinics and we can gain some practical experiences for large-scale implementation.
... everything at CMH that works well is created because the usual systems do not ... scheduling is obscure, not contemporary, and not PFF-friendly by having different ways of using it (payor class, priority of need, etc) ... billing is antideluvian in character, little real-time feedback to fine tune, no analysis of results; communication between MDs is non-existant unless by good will of each party; no real use of technology for OUR benefit outside of very low-level functions that benefit the hospital ... when we wake up and smell the coffee burning? we are a technology-dependent, but highly insufficient group (PFF) that will continue to suffer ... and without the financial resources to overcome the hospital systems that we accept willingly.
Epic needs to be accessible from other sites. we also should look into voice dictation systems. Furthermore, we need to be able to dictate inpatient notes that are transcribed into the chart within 24 hours.
From a technology perspective I have 2 major issues. First, the lab does not bother to send back results. They say they have a system for this, but it doesn't work. This creates a HUGE liability risk. Second, I find the children's "point" system extremely hard to negotiate and under-utilized. In comparison, some poor community hospitals have the "meditech" system. This system includes all labs, demographics, xray results,visit history, and most importantly: All the dictated consults and discharge summaries. Why can't we have a system like that? We spend so much time trying to track down subspecialty consults, etc.
Alpha numeric pagers, spectra link phones, electronic charts, electronic tracking, electronic med ordering
It would also be important to remember that we have a large unit at Prentice and our existing neonatal database is very old and obsolete and needs replacement urgently.
A standardized PDA system for faculty to align with would be helpful. If CMH doesn't provide the PDA as for house officers, but at least the same software should be available if a faculty member purchases a compatible unit. Faculty should be advised to consider purchasing a PDA that would be compatible with current/planned equipment the house officers are/will be using. All conference rooms should be wired for access to the intranet/portal, if not equipped with a PC or dumb terminal that provides portal access.
Several initial programs have been initiated in our division including computer callup of previous dictations for review (2 year window), FAXing of completed, corrected dictations, and e-mail communications with COA's, nurses, patients, and occasional physicians. This has made a significant improvement in ease and clarity of communications. However we have a very poor system of telephone communication so that many messages from patients are lost or there are long delays in response. Also, our computer solutions do not have backup so that while ideally, we can call up previous dictations to answer an e-mail query, we have only a certain percentage of dicatated charts that can be called up, and when we have the patient visit information, we lack information regarding telephone communications regarding drug changes, etc. I understand that many of these problems will be solved with the introduction of the EPIC program. However EPIC will not address our telephone problems which needs separate attention. My own thoughts are that a few low-level filing clerks available to physicians would be an effective bridge until our technology growing pains resolve.
access to 'the point' is awkward, eg cannot be logged on and still get email etc. recommend on-line subscriptions to more journals such as Mol. Psychiatry faculty should have individual web pages, with research/practice special interests etc. ..its hard to find out who's here and whom to contact for professional information, collaborations etc
Billing is improving, yet I don't think I am billing to maximum. WOuld like to see somebody assisting increasing our billing. Process of dictating, then having transcriptionist put in laboratory studies, then making changes and finally sending letter out is not time efficient. Also if letter is sent and dictated without labs, then no system to track outstanding labs. Also if labs recommended in between appts, no tracking system. Increased nursing support is mandatory in order to become more efficient. Also, I (or a nurse) continue to spend time trying to fit in patients, because of filled clinic slots.
Many of us use personal laptops for much of our work, both at CMH and other places. Is it possible to utilize an interface to make the systems compatible? e.g. Can I hook up my laptop and do patient letters in the clinic area etc?
The CareVue system is oboslete and should be replaced with a clinical information system or systems that would better support the varied activities of the nurses and physicians at CMH and its satellites. ...
Faculty Email Software.

Faculty use different email software, primarily Eudora and Outlook. Eudora is recommended by NU and CMH supports Outlook. The principle "other" method is reading email via a web browser.
Faculty Email Providers.

Faculty read email from the NU and/or CMH servers. There are a significant number who cannot be reached through either one alone.		    
Current systems do not work well. Departmental leaders want a fix.

Current State.

Division Chiefs and CPDs rank the overall current state of technology (not shown) as poor (grade=D). Each of the specific areas surveyed was ranked poorly, as shown.

The verticle axis is the number of responses; the horizontal axis is the score (1=poor; 10=excellent).
Interest in fixing things..

Division Chiefs and CPDs have a strong interest in fixing the current problems.

The verticle axis is the number of responses; the horizontal axis is the score (1=low; 10=high interest).
Commitment to fixing things..

Division Chiefs generally have a strong interest in fixing the current problems. Their view is that their own interest exceeds that of the CMH administration.

The verticle axis is the number of responses; the horizontal axis is the score (1=low; 10=high interest).
Technology support. CPDs and Division Chiefs ranked technology support as D+. This question was designed to distinguish between the functioning of systems (see above) and the support faculty obtained in addressing problems. This ranking is similar to that of the Division Chiefs in assessing CMH administration's commitment to changing the technology landscape.
Priorities for change are identified.

Introducing the ambulatory and in-patient EMR, including professional billing were highest priorities. Scheduling and reporting functionality is currently available, but it's rankings suggest that its use can be expanded and improved.

Division Chiefs.

CPDs.

Faculty.



Patient Safety

CALL TO ACTION FOR PATIENT SAFETY (9/26/03)

In the Spring of this year, a child died unexpectedly at the Boston Children's Hospital. This despite the fact that he had several attending physicians, numerous fellows, residents, and nurses involved in his care. It appears that the attending physicians were unsure as to who was ultimately responsible for the child and that the housestaff and nurses communicated poorly with one another and with the attending physicians. This death resulted in a massive review of the hospital by all authorities (JCAHO, the Commonwealth of Massachusetts, CMS). The Boston press has been aggressive in its criticism (see below).

This case exemplifies the strengths and weaknesses of an academic pediatric medical center. Sophisticated care can be provided. However, the complexity of relationships of involved staff at all levels place the patient at risk. Boston Children's Hospital has pledged to totally revamp its care of patients. Clear lines of authority and review of the management of trainees are among the issues that must be addressed.

As you know, we confront these issues on a day-to-day basis and all of us certainly wish to avoid the tragedy which occurred in Boston. Medical Staff and Hospital Leadership are pledged to review the practices and systems here and to devise and implement practices which will assure the safety of all patients.

If you are interested in participating in this endeavor, please contact me at x4012. In addition, a working group will be asking some of you to assist in identifying issues and problems and methods of remedy.

Thank you very much.

Edward S. Ogata, M.D.
Chief Medical Officer
Children's Memorial Hospital
773/880-4012
eogata@childrensmemorial.org

The Institute of Medicine (IOM) issued the Call to Action on Patient Safety. But it is an old issue and action was long overdue. There are many aspects of Patient Safety and many revolve around data management and communication.

The EMR will be important in patient safety for many reasons, such as:
  1. Ready access to clinical information
  2. Legible output (avoid handwritting errors)
  3. Alerts for drug allergies, contraindications, etc.
  4. Reminders about missed appointments, review of lab results, etc.
  5. Cross-checks: drug interactions, guideline availability
  6. Verifiable electronic data exchange about orders to pharmacy, lab or consultants
  7. Enhanced implementation of guidelines
  8. Enhanced use of algorithms for disease management and quality improvement
  9. Enhanced access to patient educational materials, addressing health literacy and compliance issues
  10. Enhanced ability for patients to directly participate in their care
  11. Facilitates communication between healthcare team members, the breakdown of which is the root cause of many errors (see InfoBox)
  12. Support for error reporting and/or identification which are important in assessing risks, near-misses and root cause analysis
Patient safety is a critical variable in maintaining a hard earned reputation. Widely publicized errors have tarnished the reputations of several leading academic medical centers. Technology has a proven track record in reducing errors by providing alerts; reminders; legible, timely, and pertainent data; cross-checks; algorithms; and decision support.

Errors also result in successful malpractice ligitation. Currently there is no direct data that links an EMR to reduced litigation costs. However, the insurance industry has embraced this concept and is now offering premium reductions if a suitable EMR is deployed in the clinical environment (see ISMIE policy). Of course, greater savings will result if actual reduction in claims is achieved.

Patient safety has emerged as a major issue in healthcare. This lead the AMA, in 1997, to invest in the founding of the National Patient Safety Foundation. Many influential voices now participate in the dialog about patient safety:
  1. National Patient Safety Foundation
  2. Leapfrog Group
  3. U.S. Pharmacopeia
  4. The Institute For Safe Medication Practices
  5. National Quality Forum
  6. Partnership for Patient Safety
  7. Quality Interagency Coordination Task Force (QuIC)
  8. Agency for Healthcare Research and Quality (AHRQ).

One of the recurring themes from these organizations is the importance of the EMR and robust systems for communication. Their work is thus important in the assessments of the PTTF. The American Academy of Neurology Patient Safety Workgroup (Chaired by the PTTF Chair) has created a glossary of patient safety terms based on the IOM reports.

Handwritten Documentation

Currently, most clinical encounters are documented with written notes to the chart. In office settings these are often not standardized. In phone contacts there may be no written documentation. There are currently several repositories of handwritten records.

Handwritten documentation is problemmatic. It is difficult to read and errors can result. It cannot be searched, filtered or otherwise processed using computer technology. It is expensive to organize, achive, retrieve and copy. Generally, it can only be in one place at a time.

Access to Data

Currently charts are generally pulled for phone calls, clinic visits and in-patient encounters. Most laboratory results are available electronically through the portal. Radiology images are also available through PACS. Most users cannot access data remotely. A small pilot of VPN access is underway and permits users to access Epic Lite data and PACS images through remote internet connections.

The lack of ready access to data results in decisions being made without a full understanding of issues. These scenarios were highlighted in the IOM reports (see below) as major safety risks and were emphasized by the Leapfrog Group in their recommendations for more robust access to data.

The Committee on Health Care Quality in America in their report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices, the Agency for Healthcare Research and Quality (2001) specifically note that, “One of the most distressing safety issues of the clinical encounter is the failure to follow-up on diagnostic tests, particularly when a patient is not notified of an abnormal result.”

Communication

Medical teams are complex and communication between members is critical. Hospital discharge summaries and clinic notes are dictated and mailed to referring physicians. This typically requires several weeks. It is also unreliable and there are frequent complaints of poor communication. A few clinics are making use of fax summaries at the time of clinic encounters; while well received, they provide limited information. There are many different systems for dictation in place. Telephone, fax and paging communication are addressed in the Infrastructure Document

Standards (see also Data Standards and Business Case: Call to Action)

HHS's Consolidated Health Informatics

Adopts a portfolio of existing health information interoperability standards (health vocabulary and messaging) enabling all agencies in the federal health enterprise to “speak the same language” based on common enterprise-wide business and information technology architectures.

http://www.whitehouse.gov/omb/egov/gtob/health_informatics.htm
While there are a number of well developed data standards, formal acceptance of these across the industry has not yet occurred. Enforcement of standards has not been possible. In several market segments there is widespread acceptance and use of standardized data sets, but even in these venues there is not an enforcable standard.

Recently the Secretary of HHS has initiated the Consolidated Health Informatics initiative which is intended to address this pressing problem. HHS contracted with outside vendors to identify "essential elements" and to hold a series of "townhall meetings" to receive comments. HHS intends to promulgate rules which will be open for comment before finalization. The current status of standards is listed in the Data Standards document within this report.

Patient Safety Organizations

Patient safety has captured the attention of Congress and regulators. Everyone recognizes the importance of data in assessing and managing safety issues. Currently there is too little, particularly in the ambulatory setting. The debate has focussed on the details. Physician groups have lobbied for voluntary systems, safe harbors, and protection from discoverability. Legislation currently before Congress, "The Patient Safety and Quality Improvement Act of 2003," (S.720; H.R.663) is consistent with these views. Thus, all key parties seem aligned on the creation of Patient Safety Organizations (PSOs).

PSOs will collect safety data from providers of healthcare. Their safe harbor provisions will permit them to identify patients and providers and allow root cause analysis. PSOs will transmit de-identified data to regulatory agencies. The details will follow the legislation using standard government rule promulgation.

One thing seems clear: we will need systems for collecting, organizing, and transmitting data to PSOs in order to comply with new regulations. Doing this within the framework of an EMR would provide many advantages.

Health Literacy

The term “health literacy” refers to a patient’s ability to understand common health care communications, such as prescription instructions, test results and insurance forms. Based on research by the National Adult Literacy Survey, 90 million Americans – half of all adults – may struggle with low health literacy. Further studies show that people from all ages, races, and income and education levels are challenged by this problem. Individuals with low health literacy incur medical expenses that are up to four times greater than patients with adequate literacy skills, costing the health care system billions of dollars every year for unnecessary doctor visits and hospital stays.

Health literacy is emerging as one of the major factors contributing to patient safety lapses. Medical informatics, by applying educational video presentations can overcome difficulties with reading and language barrier. Feedback loops in the EMR might also detect difficulties (e.g., missed appointments, ER visits) that reflect literacy problems.

IOM Reports

The healthcare industry was rocked by the Institute of Medicine's 2000 Report, To Err is Human which enunciated pervasive safety issues and under-utilization of technology to address them. This theme has been enunciated in a series of reports as enumerated here:

Year   Source   Report
1997   IOM   The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition
2000   IOM   To Err is Human
2001   IOM   Crossing the Quality Chasm: A New Health System for the 21st Century
2003   IOM   Patient Safety: Achieving a New Standard for Care
2004   IOM   Keeping Patients Safe: Transforming the Work Environment of Nurses
 Local History

Technology wonks at CMH have been frustrated. The reasons are many. Fundamentally, managing change of the type required is very difficult. An expanded effort is required to complete planning and to reach concensus about the resources necessary to achieve common goals.

CHM has had an excellent Information Management Department. They operate with direction primarily from the business managers of the hospital (see organizational chart). To address this shortcomings in physician input, CHM appointed the IM Medical Director, Dr. Michael Miller. In this role, Dr. Miller has been effective in coordinating discussions at a high level, involving numerous physician constituencies of CMH, including the Pediatric Faculty Foundation. Coordination has been done through the Information Management Steering Group (IMSG) and the Academic Technical Advisory Group (ATAG).

Administrative hierachies at academic medical centers are also challenging. Hospitals and faculty have parallel structures (see digram) and agendas, which are not always aligned on key issues. Part of the frustration has been a lack of coordination around technology at the interface between CMH and the Department of Pediatric faculty. Primarily this has been a lack of planning by the physician practice (PFF) and academic enterprises. Herein lies the rationale for the PTTF.


David A Stumpf, MD, PhD

Changes are Required

The PTTF determined that the high level of dissatisfaction and the commitment to change required a vigorous response. The changes required are significant. The situation has a sense of urgency because of competitive, safety, and other issues. Implementing these changes will require a new visionary approach with a total commitment from the administrations of all key stakeholders. The PTTF Report is designed to create a roadmap for the Department of Pediatrics as it approaches the challenging changes ahead.

The CMH campus has, because it is behind, opportunities not available to more mature environments. There will be pressure to urgently fix specific issues and the rush to a fix risks overlooking the economies of scale and synergies that might be realized by a more considerate attention to the big picture. The PTTF strongly encourages solutions that are designed to simultaneously address all the core missions.