So St. Luke's, which has a nursing documentation system from San Francisco-based McKesson Corp. and an emergency department information system from Wakefield, MA-based Picis, for example, has made it an organizational priority to practice conducting tracer activities. Reiter may ask a nurse to show the preoperative history and physical of a patient who has had surgery and is now on the medical-surgical floor or to find the consult by a pulmonologist on an ICU patient. "The more you make them work with it, the more comfortable they become. If you don't show them they need to access it, they won't," Reiter says. At the 143-staffed-bed hospital, 10 practice tracers are done a month, rotating between units. "We have five executives and we each do two a month," she says.
St. Luke's has also trained its float pool nurses to be trained as super users for the system and has an informatics resource nurse, who serves as an educator, says Reiter.
Focus on the end game
When Good Shepherd Medical Center in Longview, TX, implemented its ED information system from Addison, TX-based MEDHOST in 2005, it focused on key performance indicators that leadership wanted to track as a measure of success. For example, Good Shepherd looked at financial return on investment, throughput time, individual physician metrics, and how many medications were ordered through the system.
Executives at the 340-staffed-bed hospital also realized that making data transparent is a great motivational tool for changing behavior. One of the hospital's efforts was to reduce its use of Demerol for pain management in ED patients. Good Shepherd posted all physician narcotics orders so ED physicians could see where they ranked and who was ordering Demerol the most. "Within six months, we were down to less than one Demerol order per thousand patient visits in ED. We practically eliminated it," says Ron Short, Good Shepherd's vice president.
Hospitals need to fund the effort beyond purchasing the system, says Kiely. Middlesex has not overreached or rushed in to buy systems too quickly, says Ludwig Johnson, the hospital's vice president of information services, adding that the administration has been very supportive.
Middlesex went live with the CPOE component of its EMR from North Kansas City, MO-based Cerner in 2008. To date, it has about 750 users on the system and has placed approximately 2.3 million medication orders internally. It's currently creating evidence-based pathways with a business intelligence system. "We are starting to do physician profiling to show the difference in pathways and the difference in performance," explains Johnson. "We will have a closed loop process by the end of next year." Then, the hospital will be able to take pneumonia cases, sort by physician, and see variance on the effectiveness and cost of the individual physician's treatment plan. The organization intends to take that physician profiling component and decide on evidence-based pathways and then create alerts, he explains. Physicians can override the alerts, but they will have to give a reason.
Absent the ability to measure cost and clinical outcomes and analyze the results, organizations don't know if they are making changes for valid reasons, says Johnson. "We want the system to guide physicians through the process in a way that makes sense."