Behind The Wires

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Improving on Success

Brian Jacobs, M.D.
Chief medical information officer
Children’s National Medical Center,
Washington, D.C.

The pediatric hospital is an environment rife with potential for serious errors. That’s why Brian Jacobs, M.D., whose background is in pediatric critical care, has aimed his career down the path of medical informatics. A longtime practicing physician at Cincinnati Children’s Hospital, Jacobs took a full-time job in summer 2006 as chief medical information officer at Children’s National Medical Center. It’s a homecoming of sorts for Jacobs, who served a three-year fellowship at the Washington, D.C.-based teaching hospital in the early 1990s. The move also marks a major leadership challenge for him as Children’s National looks to capitalize on the considerable information technology it already has in place; the teaching hospital has implemented results viewing, nursing documentation, computerized physician order entry, electronic medication administration, a bi-directional pharmacy and lab system, and a picture archiving and communications system.

Jacobs is charged, in essence, with adding new clinical applications to the mix, then helping devise ways to use the hospital’s growing storehouse of electronic data to better support clinical caregivers. “We are very good about putting data into our EMR but very bad about getting data out in a meaningful way,” he says. “We are looking for the next level of transformation, moving from the implementation of the EMR to utilizing the technology to improve quality of care.”

At Cincinnati Children’s, Jacobs directed a six-year effort to bring multiple forms of electronic documentation into the inpatient setting. But this will be his first formal C-level position. What lured Jacobs to Children’s National was staff enthusiasm over the continued build-out of clinical applications. “Frontline nurses, house staff and attendings are eager to move the next step,” he says. Children’s National also has an IT governance structure that Jacobs says keeps projects moving quickly and ensures adequate executive support. Chaired by the hospital’s chief executive officer, the 15-member IT governance board includes top executives from the medical and administrative staff. “We can evaluate, select, design, build, educate and implement in an efficient manner,” he says.

1. EMR Build-out, Phase 2

Throughout 2007, Children’s will continue the rollout of multiple clinical documentation modules from its primary vendor, Cerner. Children’s deployed Cerner’s order entry system in late 2005, adding basic nursing documentation functions such as vital signs capture and results viewing. As part of the $5 million initiative, the hospital will expand documentation capabilities for nurses, physicians and the host of other caregivers—including the chaplain—who treat patients. In addition, Children’s will add new modules for its emergency department, its perioperative surgical suite and its health information management department. And as if that weren’t enough, biomedical device integration with the electronic chart is also among the new features Jacobs hopes to implement by spring 2008.

The integrated package will supplant a hybrid electronic-paper system that makes assembling an accurate clinical portrait of a patient difficult, he says. In the ICU, for example, nurses document dozens of clinical values on handwritten spreadsheets that quickly transform into thick manuals. Trapping data directly from cardiopulmonary monitors and ventilators will be a real time-saver for them, Jacobs says. “Physicians, nurses and therapists are consumed with paper documentation,” he says. “The only issue is the amount of change the culture can accommodate.”

To drive the project, which Children’s dubs its “clinical transformation initiative,” the hospital has formed a senior leadership group to keep tabs on its progress. Jacobs is banking on the system’s improved efficiency as a way to help caregivers adjust to the inevitable hurdles and changes in workflows. “Their patient database will come from the electronic chart, and they will not be required to go to the bedside to see the medical record,” he says.

2. IT Strategic Plan

You could call it the mother of all committees. Since fall 2006, Jacobs has chaired a 20-plus-member group charged with writing a long-term strategic IT plan. Representing every major department in the hospital, the group is hammering out—with the assistance of a consultant—a vision statement that will guide Children’s projects during the next eight years. Traditionally, the hospital’s IT planning revolved around hardware and infrastructure issues, Jacobs says. Now, the effort has become clinician-driven. “Our primary focus will be clinical care, but research, education, financial services and patient access to technology are also in the mix,” he says. “We need to get ideas out on the table to mesh with our capital planning.”

Because the plan may include “big-ticket items, like a clinical data warehouse,” Children’s chief financial officer will have a seat at the table as well, Jacobs says. While the group cannot commit to future spending, it does need to have a sense of what is financially feasible, he adds. The report is due this April—a short time frame that spurred Jacobs to hire a consultant to facilitate meetings. “As a physician, I don’t know how to get 20 people to the table,” he concedes. “We need an outsider to keep us on track and on time.”

The group has many issues to tackle, he says, including the makeup of its budding EMR, the expansion of Children’s telemedicine program and the hospital’s IT infrastructure. The planning committee is also mapping its future participation in a regional data-sharing effort to create a pediatric healthcare network with other hospitals and clinics. Once the plan has been written, Jacobs will present it to the IT governance board for consideration. “Then we’ll need a prioritization scheme.”

3. Center for Pediatric Informatics

As part of Jacobs’ employment package, Children’s gave its new CMIO the chance to build a department that will be part think tank, part application builder. Serving as executive director of the Center for Pediatric Informatics, Jacobs is supported by a small staff of 3.5 full-time equivalents who handle data extraction, reporting and analysis. But he has already taken on several projects that could exploit the capability of the hospital’s IT portfolio. For example, the center is devising an automated adverse event detection system that can reveal medical errors. The project could shine light on a dark corner of healthcare delivery. “For every 20 to 40 adverse events, only one comes to the surface as a voluntary incident report,” he observes. “Most are brushed under the rug.”

Not until a serious injury or death occurs do most hospitals investigate medical errors, he says. “We want to detect the sea of events around an issue, not just the worst ones,” he says. For example, Children’s EMR could detect the prescription of a drug used as an antidote for an overdose of another drug. By compiling these records, the hospital can look for patterns, then determine whether interventions are needed. The focus, Jacobs says, must remain on process and workflows, not individual caregivers. “We want a blame-free environment,” he explains. “Most errors are not the fault of an individual.”

Gary Baldwin is technology editor of HealthLeaders magazine. He can be reached at




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