Clinical technology boosts quality. Everyone knows that, right? So prove it.
Does clinical information technology boost the quality of care? For many, the answer is an almost instinctive-and unequivocal-yes. The sheer volume of medical knowledge almost defies comprehension in a paper-based delivery world, where physicians are expected to make clinically sound decisions on the fly. That's one reason IT proponents tout computerized order entry as a godsend, citing the many built-in decision-support tools the technology provides.
Yet for hospitals that have implemented order entry and other forms of clinical IT, measuring the actual impact on the quality of care delivery is difficult. Part of the problem is that medical errors and ineffective clinical decisions are difficult to detect in paper-based systems, meaning there are few baseline measures for change. And early adopters become so focused on the implementation, actually measuring change loses priority. Nevertheless, despite these hurdles, many hospitals are indeed discovering improved quality scores and other indicators suggesting their multimillion-dollar EMR systems are worth it.
As IT works its way into the modern healthcare setting, hospitals themselves are becoming proving grounds, attempting to measure their systems' impact on quality of care. "There's no doubt that IT improves quality," says J. Michael Kramer, MD, chief medical information officer at Novi, MI-based Trinity Health system. "The problem is proving it." Kramer is leading the charge on one of the industry's largest IT overhauls, as Trinity is standardizing its clinical, financial, and administrative systems across 31 hospitals. Beginning in 2003, its "Project Genesis" is slated to be complete by 2009. Through last April, Trinity was about halfway through the massive installation, which includes order entry and standard order sets across the enterprise.
According to Kramer, Trinity has already seen improved care performance in such areas as medication turnaround time. After order entry was automated at St. Joseph Healthcare, Clinton Township, MI, medication turnaround time for STAT/Now orders went from 2 hours and 38 minutes to 1 hour and 33 minutes. Other hospitals deploying order entry systems have reported similar quality improvements. AnMed Health, a 340-staffed-bed facility in Anderson, SC, logged a 42% improvement in community-acquired pneumonia patients receiving antibiotics within four hours of admission. Since 2006, AnMed has been using electronic order entry at the front end buttressed by barcoded medication administration at the bedside, with a number of automated checks in between, says Tim Hipp, pharmacy systems manager. "The barcode system is a big safety net between the patient and the nurse," he says.
Before the automated system, some medical errors-called "near misses"-were impossible to detect, Hipp adds. For example, AnMed's system tracks instances in which nurses were about to give the wrong medication, then realized their error, backing out of the system after the computer flashed an alert. In other cases, nurses may give drugs despite the absence of an order in the system.
The system enables AnMed to analyze these instances, says Jane Rivers, RN, a nursing informatics specialist. Last February, AnMed logged nearly 159,000 administered doses through its medication fulfillment system. That included 1,800 instances of no-medication order overrides, of which the hospital is able to explain all but 300, Rivers says. Automating the complex chain of events that culminates with medication administration has been a boost to physicians, pharmacists, and nurses, says Leigh Miller, RN, director of clinical outcomes. "If you believe in patient safety, you embrace tools that help uphold it," she says.
The performance data that AnMed and other hospitals are tracking become the foundations of their clinical quality improvement programs. This need for measurable results underscores the value of clinical IT, observes Bill Fera, MD, vice president of medical technologies, University of Pittsburgh Medical Center. "Order sets and decision-support tools lead to improved quality," he notes. "But the real issue is that they allow you to measure in real time what you are doing. Without IT, the data is impossible to collate."
UPMC is in the midst of deploying common IT tools across its 20 hospitals, Fera says. UPMC measured the impact of its order entry system at one of its community hospitals, discovering what Fera called "dramatic improvements" in the use of beta blockers for heart attack patients and delivery of antibiotics for pneumonia patients. "Our pneumonia data moved us to the top 1% of all hospitals in the state," he says.
IT experts caution against attempting to make too many measurements of the clinical impact of clinical IT, however. "Pick just a handful that really matter," advises Kramer, the Trinity CMIO. Further, just because systems are in place does not mean that clinicians will be using them to their greatest potential. Alegent Health, a nine-hospital system in Omaha, NE, found that nurses took up to three hours to enter vital patient data into its EMR after they collected it-an unacceptable lag time that can lead to errors, says Michael L. Westcott, MD, chief medical information officer. The problem, Westcott explains, was bulky computer equipment. Nurses did not like to push around the heavy computer-on-wheels workstations and would re-enter data after they left the patient room.
To address the problem, Alegent turned to lightweight portable PCs from Motion Computing that had built-in barcode scanners. The lighter devices led to greater nursing satisfaction, and now data is collected at the bedside, Westcott says. As Westcott points out, the quality-improving features of IT mean little if caregivers are not comfortable with the equipment.