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Biggest gains will go to biggest innovators and best networkers
Hardly any part of health care remains untouched by technology, and, in many respects, we’re better for it. Information management systems have already produced dazzling improvements. Inpatient procedures are faster and more accurate. Wait times are down. And the near future promises even more. But the technologies are only as effective as the human skills and judgments behind them.
Indeed, some QI leaders and clinicians believe that unless we discern exactly what the technical solutions can — or should — fix, advances are worthless. The most sophisticated machines make little difference unless health care workers actually use them. For all its wizardry, we must not succumb to complete dependence, for technology is notoriously temperamental. That’s why some advise us to keep the pencil and paper systems ready at all times.
While no one doubts that technology will continue to revolutionize health care, experts caution us to consider continually how and whether each new change improves health through the patient’s eyes.
It takes human ingenuity to figure out which of our problems really need a technical fix. "If not thoughtfully applied to a discrete need, technology will not be worthwhile," insists Charles M. Kilo, MD, MPH, director of the Idealized Design Initiative at the Institute for Healthcare Improve-ment (IHI) in Boston.
The initiative develops designs for optimum work flow in ambulatory care offices. Kilo notes that when we plunk a new technical step into the middle of a process without first adjusting users’ attitudes and the tasks that dovetail with it, we have chaos. "Like thinking the electronic medical record will solve all our problems. It’s costly and there are big disparities between the needs and the information technology solutions." This is more apparent in the ambulatory realm than the inpatient, he adds.
To align ambulatory care needs with technical solutions, IHI’s Idealized Design Initiative has identified 20 to 30 discrete information management needs. They will eventually become a set of standards for technology vendors. Sizing up the current state of affairs, he observes, "If you picture a grid with 30 needs across the top and solutions from vendors down the side, and you fill in vendors who meet the needs, a lot of the cells are empty." For example, a critical feature of a patient information management system would be the ability to create registries of patients to facilitate proactive contact and management of populations needing regular care, such as diabetics.
"That registry function is not present in any of the electronic medical record software packages out there at this time," Kilo notes. "The product vendors are fragmented, and the products don’t talk to each other." That’s why, he reiterates, before we spend the first dollar on solutions, we can do ourselves a big favor by asking, "How do we thoughtfully use information management to solve some of the problems we have?"
When James Espinosa, MD, director of the Emergency Department at Overlook Hospital in Summit, NJ, has his way, new technologies meet one simple, rigid criteria before they go into use. He wants to know, "Does the tool make a difference the day it’s installed at the bedside?"
The cardiac markers system passed with honors, Espinosa says. It performs bedside enzymes tests. Within one minute of applying eight drops of blood to a pre-treated card, the nurse knows the presence of three cardiac enzymes indicating an infarction. "If a patient had a nonspecific cardiogram, it used to take us 24 hours to know whether he or she was infarcting. Now it’s 15 minutes."
On the inpatient side, "clinical information systems are the biggest duck we have in our row of QI advances," says Marge Freundl, MSN, RN, CNAA, corporate director of Disease Management at St. John’s Health System in Warren, MI. Still, the systems are only as good as the input data that drive them. "With the job market as tight as it is, and health system budgets being what they are, are we going to have people who understand the seriousness of what they are doing when they transfer data into the computer? And are we going to build in validation of data accuracy in our systems?"
Sometimes a simple device makes more impact than its smarter counterpart — even if your budget could support more. Joyce Thomas, PharmD, supervisor of clinical services in the pharmacy department at Deaconess Hospital in Evansville, IN, explains why. "The environment where you want to implement the technical advances — the cooperation of your staff and the training resources at your disposal — are often more influential in the speed with which you adopt technology than the availability of the technology in the marketplace."
Case in point: Thomas explains that Deaconess is currently looking at ways to improve the legibility of fax copies of pharmaceutical orders because "it’s always difficult to read some physicians’ writing," she says. "For example, if someone writes lightly, the legibility of the fax copy is compromised. The ideal would be to eliminate the handwriting altogether by having the doctors place their orders on the computer," she concedes. But that would be easier to accomplish with hospital-employed physicians than with the community-based doctors who admit patients to Deaconess, she adds.
Even with simple technology and good training, it’s dangerous to assume that people will welcome it. We see two distinct cultures among health care workers, notes Mike Rudolf, director of Improvement Services for VHA East Coast, the Berwyn, PA-based local division of VHA Inc., an Irving, TX-based national alliance group of not-for-profit organizations. You pretty well know them by their age, Rudolf explains. Take e-mail. "It has taken a while for us 35- to 55-year-olds to get used to it, and we’re not there yet," he says. "But once we get comfortable with it, it will change the way we do business."
All caveats aside, quality experts and clinicians agree that any system that provides access to clinical data on-line can improve care. It shortens diagnosis to treatment cycles. It reduces duplicate tests. Built-in rules and triggers reduce the risk of error.
"When I think back to the 1980s compared to the 90s, I think of the profound effect of the ability to look at data from a systems perspective," observes Barry Malinowski, MD, medical director of Group Health Associates, a multispecialty ambulatory care facility in Cincinnati. "We used to look at infection rates and the like. But we have really tuned in to looking at outcomes. It’s had a profound effect on accountability, and it’s just the tip of the iceberg. In the future, we’re going to be looking at much deeper issues like how care affects the quality of a patient’s life."
One breakthrough, which the Group Health clinicians love, is the five-minute cycle between hospital discharge to discharge summary. Malinowski describes it as "so real-time, it’s incredible!" The system’s hospitalist-nurse team e-mails the summary via laptop computer to the primary care physician within five minutes of the patient’s departure.
Thanks to a clinical management software program, Malinowski says, "We’ve taken Coumadin management from the physician and given it to the nurse. The program shows when a patient needs to increase or decrease the dose. Compliance is much greater, and the outcomes are better."
The systems view of data enables instant adjustment of processes to correct "dis-quality" in real time, "which is where the patients experience it," says Espinosa.
At Overlook’s emergency department, for instance, the standard is to have patients in and out within 60 minutes. To uphold the standard, the staff are authorized to call in extra help if waits for radiology or lab results exceed a pre-set threshold for 15 minutes. "This way, we can smooth out the bumps in real time instead of waiting six months for the aggregate data to show up. Patients don’t experience their emergency room visit in the aggregate," he adds.
The concern for patient satisfaction and the impact of care on quality of life have driven technologies, insofar as they influence the way care is planned, delivered, and measured. "The advent of patient satisfaction into medicine has led to breakthroughs in the way we do business," says Espinosa. It has led to new measuring tools such as provider report cards and the strategies for validating them.
The most exciting breakthrough we have ahead of us, he continues, is the assessment of how medical treatments shape the human experience. "This is one we have yet to fully embrace in our quality measures. Can patients walk better because of a new technology? It’s the old question — the cat lives, but will it ever catch mice again?"
While physicians may retain a modicum of control over when or whether they adopt clinical technologies, a more fundamental change is complete, and there’s no going back. Kilo says, "Physicians used to be the keepers of medical knowledge. It was within their power to dispense or not to dispense it. But the Internet has changed all that, and many physicians are hardly aware of the revolutionary power of this development."
Doctors no longer hold gatekeepers’ privileges over medical information, Kilo notes. However, the physician can become a positive force in the change. Instead of being intimidated when patients come to appointments with papers from an Internet search, doctors could serve as knowledge brokers, guiding people to credible Web sites and helping them filter the information.
Don’t let anyone tell you it’s foolish sentimentality to keep your manual systems tuned up. Remember that electronic networks will fail. The only unknowns are when and how often. "That’s my biggest fear as we move forward," Freundl admits. People used to carry the procedures in their heads — how to deliver specimens and orders to the lab, for example. "But as we get comfortable with using the new ways, we forget the old ones. And many of the new people have never used the manual systems."
Backup procedures for automation breakdowns should be a routine component of training for all systems, Freundl believes. "We need to keep people tuned in to the old methods of processing the paper slips and handling lab orders."