Longitudinal records enable instant QI changes

Big difference in meds-related patient safety

A multifaceted system of electronic record keeping has enabled the quality staff at Evanston (IL) Northwestern Healthcare (ENH) to quickly identify and respond to improvement opportunities while also reducing the chances of medication errors.

ENH estimates the system will save the organization $10 million per year.

The ENH system integrates computerized physician order entry (CPOE) with electronic medical records, so all charting of patients, ordering of tests, procedures, medications, registration, scheduling, and physician billing are done electronically through one system.

"It creates a longitudinal patient record, which is very powerful," says Peggy King, RN, CHE, senior vice president of quality initiatives.

"Continuity of care is inescapable. The patient information from prior visits to our organization is available to subsequent treaters, and all results from our lab, radiology, and cardiology systems appear in Epic [the computerized system created by Epic Systems Corp., Madison, WI]," she explains.

"We still have departmental systems," notes Tom Smith, CIO. "They also feed data back to Epic."

In recognition of the system's effectiveness, ENH was named the sole winner of the 2004 HIMSS (Healthcare Information and Management Systems Society) Nicholas E. Davies Award of Excellence for Healthcare Organizations.

Thinking big works

ENH considered such a system several years ago, Smith notes, but the quality of available software "was insufficient for patient safety or for improving the work environment for docs and nurses. Finally, Epic created a system for large physician groups and decided to move into the hospital market."

As HIMSS noted in presenting the award, the system was rolled out successfully in the system's three hospitals in fewer than 18 months.

"The key was, once the decision was made, we had complete top-down support and prioritization, and it was the major strategic focus at all levels of the organization," King explains.

"The breadth and scope at which we did it was the only strategy you can have," she says.

"We did not go into this as a pilot or a `maybe,' but as a done deal," Smith adds.

Just the process of installing the system had quality benefits, King notes. "We took the first six months with interdisciplinary teams involving everyone who contributes to patient care, to drill down and understand processes. I look at this as the organization's largest PI program ever."

The teams examined what was done in each unit; how it was done; identified the resources with which they did it and with whom they interacted to get the job done.

"We did a workflow analysis of current processes, laid Epic over it, and saw what was possible - how to eliminate nonessential redundancies, variations, and build to that workflow," King explains. "Once that was complete, then we started the systems analysis and retooling everywhere."

Of the three hospitals, two had been together 20 to 30 years, but the third had only joined the system in 2000, Smith notes.

"We had migrated them to our computer systems, and that certainly helped, but there were still a lot of different workarounds," he says.

"We also have 500 employee docs practicing in 65 office locations, and each of them did things a little differently. We now had the ability to get all of them to do the same thing, at least as much as possible; and in general, we now have one set of workflows," Smith explains.

"As it grows, we have the opportunity to build tools that are decision-support systems and can promote evidence-based medicine through order sets and plans of care," King adds. "Then the data accumulate, and we find ways to extract discreet data to see how we're doing."

Real-world benefits seen

The system already has demonstrated its value many times over. Take, for example, the recent recall of Vioxx. Within hours of the announcement, ENH built an alert into the patient record system that blocked new prescriptions or renewals for Vioxx, offered other medication options to physicians, and provided a link to the Food and Drug Administration press release.

Simultaneously, ENH identified any of its patients who had ever received a prescription of Vioxx, which amounted to more than 2,700 in the past 18 months. It sent each physician's office a list of their affected patients so the offices could proactively contact them.

Another example involved paradoxical reactions of patients to Dilaudid. "They had no lasting harm, but they were still unanticipated reactions," King says.

"We understood that the way physicians were ordering the drug did not necessarily take into account whether the patient had previous experience with [Dilaudid] or not, and might be more prone to some complications," she says.

So the committee came up with two different order sets - an opiate-na‹ve one vs. one for patients who had had the drug.

"We put it immediately into Epic, so it reminds the physician to take it into consideration and select the appropriate order set," King says.

When it came to the Joint Commission on Accreditation of Healthcare Organization's national patient safety goals, one of ENH's desires was to identify strategies to prevent deep vein thrombosis.

"Our multidiscipline team looked for ways to help prevent it, and they were very quickly able to load into Epic a risk-assessment tool the physician could fill out with admitting orders, and if the patient scored above a certain level, there were recommendations associated with different scores," King explains.

"Because you can load something like that overnight, the clinician can get to use it very quickly," she says.

Big savings projected

It was Smith who came up with the $10 million savings calculation. "We spent $30 million in capital money up front," he notes, "But the savings come about from a series of relatively small increments in individual departments."

Two-thirds of the savings are in personnel - not through downsizing, but through shifting workers when other positions were eliminated.

"For example, we no longer have to scan medical records into the documentation system, so five or six employees took other positions in medical records," King points out.

There also were big savings on the revenue side. "We either get the money faster, because we're not denied the first time, or the percentages of money collected more quickly are up, and so on," Smith adds. "We do a better job of checking addresses, so we save on returned mail," he says.

"Averted costs are difficult to quantify, but if you avoid a malpractice claim by not placing a decimal point incorrectly in the pharmacy, that can save you a lot of money," King notes. "You can make assumptions based on past experience and project it out."

In addition, she notes, having sophisticated clinical pathways embedded into the system guides clinicians to consistently hit evidence-based best practices, which is "very powerful. It really promotes dialogue and the advancement of care, and when you identify an opportunity for improvement, your ability to respond is almost instantaneous," King points out.

Finally, the paper chase is a thing of the past at ENH. "We basically have no charts in the hospital now," Smith adds.