ZIFFPAGE TITLESystem OperationsBy Deborah Gage Print
Physicians at Cincinnati Children's Hospital figured if they picked the right technology and the right vendor, establishing an electronic means of ordering drugs and recording patient treatments would easily reduce mistakes and improve care. But there wasSystem Operations
Today, the hospital has ICIS in place. The system is based on a software bundle from Siemens Medical called Invision that helps Cincinnati Children's and scores of other health-care providers with everything from record-keeping to billing to order entry to tracking patients' medications.
In the mid-1990s, the hospital was using Invision for billing and other financial functions. But it wasn't until 2000 that it tried to computerize the way doctors entered orders for medication and other clinical treatment of young patients, and to keep a digital record of vital signs, weights and assessments of a patient's condition.
That didn't mean the Siemens system could do all that. The Siemens software, for instance, couldn't check the accuracy of doses of medicine prescribed for young patients, couldn't fully process critical-care nursing documents, and didn't easily integrate with other systems the hospital decided to use. In addition, the hospital's information-technology staff had to come up with a way within the system to, for instance, capture and program the order sets that would standardize repeatable medical treatments.
The icis software, and the hardware needed to run it, cost about $14 millionno small amount for a hospital with an annual budget of about $20 million for information technology. The hospital would also find that its new software would overload its mainframe system, necessitating the $1.8 million purchase of new computer and storage equipment.
"We ran into our share of implementation issues," Johnson says.
There were people challenges as well. Doctors, long accustomed to simply telling nurses how they wanted patients cared for and scratching a few lines on a prescription pad to order medication, now would be required to fill out specific fields on screen to say how a patient's care should proceed. Even a simple request for aspirin would have to be typed in before it could be sent to an on-site pharmacy.
The time taken to order treatment can be as time-consuming as the treatment itself. Ear, nose and throat specialists, for instance, can often perform a simple ear-tube insertion procedure, which helps kids drain fluids from their ears, in about 5 minutes. In the past, when they were done, they could just tell a nurse how they wanted their patients to be looked after.
The system requires these doctors to sit at a computer terminal, log in, fill out an ordersay, for an antibioticand log back out. That could take 5 minutes each time. With 20 or more procedures a day, that can add hours to their schedules.
To overcome this problem, Johnson says the team honed the ENT order set. Since ENT doctors rarely deviate from common after-care orders, they weren't presented with multiple choices on which drugs to order or the amount of time the child should be watched by a nurse before discharge. The system instead presents a complete screen the physician can simply OK with a few clicks. Additional choices are presented only if the care deviates from standard procedure.
Other problems weren't as easy to solve. One of the biggest hurdles was adding a dosage-checker for kids and newborns such as Baby J.
Many systems for adults, including one from Siemens, come with a program that checks medications against a list of characteristics and requirements, such as how the drugs interact with other pharmaceuticals and a patient's maximum allowable daily dose. When there are potential problems, such software may flash a red "Dose Check Warning" message on the screen when a single order exceeds the recommended daily dose.
But few if any vendors on the market offer a product to check for errors in pediatric prescriptions. Part of the problem is that dosing children is a major challenge, says Marianne James, the hospital's vice president of information services.
"In an adult hospital, you dose based on a vial of this or a capsule of that," says Dr. Brian Jacobs, the hospital's director of technology and patient safety. "We take care of children who range in size from 500 grams [about 1.1 pounds] all the way to 150 kilograms [about 330 pounds]. In children, we always dose per kilo. So a dose of morphine is 0.1 milligrams per kilo. That's a very different dose for a premature infant than it is for an obese adolescent."
Cincinnati Children's team used a database from a company called First Databank that contains information on the properties of all drugs approved by the U.S. Food and Drug Administration, plus information on the characteristics of herbal and dietary supplements. Then it tied the database into an electronic list of the drugs the hospital uses, and added a homegrown program to make sure the doses doctors ordered were in line with their pediatric patient's weight and age.
That was the easy part.
What took time and effort was setting the error warnings. Cincinnati Children's recruited a team of doctors to figure out the trigger points for the alarms.
The hospital has some 3,800 drugs listed in its system, with 470 considered potentially toxic. While a doctor might prescribe 20 milligrams of morphine to a terminal cancer patient in severe pain, a 20-milligram dose of the drug could be fatal to an infant. It took the hospital three to four months to check all of the drug possibilities.
"It's quite onerous," says Johnson.
Considering the effort, it's somewhat ironic that the alerts were partly responsible for the incidents in which doctors mistakenly ordered the 325 tablets of Tylenol and the overdose of Adenosine.
Granted, that's just two incidents out of 4.2 million drugs ordered since the system went live in 2002, but they forced the hospital to confront such unintended consequences head-on. For instance, Jacobs, who was the ICIS project leader, says it became clear early on that the system generated too many alerts. A poll of physicians found about 75% of the alerts were useless. Oncologists, for instance, didn't need to see a warning every time they ordered 20 milligrams of morphine.
Since then, Jacobs and his team have been going through the program and simply suppressing those alerts they think extraneous. But in a follow-up poll, doctors said they still found 50% of the alerts useless.
"It's well known that if you have too many alerts, people just dismiss them without reading," Johnson says.
With that in mind, he explains, the team realized it needed to build "blocks" into the system that would not allow doctors to prescribe excessive doses of dangerous drugs. The hospital put blocks on 105 of its 470 toxic drugs.
Today, if a doctor mistakenly tries to order a harmful dosagesay, 2 milligrams of the anesthetic Lidocaine for each kilogram of the patient's weightthe system will not let the order go through. If the doctor really wants the drug, he has to call down to the pharmacy and explain why the dose is necessary.
The measures appear to be working, but the hospital had to come up with its own metric for determining that. The reporting of errors and near-misses is voluntary in most hospitals. So Jacobs says Cincinnati Children's began to track the use of drug antidotes as a measure of the system's success. By looking at the number of orders for Narcan, a morphine overdose medication, for instance, the hospital can back into a count of morphine medication errors. The hospital says there were eight Narcan orders in the six months leading to the launch of the system, but only one in the six months after it was deployed.
Meanwhile, the team working on the ICIS computer interface redesigned the screen for ordering a drug. Where once a doctor had a pull-down menu to choose between administering a drug as a liquid or tablet, the physician now has to type in his preference. This eliminates "form errors.''
"We've eliminated a lot of those form options because mistakes were made," says Gayle Lykowski, a registered nurse now working as a systems analyst in the information-systems department.
But as hard as the staff worked to fill the gaps and get the system right, the hospital in some ways is just scratching the surface, Johnson believes.
For instance, after a doctor prescribes a medication, the system sends the request to a printer in the pharmacy. The druggist takes the printout and rekeys the order into the pharmacy's own inventory control system, called Worx.
According to John Hingle, operations specialist in the department of pharmacy at Cincinnati Children's, Siemens owns the proprietary code needed to integrate ICIS with outside pharmacy systems and does not share it. Siemens says it often shares code, but has not yet created software that will connect its application to the hospital's pharmacy system.
Tying its systems together, especially as it tries to create a holistic view of patients in its care, is a challenge for Cincinnati Children's. According to James, the hospital has a dozen systems. One system tracks cardiology patients, another tracks psychiatric patients, and yet another tracks cancer outpatients. In one case, the struggle to tie the Siemens-based ICIS to a GE critical-care notation system has delayed a long-standing plan to electronically document the care of critically ill patients.
"It's tough sometimes to get [the vendors' products] to work together," says James.
In the critical-care units of Cincinnati Children's, doctors and nurses use a large piece of paper called a flow sheet to track their patients' progress. The document includes vital signs, readings of ventilator settings and details on the medications and liquids delivered to the patient. The single sheet allows clinicians to quickly determine the next course of treatment.
A digital version of this would allow clinicians to view data in side-by-side graphs and also automatically chart data, so they can more quickly spot changes in patients' health.
Cincinnati Children's chose to bring in GE's Centricity Acute Care package to keep track of vitals, medications and treatment because it felt the GE package could clearly present data such as the relationships between factors like medications and vital signs. Siemens was working to bolster its critical-care product, but Donald Rucker, a medical doctor and Siemens' chief medical officer, admits the software had its "limits" when Cincinnati Children's was making its decision in 2002.
The challenge now is that while doctors will be planning care with the GE package, they'll still need access to the ICIS system to order painkillers, antibiotics and other medications.
The hospital decided to go with a third-party software package from Sentillion, an Andover, Mass., company that helps health-care organizations link different computer systems. James thought Sentillion would best meet the hospital's needs. The Sentillion product, Vergence, is designed to let doctors sign on once and access both the GE and ICIS systems. In this setup, Sentillion sits between the two systems. When a user logs in to ICIS, Sentillion will connect to Centricity and tap into it on request, allowing the GE program to appear as a selection on the ICIS screen.
But the pilots have resulted in some "flippy" exchanges, says James. Sometimes when a nurse or doctor picks a patient from one system, they get an "Other Patient Not Found" notice when they look for a file in the other system. "It doesn't work half the time," James laments.
"It's a question of working out the bugs," she says. "It's part of being on the edge of trying to do things that are different."
The cultural challenges, however, proved to be just as tough as the technical travails, Johnson says.
Cincinnati Children's knew from the beginning that if it was to have any chance of success, it needed to get its medical department directors, doctors and nurses to use the system consistently and happily. But the hospital did have an edge. Unlike a community hospital, in which private practitioners treat patients in the facility, the doctors who work in Cincinnati Children's are hired hands. Being the boss gave the hospital's managers the ability to mandate usage of the system.
"I don't know how [one] puts these systems into a hospital where all the physicians are independent, private practitioners," Johnson says.
Throughout the process, both Johnson and Jacobs said they wanted to be sure there were no revolts like the one that led to systems suspension at Cedars-Sinai in Los Angeles.
The plan: provide extensive training tailored to doctors' schedules. Also, offer one-on-one sessions and plenty of 24/7 support when the systems went live in the units.
Nurses, though, took the brunt of the implementation headaches. Installation of the computer terminals disrupted the daily flow, as new machines were put on the floors and both the paper and electronic systems had to run in parallel during installation so no orders were missed. Plus, while doctors come in and out of the units, a large part of a nurse's day is taking vitals and administering meds, which had to be done electronically.
Yet some of the nurses had never touched a computer. For the "newbies," the hospital provided basic computer training. And the hospital's nursing managers held some hands and held others' feet to the fire, to get the staff using the system. "Nursing leadership was big," Johnson says.
The project team also rolled out the system in stages. Johnson and the ICIS leaders came up with a plan called Radiology Lite, a pilot system that allowed one group, intensive care, to perform one task, radiology orders, on the system.
The pilot introduced doctors and nurses to the system, promoted its acceptance, and allowed the ICIS team to test the system in the real world. After its success, the full order entry and clinical documentation system was piloted in two medical surgical units in the spring of 2002, with rollouts to the hospital's other units through the end of that year.
Today, ICIS is widely used throughout the hospital, although some pieces are still not up. In the hematology/ oncology unit, an order set for chemotherapy treatments has yet to be built. Chemotherapy is based on a number of factors, including how well a treatment works and how a patient responds to a dose. Because of the variables, the staff has had to spend additional time checking order sets.
And Johnson is working on a PACS upgrade. He's leading a team implementing an image and record-keeping system that will feature voice-recognition dictation. That way, radiologists could sit at a terminal, look over results and dictate the findings, all in one sitting. The goal is compiling radiology reports in as little as an hour, Johnson says. His department and GE are trying to work this through. But much of the code the vendor is writing is new. For GE, he says, "It's like starting over."
Perhaps a more strategic initiative is getting single, complete records for every patient the hospital treats.
The outpatient department is testing GE's Logician software, which is tailored for handling one-day visits. The outpatient staff is just beginning to make decisions on how the system should collect and send admissions, orders and test results to inpatient and other patient care systems. For now, inpatient and outpatient electronic medical records are not unified.
But Johnson isn't sure the hospital should even call the end result an electronic medical records system.
"I hate that term," he says. He doesn't feel it accurately describes what happens in the hospital, as the systems are more than just a electronic copy of a patient's chart. What Cincinnati Children's is using, he says, is a clinical information system: "The chart doesn't say, 'Doc, it's the wrong dose.'"
The Bush administration's electronic health records push is also looking at more than just electronic charting. The aim is to create an information infrastructure that can be used not just to record what's happening to current patients, but to improve care of all patients in the future.
But Johnson wonders whether Washington understands the challenges. "It's good that the national political scene is paying attention. But I'm personally concerned," he says. "Just as the expectation of the doctors hereeven a few years agowas that if we picked the right vendor, got the right technology and installed it, everything would work perfectly. That is no longer the myth it used to be in this institution."
Johnson says he's worried that people outside health care don't realize the technical and cultural challenges involved. And they may not be ready for the unanticipated consequences.
"Throwing money and technology alone at hospitals will not [give] them integrated, beautiful electronic medical records anytime soon," Johnson says. As Cincinnati Children's has found out, "It's a long slog."
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