Behind the Wires

Few people could comprehend the workplace conversations of Reid Coleman, M.D. It’s not that he’s inarticulate—quite the contrary. But Coleman, originally trained in internal medicine, is multilingual. He serves as medical informatics officer at Lifespan, a community hospital system based in Providence, R.I. And in that role, Coleman must be glib in med-speak, tech-speak and, on occasion, admin-speak. “My job is translation,” he says. “It’s conveying to physicians and nurses what technology is and is not capable of doing and conveying to technology people what clinicians need for improved care.”

Translating is exactly what Coleman’s doing at this 7 a.m. meeting with seven administrators at 247-licensed-bed Miriam Hospital, one of four hospitals in the Lifespan system. Topic: medication reconciliation process. The administrators are trying to unravel the Joint Commission on Accreditation of Healthcare Organizations’ implementation expectations 8A and 8B for medication administration. Compared to the down-to-earth chatter of the physicians and nurses, the regulatory language is hopelessly bureaucratic, if not downright opaque. The administrators just know they are being called upon to document medications—before, during and after inpatient visits.

Coleman’s there to offer advice—and nudge the group toward an IT solution. If Miriam can figure out its medication administration workflows, the hospital could uphold JCAHO requirements by use of a medication history application, explains Coleman. The application could be linked to the hospital’s clinical documentation system, primarily from Malvern, Pa.-based Siemens Medical Solutions. Two other Lifespan hospitals are already preparing to use the application, he tells them.

But the road to automation is not easy, and Coleman works with the group as it maps out its medication administration processes. A facilitator creates a flow chart, which grows to three parallel tracks—physician, nurse and pharmacist—and includes two dozen decision points and tangential events. The complex chain of events is beyond any one person’s knowledge. Coleman helps by clarifying a medical staff policy change. Patients moved from the intensive care unit to another unit are no longer required to have their medication orders discontinued before they transfer.

The completed flow chart will set the stage for Coleman’s next big task: helping the IT department design the application around Miriam Hospital’s needs. If Coleman is lucky, Miriam will follow the other hospitals and require minimal customization. The Miriam group endorses that idea, at least in principle. For Coleman, that is good news; managing the development of one application is tough enough, let alone three customized versions of the same thing. And there are system limits. For example, incorporating patients’ home medication lists into Lifespan’s pharmacy system would require a major overhaul.

Midway through his fourth year as medical informatics officer at Lifespan, Coleman has become an expert in tempering expectations. Even though Lifespan has made strides automating the flow of patient data, the organization has struggled to automate—and standardize—workflows across disparate cultures. A few projects have not gone smoothly—a recently installed radiology information system, for example, teetered at the outset, initially delivering test results to the wrong printers. As a result, some staff view IT “solutions” skeptically. During the meeting, one staff person suggests the group develop a paper form to fall back on when (not if) the computer system crashes. The best way to build support for information systems, Coleman later says, is “peer pressure and success stories.”

Since Coleman became medical informatics officer in 2002, he has had plenty of those stories to tell. Lifespan has built a Web-based physician portal rich in clinical information. It has deployed an order entry system, which now processes some 12,000 daily orders of all kinds. And the community hospital system has closed the loop on medication administration safety with a bedside barcoding system. Now medications are tracked and verified from the point of order, through the pharmacy and back to the hospital floors. “Nobody has a chance to make a mistake,” says Coleman, who still practices medicine one day a week.

In addition to helping design and develop these systems, Coleman also serves as an IT missionary. During his morning, he delivers a cell-phone tutorial to a physician, sounds out a nurse on how automated medication scheduling must be revised and hobnobs with residents in the pediatric emergency department. During the discussions, Coleman’s medical training often surfaces in the relentless attention to detail he foists upon the care delivery process. Explaining the order system, Coleman launches into a detailed explanation of the difference between “reflex orders” and “add-ons,” quickly overwhelming the questioner. “Reid, you’re giving me too much information,” she protests.

As Coleman attests, modern medicine is all about too much information. For him, IT is just one way to streamline its delivery to clinicians. The key to IT adoption, he says, is to involve caregivers in all stages of system design. “You can’t design a good EMR in a conference room,” he says.

Project 1
ED order entry system

Lifespan’s inpatient computerized physician order entry system has been humming since its inception in 2001. To destigmatize the technology, Coleman insists on calling CPOE “physician order management.” Order entry systems, he explains, are not about turning physicians into clerks. It’s true that entering orders replaces handing off a scribbled note to an assistant, he says. But Lifespan’s system includes a host of supporting references and alerts to assist physician decision-making. Making effective use of the system requires clinical knowledge, he says.

More than 85 percent of medication orders are entered by physicians into the computer. It’s an acceptance rate that dwarfs that of many hospitals, but Coleman is quick to share the credit. Whenever he discusses IT successes, he slips into the “we” voice. The orders system took off, he says, thanks to a massive—and prolonged—effort to involve physicians in its design and deployment. Over a four-year period, Lifespan rolled out the technology hospital by hospital, resolving workflow issues along the way. “Physicians were ready to be upset,” he recalls. “They had heard about so many bad hospital experiences with CPOE.”

Coleman tackled the resistance question headfirst by involving 12 resident users of the system in a one-month elective on system planning. The residents earned their academic hours, and Coleman got a lesson in what CPOE users need. “They taught me more than I taught them,” he says.

Now Lifespan is expanding the reach of its electronic orders capacity by implementing the technology in its emergency departments. It’s almost an entirely different task, Coleman says. For one thing, its primary IT supplier, Siemens, cannot accommodate ED order entry. So Coleman turned to another vendor, Addison, Texas-based MedHost. More important, ED workflows are vastly different than inpatient ones. “Keeping track of where patients are and getting results back to them is a major problem in the ED,” he says. “ED work is done in small, fast batches. Treatments are not continuous.”

To help solve such problems, the MedHost system includes a map—a schematic diagram of the floor—with patients’ names appearing in the rooms and visual icons giving the status of their test requests and results. The orders component is integrated into the application, enabling staff to keep tabs on the entire division from one screen. To date, Lifespan has deployed the system in its adult emergency departments at Rhode Island and Newport Hospitals and the pediatric ED at Hasbro Children’s Hospital, Rhode Island Hospital’s pediatric division. Miriam Hospital, its flagship, is to come.

Miriam will deploy the system when its executives—not the IT department—decide the hospital is ready. “The solutions are going to be enterprise-wide, but the affiliates get latitude about when to implement,” he says.

Project 2
Automated discharge summaries

With more than 50,000 annual discharges, Lifespan churns out vast quantities of discharge reports, primarily by mail and fax. Coleman’s vision is to dispatch the form electronically to physicians statewide. More than half of the state of Rhode Island’s hospitalizations occur at Lifespan facilities, so the need is great, he explains.

To expedite the delivery of the discharge summaries, Lifespan is developing its own electronic “continuity of care” record, or CCR. The form, which is based on Rhode Island state standards, includes diagnoses, prescription drugs, test results and demographics. Getting the form into physicians’ hands could improve subsequent care and avoid duplicate tests.

For now, Coleman’s biggest challenge is figuring out how to deliver the CCR, which is scheduled for completion in one year. He has three options. Lifespan could e-mail or transmit the form directly to physicians. The system could develop a Web portal and grant non-aligned physicians access to its information systems. Or Lifespan could lean on an emerging regional health information organization, or RHIO, to deliver the reports. However, few physicians have the electronic medical record systems to accept the form directly. The portal is an option, but Coleman does not want to preempt the work of the RHIO, which may build its own portal. The as-yet unnamed RHIO is still in its infancy, but ultimately Coleman thinks a joint data-sharing venture would be the ideal solution. “We need a unique patient identifier to make it work,” he says.

Project 3
Hospital information system upgrade

This summer, Lifespan expects to accept delivery of the latest version of its Siemens clinical information system, marketed as “Soarian.” The new version offers more flexibility and more powerful decision-making support, Coleman says. An embedded workflow engine will keep track of orders and suggest relevant tests, for example. Lifespan’s old Siemens system has been highly customized since it was deployed in the 1980s, so Coleman figures Soarian should require less maintenance. In addition, Soarian promises better reporting capabilities; Lifespan can use it to analyze clinical practice patterns or uphold Joint Commission regulations and Medicare quality metrics.

Lifespan will likely roll out Soarian on a module-by-module basis, first testing and piloting each new feature. Coleman discusses the system with a blend of optimism and skepticism. He’s well aware of the potential, but like most healthcare IT executives, he is wary of overblown vendor promises. Any vendor system requires a great deal of development work before clinicians can use it, he explains.

Coleman’s team already has built more than 300 order sets for its CPOE application. They work well, but with Soarian, it should be easier to add new ones. The risk? “Soarian might not be as functional as our highly customized system currently is.”

Gary Baldwin is technology editor of HealthLeaders. He can be reached at gbaldwin@healthleadersmedia.com.