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The Power of Consolidation

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When William Greskovich became chief information officer at Baltimore’s St. Agnes Hospital in 1997, he made a strategic decision that changed the course of information technology at the community facility. Rather than adhering to the hospital’s “best of breed” tradition of buying multiple systems, Greskovich convinced the hospital’s board that consolidating on a single platform would yield operational and financial dividends. During the spring of 1998, St. Agnes began an 18-month transition to a hospital information system from Westwood, Mass.-based Medical Information Technology Inc.

The “Meditech” system laid the cornerstone for information exchange that might be the envy of many more affluent hospitals. Running integrated clinical, administrative and financial applications, the system reduced St. Agnes’ annual operating budget by $1 million, shaving the number of system support staff by seven. Moreover, the hospital’s electronic medical record has enjoyed growing support from clinicians. In 2000, some 90,000 patient charts were opened each month by physicians, nurses and other authorized users. By January of this year, that number had grown to nearly 800,000.

The key, Greskovich says, is to design clinical applications around physician needs—and offer multiple pathways to data. Offering electronic signatures through a physician portal in 1997 was among the early moves the CIO made, enabling physicians to sign their charts remotely. Likewise, building a clinical data repository exposed physicians to the value of navigating clinical data electronically. The following year, Greskovich added a wireless network, which let caregivers document on the fly—a crucial acceptance factor, he says. In 2002, St. Agnes deployed picture-archiving and communications technology from San Francisco-based McKesson Corp. Interfaced to the Meditech system, the $4 million package has sped delivery of radiology results, virtually eliminated film and pushed St. Agnes even closer to Greskovich’s paper-free vision. “We are 80 percent digital now,” he says. Once he completes his next three technology projects, the CIO will be even closer to helping his facility earn the elusive title of “digital hospital.”

1. Order entry

Greskovich hopes that the third time will be the charm for computerized physician order entry. Twice he launched efforts to automate how physicians initiate lab, radiology and medication orders. And twice he has bailed out, calling off CPOE pilot projects in 1998 and 2000. The problem: immature software. Ever the optimist, Greskovich thinks the current pilot in the 16-bay adult intensive care unit will pass muster. For one thing, Meditech’s software can now handle complex medication orders. Perhaps more importantly, in the past few years the industry has focused on the issue of medical errors. Physicians realize the merits of creating legible medication orders aided by decision support tools. “We were too far ahead of the curve for the first two pilots,” he says. “There is a higher probability we can meet physicians’ needs now. There is less emphasis on the time it takes to place an order and more emphasis on patient safety issues.”

By starting the pilot in the intensive care unit, Greskovich is putting the software to the acid test. Medication orders in the ICU are among the most complex that physicians write, he explains. In this environment, St. Agnes physicians will test out the software’s order sets—created by a group of staff physicians—and evaluate the clinical effectiveness of the program. Unlike the first two pilots, this one will use standardized, evidence-based order sets. “If CPOE can play in the ICU, it can play anywhere,” Greskovich says. The CPOE pilot will run in the ICU through the spring of 2007.

2. Barcode medication verification

Before Greskovich activates the medication ordering system, he wants to be sure St. Agnes’ barcode system is working properly. Now in the early stages of deployment, the barcode system will ensure that the proper medications are being administered to the proper patient. Representing an investment of about $180,000, the system requires the pharmacy department to affix unit-dose barcodes on medications—a time-consuming process to implement, Greskovich says. Nurses will be the primary users of the system, logging on to Meditech’s medication administration module, then pulling up individual patient orders. During the administration process, nurses scan both the patient wristband and the medication. The software then checks the medication against the order.

With the barcode system, Greskovich has followed his tried-and-true project methodology: Pilot first in a select unit (med-surg in this case) and maintain a meticulous project management timetable. The barcode project plan, for example, spells out an implementation timeline, but also includes a list of project team members, budget requirements and other technologies affected by the technology.

Of note is the consultant budget: $0. It’s almost as if Greskovich, a former consultant, is trying to make a statement; he relishes discussing how he pulled off the initial Meditech installation with virtually no consulting help. For Greskovich, getting department members in the same room and giving them carte blanche to discuss process can yield the same result—if not more staff acceptance—as high-priced outside advice. “When we deployed Meditech, we broke the system into components rather than hire outside consultants” to manage the roll-out, he says.

3. Physician documentation

Automating inpatient physician documentation is an example of what Greskovich dubs the “high-hanging fruit.” In his vision, physicians would document their inpatient care electronically, rather than using dictation services after the fact, while they placed their orders. But until recently, Meditech’s software has not been up to the task.

That’s why, three years ago, St. Agnes began adapting Microsoft Word as an electronic documentation tool, one that can be used on the fly as physicians make rounds. The makeshift solution works well, but has limited value compared to an integrated system. Nevertheless, the stopgap measure has demonstrated the value of having data stored electronically, rather than requiring physicians to look both online and in paper charts. Last year, St. Agnes invested $210,000 in a software upgrade to enable physicians to enter notes directly. One key feature that may spur adoption is the software’s capacity to flow lab values directly into the clinical note, Greskovich says.

Physicians will still have the option, however, to generate notes by storing their dictation or entering comments with voice-recognition software. For some, typing will be the last resort, even though the system can generate templated clinical phrases common to many patients.

Because St. Agnes is a community hospital, it is not in a position to mandate use of any technology to its affiliated physicians, Greskovich says. But he figures that as computer-savvy residents use clinical documentation tools, the rest of the staff will follow suit.

“After you enter patient data, the payoff is that it is available anywhere and anytime,” the CIO says. “You get a call on the patient, and now you can see the complete record.”

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