Behind the Wires
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It’s 7 a.m., and Michael Westcott, MD, is fielding a nephrologist’s question at a medical staff meeting. The specialist wants to know how to interpret input/output data on the hospital’s electronic chart. Listening attentively, Westcott explains how the data is organized and collected. Because some of the data is a running total, reading the chart can be confusing, the nephrologist says. “Gotcha,” Westcott says quietly, agreeing to revisit the screen design, before opening the floor for other questions.
Endeavors such as electronic chart design might not seem compelling to many physicians. For Westcott, who practiced emergency medicine until 2004, it has become a second career calling. Serving as chief medical information officer at Alegent Health, a nine-hospital delivery system based in Omaha, Westcott is now a full-time devotee to the electronic medical record.
Alegent has already made major strides in capturing its clinical data electronically. Using a hybrid approach, its flagship hospital, Lakeside, is virtually paper-free, sporting one tiny chart room. Many documents, such as nurses’ notes, originate as electronic files. Others, such as emergency department and operating room records, are scanned and appended as electronic images. Alegent’s other hospitals all have plans in place to retire their paper charts, as well. As the key physician executive in the overhaul, Westcott must tend both to minute and grandiose issues to make it happen. “Getting physicians trained to use clinical IT is a huge challenge,” he says. And Westcott—whose 15 direct reports provide user training and support—has had to alter his implementation strategy en route. Group training sessions with physicians, for example, just did not work, so Westcott promptly abandoned it in favor of one-on-one tutorials and informal early morning gatherings.
Hurdles aside, Westcott says that gaining physician acceptance of clinical IT has been one of his department’s biggest accomplishments. “We showed physicians how it is easier to look online to get clinical data,” he says. And offering small, time-saving features, such as electronic signatures for chart completion, whetted the medical staff’s appetite for additional IT applications, Westcott says. Clinical staff at Alegent have plenty of opportunities to put clinical IT to the test, as the health system is awash in new technology. Eventually, the digital chart will be in place systemwide—even in Alegent’s rural hospitals in neighboring Iowa. “No one practices in a vacuum any more,” Westcott says.
1. Medication Administration
Barcode technology drives Alegent’s medication administration system, which is in place at three of its hospitals. Using the system at the bedside, nurses scan their badges, the medication and the patient armband before administering. The system not only tracks the encounter, but will also display alerts if something is awry in the complex information matrix that precedes administration. “If anything is wrong, such as the patient, the drug or the time, the system pops up a big ‘X,’” Westcott explains. “When all three elements are correct, the nurse sees a green check.”
Aimed at boosting inpatient safety, the medication system runs on a module from Siemens, whose all-purpose “Soarian” technology forms the core information system at Alegent. For Westcott, computer monitoring of medication administration plugs a major safety gap. “Reporting errors has always been voluntary, and many errors were never reported,” he says. “Most don’t cause harm, but it is a huge patient safety issue.”
Alegent uses robotic technology to apply the barcodes to medications prior to arrival on the floor, which has helped the health system streamline one of the thorniest issues around barcoded medications. But training nurses on how to use the barcode scanners, which attach to wireless rolling carts, has been challenging. Like physicians, their time is scarce, and many are overworked. That’s why Westcott is working with Siemens to develop an interactive online tutorial. It’s a big training job, one that will fall on Westcott’s 15 direct reports—themselves all nurses—to accomplish. At Bergan Mercy Medical Center alone, “we will train 1,000 nurses,” says Westcott, who’s banking on the online tutorial to streamline the effort.
Setting the technology stage for the medication administration is also a challenge. Before implementing the bedside technology, the hospital needs to have its new pharmacy system in place, then affix barcodes to the various drugs, building the knowledge into the clinical database. Alegent is on course to complete five hospitals by early 2008, with its smaller rural facilities to come later. They need an infrastructure upgrade before proceeding. “There is a lot of prep work,” says Westcott.
2. Critical Care Information System
With some 100 ICU beds scattered across five hospitals, Alegent faces a big challenge tending to the sickest of the sick. Historically, ICU patients have had their data compiled manually, as caregivers transfer values from medical devices and monitors to giant spreadsheets. “If you go into any ICU, you will find these big flowsheets, with hundreds of data points,” Westcott observes. “We are trying to make it electronic.”
Alegent’s new model for critical care revolves around a central monitoring station, or ‘e-ICU,’ which is staffed by intensivists and nurses. At the e-ICU, clinicians monitor dozens of patients at once, rather than having specialists scattered across the greater Omaha area. The e-ICU uses software and telemonitoring equipment from Visicu, receiving much of the data electronically rather than across fax lines. Replacing the fax with direct data feeds from the devices will require another Soarian module, particularly for the non-Siemens devices. Any Siemens monitors are “plug and play” with the central monitoring system, Westcott says.
Once the e-ICU is in full swing, Westcott figures that Alegent will be able to care for more complex patients in its outlying rural hospitals. The system’s videoconferencing capabilities is highly sophisticated—and precise. “The camera can zoom in and read the label on an IV bag,” he says. A centralized monitoring system also helps Alegent cope with the shortage of physician intensivists.
Westcott’s third major project, computerized physician order entry, may prove to be his toughest challenge. Now in its early phases, the project has no firm timelines, Westcott says. “We will roll it out when it is safe.” Replacing hand-written physician orders ultimately will boost patient safety and help Alegent embrace evidence-based medicine, he says. Handwritten orders are hard to read, and physicians across Alegent depend on widely varying order protocols for common diagnoses. Westcott is not only transitioning physicians to a new role, he is asking them to accept standardized order sets.
To tackle the project, Westcott formed an evidence-based care team. Its function: Search for various order sets already in place, then engage groups of specialists and primary-care physicians to create new standardized sets. As a starting point, the team is using software from Zynx, which offers decision-support guidelines for major illnesses. The teams are building the proposed order sets, which are posted on the Alegent intranet for medical staff review. Ultimately, order sets must go before the medical executive committee at each hospital for approval. But none of the 20 or so proposals completed through mid-summer had been turned down, Westcott says, attesting to the value of gaining physician buy-in along the way. Even with the Zynx tools to assist, the work is time-consuming. “We have four different order sets for myocardial infarction.” Westcott says. They vary “depending on if the patient was admitted through the ED or through the physician office.”
Having standardized electronic orders will boost efficiency across Alegent, Westcott says. For example, if a drug is recalled, a simple software update would instantaneously modify any affected order sets across the health system. The electronic system should also expedite order completion, a selling point that Westcott makes to physicians who are faced with the prospect of entering their own orders—a task some dismiss as clerical. But the old hand-off system can result in significant delays as paper orders get stuck in the bottom of the pile. “It can take up to three hours to get an order into the system,” he says.
Entering orders electronically, however, is no simple task. Even a simple X-ray order has multiple components, such as how many views the patient will need, assigning someone to escort the patient to radiology, and determining the urgency of the image. “Physicians have not had to pay attention to all these details in the past, so we have to automate those things,” Westcott says. ‘That has slowed the project down.”
If such obstacles weigh on Westcott, he doesn’t show it. “It is an exciting time to be in medicine,” he says.
Gary Baldwin is technology editor of HealthLeaders magazine. He can be reached at firstname.lastname@example.org.
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