This article appears in the February 2012 issue of HealthLeaders magazine.
Changes wrought by technology are making an indelible mark in service lines for health systems big and small. This is being reflected in a hospital when a patient is given an iPod with a Pandora app to listen to any music she wants to hear as she waits for an oncological exam (You want Motown, you've got it!) and in the surgical suite where physicians use da Vinci robotic systems for minimally invasive procedures, as well as new cloud-based data systems that allow clinicians instantaneous access to a patient's heart rhythms.
Health systems are moving ahead quickly in pursuing technology improvements, using robotics, apps, telemedicine, clouds, electronic medical records, device journals, or other innovations to provide value and add volume to their service lines. Leaders of healthcare systems say they are working to improve patient experience and patient flow in highly personalized programs while using smartphones and tablets to monitor health conditions and evaluate symptoms. Part of the rush is based on federal incentives under meaningful use requirements.
Edward W. Marx, senior VP and chief information officer for the 3,800-bed Texas Health Resources system in Dallas, says health systems have little choice but to embark on technological improvements to advance care.
"We work under the strategy that IT exists to transform, grow, and help run the organization and to be viewed as a strategic asset," says Marx. "It's all about patient experience and quality of care. We talk about transforming growth from a business perspective. Innovation is who we are and who we aspire to be. It is pretty much strategic for the organization. We try to live that culture of being innovative, and it expresses itself in many ways."
Texas Health Resources has initiated an array of technological changes that have improved efficiencies and patient care, Marx says. The system has encouraged doctors to use medical apps and smartphones and, on a limited basis, personal health devices such as EKG systems and blood pressure monitors that patients can use at home to help keep them out of hospitals, as well as handheld monitors to ensure they keep appointments.
Health systems are making both tweaks and large-scale improvements to tech initiatives they have had in place for years, such telehealth, EMRs, or robotic programs.
But that doesn't mean all health systems are fully embracing technology just yet. According to the HealthLeaders Media Industry Survey 2012, 20% of leaders say their organization is cutting back on high-level, high-price technology for service lines.
"A lot of hospitals are feeling pressure to get something, and that the technology is going to solve all their problems," says Gregory K. Feld, MD, director of the cardiac electrophysiology program for the 600-plus-bed UC San Diego Health System in La Jolla, CA. "The fact is they have to be careful what they do."
Ferdinand Velasco, MD, vice president and chief medical information officer for Texas Health Resources, notes that while some apps "provide less return than others, they are still important, especially as you begin to experiment with innovation.
"If it is a vanilla app but gets users comfortable with the technology or concepts, but has little value to the business, it is still a major win," Velasco says.
Texas Health Resources has created internal committees to serve a checks-and-balances function regarding technological improvements, he says.
Presbyterian Healthcare Services, based in Albuquerque, NM, is using a two-way video chat program to divert nonemergent patients from the ED and to help them find a primary care physician, schedule appointments, and educate them. The program operates out of the 453-licensed-bed Presbyterian Hospital in Albuquerque.
Patient navigators there operate the video chat program for patients at two of the eight-hospital system's smaller facilities, the 198-licensed-bed Kaseman Hospital in Albuquerque and the 68-licensed-bed Rust Medical Center in Rio Rancho, NM.
Through the video chat, patient navigators help direct nonemergent cases to an appointment or follow-up care with a primary care physician, if a medical screening in the ED shows they do not need immediate care, says John D. Johnson, enterprise director of the customer service center for Presbyterian Healthcare Services.
Patient navigators meet face-to-face with patients at Presbyterian and counsel patients at Kaseman and Rust Medical Center via the video chat program when they are not handling cases in person.
Since 2010, there have been more than 8,000 patients seen by patient navigators. At least 76% of patients who went to the ED were referred to primary care physicians with "minimal complaints," Johnson says. "Our goal is to educate patients and get them established with a primary care physician, thus improving continuity of care."
As a result, the health system is predicting a savings of as much as $15 million for the three hospitals during a five-year period, according to Johnson.
The hospital system employs 10 patient navigators stationed at Presbyterian Hospital.
"We're doing the right thing for the individuals and community," he says. "Patient navigation is about connecting patients with the right provider and the right venue at the right cost."
Success key No. 1: Telehealth
Telehealth is one of the most popular technological innovations for health systems because of its capability of having a broad reach for patients, especially those who live in rural areas and at great distances from hospitals. Health systems that have been successful in developing telehealth systems are now focusing on using programs for specific service lines, such as the intensive care unit.
When the Sutter Health system launched its telehealth eICU patient safety system in the San Francisco area several years ago, it was one of the first health networks to bring online two ICU centers for constant monitoring of critically ill patients.
The eICU system has enabled Sutter to detect sepsis through a standard set of screening and treatment processes throughout its 26 hospitals, and it monitors as many as 30,000 patients from its ICU hubs in Sacramento and San Francisco, says Teresa Rincon, RN, BSN, CCRN-E, the eICU nurse director at Sutter Health.
The process also has had a carry-over effect: Sepsis-related deaths in the hospital system have decreased 29% since 2008, with more than 1,300 lives saved between 2007 and 2010. The hospital has estimated that it has saved $21 million in costs because of reduced time patients spent hospitalized during that period, according to Rincon. Length of stay has been cut at least 17%, she adds.
Screening patients for early signs of sepsis and use of sepsis bundles—a series of checklists and recommendations for providers to follow—have been implemented systemwide, especially in the EDs, ICUs, and medical-surgical units under multidisciplinary team approaches, Rincon says.
"The reality is that healthcare has evolved. In the past it has honored individual expertise and individual smartness," not working as a team, which she dubbed "colony smartness."
Nurses, too, had been used to working in silos. With the ICU "you need to work well with the emergency department and the medical-surgical units to coordinate care," Rincon says.
Under the program, intensivists and ICU-trained nurses use early warning software, advanced video, and remote monitoring to check on critical patients. Physicians monitor the system around the clock.
The system includes video camera feeds from each ICU patient room that sends patients' vital signs to eICU computer systems.
According to a review compiled by Rincon and her colleagues, ICU patients were screened for severe sepsis upon admission to one of 12 ICUs located in 10 hospitals between 2006 and 2008. In those years, nurses identified more than 5,000 patients meeting the criteria for severe sepsis. The evidence-based checklist program resulted in antibiotic administration that increased from 55% to 74% between 2006 and 2008 and central line placement (without infection) that increased from 33% to 50%.
Sharing patient data electronically, eICU nurses are now able to check with specialists who are off-site, she says.
By tracking vital signs, lab results, and orders over a period of days, eICU nurses "may pick up subtle clues and take action to stop a decline" in patients, Rincon says.
Success key No 2: Electronic medical records
As hospital systems are spurred by the government to initiate widespread EMRs in their programs, an important concern is maintaining oversight of records for specific service lines, and that's what Texas Health Resources has done with an EMR automatic risk assessment tool designed to curtail hospital-acquired blood clots.
Three years ago, the THR officials initiated a project to use EMRs to assess each patient's risk of developing a condition, and since then they have continually upgraded the program to refine efficiencies and improve outcomes, says Velasco, the CMIO.
Physicians are alerted when patients are declared at risk for venous thromboembolism and then they can establish medication procedures. Since implementation of the program, the hospital system has seen a reduction in postoperative pulmonary embolism/deep vein thrombosis by more than 20%, Velasco says.
The support program includes a protocol that detects if preventive therapy is not ordered within a timely fashion after a patient's arrival at the hospital; an alert appears in the EMR, reminding the provider to order VTE prophylaxis and suggesting use of a VTE risk assessment calculator, a support tool. With the risk assessment calculator, a clinician uses preventive therapies, such as blood thinning medications and mechanical compression devices, to promote blood flow in patients.
Through its plan, THR achieved stage 1 meaningful use requirements and received federal and state Medicaid incentive payments. Developing a leadership committee to initiate the plan was a key to its work, Velasco says.
The hospital system's chief quality officers council created a multidisciplinary VTE performance improvement committee and appointed a hospital chief quality officer as a chairman. The committee worked with staff to carry out the program."We needed hospital staff buy-in to harmonize paper-based risk assessment tools and order sets at our hospitals," Velasco says. In addition, the health system's multidisciplinary committee agreed on a set risk assessment methodology to use through varied hospital disciplines.
Among the challenges that the hospital system had to overcome was replacing paper-based risk assessment tools and order sets.
"The primary key of our success is our strong belief in the use of the electronic health record to help advance quality and patient safety," Velasco says.
Success key No 3: Robotics
Hospitals are continuing to invest millions of dollars in robotic devices for various service lines, whether it's for general, pediatric, gynecology, urology, cardiothoracic, or other minimally invasive procedures.
In essence, hospital systems are counting on robotic systems now, despite the cost and possible lack of ROI, because of what it may bring in the future: improved efficiencies and an allure for patients.
Jacques-Pierre Fontaine, MD, a thoracic surgeon at the 206-bed H. Lee Moffitt Cancer Center in Tampa, FL, says he understands that the robotic procedure in some cases may be no different in terms of clinical outcomes compared with other minimally invasive procedures.
"It's not worse for the patient; it's the same," he adds, referring to outcomes with robotic and open surgeries. "It may be more expensive for the hospital now, but we're seeing a future in it and embracing it.
"We're embracing it because the future is going to be robotic technology. It will surpass what we have now for other minimally invasive techniques. If you surf, you don't want to be behind the wave and catch up to the wave; that doesn't work. It works if you are in front of the wave and then you ride the wave."
Such an attitude is helping to drive use of the robot systems used to perform minimally invasive heart, prostate, and other surgeries.
Use of the da Vinci device, for instance, has quadrupled in the past four years, being used in thousands of hospitals for various surgical procedures. Da Vinci is a multipurpose robot that can be used for lung cancer surgery, heart bypass and valve repair operations, hysterectomies, prostate removal, and other procedures.
The popularity is increasing despite reports of uncertainty that the estimated $2 million investment may not produce better results.
However, there have been studies showing that the da Vinci devices also result in fewer complications and improved recovery.
Despite the conflicting reports, officials of some hospital systems say they are confident in the robotic device and what it means for patients as well as hospital system ROI.
The 175-staffed-bed Methodist Willowbrook Hospital in Houston, an enthusiastic supporter of robotic surgery, has shown an increased patient load as a result of the technology. It is still compiling data, but preliminary evidence shows that patients are recovering quicker and there has been greater volume, says Patricia Worley, RN, BSN, director of surgical services for the Methodist Hospital System.
It has been important for the hospital system to use the robot for a wide variety of procedures, with its largest volume in its gynecological program and then general surgery, while building volume in bariatrics, Worley says, noting that the robotic surgery system has been used in 300 cases from August 2010 to November 2011. "Our robot is used very frequently," she adds. "We are very efficient with turnovers," adding that sometimes the robot is used for three to four cases a day.
While the hospital system is still evaluating data, preliminary information supports findings of a "decreased length of stay for inpatient cases of up to two days, which could offset the charges needed to support the da Vinci use," she says.
Despite the necessary capital investment needed for the robot, the hospital "community wanted it," she says. "It was a win-win situation. Our CEO was very supportive, and we branched out into the urology program. There have been so many interested surgeons getting trained in it across specialties. The docs have been interested, and it has taken off."
The 175-staffed-bed Methodist Willowbrook Hospital in Houston, an enthusiastic supporter of robotic surgery, has shown an increased patient load as a result of the technology. It is still compiling data, but preliminary evidence shows that patients are recovering quicker and there has been greater volume, says Patricia Worley, RN, BSN, director of surgical services for the Methodist Hospital System.
It has been important for the hospital system to use the robot for a wide variety of procedures, with its largest volume in its gynecological program and then general surgery, while building volume in bariatrics, Worley says, noting that the robotic surgery system has been used in 300 cases from August 2010 to November 2011. "Our robot is used very frequently," she adds. "We are very efficient with turnovers," adding that sometimes the robot is used for three to four cases a day.
While the hospital system is still evaluating data, preliminary information supports findings of a "decreased length of stay for inpatient cases of up to two days, which could offset the charges needed to support the da Vinci use," she says.
Despite the necessary capital investment needed for the robot, the hospital "community wanted it," she says. "It was a win-win situation. Our CEO was very supportive, and we branched out into the urology program. There have been so many interested surgeons getting trained in it across specialties. The docs have been interested, and it has taken off."
Simply having a robot is a hook for patients' interest in the hospital system, Worley adds.
"We have noticed that patients are seeking use of the da Vinci when choosing physicians and hospitals that have one and/or are trained on the robot," she says. "Patients are reading bout it; they recognize the bigger cases and know that recovery times will be less … They are going to the doctors' offices and asking, ‘Do you use the robot?'"
Success key No. 4: CT scans
The Moffitt Cancer Center is using CT scans to detect lung cancer tumors after recent studies showed that they are more effective than standard x-rays.
The hospital's use of the CT scans for lung cancer screening reflects a new terrain for many healthcare systems. While some hospitals and radiology programs are using the high-tech scans in hopes of saving the lives of lung cancer patients, others are not because of continued debate over whether benefits outweigh risks. For that reason, insurance companies have been reluctant to cover the scans.
Despite the insurance issues, the Moffitt Cancer Center is using the scans, and the program has been successful in delivering more patients, says Fontaine.
Moffitt began its program after participating in a study that found screening certain heavy smokers and ex-smokers could significantly reduce their chances of dying from lung cancer. Using CT scans to screen smokers for lung cancer cuts the risk of death from the disease by about 20%, according to a National Cancer Institute study.
"Sometimes you can't wait for the government and insurance companies to make improvements," Fontaine says. "If we think as a physician and cancer institution that we can help our patients, we're going to offer it."
The NCI study, called the National Lung Screening Trial, was conducted on people at high risk of developing lung cancer to compare the differences in death rates between smokers aged 55 to 74 who had been screened annually with low-dose helical or spiral CT versus the conventional chest x-ray. The trial was developed over more than a decade and involved at least 53,000 people. Moffitt was one of 33 study sites that participated.
Lung cancer is especially deadly and difficult to diagnose and treat. More than 157,000 people annually die annually from the disease. CT scans are seen as more likely to spot small tumors compared to chest x-rays.
Armed with the study showing good outcomes from the CT scans, Moffitt Cancer Center is now offering low-dose CT lung cancer screening to patients. It is targeting people ages 55 to 74 who have had a 30-year history of one pack a day cigarette smoking. Pulmonologists at the hospital's cancer program discuss the screening with patients.
The promise of CT screening lies in the early detection of lung cancer when it is most curable, and the tool will save lives, Fontaine says.
Under the program, it is important that interdisciplinary teams evaluate the CT scans to minimize any unnecessary procedures and follow-ups such as biopsies and surgeries, he says. The results are evaluated by a lung cancer tumor board, which includes oncologists, pulmonologists, pathologists, and surgeons.
This article appears in the February 2012 issue of HealthLeaders magazine.
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
