Some academic medical centers are extraordinarily big, supporting faculties that may top 1,000 physicians. Like their brethren in community hospital settings, these centers feel the constraints of dwindling reimbursement and increased charity care loads. A bastion of specialties, these organizations teem with support staff of every ilk.
Building enterprise electronic health records in this setting requires hefty doses of vision and capital. And on occasion, it also calls for tough-minded management to break through the bureaucracy and department fiefdoms.
"Academic medical centers do the same thing that all hospitals do, but we have many more players," observes Jessica Cronin, R.N., director of nursing informatics at University of California San Diego Medical Center. Accommodating those players poses a big challenge to CIOs.
"We have attending physicians, but also residents, fellows, nursing students and medical students," Cronin continues. "Our core mission is education. That adds a layer of complexity to I.T. The staff needs access to the right systems, but not so much access that they can do things they are not supposed to."
Following are snapshots of a handful of teaching hospitals that are forging ahead with EHRs.
PATIENT SAFETY PREVAILS, NOT 'SEXY SYSTEMS'
Organization: University of California San Diego Medical Center
Size: 550 beds, 550,000 annual ambulatory visits
Staff: Faculty includes 1,000 physicians
I.T. Staff: 140
Annual I.T. Operating Budget: $15 million
EHR Achievement: 100% physician order entry
University of California San Diego Medical Center sits among an elite group of hospitals. It's one of just 22 hospitals that have attained the so-called "stage 6" level of adoption of electronic health records, as measured by Chicago-based HIMSS Analytics, a market research and consulting unit of the Healthcare Information and Management Systems Society (to read about another stage 6 hospital, see following story on Memorial Health University Medical Center). Attaining that ranking puts UCSD in rare company: stage 6 accounts for less than 1% of U.S. hospitals, with virtually none at stage 7, the highest. To warrant the designation, UCSD has implemented such complementary technologies as an enterprise PACS, a clinical data repository, a "closed loop" medication administration system and clinical decision support.
CIO Ed Babakanian, however, takes it all in stride. "I.T. is not just about I.T.," Babakanian says. "We don't do I.T. because we like sexy systems. It has to be an enabling factor to improve outcomes and safety."
A 14-year veteran at UCSD, Babakanian says that his toughest challenge is overcoming old habits. "Educating groups is always a challenge," he says. "It took a while for the medical staff to see that computerized physician order entry is good."
Using technology from Malvern, Pa.-based Siemens Healthcare, the two-hospital academic medical center has been running CPOE for six years (for more on CPOE, see cover story, page 18). All orders are automated from the time a physician selects a medication to the point of delivery at the bedside, where bar code technology assures a proper match.
Implementing CPOE, however, required changing more than physician attitudes. "Pharmacy likes to be in control of meds," Babakanian says. "They wanted a system that met their needs. But the pharmacy system is not for pharmacists. It is one system that enables a safe, high-quality practice. And asking nurses to verify (proper drug administration) is like a professional insult to them."
Now that the technology is in place, Babakanian has documented quality improvements that have helped push aside professional territoriality. For example, the cycle time for delivering medications dropped from two hours to as low as three minutes. "We have eliminated transcription errors," he adds.
The hospital's network processes some 700,000 daily transactions, including medication orders, record look-ups, and clinical messages. Although UCSD is running technology from Siemens on the inpatient side, it has turned to Epic Systems Corp., Verona, Wis., for its outpatient clinics and physician practices. During the next three years, the hospital will sunset its Siemens technology, seeking greater data integration by standardizing the operation on Epic.
That's a project that may be as difficult as converting from paper to computers, notes Cronin, the director of nursing informatics. "We are very electronic now," she says. "We have to look at electronic workflows and make sure we properly migrate."
The standardization around Epic has been a tough sell for Babakanian at times. One of the last pockets in the organization to transform to electronic documentation was its cancer center. Physicians there, the CIO recalls, were enamored with a highly specialized chemotherapy management system touted at a trade show - one that would have been difficult to integrate.
"We promoted the idea that the cancer center should use our ambulatory EHR and that we have Epic modules to add to the system to handle chemotherapy. It took about a year to educate them about the power of integrating information. We can't have islands of information. But the medical director eventually thanked me for the integration."
Getting appreciative nods from powerful physician leaders may not be an everyday occurrence for CIOs. But Babakanian has helped devise a management structure that, at the minimum, assures I.T. a seat at the table with the organization's top decision makers.
He has crafted two I.T. governance groups, one devoted to clinical efforts, the other to financial programs. Both are staffed by department executives from the very top of the organization.
"We need two committees because of the size of the organization," he says. "No single committee can understand the complexity."
For Cronin, who sits on the clinical steering governance group, having the organization's executive leadership nearby offers re-assurance. The clinical I.T. steering committee approved the decision to standardize systems across inpatient and ambulatory settings, she recalls.
"Anytime you embark on something that large, you want to make sure you do the right thing. We did not want to harm patient safety."
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