The idea of the "health system" - an organization offering the full array of services needed by the local population - is a noble one. After all, by consolidating resources, these multi-hospital, multi-clinic organizations may run more efficiently and help patients avoid the frustrating experience of receiving their care in a fragmented setting. In practice, however, the business of assembling an integrated delivery system is extremely difficult.
For many systems, the electronic health record has become the linchpin of the entire organization. That's because the EHR is the common bond that enables caregivers to share information across clinics that are widely dispersed. A handful of leaders are making the vision of a "single patient, single record" come to life.
But there's way more to the challenge than implementing an enterprise EHR. Standardized workflows, standardized order sets and standardized treatment protocols are part of the mix as well. Following are snapshots of a handful of health systems that have tackled these challenges, embracing what may be the industry's toughest challenge.
BECOMING THE 'JOHNS HOPKINS' OF COMMUNITY HOSPITALS
Organization: Trinity Health System
Location: Novi, Michigan
Size: Owns or manages 44 hospitals across 8 states
Staff: 44,500 employees, 8,000 physicians
EHR Achievement: Common data repository across 32 hospitals
What's Next: Measure clinical effectiveness
In mid-2008, Trinity Health System achieved a milestone in its ambitious "Genesis" undertaking. Once called "Project Genesis," the effort refers to a systemwide implementation of common clinical, administrative and supply chain management software.
What became operational was a single data repository, one that is accessible across all of Trinity's 32 owned hospitals. Driven by software from Kansas City, Mo.-based Cerner, the data repository includes detailed information on 6 million patients, says Paul Browne, corporate CIO.
Trinity renamed its effort in recognition of the fact that it has no clear endpoint. "The word 'project' suggested a discrete start and end," Browne says. "We recognize that this is a strategic focus that will continue for many years." Browne is quick to point out that under Genesis, the electronic health record is just the beginning. The vision requires standardized workflows and operational processes, he says. In essence, Trinity is attempting to drive out the widespread variation in health care delivery that can result in less-than-optimal care.
For example, Trinity has developed 180 evidence-based, standardized order sets for use with computerized physician order entry. It's looking to standardize practices well beyond care delivery as well. Browne notes that by deploying a common supply chain system, from St. Paul, Minn.-based Lawson Software, Trinity stands to save $40 million annually. Not only that, the health system wants to tie its supply purchasing to clinical outcomes, using products with demonstrable value, he adds. "We will marry up supplies, including pharmacy, with clinical outcomes," he says. The clinical record, he says, "goes hand-in-hand with the revenue cycle." Trinity is deploying financial and administrative systems from San Francisco-based McKesson Corp.
By implementing common order sets, Trinity has already begun to measure clinical outcomes improvements. For example, the health system has seen a 22% decline in severity-adjusted mortality rates, compared with benchmark data from CMS measuring comparable health systems. "We are starting to understand variation in process and how it impacts clinical outcomes," Browne says.
Trinity's clinical systems deployment is built on a two-pronged approach. First is the common data repository, results viewing and adverse drug event alerts. The second phase entails CPOE, nursing documentation, pharmacy and emergency department automation. The full suite of clinical applications is operational in about half of Trinity's hospitals, with these institutions representing nearly 70% of Trinity's patient volume, Browne notes.
The clinical data warehouse enables local hospitals to conduct their own quality studies. "We want to unleash creativity in every one of our markets," he says. "Many studies are based on small sample sizes and on paper records. We now have sample sizes of tens of thousands of patients across multiple states. We want to be looked at as the Johns Hopkins of community medicine. The academic medical centers can do research, but we would like to inform the nation what happens in the community hospital setting."
An Early Adopter
Some technologies in place at Trinity are just beginning to emerge nationally. For example, the health system is head first into an effort to pull intensive care unit data directly from monitors and import it into its electronic health record.
Two ICUs have been automated thus far, and Browne says the technology is transferable to other hospitals. "We have seen a 50% reduction in ICU nursing time needed to document patient vital signs on an hourly basis," he says. Genesis has yielded other benefits for nurses as well. They now spend more time at the bedside, Browne says. "Nurses spend slightly more time documenting at the computer, but they save a ton of time not looking for the paper chart."
In addition to enhancing the working lives of nurses, Trinity has made headway in regional data sharing. Its owned hospital in Mason City, Iowa, is serving as the hub of an electronic health record that extends to a dozen critical access hospitals in the area. Trinity manages these facilities but does not own them.
"We have enabled clinicians who treat patients in these hospitals access to the same record used in Mason City," where many patients are referred, Browne says. Prior to completing the network last summer, patients might arrive at Mason City in an ambulance without their paper chart. "Simple, dumb things can delay treatment," Browne says.
COPING WITH INTEROPERABILITY IN A BEST-OF-BREED ENVIRONMENT
Organization: University of Pittsburgh Medical Center
Size: 20 hospitals, 3 million annual ambulatory visits, 175,000 annual inpatient discharges.
Staff: 2,500 employed physicians plus 2,500 affiliated physicians
Number of Applications: 200 clinical, 1,200 total
EHR Achievement: Two hospitals designated "Stage 6" by HIMSS Analytics
What's Next: Expand use of "closed loop" medication administration, other systems.
By any measure, UPMC is big. Encompassing 20 hospitals, UPMC typifies the modern health care delivery organization with both academic medical centers and community hospitals among the mix. On the EHR front, UPMC has invested heavily, spending more than $1 billion in I.T. over the past five years. The board-mandated deployment challenge has been enormous, with clinicians playing leading roles both as systems champions and hands-on analysts. Among UPMC's 1,400 I.T. staff, approximately 300 have clinical backgrounds, notes Dan Drawbaugh, CIO.
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