Feature | May 21, 2006 | Kim Phelan

Clinical Information Management Systems: Walk Softly But Carry a Big Carrot

An acute care unit, an ED and a respiratory care department all find great rewards from CIMS automation — even among their biggest skeptics.

One of the best strategies Greg Martin uses to make friends is to find his enemies — at least when it comes to fostering adoption of new technology among potentially techno-phobish clinicians, or those resistant to change. Martin, who is CIO at Arnot Ogden Medical Center in upstate Elmira, NY, placed value on recruiting skeptics into a major decision-making process and ended up with the makings of a fan club.
In order to pull user adoption of a new clinical information management system through the acute care area of the hospital — rather than pushing it down and meeting with resistance — Martin took the team approach.
“It’s important to include leaders all along the way, or what we call centers of influence,” said Martin. “It might be a local unit clerk, somebody who is bigger than life. We actually did have a unit clerk who was very vocal on the previous system, so we included her and she became a big proponent. We also picked some of the other vocal opponents of electronic systems during our search and they completely became converts.”
The search began in the late ‘90s, and the process boiled seven vendor candidates from an RFI process down to five who did demos for the hospital — from there three were chosen for site visits, two finalists did second demos, and in the end, Martin’s team of multidisciplinary end users elected to purchase the CPR system by Misys, which went live at Arnot Ogden in July of 2000.
The hospital cut its teeth on clinical information systems back in the early ‘80s, and thus came into the buying process some 15 years later with a well-defined set of priorities.
“We learned with our first experience that our No. 1 priority is flexibility,” said Martin. “We needed to have a system that was highly configurable and flexible, one that would provide us with a lot of ability to customize it in house. Basically, it’s the old adage: You don’t know what you don’t know — unlike financial applications that are very static, the healthcare process is very dynamic. Not only do the protocols and practice of medicine change, but the workflow associated with them also changes. We needed to have a system that would complement the practice of medicine here, and we knew we needed to have a very flexible system.”
The Misys system Martin acquired was delivered with a toolset that allowed his IT team to more or less build and adapt it to their particular requirements and preferences. And, since installing the system approximately six years ago, Arnot Ogden has received about 15 upgrades from the manufacturer, most of which, says Martin, were retouched in some fashion with internally developed enhancements.
Showing tangible value to physicians and nurses while simultaneously encouraging their input has helped to drive true ownership of the system.
“We walk softly but carry a big carrot,” said Martin, “and we’re more interested in hitting the singles than the instant home runs. By taking little baby steps and adding value, we begin to build credibility with what we’re trying to do with the system.”
An important carrot stick is the Web-enabled, wireless capabilities of the Misys system that allow doctors to review cases from remote locations — one told Martin he prefers to do rounds at home in his boxers.
Conversely, strategically placed bedside workstations for nurses — rather than wireless notebooks — deliberately keep caregivers close to patients throughout the documentation process, forcing them to spend more time in the room, which the leadership intuitively believed would lead to better outcomes in the long run. The hospital has increased the time nurses spend in the patient’s room by 23 percent, says Martin, and because medications are stored in locked drawers beneath the keypad, med administration can occur more responsively to patient pain levels as the nurse interacts at the point of care.
Letting Go of Paper
Patient safety and quality of care, not to mention basic, welcome-to-this-century efficiencies, were all at the heart of Providence Newberg Hospital’s pursuit of an ED clinical information system last year — the department went live in December with its new Picis Ibex Pulsecheck system — specifically designed for EDs. A small, 36-bed hospital that’s part of an expansive Providence Health System in the Northwest, Providence Newberg in Oregon will double its ED’s eight-bed capacity after a move this spring into a new greenfield facility.
Emergency services manager Julia Florea said that her department — which initiated and controlled its own system search — broke from the large organization’s wide dependence on McKesson solutions after a few cross-country road trips to other hospitals and many hours of needs assessment and product research. But integrating the Picis system has been smooth, and the transition from a totally paper-filled environment to automation has been successful, to say the least.
“We were very excited to do this,” said Florea, “and our physicians were ecstatic. We did a lot of training and a lot of talking about it to get people up to speed ahead of time before the Picis people ever got here. We think we had a really great implementation.”
The Ibex is used in some 150 hospitals nationwide, according to Florea, and she said she was impressed to learn that the system has never been uninstalled by any of its users.
She says the support from the vendor, both pre and post “go-live” was key to her ED’s positive adoption of CIMS. A large contingent of Picis staff took up residence for 60 hours to work with every shift of ED personnel to ensure thorough training. For an additional fee the vendor also “attached” a physician trainer to a highly resistant physician who refused to buy in to the system; 12 hours of continuous, side-by-side assistance brought him around to full acceptance and he now “uses the system as well as anybody,” said Florea. Fast response to questions or problems that have surfaced reinforces Florea’s confidence and peace of mind in the choice she and her staff made.
Improved documentation may be the greatest stride Florea’s ED has realized with Ibex, which features template documentation that cues clinicians to ask all the right questions for a cleaner, more thorough and consistently documented report. The department paired the system with computers on wheels (COWs) — which will number one for every room in the new facility — as well as three departmentally shared, wireless tablets. Nurses use the tablets to have patients sign off on their discharge instructions and ED physicians carry them to the bedside while interviewing patients.
Florea explained a scenario in which, together, the CIMS and the wireless tablet put the power of rapid treatment into physicians’ hands.
“The patient might tell the doctor, ‘I’ve had this horrible abdominal pain since 9 o’clock this morning and I can’t stand it,’ and the doctor can say, ‘before we go on with this interview, I want to get you something for your pain. Let me get the nurse working on that,’” said Florea. “He will take the tablet and order up his medication and that puts a big red M up on the tracking board in the nurses’ station. While the doctor is still interviewing the patient the nurse has been able to get the medication and bring it to the bedside, often before the doctor has left the room.
“That’s huge,” said Florea. “It has been a big advance for patient care.”
Because all ED documentation has gone from a paper log to electronically stored data, Florea is able to see summaries and trends that were never possible in the old paper world. Because she can track and sort a wide range of information, she has been able to determine, for example, the ED’s busiest days and times of the week, which is helping her forecast and plan for staffing needs in the new building.
“I never would have told you that Sundays are my busiest days and Tuesdays are my second busiest — those are things that I couldn’t easily get my hands on before.”
Untethered in Respiratory Care
Thirteen years ago Rick Ford participated in the buying decision for what Puritan Bennett then called CliniVision and has since been upgraded and renamed MPC, Mobile Patient Charting. The one-time purchase and monthly support fees automatically put all upgrades and new software versions into the hands of the vendor’s customers, in this case, the University of San Diego Medical Center (USDMC) where Ford is director of Respiratory Services.
The new system, installed in 2002, is used exclusively by his department’s respiratory therapists but connects at multiple levels within the rest of the hospital enterprise. First, Ford explains, billing is generated within MPC and an interface automatically transfers all that information to the hospital’s billing system. Second, documented therapy and therapy outcomes are made accessible through any computer terminal in the hospital within seconds. And third, MPC “talks” to the hospital system through an ADT (admission, discharge and transfer) interface that maintains patient name and demographic information from the point of admission and throughout the care continuum.
For Ford’s staff, wireless point-of-care documentation has been critically important.
“Our staff [members] are covering multiple areas of the hospital and we didn’t want them to be tethered in any way,” said Ford. “So the wireless was huge for us.”
The USDMC practitioners are using the line of Fujitsu slates and are also just beginning to implement wireless pocket PC devices that run over the hospital’s Wi-Fi network installed in all areas of both USDMC hospital facilities. The devices are not only connected to CliniVision/MPC but also to the hospital’s X-ray PACS, the Patient Care Information System for access to lab results and nursing notes, and it’s Web-enabled to allow access to patient education materials, among other resources.
“The important thing is that the practitioner doesn’t have to go anywhere else to get information,” said Ford. “It’s the mobile, immediate access to information that is really important. It’s what helps us make good medical decisions and minimize errors. Without that access, patients can be placed at risk and care may not be as good as it could be.”
Because MPC can capture the outcomes of Respiratory Care’s interventions, it has proven vital in the hospital’s protocol-driven care in which the practitioner can refine and change therapy based on the patient’s condition.
“You can’t change and refine therapy unless you understand what the patient’s condition is, unless you know how the patient has responded to a particular intervention over the past day or week or since the last treatment,” said Ford. “The only way a clinician can really get that type of information is through the help of automation. It is unrealistic that the unaided human mind can process all this, especially if it was spread out over dozens of papers and documents.
“Perhaps the most value that these systems are providing today,” Ford continued, “is that you can make better, quicker decisions that minimize complications in our patients. [We can] get them out of the ICU quicker, get them out of the hospital quicker, and, of course, when a hospital can do that, they are going to save money.”

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