Small Hospitals, Big IT Ideas

Larger hospitals and health networks might have more resources to devote to health IT, but smaller facilities and physician groups aren't standing still. In fact, they may have a louder imperative to harness health IT to improve care than their larger counterparts. In the following pages, CMIO spotlights small hospitals and healthcare practices using health IT to the max—via effective device-to-HIS interfacing, clinical decision support and tele-ICU to deliver better care, improve efficiency and reduce costs.

Stillwater Medical Center | Stillwater, Okla.

119-bed acute care, not-for-profit general hospital

• Big IT Idea: Automated integration of ICU and ED patient monitor data into the hospital's EHR via a customizable ADT interface
• Results: Increased time for nurses to care for patients, faster access to vital information and more reliable data.

In 2010, when Stillwater began to replace its aging ICU and ED monitors (Philips), "we knew we had to marry information coming out of the Philips system with assessment queries in the Meditech hospital information system. In the past, this was a manual process of collecting the data and then entering them into the Meditech assessments," says Chris Roark, Stillwater's CIO.

Interface software (Accent on Integration, AOI) sits between the monitors and the HIS and formats outbound and inbound information. The interface enables monitors to receive messages and send over clinical data to the EHR. The HIS sends admission/discharge/transfer (ADT) data and receives clinical data, according to Roark.

Stillwater evaluated the option of using a point-to-point interface between the HIS and patient monitors, "but there was middleware software that Philips used to do this, which in effect is the same as having an integrator involved," Roark says.

Before the HIS-patient monitor integration project, nurses would write down vital signs in a log or on a spreadsheet. When time permitted, they would manually enter the information into the Meditech HIS. Eliminating the manual data entry is not only giving time back to the nursing staff, it's also getting data into the HIS faster, making data much more readily available to clinicians, he adds.

"In the ICU, they're collecting vital signs every 15 minutes, so if nurses are spending three minutes on data collection every 15 minutes, that adds up to a lot of time throughout the day. The integration of these data gives back a lot of time to the nurses," says Roark.

In addition, Stillwater has seen an increase in data accuracy because nurses can verify vital signs as they are brought into the HIS. "So, for instance, if it's tracking every 15 minutes, then in an hour you've got four different sets [coming] in. The nurse looks at those within the Meditech system, and verifies that they are correct before bringing them in."

Fast, accurate delivery

Increased data accuracy is a big advantage of the integration project, says Kathy Hawkins, RN, IT analyst at Stillwater. "The time-savings comes in because the nurses or the technicians don't have to enter the data in at least two places, sometimes three. Mostly in the ICU, they had to put [data] into the computer, then on the flowsheet. By having the interface, the physicians are able to look at data in a graph or flowsheet type format, [and] they have the accuracy of having them come directly, without transcription," Hawkins says.

Stillwater is now integrating patient monitors in its same-day surgery area with the HIS, according to Roark and Hawkins.

There's some training involved for nursing staff, who have to know where to find their patients in the monitoring system to place patients into rooms, and there's training on the HIS to get the monitor results and pull those back in. "But all in all, it's a 15-minute training process," says Roark. "We had some super-users with some more in-depth training so they would be able to trouble-shoot as well as guide new nurses through the process."

Because the integration happens behind the scenes, the only difference that physicians have seen is faster retrieval of information in the EHR, Roark says. "It was pretty seamless for them because data are still going into the same place that they [were] prior to the integration of the system."

Hawkins adds, "As nurses enter the data, they call the physician, and he or she is able to look right at what's been, what is being seen, without having to tell the physician verbally and depend on that verbal communication, which can be misinterpreted."

Anecdotally, "ICU likes it because they don't have to do that all by hand, it's easier to see, and I know we're going to do something later with the floors because the accuracy is better. There are documentation errors just by transposing a number here, a number there. You verify the data when pulling it for documentation. You're not having to go back and recheck monitor data with handwritten data again," Hawkins says.

Willamette Valley Providers Health Authority | Salem, Ore.

Physicians group serving predominantly small, independent clinics in Oregon's Marion and Polk Counties

• Big IT Idea: Centrally hosted implementation of commercial EHR with integrated clinical decision support
• Results: Increased efficiencies from using EHR system, CDS-driven quality improvement in clinics and small-office settings and expedited preparation for meaningful use.

Willamette Valley Providers Health Authority has found the recipe for effectively integrating clinical decision support into its EHR. A study published in April in the Journal of the American Medical Informatics Association cited WVP Health Authority (formerly Mid-Valley IPA) as an example of "an organization which is using a commercially available [EHR] system with CDS well."

"The leadership—both of the [independent physician association] itself and of this particular effort—did the right thing in moving it forward," says Joan Ash, PhD, Department of Medical Informatics and Clinical Epidemiology at Oregon Health & Science University's School of Medicine, in Portland, Ore. Ash lead the qualitative research for the study, which was funded by AHRQ.

Getting beyond 15 percent

"The decision-makers in the physicians association back in 2003 to 2005 decided to do this because the adoption of EMRs was stuck at the 15 percent level," says Greg Fraser, CMIO of WVP Health Authority, which serves Marion and Polk Counties. "The thought was if ... you're going to improve quality and efficiency of care, we've got to move in this direction. But all of the government mandates were unknown... It's gotten more interesting because all these other things have come down the pipeline since we got started."

The physicians association includes many small (fewer than 10 healthcare providers), independent clinics in semirural and rural settings. Currently, 53 association practices are in some state of implementation of an EHR system (NextGen) and 45 practices are using the EMR, says Fraser.

The CDS tools built into the EHR include an e-prescribing module with drug interaction checking, direct formulary checking, tools for building in alerts and reminders for health maintenance and chronic disease management interventions, according to Fraser.

The CDS tools required very little customization, he adds. "When we talk about drug/drug, drug/allergy and drug/condition checking, they do have some ability to modify which alerts they receive and don't receive. They don't have the ability to turn it off completely. That was a community decision."

A central data center manages the EHR and performs server maintenance and backups. The EHR vendor provides updates, and the association's information services group modifies and maintains CDS features as well.

"For the most part, physicians have been approaching us and saying 'I hear you can help me, I need to do this,'" says Fraser, who practiced family medicine for 17 years.

Preparing for meaningful use

Although meaningful use wasn't part of the picture when WVP Health Authority began its EHR efforts, it will be soon. "We're still in the process of installing a series of upgrades that will create the complete technology environment necessary for meaningful use," says Fraser. "We'll have done that by the end of August so there will still be time for practices to do a 90-day year one qualifying period before the end of this year."

"Based on our outreach and conversations and preliminary measurements on the use of the system, we think our physicians are pretty well-positioned even though they are facing workflow changes for some new capabilities that are coming in these upgrades," Fraser says.

Anecdotally, practices have reported experiencing a number of efficiencies to their business, such as reduced overhead. "Interestingly, the efficiencies are typically enjoyed by front- and back-office staff and not so much by the physicians themselves," he says.

WVP Health Authority is about to start communitywide population-based quality measurements, Fraser says. "The impetus for that really has been clinical quality measures associated with meaningful use and we're getting some new tools from [our EMR] that I think are going to facilitate that."

"We've been fortunate that we have a technology partner that is dedicated to doing most or all of the right things. We don't have to invent the wheel too much on our own," he says. "Having a good tech partner is very important."

Baptist Health South Florida Tele-ICU/Transfer Center | Miami, Fla.

Baptist Health South Florida’s tele-ICU enables nurses and intensivists to see patients in real time. Source: Baptist Health South Florida

126 hard-wired beds across six facilities including one critical access hospital and one rural facility

• Big IT Idea: First-in-the-nation tele-ICU paired with a transfer center
• Results: Tele-ICU system enabled 24/7 access to intensivists, allowing more rapid interventions in facilities with limited staff. Better coordination of the patient transfer process reduced the time needed to transfer patients from days to hours.

Baptist Health South Florida is not a small organization, but is assisting its critical access hospitals and a rural facility by teaming its tele-ICU with a transfer center. It began two and half years ago, when the transfer center needed 24/7 access to a physician. The organization's tele-ICU has a physician available around the clock.

Out of the silo

Two and half years ago, "each hospital handled transfers in and out of that hospital in a silo. We thought, 'Let's put the two services together and see how this works,' " says Beth Willmitch, RN, BSN, operations director of tele-ICU at Baptist Health South Florida.

"When we started this, the transfer process was done by whatever nurse or social worker was given the order for a transfer," explains Leslee Gross, RN, director of the transfer center.

Transferring patients is always problematic because "one facility is trying to [move a patient] they don't have the resources for, and the other facility is trying to fit a patient into their system," Gross says. Therefore, "you need doctor acceptance, you need to make sure the patient's stable, you need to know where to call the report… [and] you need to see who's on call. But nobody ever paid attention to it because there was no systematic approach."

Transferring patients is labor-intensive, too, requiring a minimum of 15 phone calls, equating to about five hours of work, explains Gross. "We developed a transfer center to try to have one hub that handles it all." And the new strategy has paid off: Reallocating responsibility from nurses and physicians to the transfer center amounts to a cost savings of about $1.6 million annually, she adds.

Baptist Health South Florida's tele-ICU system (Philips) has been up and running for six years, according to Beth Willmitch, RN, BSN, operations director of tele-ICU. At the time it was established, only one hospital had a 24/7 intensivist at the bedside. In addition, "four of our hospitals didn't have a lot of physicians at night, because [they] were not teaching institutions. We were depending on ED physicians or maybe anesthesia [to take care of patients in ICU]," she says.

24/7 crisis management

"For us, it became a no-brainer, in a sense, to have a physician at 2 a.m. who can, at the push of a button, camera in to a patient's room, assess a patient he or she already knows about [and] who can immediately help you manage a crisis or any kind of issue," Willmitch says.

The organization has seen a significant return on investment over time. "Over the last six years, we've seen quite a reduction in severity-adjusted mortality ratios, by about 50 percent, and a reduction in ICU length of stay by about 30 percent [using Cerner's Apache Severity scoring system]. So we know there's cost-avoidance," Willmitch says. "Just by the length of stay reductions we've made, we estimate [we saved] $10 million in 2010. That's just based on days saved."

Each tele-ICU room includes a video camera and microphone. Clinicians can push an alert button, and the tele-ICU gets a popup on a computer screen that shows who needs assistance. "Cameras are only on when a call comes in or we are making rounds on the patients," says Willmitch. Tele-ICU clinicians can see exactly what the nurse sees on the bedside monitor: "We connect to a computer server on the BHSF network, to have real-time vital signs on all critically ill patients—their ECG wave forms, heart rate, oxygen saturation, respiratory rate and blood pressure."

In all, the tele-ICU monitors 126 hard-wired beds at six hospitals. In addition, there are five mobile devices—computers on wheels equipped with a camera, alert button and two-way video—in most Baptist Health South Florida EDs to assist the staff. Some of the hospitals hold critical care patients waiting for an ICU bed to open up. "We can camera in and help them get the appropriate therapies or protocols started," Willmitch says.

"At the critical-access hospital, we'll monitor some of the patients who are waiting for transfer," she says.