Heatlh IT Innovation Awards: 5 Health IT Projects that Improved Care

The term innovation may date back to the 15th century, but it is very much alive and well in 2010 medicine. This change in the thought process for doing something, a new method for doing something or the useful application of new inventions or discoveries is at the heart of this month’s CMIO Health IT Innovation Awards.

CMIO magazine’s call for Innovation Awards garnered 28 entries from 23 states—an impressive response for a first-time contest. We received submissions from organizations that are renowned for healthcare IT efforts, but we also heard from less-well-known facilities. The contest was open to CMIOs or equivalent clinical IT leaders in ambulatory or inpatient facilities, group practices or multi-hospital organizations/integrated care networks. All entries spotlighted HIT innovations that make care more patient-centered, more effective, safer, more affordable, more timely, more efficient, more equitable or that boost workforce vitality—with a minimum of 90 days of measurable evidence to back up that claim. Projects had to have been completed during the past 24 months, either using technology new to the organization, or making innovative use of existing technology.

The projects detailed in these submissions were remarkable, and ranged from start-from-scratch initiatives to build a data center to tapping existing systems to reduce patient falls and prevent medication errors, to building better telehealth systems. Choosing five winners wasn’t easy, and speaks volumes about the breadth of technology and tactical process improvement that is now occurring in healthcare facilities. We salute all entrants for their health IT innovations. (And please note that our winners are listed in alphabetical order.)

Brigham and Women’s Hospital, Boston

Project: A patient safety project to implement a closed-loop medication administration process with the features to address the complex scheduling of chemotherapy treatment plans.

Problem or challenge background: BWH had already implemented and fully integrated computerized physician order entry (CPOE), pharmacy system (RX) and electronic medication administration records (eMAR). All inpatient clinical services were using this closed-loop medication process, except for oncology services. Scheduling and administration of chemotherapy is complex, and precision is especially important with chemotherapy medications because they have low therapeutic windows with severe side effects. In addition, the patients are often quite ill prior to treatment.

The complex treatment plans include not only chemotherapy medications, but also related medications including pre/post-hydration, anti-nausea, anti-anxiety and other medications that are given before, during and after chemotherapy doses. The treatment plans specify the medications and dictate precise dosing, frequency, duration, and timing of chemotherapy and of the supporting medications that treat the side effects.

In order for patients in oncology services to fully benefit from the safety features of the electronic closed-loop medication use system, we needed to address the complexity of the chemotherapy regimens. To achieve this, we created relationships/links between the chemotherapy, hydration, and other supporting medications. BWH identified four types of administration relationships (or links) required for precise chemotherapy scheduling and administration:

1. Mix Together Linking for medications that are administered to the patient at the same time and are mixed together in the same vessel. (e.g.; bag, syringe)
2. Mutually Exclusive Linking for two or more medications where all are ordered by the physician, but the nurse will only administer one to the patient.
3. Time Offset Linking for medications that are administered in a predefined sequence with specific lengths of time between start of administrations.
4. Sequential Linking for medications that are administered in a specific sequence, but are ambiguous to time, often defined as “give before” or “give after.”

Each link type has a set of rules associated with it to ensure the link can be interpreted by CPOE, RX and eMAR.

Technologies and Systems Used: Programming languages: Intersystems Caché object script, C# .Net, Javascript + AJAX, Intersystems Caché server pages (CSP), XHTML, XML and SQL. Databases: Intersystems Caché objects, Caché globals. Intersystems Caché was chosen because it was a known and proven technology at Partners Healthcare. Tackling the business needs for this project was challenging, but familiarity with Caché gave them one less hurdle to jump.

The linking database is the source of truth of all linking information. The linking database is the only place that houses link information. Every consuming group retrieves linking information via web services or MSP (managed service provider) services. 

Methods: After an exhaustive analysis of chemotherapy treatment plans and clinical trials, the multidisciplinary team identified four scenarios where the schedule of one medication was dependent on another:

1. The start time of many medications relied on the start or end of another medication.
2. Some medications needed to be administered simultaneously by mixing them in the same vessel.
3. Some medications were written as “Only give one of these, not both.”
4. Some medications needed to have a single dose split into two or more administrations.

Team members identified the types of schedule dependencies, then conducted workflow analysis to understand how clinicians agreed on a final schedule for the medications in the treatment plan. All scenarios for each link type were reviewed to fully understand the downstream affects for each of the three applications involved in the project (CPOE, RX, eMAR).

In the end, four types of medication relationships were identified that dictate schedules and control administration. The solution was to create links among two or more orders. The links were defined by the CPOE system and applied to the patient medications when the oncologist ordered the treatment plan.

The automated scheduler in the Pharmacy application set administration times based on the rules defined by the links, and the link definitions added a layer of alerting to the nurses to avoid administering medications at incorrect times, out of sequence or when the medication administration should beblocked because an alternative medication was given.

Results: Since the implementation of linking services in June 2009, links of all types have been widely used:

Pharmacists have reported that they feel more secure in the schedules being appropriately set up and are enjoying the efficiency of automated scheduling based on the rules of the link. Nurses have expressed the added sense of security in knowing that important medications such as pre-hydration won’t be forgotten and that alerts will appear if an attempt is made to administer chemotherapy out of sequence.

Conclusions: This linking feature was first deployed June 8, 2009, for all adult inpatients receiving chemotherapy medications at BWH in Boston. The BWH clinical services that order chemotherapy are Oncology, Gynecology and Bone-Marrow-Transplant. The linking safety features have been so well received that BWH will implement linking for scheduling medications on all other adult clinical services in the fall of 2010.

What makes this a particularly innovative health IT project? To the best of our knowledge, BWH is the first institution to fully implement the closed-loop medication administration process with the features to address the complex scheduling of chemotherapy treatment plans. Our linking system ensures adherence to the tightly orchestrated schedule for medications contained in the chemotherapy treatment plans, and represents an additional layer of safety beyond CPOE and barcode medication verification systems.

The Chester County Hospital, West Chester, Pa.

Project: Using business process management (BPM) tools to reduce catheter-associated urinary tract infections in an acute-care setting.

Problem or challenge background: Catheter-associated urinary tract infection (CAUTI) has been associated with increased morbidity, mortality, hospital cost and length of stay. The most effective way to minimize CAUTI is to limit use of indwelling urinary catheters. With a manual process, it was difficult to manage the patient population with urinary catheters and assure that proper medical review was being conducted. Also there was no easy way to track which patients had urinary catheters or how long each catheter had been in place. Moreover, communication barriers hindered the entire care team from being involved in the urinary catheter review.

Technologies and Systems Used: The Chester County Hospital sought to reduce its incidence of CAUTI with a two-pronged strategy: (1) Promote alternatives to urinary catheter placement for bladder drainage and removing standing orders for urinary catheters from order sets where possible; and (2) Use business process management (BPM) to track all patients with urinary catheters, and to alert clinicians with daily prompts to re-evaluate the need for a urinary catheter in their patients.

The primary technology used was a Tibco BPM engine incorporated into the hospital’s Siemens Soarian clinical information system.

Methods: The BPM engine monitors all nursing documentation for the presence of an indwelling urinary catheter. The system automatically calculates the length of time the catheter is in place and generates a report cataloging patient name, location, attending physician, consultant physicians and the length of time since the last medical evaluation. A clinical decision support alert is directed to all physicians caring for every patient with an indwelling urinary catheter, starting 48 hours post-insertion.

The clinician has two options on the alert: 1. discontinue the catheter; or 2. attest that the catheter continues to be medically necessary. If the first option is selected, the system places the order to discontinue the catheter and alerts the nursing staff to remove it. The system also monitors nursing documentation for evidence that the catheter has been removed. If, after eight hours, the nurse has not documented that the urinary catheter was removed, an escalation alert is raised to assure the discontinuation order was received and acted upon. If the second option is selected, the alert is removed but is regenerated in 24 hours to support daily review of medical necessity.

The system produces precise real-time reports of clinical activity monitoring which gives key personnel the ability to see the status and medical review of every indwelling urinary catheter for all inpatients.

The electronic system was foundational to identifying and tracking the patient population. However, the ability of the CMIO and other members of the quality improvement team to explain the process, promote attention to alerts, and monitor compliance was key to achieving results.

Results: The CAUTI rate for the 12 months before this solution was fully deployed was 5.61 infections per 1,000 catheter days. This rate dropped by more than 50 percent—to 2.74 infections per 1,000 catheter days—in the 12 months following full training and deployment. Much of this improvement is attributable to the advanced BPM process. Nursing education in proper insertion technique and catheter care, and physician education on minimizing use also contributed to the decline in CAUTI rate. The lynchpin of the process was the automated electronic monitoring and alerting system, which allowed all patients with indwelling urinary catheters to be monitored and managed effectively.

Conclusions: Using BPM, the hospital significantly reduced the rate of CAUTI, the most common healthcare-associated infection. Merging powerful technology with traditional process improvement efforts improved patient care at The Chester County Hospital in a measurable way.

What makes this a particularly innovative health IT project? BPM technology has rarely been applied to the clinical care setting. The integration of BPM into a clinical setting via the EMR system has allowed The Chester County Hospital to move well beyond simple CDS and rules-based alerts to actual process oversight and management. The work at The Chester County Hospital convincingly demonstrates that BPM can improve efficiency, consistency and outcomes in the acute-care setting.

Cooper University Hospital, Camden, N.J.

Project: Implementation of cardiology PACS and cardiovascular information system (CVIS) on a virtualized server solution.

Problem or Challenge Background: Cooper University Hospital (CUH) IT faced three challenges:

1. Selecting a digital cardiology PACS and CVIS that would meet cardiologists’ needs to provide excellent patient care and improve efficiency.
2. Multi-facility practice spread over a large area was using VHS to record analog images. This presented logistical challenges to bring the tapes to the reader.
3. Balancing business growth and containing cost, space and energy use without sacrificing data safety and application functionality.

Technologies and Systems Used:

• McKesson’s Horizon Cardiology PACS and CVIS tool

• VMware server virtualization technology
• Data storage on storage area network (SAN) using EMC system

Methods: CUH’s IT and Cardiology departments brought VMware, Dell, EMC, McKesson and Cisco to work together to meet our business goals—they saw they could offer a low-cost CPACS solution to other customers. The project was managed jointly by Cooper IT, Cooper Cardiology and McKesson implementation services.

Results: Cooper was live with digital picture acquisition of echo studies including ADT and Orders interface on March 1, 2010, followed by echo reporting April 5, 2010. A post 90-day review of the project determined the following business goals were met:

• 100 percent digital transmission and archiving of images.
• Physician access to 100 percent of the studies online from any computer in the Cooper network.
• More than 90 percent of the studies are read, reported and delivered within 24 hours of acquisition—an improvement from 80 percent immediately prior to go live.
• Consolidated reading schedules that free physicians’ schedules for patient appointments. The goal was to add 10 patient sessions per month; they have added 28 sessions per month.
• 100 percent compliance from three physician groups including more than 30 cardiologists, 15 fellows and 12 sonographers.
• 98 percent of results are interfaced to Cooper’s EMR system, and are available to other clinical personnel immediately after they are finalized.
• 0.09 percent unscheduled downtime for the first three months of the project.

Conclusions: CUH’s digital cardiology PACS and CVIS virtual solution met IT’s architectural goals. By partnering with the vendors, not only was the facility able to save approximately $400,000, they also decreased the IT hardware footprint, electricity and cooling. This translates into reduction in operation and capital expenses.

What makes this a particularly innovative health IT project? Virtualization is rare in healthcare IT. CUH is the first hospital in the nation to virtualize McKesson’s CPACS and CVIS.

Parkland Health & Hospital System, Dallas, Texas

Project: Increase rates of influenza vaccination in pregnancy: A clinical management project in a safety net health care system.

Problem or challenge background: Pregnancy is a high-risk indication for the influenza vaccination, however, rates of vaccination fall short of the recommended guidelines. In 2003, a CDC prevention survey highlighted the national rates of vaccination during pregnancy at only 13 percent. Historical data from Parkland Health & Hospital System revealed a rate of 30 percent vaccination during pregnancy.

The goals of the project were to:

• Increase the rate of influenza vaccination among prenatal patients, with a target of more than 95 percent of all prenatal patients offered an influenza vaccination; and more than 50 percent of all eligible prenatal patients receiving the influenza vaccination.
• Develop and implement integrated inpatient/outpatient management guidelines for prenatal patients who present with influenza or flu-like symptoms, including prenatal care system implementation of clinical management protocol, best practice alert, virtual clinic and telephone encounter follow-up process.
• Improve the charge capture for influenza vaccinations, with a target of more than 90 percent of all ordered influenza vaccines charged.

Technologies/systems used:

• Creation of an Influenza Management Protocol.
• Design/implement a Best Practice Alert (BPA) in the Epic EMR to increase influenza vaccination rates and reduce missed opportunities.
• Initiate a virtual “electronic clinic” module within the EMR to provide 48-hour follow-up on patients treated as outpatients in any prenatal care system location to ensure continued patient safety.
• Complete and optimize an influenza vaccine charge.
• Conduct a retrospective and current state analysis of influenza vaccination rates.
• Create an ongoing process for monitoring and review of metrics.

Methods: We designed and implemented a BPA in our Epic EMR and linked it to a Health Maintenance Alert. This BPA reminds the provider to offer the vaccine, to document if the patient declines and to provide consistent choice for the reason a patient declines. The BPA also provides a shortcut to placing the order for the vaccine, and to linking the order to a charge. When a patient meets criteria, the trigger turns the BPA section of the EMR highlight yellow and turns the Health Maintenance Alert icon, located in the patient header, red.The “virtual clinic” utilizes the EMR effectively to manage the integrated system process and consolidates data for use by midlevel practitioners in performing telephone encounters.

Results: By implementing BPA and alerts in our EMR, instituting a systemwide education campaign, and facilitating a better way of capturing charges, the plan dramatically increased compliance and charge capture for influenza vaccinations.Prior to this initiative Parkland's rate of vaccination, although low, was higher than the national rates. In 2008-2009, for example, it was approximately 35 percent. They experienced fluctuating results during the campaign, which started Sept. 21, 2009 and ended April 30, 2010.  From Oct. 18 to Nov. 29, 2009, supplies were depleted thus vaccines could not be offered. When the vaccine was available in mid to late December, the acceptance rate rose to 55 percent. For the final three months of the campaign, Parkland surpassed its goals: Of the 9,938 women who initiated prenatal care, 9938 were offered the vaccine and 7,161 — or 72 percent — were vaccinated.

Conclusions: A methodical process utilizing the EMR as well as concerted efforts of a department can significantly increase influenza vaccination in a high-risk population, even accounting for vaccine shortages. In this example, the Department of Obstetrics at Parkland Health & Hospital System increased baseline rates of vaccination to levels well above the national average, and at times to rates never before seen in the OB population anywhere in the country.

What makes this a particularly innovative health IT project? This project utilized the hospital’s familiar EMR to its fullest in facilitating influenza vaccination to a high-risk population. The result was by far the best overall influenza acceptance rates in the nation. Along with this improvement in vaccinations, Parkland also has utilized technology to better capture and collect on vaccinations administered to ensure ongoing viability of our organization.

Thayer County Health Services | Hebron, Neb.

Project: Health Information Ex–change for rural, highly mobile patient population in Southeastern Nebraska.

Problem or challenge background: Thayer County Health Services (TCHS) comprises a 19-bed critical access hospital and clinic in Hebron, Neb., with five satellite clinics. TCHS serves a population of 1,700, and their patients are a very mobile group. Recently, when TCHS counted its open patient records, there were records for 32,000 people, demonstrating that the system also is treating patients from areas outside of the county. Our challenge was to provide secure access to a patient’s health information electronically—both within our system and from other care organizations—by adopting NHIN standards. A secure HIE also would help TCHS reduce costs by eliminating duplicate procedures such as tests, scans and X-rays and allow them to better serve patients by providing access to up-to-date medical records so physicians, nurses and pharmacists can accurately diagnose and make treatment decisions based on the latest data.

TCHS is an early adopter of NHIN-based technologies, and is definitely the smallest organization doing so.

Technologies/systems used:

• CONNECT, Nationwide Health Information Network (NHIN)-based open source interoperability software built through collaboration of 26 federal agencies and the CONNECT open-source community.
• HMS electronic health record (EHR) system
• Mirth Meaningful Use Exchange (Mirth MUX)

Methods: TCHS applied for and received a federal Rural Health Flex Grant of $1.5 million, which enabled TCHS to set up an HIE for southeastern Nebraska that would serve as the backbone for connectivity in the region. TCHS used the funds to implement an EHR system and build the interoperability to allow for secure data sharing among organizations.

TCHS decided to pursue the NHIN for nationwide interoperability versus simply looking at the state level. With their EHR vendor, HMS, they built an HL7 admission/discharge/transfer (ADT) feed into the data repository, which then connects to the NHIN.

In implementing a NHIN backbone for the southeastern Nebraska HIE, TCHS is providing members with maximum flexibility in the technologies they use for interoperability. As long as what they’re using includes NHIN standards and specifications, it will be interoperable with the HIE.After NHIN standards were selected as the mechanism for nationwide exchange, TCHS began working with Mirth to implement the NHIN interoperability strategy.

CONNECT software uses NHIN standards and governance to ensure the HIE is compatible with other exchanges.

In September 2009, TCHS finalized a contract with Mirth to build the NHIN interoperability. By the end of second week, Mirth MUX was already interfaced with TCHS’ EHR system. By the end of September, Mirth and TCHS were setting up inbound and outbound requests to the NHIN via CONNECT.

Results: Thayer County Health Services has seen medication errors drop from 48 per quarter to 6 per quarter. They also have increased the level of medication reconciliation through e-prescribing from a range of 12 percent to 33 percent, to 75 percent to 100 percent today. This enabled them to achieve cost savings and reduce the likelihood they’ll overlook an allergy or prescribe drugs that interact poorly.

This project has been a key part of TCHS’ efforts to achieve HIMSS Stage 7 EMR Adoption.

Conclusions: By achieving near 100 percent e-prescribing, medication errors have dropped from 48 true medication errors per quarter to between six and nine real errors and near-misses. The system also tracks the timeliness of medications administration, so even if a nurse delivers a medicine a minute late, it appears as an error. By providing a more accurate medical record for patients, doctors and nurses are better able to help patients more effectively.

In addition to better treatment within the TCHS system, as the network of NHIN-based exchanges grows throughout the country, when patients travel, their records can follow them.

What makes this a particularly innovative health IT project? Most organizations that implement the NHIN and CONNECT are large, nationally recognized care organizations throughout the country. Thayer County has shown that a little hospital in rural Nebraska can do it, too.