A leading pediatric hospital opens up on how sophisticated information technology helps keep them on top
BOSTON – “We’re not award seekers,” said Daniel Nigrin, CIO at Boston Children’s Hospital. Standing among a meager 1.2 percent of hospitals achieving the HIMSS Stage 7 Analytics Award, Boston Children’s Hospital has one of the nation’s most sophisticated electronic health records system, garnering nine ‘Most Wired’ titles from the Hospitals and Health Networks. Knowing this, it’s hard to believe Nigrin’s assertion, but any visit to the hospital will confirm that it really is all about the patients.
Boston Children’s officials shared with Healthcare IT News what being completely paperless entails, the role of robots in pediatrics, the theology of telemedicine and how being one of the world’s most connected hospitals has precipitated a new paradigm of patient care.
Electronic record evangelists
Boston Children’s has the right connections – electronic health record connections, that is. With more than 10 years in the making and expenditures in excess of $50 million, officials at the 395-bed pediatric hospital say the complete automation of patient records was well worth the effort – and the hefty price tag.
Scheduling in excess of 557,620 visits annually from pediatric patients worldwide, it is no surprise that holistic clinical data is key, and more importantly, the timely and accurate access to clinical data.
Enter the hospital’s electronic health record (EHR) system.
“We now have centralized in a single place basically all of the clinical information about your patient, whether it’s ambulatory, emergency department, in-patient, surgical,” said Nigrin. “It’s all right there, and it’s all neatly organized.”
Years ago, he explained, this was never a possibility. “In the past, if Johnny was admitted to the in-patient unit, you had to go up to the unit, to the nurses’ station, pull out the big fat chart, and if Johnny was a complicated patient,” Nigrin added, “You literally had a stack of files.”
Today, with a little diet and exercise, Johnny’s file is considerably more slender, as health IT has transformed the antiquated stack into sleek, virtual volumes of patient data that clinicians can access with a mere click of a button. Ambulatory notes, X-rays, hospitalizations, immunizations, projection and probability graphs – essentially an unabridged patient history can be accessed through the EHR, which has helped curb medical errors and save time.
“Having everything electronic and nicely catalogued in a single place that you can quickly put your finger on the piece of data you need is a huge, huge win, both for providing good clinical care, but also in respect to time-savings,” said Nigrin.
When asked about the complexity of the hospital’s EHR system, Nigrin describes it as really dozens of systems that are just very well interconnected. “We tried and hide a lot of that complexity from the end users, because the end users don’t care what system it’s in, right? They just want to do their work, so we try very hard to make the seams between these systems as seamless as possible.”
Some of the major vendors providing these systems include most notably Cerner, which the hospital uses primarily for clinical tools. They also have a significant Epic implementation for things like registration, demographics and scheduling, and for PACS systems – Fuji SYNAPSE is choice.
With patient privacy pegged as a chief concern, proper employee access to these systems is taken seriously. “[The EHR system] works in multiple layers of access,” said Marvin Harper, MD, chief medical information officer at Boston Children’s. “For a whole variety of reasons, we have over 200 different access positions to our EHR, and what you see and how you see is governed by that.”
The road to here and now
The voyage to paperless was not always smooth sailing, but the benefits have made it impossible, “unimaginable” to regress to old ways.
Recounting past memories as a medical student, Harper remembers patient health records being – how to say – a little less HIPAA compliant? “One of my jobs at the VA hospital was to go run down, and they would have alphabetized shoe boxes of the results on the lab tests, and you’d go and write down the results and then go back to the team.” You just can’t go back to that kind of system, he said, likening it to a journalist today using a typewriter for a story, and then sending it in via fax. It’s just not going to happen.
Now that there’s no going back, Harper and Nigrin have their eyes fixed on the future. So, what’s the next step? Data management, they said.
“We’re trying to figure out if you’re swimming in a sea of data, how do you organize the data so it’s useful to people,” said Harper.
This next step comes in the form of the National Institute of Health-funded i2b2 Center (Informatics for Integrating Biology and the Bedside). It’s a mouthful, said Nigrin and Harper, but that mouthful may bring myriad benefits for patient care.
i2b2 allows the clinician to access already existing patient data to identify groups of patients based on certain attributes a clinician is looking for. Nigrin illustrated this by searching for patients with both hypertension and diabetes. He entered the medical specifics into the Web-based system, and upon searching hundreds of thousands of patient accounts, 485 patients meeting those criteria were listed after a span of only 7.1 seconds.
“You can imagine this is an incredibly useful tool for doing research, but even for trying to optimize quality care,” Nigrin added.
He cited the hypothetical example of a medication found to have an adverse health effect. Because each and every patient medication is listed in the system, “We can ask a tool like this to find us all of the patients who are on medication X that we know of, and quickly get a list and contact them,” he said.
This is considered population management – a relatively new category of medicine, but one that has proved itself a valuable asset to the field of medical research.
“You can define your population by a drug they take, an allergy they have, by a disorder they have, and be able to suddenly both identity them but then track certain characteristics about them, which will tell you how well or how poorly you’re doing in managing that population,” Harper said. “Instead of on a patient-by-patient basis having to make medical decisions, you can start to make medical decisions by groups.”
Strolling through Stage 7
For Boston Children’s, Stage 7 was by no means the goal of the hospital’s EHR implementation, but rather just a welcomed byproduct.
HIMSS awarded the hospital its Stage 7 award in December 2010, a time when only 52 hospitals nationwide had received this designation. That number has since jumped to 92.
Because boosting IT support for clinical care in hopes of improving patient safety was the primary goal, the feat never proved a big challenge for the hospital. “The vast majority [of our EHR implementation] was well before meaningful use was a twinkle in an administrator’s eye,” Nigrin said. “We didn’t do this knowing meaningful use money was coming in,” he said.
The hospital now enjoys being completely paperless, and all entities within Boston Children’s health information exchange network can now exchange data securely and efficiently.
Barcodes boost quality
Another technology the hospital utilizes that has precipitated improved patient care is its bedside barcode medication scanning.
The Institute of Medicine estimates that medication errors harm more than 1.5 million people each year, and cost hospitals an excess of $3.5 billion a year. With such alarming national statistics, Boston Children’s set out to curb these all-too-common medical errors.
The process entails the nurse first scanning his or her ID to record who administered the patient’s medication, then scanning the patient’s barcode bracelet, then finally the medication.
Upon the implementation of the barcode scanning, the number of errors the system caught was astounding.
“We always knew it would provide an additional level of medication safety, but we weren’t expecting the degree to which that was the case,” Nigrin said. Numerous studies have shown that barcode scanning could reduce potential medication errors by up to 97 percent.
“When you introduce these systems, you become aware of issues you weren’t aware of before,” Harper added. “So if I accidently gave you the dose of Tylenol I was supposed to give to Johnny, it might be I never figured out that I made that mistake,” he said. The barcoding system automatically alerts you each time this kind of mistake happens now. “The system makes you aware of what you’re intercepting but it also makes you aware of what you were doing before,” Harper added.
The telemedicine trio
Implementing one of the nation’s most advanced EHR systems in conjunction with achieving Stage 7 are not the hospital’s only accomplishments meriting bragging rights.
In July, Boston Children’s also launched three telehealth pilot programs, aimed at testing the viability of the fledgling tele-technology, that officials say is just starting to make its big debut.
“The telehealth industry generally is pretty young," said Naomi Fried, chief innovation officer at Boston Children’s Hospital. “You can’t go to literature and read that everyone’s done these things already.”
Fried heads the hospital’s Innovation Acceleration Program, a two-year-old program responsible for spearheading several initiatives aimed at spurring innovation technology at the hospital. One of these initiatives consists of the three pilots currently being tested at the hospital.
The trio of pilots includes TeleDermatology, TeleConnect and TeleUrology.
"With all of these projects, I think the mantra is the right care, at the right place, at the right time,” said Shawn Farrell, the Telehealth and Telemedicine program manager at Boston Children’s.
The TeleDerm pilot was created in response to first dermatology being one of the most sought after medical specialties – with wait times often averaging two-to-three months – and second, there exists an insufficient number of dermatologists to meet the growing need of patients.
The TeleDerm pilot allows clinicians to securely send patient skin images and data to a dermatologist rather than having the patient visit the hospital.
Despite the physician-to-physician nature of the pilot, Fried maintained that the big beneficiary is ultimately the patient “because of the access improvement, because they’re getting diagnosed potentially more quickly, and because of the tremendous convenience of not having to go to another clinic appointment.”
The second pliot, TeleConnect, consists of a med surge intensive care unit clinician at Children’s providing their expertise and clinical support remotely to a community hospital emergency room. This pilot, Farrell explained, is “about getting that physician to the bedside in the emergency room in an acute emergency moment to help make better decisions about the care and treatment of that patient.”
Because the intensivist can visualize and continually monitor the patient, better care decisions can be made, particularly when it comes to patient transport. Critical care transportation, Farrell said, is both costly and in high demand. By reducing the number of unnecessary patient transports, the hospital can really begin to drive down costs. “We want to try to make the best decision about resource utilization,” added Farrell.
The third pilot program, and the most interactive among the three, is the VGo TeleUrology robot, a project spearheaded by Bob Nguyen, MD, urologist at Boston Children’s.
Robot revolution reforms care
A lot of children who’ve had urological surgery require monitoring, Nguyen explained. They don’t, however, require the level that you receive in the hospital, but they do need more monitoring than the parents can provide. Enter the VGo robot, which graciously accompanies the children home to further monitor their health.
“We thought this was the perfect patient population to send a robot home with them, so that they could take care of these kids, provide that high quality care that we’ve always been wanting them to have, but not having to spend the money of them staying in the hospital.”
The approximately three-foot tall robots are all named after SpongeBob characters. Healthcare IT News interviewed Mr. Krabs, who, interestingly enough, proved to be altogether pleasant.
The results of Mr. Krabs and his cohorts, thus far, have been remarkable. Nguyen has witnessed children connect with the robot, ultimately leading them to be more involved in their own health.
He told a story about how a child patient outfitted her robot in a dress because she thought it was naked, or the child who rushed home from school each day to greet the robot. This connection, Nguyen said, has powerful implications for the child’s recovery and health.
“The kids became more engaged in their healthcare. They suddenly cared about what was going on with them; they suddenly cared about what surgery they had and why they had it, and they cared about what they should do in the future to keep themselves healthy,” Nguyen remarked.
Kids began to ask questions about their health. “It really became something where these kids start going, ‘Well, why do I have reflux?’ No one ever asked me that before. The parents may ask you, but the kids, never."
"Or the kids go, ‘If I drink more water, that means I won’t get these infections, right?’ Kids are starting to preempt a lot of the things we’re trying to do.”
Nguyen is working on developing a robot that can take urine samples from the child or perform such things as finger pricks to then relay data levels back to the clinician. This prototype will also be capable of simulating interactive educational modules for the children, which he said would further engage the child in the recovery process.
In addition to the child being more involved with his or her health, which translates to health benefits, Fried expects the pilots will show that telemedicine implementation will ultimately translate into cost savings. “When you take care to the patient, you don’t require a brick-and-mortar space for them anymore.” Although patient outcomes are the predominant driver behind the telehealth pilots, Fried said the extra benefit of financial savings is a welcomed bonus for an industry continuing to see rising costs.
Biggest reason for success
Health IT has clearly played a crucial role in transforming pediatric care at Boston Children’s Hospital, but all individuals interviewed point to clinician engagement as the driving force behind its success. “I think it’s one of the primary reasons that over the years, we’ve been successful is that we’ve used clinicians to be part of the team,” said Nigrin.
Thus, despite the shift towards a culture of cutting-edge creations, towards paper-tossing and chronic-cased computing, there can be no forgetting the human drive, the uniquely biological enthusiasm and determination to improve status quo. Here, there can be no forgetting the minds behind the metal.