Health IT promises new paradigm of patient care

Bob Nguyen, mD, leader of boston children’s Hospital’s teleurology pilot, and his team, have already seen positive results with the robotic technology.

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.