The road less traveled
Boston Children's Hospital knows a little something about what it takes to be at the top. Consistently recognized for its medical specialties and patient care, it is considered one of the best pediatric hospitals in the world.
The exceptional care administered by the nation's leading physicians and nurses stands as a primary driver of success, but often off to the side of the spotlight stands the hospital's advanced health information technology that has been instrumental in transforming the quality of patient care.
The hospital's sophisticated electronic health record system, for instance, is one of those things you might write home to your mom about.
For 10 years, Daniel Nigrin, MD, chief information officer at Boston Children's, has been working on implementing the hospital's EHR. The end result? "It's literally a single application that you can see all of the information about your patient," he said. Ambulatory, in-patient, outpatient, surgical, pharmacy, and emergency patient care are all integrated into the system - which turns out to be really dozens of systems seamlessly connected.
In 2010, the path to paperless was complete after a collaborative effort - including Nigrin, Marvin Harper, CMIO at Boston Children's, in addition to numerous physicians, nurses and IT staff - eventually yielded a HIMSS Stage 7 Award. Boston Children's is one of 1.2 percent of hospitals achieving this distinction.
In addition to achieving Stage 7, the hospital has also received nine 'Most Wired" awards from the Hospitals and Health Networks and the 'Most Connected' designation bestowed by the U.S. News and World Report.
The exemplary health IT endeavors of Boston Children's officials has suggested that the road less traveled by has indeed made all the difference.
On achieving nine 'Most Wired' awards
Nigrin: Way back when we started on this journey 10 years long, it was primarily focused on improving patient safety and optimizing care processes, making things more efficient where possible. I think just as part of that process, the way that we've achieved going after that stuff has resulted in us also garnering some awards along the way, because I think, in large measure, many organizations are trying to move along the same path, and so a lot of these awards are benchmarked based on achieving certain levels of achieving automation, clinical order entry, how automated you are, telemedicine, etc.
What advice do you have for hospitals working to successfully implement this kind of system?
Nigrin: I think the single most important thing that was responsible for our success has been our involvement with clinicians all along the way. That's the first thing that I tell people. The second thing, not just any clinician, I actually think nursing involvement is absolutely critical. A lot of places focus on the doctors because the doctors make a lot of noise...but honestly, when you fully implement one of these EHR systems and automate as much as we've done, the nurses are actually the ones who interact more with the system than the doctors. The nurses are constantly charting vital signs, input and output. They're in there a lot more than the doctors are, and there's a lot more nurses than doctors too. I think focusing in on them was another thing we did right.
What's the next step for data accessibility?
Nigrin: Now that we have the data digitally, we can now present it to different people, use it for different purposes. (provider portal, patient portal, etc.) The idea now is that you don't have access to your entire record. I think that will come with time. But as we start to explore being able to give information, raw medical data, back to family, we're finding that families actually do quite well with it.
Where are you moving towards now that you've achieved Stage 7?
Nigrin: I think the environment is really forcing a lot of the thought around what we do next. What I'm referring to is the expectations of being able to exchange data fluidly with other organizations. So if the Mass General refers a kid over to us or if Longwood Pediatrics refers a kid over, we should be able to seamlessly receive inbound a summary of that patient - what meds they're on, what their problems are, maybe some text descriptions, and likewise when we're finished caring for the patient, we should be able to be able to seamlessly route the data back to their systems. And not just as a PDF document, which frankly is to some degree what we do currently, but basically to have the information flow right into those categories onto the chart. Technically, we've got the ability to do this now, and it's just a matter of orchestrating with the country, to some level, because we're all trying to get this big interoperability framework established.
Would you do anything differently?
Nigrin: I think one thing that we could have done better that forced us to actually circle back and improve on what we originally rolled out was we tried to standardize our practices across the organization when we went to an electronic system because we wanted to order medications in a certain way and have that be a standard across the organization; we wanted to do our documentation a standard way...I think we weren't, in some instances, flexible enough, and we were a little too rigid in how we deployed the system.
A lot of smaller hospitals are struggling with the cost portion of implementing an EHR system. How expensive is this endeavor?
Nigrin: It's incredibly expensive. On the order of magnitude, if you look over the past decade or so, we're in excess now of $50 million that we've spent to implement these systems. These are not checks we've written to Cerner - some of it is obviously written to Cerner, Epic and the other vendors. A lot of it is around the cost to implement them that we need to pay our own staff. But that's a huge burden. Obviously, we're a bigger organization, and it's a big number to us still, but we can imagine a smaller community hospital that's barely keeping their head above water cannot - obviously it wouldn't be a $50 million implementation - but even if it's a $10 million or $5 million, that's a lot of money. To some degree, I think the stimulus measures, the meaningful use funds, will be helping, certainly down to the smaller individual practices.