EXECUTIVE SUMMARY
CIOs and CMIOs whose organizations have been reporting and analyzing various quality outcomes and other clinical data for some time already say they anticipate that hospital organizations just beginning now to establish data reporting systems to comply with meaningful use requirements will face multiple challenges. Meanwhile, those organizations already in the “advanced” category in terms of reporting and analyzing clinical data are branching off into a very broad range of initiatives to improve patient safety and care quality.
As CIOs, CMIOs, and their colleagues at hospitals around the U.S. rush to begin to comply with the meaningful use requirements under the federal American Reinvestment and Recovery Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act, most are just beginning to collect, report, and analyze clinical outcomes data in a serious way. What can they learn from the IT leaders at pioneering organizations that have already blazed trails in this critical area? Some of those pioneers have already made inroads in areas specifically cited in the meaningful use requirements, while others have been focusing on different areas, across a tremendously wide spectrum of potential activity.
YOU CAN'T JUST BE SITTING IN THE BACK CREATING ANALYTICS WITHOUT UNDERSTANDING WHAT'S GOING ON AT THE FRONT END AND CONNECTING THE FRONT WITH THE BACK, IF YOU WILL.-PAUL CONOCENTI
What CIOs and CMIOs at those leader organizations can agree on is that those just starting down the path now face a welter of challenges, none of which will be resolved very quickly.
“The first lesson learned in this area is that this stuff doesn't go in quickly,” says Paul Conocenti, senior vice president, vice dean, and CIO at the NYU Langone Medical Center in New York City. For one thing, he says, “You can't just be sitting in the back creating analytics without understanding what's going on at the front end and connecting the front with the back, if you will. And you come to the point where you have the data, but it's not at the granular level to do the analysis that you need to do. And even more so, you need to understand the data.” Instead, the kind of work that the meaningful use requirements are meant to compel hospitals forward on is going to take numerous waves of implementation and refinement to succeed, he contends.
Conocenti says his organization's experience with collecting and using quality outcomes data offers a particular sense of perspective to the struggles most hospital organizations will be going through as they try to move forward to meet the meaningful use requirements around outcomes data reporting under the federal ARRA-HITECH Act. Having had some form of computerized physician order entry (CPOE) for nearly 30 years, and clinical decision support (CDS) for several years, Conocenti believes that NYU's experience underscores the very long strategic and cultural changes that will have to take place in hospital organizations across the country in order for the management of clinical data to become both routine and truly useful.
THE WORK INVOLVES FINDING WAYS TO FOCUS AND CATEGORIZE, IN A SENSE, THE LEARNINGS FROM THE EXPERIENCE OF [USING] THE COMPUTER SYSTEMS, AND THEN APPLYING THAT LEARNING TO THE FUTURE.-MARTHA RADFORD, M.D.
And, says his colleague Martha Radford, M.D., chief quality officer at NYU and a professor of medicine in the division of cardiology at NYU's medical school, “The work involves finding ways to focus and categorize, in a sense, the learnings from the experience of [using] the computer systems, and then applying that learning to the future.” As a result, numerous compromises have to be made on all sides among different groups of clinicians, as well as IT leaders and others in an organization, she notes.
Currently, Radford says, “Our three main hospital and system goals this year are to decrease hospital-acquired infections, to decrease lengths of stay and to decrease readmissions. And the infection one is particularly interesting, because we're kind of data scavengers and will take the data from wherever it is-from Sunrise Clinical Manager [NYU uses the core EMR product from the Atlanta-based Eclipsys Corp.], from administrative data, from lab data-so we bring data from all over into our analytics system.” Working forward on all these areas is extremely important, Radford says, but she and Conocenti agree that doing so requires creating a very strong foundation for discussion and consensus-building along the way, among all stakeholders in an organization.
DRILLING DOWN TO NEW LAYERS
Once a foundation has been laid, organizations can really move forward into very granular, very important, work. Take for example Northwestern Memorial Hospital in downtown Chicago. There, David Liebovitz, M.D., medical director for clinical information systems, has been working with colleagues for several years on IT-facilitated quality initiatives. “We been pursuing a few different parallel paths,” Liebovitz reports. In addition to broad public outcomes data report cards, which the hospital has been publishing on its Web site at www.nmh.org, Liebovitz notes that “We've been putting a lot of thought into explaining the basis for the report card, what it means, what quality measures mean, and how we've picked what we're presenting on the Web site.”
What's more, he says, “In addition to making reports available and having quality improvement committees, the next level is how you turn that back around into internal quality improvement. We have a long history of quality improvement, but what we're now also able to do in a health IT context is, we're taking specific measures and instead of just addressing them in a retrospective fashion, we're intervening through available real-time reports, and we've empowered different groups of users to access those reports.”
One leading-edge example of that work has been around “the area of medication usage and ensuring that we have appropriate antibiotic usage matched effectively to organisms,” Liebovitz reports. Working collaboratively with their vendor in that area, the Salt Lake City-based TheraDoc (a Hospira company), “The pharmacists in different units each have responsibility for different areas within the TheraDoc-driven triggers,” he explains. “As a result, they are being given real-time alerts in a hospital-wide, real-time surveillance program.”
DOING THESE KINDS OF THINGS IS SO GREAT, IT MAKES US WONDER WHY WE HAVEN'T BEEN DOING THEM ALL ALONG.-DAVID LIEBOVITZ, M.D.
How does this work? Let's say a patient was put on antibiotics last night; but this morning's lab test reveals that her kidney function has dropped dramatically, and as a result the dosage for the antibiotic she is on is no longer appropriate. Using this system (which Northwestern Memorial is alpha-testing with TheraDoc), the lab test result, and its relationship to the antibiotic dosage for that patient, will trigger an alert to the pharmacy, which should lead to a rapid intervention. At this point in time, the attending physician would see the lab result, but not yet the alert; though that will change as the solution is developed forward, Liebovitz says. In fact, he says, “We're looking to integrate this entire system directly into the patient's chart as well so that everyone will be on the same page.”
What's more, Liebovitz reports, “We're creating our own real-time reports within our own electronic health record” from the Kansas City-based Cerner Corp. What's significant there is that such reports are being produced in real time, allowing for real-time interventions in areas such as DVT prophylaxis. In other words, he says, “Those reports are ways in which we're trying to establish processes such that quality improvement isn't a retrospective look at what happened over the last quarter, to be monitored over the next quarter,” but rather a use of outcomes and other patient data to be used immediately to improve patient care.
Some of these areas clearly lie outside the current requirements under meaningful use, but that really is part of the point, Liebovitz says. The goal, he believes, is for any hospital-based organization to move forward to harness clinical data reporting and analysis to pursue goals that the clinician leaders of that organization believe are valuable and speak to mission and vision in their organization. As a result, Liebovitz and his colleagues continue to range widely into new areas, such as providing real-time reports to all anesthesiologists that track which patients are on active epidurals, in order to help the anesthesiologists better monitor their patients’ care. The work never ends; it only moves his organization to ever-new horizons, Liebovitz says. And, he adds, “Doing these kinds of things is so great, it makes us wonder why we haven't been doing them all along.”
QUESTIONS AND CHALLENGES
CIOs and CMIOs of the more advanced hospital organizations agree that the release in July of the final rule on meaningful use has caused them to have to evaluate their work thus far, and in some cases, reorder priorities, in order to respond to meaningful use requirements.
“Meaningful use is forcing us to rearrange, and the degree to which we're having to rearrange depends on the path we've been on,” says Bill Spooner, senior vice president and CIO of the seven-hospital Sharp HealthCare in San Diego. “The quality indicator requirements are forcing us to have to rearrange things, because we're having to focus on the specific indicators coming today out of HITECH and tomorrow out of healthcare reform. And even with the measures we already have been working on, we may even be calculating some of the same outcomes measures differently from how we're going to be asked to calculate them now,” he says.
In addition, Spooner expresses concerns around the use of his organization's data warehouse, saying, “I'm pretty sure that meaningful use will ultimately require the certification of data warehouses.” His organization has been working extensively in a number of clinical areas, including maternal and child health, diabetes, and cardiac care. In those latter two areas, it has been working closely with the organization's affiliated physicians, and has “integrated hospital and medical group measures in several areas, beginning with diabetes measures and then cardiac measures.” Sharp, and its physicians, have been very active, for example, in the Integrated Health Association quality reporting program in California.
A different set of issues is of concern to Sajjad Yacoob, M.D., assistant professor of pediatrics at the Keck School of Medicine at the University of Southern California, and CMIO, Children's Hospital of Los Angeles (CHLA). “For us, being a pediatric organization,” says Yacoob, referring to CHLA, “many of the very specific meaningful use criteria don't quite apply to us. Having said that, though, there are very specific things that we'd have to look and make sure that we can validate, that we're doing, and we are. Many of them, when you drill down and say, are you reporting on lab data, reporting on codified elements of patient demographics, yes, we have all those things, and we can show that they're meaningful and we're using them.”
EVERYONE THINKS THERE'S SOME LITTLE PIXIE WHO ENTERS DATA IN THE MIDDLE OF THE NIGHT AND THEN IT'S MAGICALLY THERE. BUT YOU ACTUALLY DO HAVE TO PUT THE DATA IN.-SAJJAD YACOOB, M.D.
Yacoob believes his CIO and CMIO colleagues in hospital organizations that have not yet made significant headway in reporting and analyzing outcomes and other clinical data will find that many very basic elements of doing so will prove surprising and perhaps frustrating to them. “When we report on data, somehow the data has to be in the system,” he says. “And everyone thinks there's some little pixie who enters data in the middle of the night and then it's magically there. But you actually do have to put the data in. Either you can have clinicians or non-clinicians enter the data; but that won't be as great data as you'd expect, especially if they're at a remove from the patient. So first, you have to understand some things, such as who handles med rec with patients? Who handles management of asthma with steroid medications? Find out who would handle that process, and make data entry part of a normal workflow. It's not rocket science, but you have to fully understand and embrace that, or you'll be introducing elements that will be blocks to normal patient care processes. And just adding pieces of data will be balky and not comfortable for the clinicians, and they'll rebel if it interferes with their workflow.”
The basic blocking and tackling will prove surprisingly complex to many healthcare IT leaders, Yacoob says. “For example,” he says, there are multiple ways of handling medication reconciliation.” When it comes to granular issues, he cites this example: “Once clinicians have the data on medication reconciliation, somebody still has to talk to the patient, or in our case, the parent, and get the data. And once they have the data, will they enter it? That's fine, that's an entry function. But then someone has to look at the list and make the cognitive decision of whether those meds are the right ones for the patient. So that's two tasks, and could be handled by two different people; or it could be one person. In some places, the pharmacist enters the data and enters it from the patient or parent, and then the physician does the validation, the cognitive task. In some places, the physician might do both things. I'm agnostic on that point,” he says, but stresses that his colleagues should be aware of how complex all this is, when such questions are multiplied on a massive order of magnitude.
And, he urges CIOs and their colleagues to consider that, “If you're going to ask me as a clinician to participate in the collection, reporting, and analysis of clinical data in some fashion, you have to make sure that the tools I'll be using are bulletproof in their validity, and that the task of doing this is not cumbersome and awkward and won't slow me down.”
Finally, says NYU's Conocenti, there is a major vendor-capability element around all this. “The focus until very recently,” he says, “has been on transactional data and systems, and the analytics side has just begun to be developed. We're now looking for an enterprise view around all analytics, not just clinical analytics, and no academic medical center is going to accept one product from one vendor” in this area, he insists. “The systems are relatively immature; none that I've seen to date would let you just slap the data in there. So the data management aspects are huge, and the technology is the least of the issue. It's all about process, and technology, and data and people,” he concludes.
Healthcare Informatics 2010 October;27(10):16-22
