Institutions tackle cultural barriers to computerization
By Deborah Gesensway
For a peek at the future of medical computing, you need to do as the physicians and administrators at Northwestern University Medical School did recently. You need to turn your sights to the few large health care institutions that have been setting the pace for the industry for the past two decades.
Look to the Regenstrief Institute for Health Care at Indiana University in Indianapolis, for example, where physicians write all their orders on computers programmed to check the directives against guidelines. Or examine Intermountain Health Care's LDS Hospital in Salt Lake City, where every hospital room contains a computer workstation programmed with sophisticated medical logic that automatically audits the patient information entered by doctors and nurses. These two, plus a few other academic health centers and large HMOs, have been so far ahead of their competitors and colleagues in clinical computing for so long that their names have become bywords for the trend.
"If you go into most hospitals and ask how much does it cost to do a [coronary artery bypass graft or CABG]--not the charge, but the cost--they can't tell you. If you ask them to go to their database and show you how they manage their CABGs, they don't have a clue," said David Classen, ACP Member, an infectious diseases specialist at LDS Hospital and one of the hospital's clinical computing experts.
Around the country, hospitals, managed care organizations and academic health centers seem to finally be hearing and heeding these examples, particularly because these systems have had more than 20 years to demonstrate their ability to lower costs and improve quality through standardization. Among group practices of all sizes surveyed by the Medical Group Management Association, for example, nearly half reported plans to automate sometime in the next two years. And more than 90% of executives at hospitals, HMOs and health systems surveyed by Modern Healthcare magazine and the consulting firms of Coopers & Lybrand and Zinn Enterprises said that improving their information systems, linking their providers and departments and generally committing resources to computerizing operations is a priority for the near future.
According to the Modern Healthcare survey, which was published in February, the rationale for enlarging and upgrading information systems stems largely from the demands of a newly competitive marketplace. Computerization, these health care executives report, is necessary to improve their ability to manage managed care. Their other goals--enhancing decision support for clinicians, integrating databases and connecting to the local networks being formed--are coming to be seen as necessary to improve productivity, reduce duplication of service and generally increase the bottom line.
And although much of what is being done is being promoted by people who are not clinicians, but business people whose top priority is not necessarily helping doctors do a better job easier, much of the spin-off effect will be to benefit physicians. For example, decision-support tools such as reminder prompts and drug interaction programs will save a health system money in the long run, but should also help physicians do a better job keeping their patients healthy.
"The [integrated health care] system can no longer afford to have five people doing the same kind of things related to a patient's care. It's got to have coordination and communication," said Edward Hammond, PhD, head of the division of clinical informatics at Duke University Medical Center. "I think the only way to make that work is by having an information system."
Plowing new ground
Chicago's Northwestern University is one health care institution acting on what it has seen. Northwestern Memorial Hospital and its medical faculty foundation have dedicated $35 million to a computerization project just now getting off the ground.
The goal is to "learn from the Regenstrief and LDS examples and then to plow new ground," said Paul Tang, FACP, medical director of information systems at Northwestern Memorial Hospital, a teaching hospital for Northwestern University Medical School.
If all goes as planned, physicians at Northwestern eventually will no longer face the situation now typical in internal medicine clinics, according to a recent study: 80% of the time, physicians make decisions for patients without all the relevant information in front of them.
"The paper record is broken," Dr. Tang said. "It's not a missing chart problem. It's that we can't find the information in the medical record. ... There certainly is the possibility that the lack of information is impacting negatively on patient outcomes. We don't know that because we don't have longitudinal studies to say that. But you would think so."
Automating clinical processes should end clinicians' reliance on this broken paper-based record, Dr. Tang said. "We want to give physicians the relevant information they need to make decisions at the time and at the place they are making them--not chasing them after the fact, but at the time they want to write the order, giving them the information they need to write the appropriate order." Added to this, he said, will be drug interaction programs, online access to medical literature and reminder systems to prompt physicians to do what they would have done if they just had thought of it.
Despite all these professed benefits, physicians have rarely led the charge toward computerization. Old habits die hard. Change is rarely freely embraced by anyone. Something else usually has to force the change.
At Northwestern, for example, the ambitious computerization project is taking place in conjunction with an even larger construction project now under way: a $600 million undertaking to replace the old hospital building with a new inpatient-outpatient facility near Chicago's Magnificent Mile.
The bulldozers, the architects' renderings, the chaos of dislocation, Dr. Tang said, are "the catalyst for an attitude that allows change to happen. ... We have a capital plan for the entire building, which includes infrastructure. An information system is just one of the pieces. We think of information as an infrastructure for helping the health care team get its job done. ... In part, [the computerization] is motivated by the new building project, but only in part, because we would be doing this anyway."
The significance of a catalyst becomes evident when you recognize, as most clinical computing experts do today, that what's blocking computerization at most health care institutions has little to do with the barriers of inadequate know-how or immature technology. In fact, much of the technology is stable--finally--and tried and tested ways exist for using fast PCs, expanded networks and sophisticated data repositories.
"The technology exists," said Dr. Tang. "But the infrastructure doesn't exist because there is capital involved. And, even more, the culture doesn't exist."
Technology isn't the barrier
In fact, the key lesson learned at the Regenstrief Institute, said Clement J. McDonald, FACP, co-director of the institute and professor of medicine at Indiana University School of Medicine, has been that the "technical barriers to the development of ambulatory medical record systems no longer exist."
It is "absolutely doable" for a hospital or a group practice to take everything that is already digitized somewhere--lab, pharmacy, radiology, EKG data, discharge summaries and more--he said, and "make it a coherent whole that can be used for immediate day-to-day care as well as for management and research."
Charles Safran, ACP Member, director of the clinical systems division at Beth Israel Hospital in Boston, says giving doctors access to the "basic facts of patient care" is technologically speaking, "simple stuff ... basically early 1980s transaction processing technology." And allowing for rapid, accurate retrieval of this very basic kind of information--a serum sodium level, for example, or the glucoses over the past five years of treating a particular diabetic patient--"is at the heart of what clinicians' information needs really are," he said.
Another piece of the technology puzzle that could revolutionize medical practice is electronic mail. "It's a basic and stable technology," he said. "E-mail is that killer application that gets people started."
Simply getting doctors communicating with one another through the Internet or other e-mail systems, Dr. Safran said, will "more profoundly change American health care than almost anything else we can do. Think about who else has e-mail besides the physicians: the patients."
After a health care system tackles these tried technologies, it can move on to more complex clinical computing, such as programming the computer to "think about the data and help physicians do better jobs," according to Dr. McDonald.
Even that generation of technology now generally exists, these experts said, and each hospital, HMO and group practice no longer has to reinvent these computer systems for themselves. Vendors are recognizing health systems' interest in spending money on clinical computing, and several companies have already introduced programs that perform these functions.
Northwestern, for example, is working with Epic Systems Corp. of Madison, Wis., on a $2.3 million research contract from the National Library of Medicine to design and co-develop a clinical information system for physicians in ambulatory care. That vendor's EpicCare computer-based patient record system is one of several market leaders. FHP Inc., the giant California-headquartered HMO, is one recent buyer, and is implementing EpicCare in two of its staff-model clinics in Utah and California.
FHP is not simply making the $20 million investment to put PCs everywhere--in exam rooms, on doctors' desks, at nurses' stations, in reception areas, even laptops for physicians on call--for academic purposes, but to make the business more efficient, productive and cost-effective, said Raymond Pingle, DDS, FHP's vice president of strategic planning. The system, he said, will be able to "do order communications, to track abnormal labs, to close the loops," thereby theoretically saving money and improving productivity and quality.
The payback, he estimates, will come in three years. "When you examine the labor that exists in your medical center that copies, moves, faxes, files, follows-up, logs, telephones--it's amazing," he said.
Other large health care providers are taking advantage of existing technologies in very different ways. Minneapolis-based United HealthCare is in the process of expanding its business-oriented ProviderLink electronic data interchange system used by doctors to submit claims and check patient eligibility. The plan is to get everyone who does business with the national HMO connected to one another through e-mail, said J.P. Little, director of advanced technology for United HealthCare.
Once everyone is connected, he said, clinical resources will be added to ProviderLink. The first of these clinical extensions, Total Recall, is being designed now, and will operate on a hand-held, wireless, portable computer about the size of a clipboard. Doctors will be able to carry these computers into exam rooms and use them to access lab, radiology and pharmacy data--even calling up on the screen an image of a chest X-ray done at a cross-town hospital--he said.
"The technology that supports high-speed communication and wireless technology is just now becoming mature at a reasonable cost," Mr. Little said.
Money and attitude
So if more health plans aren't following LDS and Regenstrief, it's clearly more due to administrative, cultural and financial barriers than to any disbelief in the reality or potential of the technology, experts say. The institutions moving ahead are the ones that can see an economic incentive to making the investment and pushing people to change. And the high cost of building a sophisticated information system clearly keeps all but the largest health care providers from taking too deep a plunge at the moment. It takes millions and millions of dollars to transform a paper medical records system to one that is computer-based.
Making that commitment is clearly easier for truly integrated health systems competing for managed care business, but most health plans are still only held together through contracts or other loose arrangements. These network-based health plans are more likely these days to be spending their information systems budgets on computerizing business operations, including claims submission and patient eligibility checks, and concluding that clinical computing is better left to the clinicians--for now.
"We figure that the people who get the most benefit from [computerized patient records] are providers," said Alicia Bergmann, an information systems consultant with PacifiCare Health Systems, a large California-based HMO. "From our experience, our doctors are really busy, and they don't have the money or the people resources to focus on that right now. So, we're trying to help our doctors get rid of some administrative tasks, to free up their time. And once we free up their time and save money, then we'll have the money and the resources to go out and do the next wave of these projects," namely clinical computing.
The health care industry has historically spent an average of about 2% of revenues on information systems. Banking, in comparison, spends 10%. According to the recent Modern Healthcare survey, most health care executives are planning to increase their investment, but by 10% or less.
"Most American industry looks at health care and laughs at the incompetence of our electronic manipulation of data," LDS Hospital's Dr. Classen said. "Imagine starting an airline today without a computerized reservation system. You'd be laughed out of the business. But you can start a hospital without a computerized system. It's unbelievable we've gotten this far."
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