Health Management Technology

Clinical information systems have become more than just integrated with other healthcare IT systems. Now they are integrated into the daily routines of healthcare providers.

By Richard R. Rogoski, Contributing Editor

While vendors continue to tout the attributes of individual clinical information systems, a growing number of end-users are viewing them as merely parts of an enterprisewide clinical system. In other words, today’s clinical information system (CIS) is the sum of all its parts—from nursing documentation and physician order entry systems to laboratory and pharmacy systems. And, because the trend to integrate more and more data continues, these clinical systems are being linked to back-office systems in order to provide a more comprehensive view of every patient.

For clinicians, insurers and IT professionals, this means more efficient and cost-effective delivery of health care. For the patient, this could mean a more rapid adoption of an electronic health record (EHR), which would allow the patient’s own physician, or one in another part of the country, to access all current information at the time of encounter. This is precisely what the federal government had in mind when it began pushing for the establishment of a national health information network.

This is not to say that individual clinical information systems aren’t important in their own right. But their integration with other systems in a hospital or group practice now allows clinicians to have real-time access to all the data they need, whether it is at the bedside, at a nurse’s station or at an off-site location.

A Total View
Systems integration has been the goal of Altru Health System for more than 20 years. Located in Grand Forks, N.D., this integrated health network serves residents in North Dakota and northeast Minnesota through a 277-bed acute-care hospital and a 50-bed rehabilitation center, along with 12 regional group practices.

As a major player in the region’s healthcare market, Altru Health recorded 27,372 ER visits, 12,000 inpatient admissions and 469,047 clinic visits in 2005.

This year, Altru Health was named Hospitals and Health Networks’ “100 Most Wired” hospitals in the nation list, says Margaret Reed, M.B.A., B.S.N., R.N., Altru Health’s chief nurse executive and administrator of surgical services. In order to facilitate systems integration, Reed says Altru Health adopted a “prime vendor approach,” relying almost exclusively on systems from Reston, Va-based QuadraMed Corp.

By building on a single, solid platform and creating a single repository “that can be accessed by anyone, anywhere,” it is less likely that patient information will fall through the cracks, although Reed concedes that the organization still has some interfaces in place, primarily for the laboratory and pharmacy systems.

Of all the QuadraMed applications that have been installed, the one that has had the most impact on clinicians is the Clinical Workstation. Altru Health originally rolled out an earlier version called Clinician Access, but upgraded to Clinical Workstation in 2003. “Clinical Workstation is a lot more dynamic,” says Reed. “Before, we weren’t able to look at charting. Now it’s organized the way a clinician thinks.”

That way of thinking revolves around body systems, vital signs and all information that was collected the last time the patient was seen. Patients can be located by using their name, Social Security number or medical record number. Once the right patient is found, “any documentation anyone has done in the record” is viewable, according to Reed. That includes all recent lab and radiology reports. “Soon we will be up on PACS, so we’ll be able to pull up images as well,” she adds.

Customizable for Physicians
Clinical Workstation is customizable, so physicians are able to customize their flow sheets so the information they want to see first appears first. Because this is a server-based system, clinicians have no trouble accessing data from any computer within the health system or from home through a virtual private network. Also, because the system is password protected, physicians can only see data pertaining to their patients, those they have been consulted on or patients of physicians they are covering for, Reed says.

The acceptance of Clinical Workstation by Altru Health’s 180 physicians and 795 RNs and LPNs has been phenomenal, says Reed. All but one physician, who is not directly affiliated with Altru Health, regularly use the system to sign dictated notes and telephone orders electronically. The success of this and other QuadraMed systems also has given Altru Health System the incentive to continue blazing new trails into the digital world. Reed says she is looking toward the end of 2008 to have all physicians up and running on an electronic medical record system, and is currently working to roll out an outpatient prescription-writing system.

Expanding the role of wireless computers within the hospital also is under way. A pilot program was begun to install computers in every patient room, instead of relying only on those set into hallway “alcoves.” Currently, each hallway PC in the med/surg unit serves five beds, she says. While a lot is being planned for the future, Reed stresses that there is a definite synergy between the clinical staff and those in IT. In fact, she says that out of an annual capital budget of $30 million, approximately $4 million goes directly to IT.

Automating Patient Records
As the scope of clinical information systems continues to broaden, the importance of electronic health records (EHR) is becoming more apparent. Carle Clinic Association in Urbana, Ill., saw the importance of EHRs early on and began looking for one in 2002, says Mike Sutter, director of clinical systems IT. A major reason for the search, he says, was that neither the scheduling system Carle Clinic was using at the time, nor the usual paper charts, would give physicians all the patient information they needed at the time of encounter. Plus, he notes, “We were looking at PACS, so we knew we were heading into the digital world.”

One of the largest private physician groups in the United States, Carle Clinic Association is comprised of a total staff of 2,900 including upwards of 300 physicians practicing in more than 50 specialties and subspecialties. Through a network of 10 regional clinics, a variety of outpatient services and residency programs, Carle Clinic physicians serve the needs of patients throughout east central Illinois. It’s no wonder that this group practice needed a robust system that also was customizable.

After looking at several products, Carle Clinic chose the EHR system from Scottsdale, Ariz.-based InteGreat Inc., which develops products aimed at the group practice market. Where it was virtually impossible to get all patient data to physicians when they needed it, now, Sutter says, “We are getting the right data on the right patient to the right physician at the right time.” But getting to this point was a long and arduous process. “We signed the contract in November 2003, then worked until August 2004 to get the hardware in and the interfaces built,” he says.

The first pilot was launched on Sept. 15, 2004 and included the six providers and 27 staff members in Family Medicine. A second pilot, comprising 22 physicians, 25 residents and 37 staff members in Adult Medicine was launched in November 2004.

Then in January 2005, a small clinic with four providers and a staff of 13 went live as the regional pilot.

But changes in technology also prompted an upgrade from version 4.5 to version 4.75 in February 2005. “This upgrade increased the system’s functionality,” Sutter explains. “With it, nurses can even document telephone encounters.”

Finally, in May 2005, Carle Clinic began its full-blown roll out—one department each month—and had all sites up and running by July 2006.

Moving a Mountain of Data
Education also proved to be an important part of this implementation. To ensure that all staff members and physicians were up to speed on the new system prior to roll out, Carle Clinic worked with InteGreat to establish a comprehensive training program with a team of 30 trainers.

Staff members were trained no more than four weeks from their go-live date which, according to Sutter, was six weeks prior to the physician’s go-live. Physicians were trained one-on-one three days prior to their respective go-live, which was approximately six weeks after the respective department go-live. In addition, there also was a week of post-go-live support. While some might call this over-kill, Sutter points out that “It takes about six months for a person to integrate an EHR into their practice.”

There are now close to 3,200 users with passwords and IDs including all physicians, physicians’ assistants and nurse practitioners. A total of eight people monitor, maintain and support the system. Sutter also says there was very little staff resistance to implementing a practicewide EHR. In fact, 25 percent of the physicians championed the adoption of an EHR in their practice.

While it took less than three years to fully implement Phase I of this EHR project, a major challenge was getting old data into the new system. Rather than create new patient records as patients were coming in to be seen, the physicians at Carle Clinic “felt they would still have to pull charts if all the data was not transferred,” Sutter says. All discrete patient data that was available electronically was transferred via an electronic interface; this was completed before the first pilot and took about eight months. A lot of data, however, which is only available on paper, has not yet been transferred. Even so, the data that was transferred included 20 million lab test results as well as eight years worth of radiology images, eight years worth of dictated notes and a year and a half of appointments.

Challenges Keep On Coming
Chart pulls still exist at Carle Clinic, but they have been reduced by 50 percent. The average cost of each chart pull in the industry ranges from $5 to $7, Sutter says, so with 1 million patient visits per year, Carle Clinic anticipates saving a lot of money just from this reduction. Plus, having all records available electronically has meant the closing of two medical record locations where paper records were previously stored.

Carle Clinic is well on its way to becoming “paper-lite,” says Sutter, although it probably will never become paperless. “Patients bring in paper all the time—insurance cards, previous medical records, referrals. Scanning is the biggest key to EHR implementation after the system is up.”

But making sure that all those scanned documents are indexed correctly and are sent to the right doctor or retrievable at some future point in the future presents another challenge. For those patients who winter in Florida or who are be hospitalized outside of the local area, chances are good that their wintertime doctors or the other hospitals will continue to send paper.

In addition, many of the medical and legal forms that patients and clinicians must complete remain on paper. “We had 1,600 different paper forms when we started the EHR project and are in the process of determining which forms are still required. Then we plan to “electronify” those forms that are required,” says Sutter. Adding to this avalanche of paper is the fact that the state has very specific forms, “some of which the state won’t allow me to replicate,” he adds.

Still, the adoption of an EHR has greatly increased the efficiency and productivity of Carle Clinic’s staff. As a Web-based modular product, InteGreat’s EHR allows clinicians to access patient data from any department or remote location. To maximize efficiency, cost-savings and convenience, physicians use wireless tablet PCs which are about the same size—and sometimes the same weight—as a patient’s paper chart. Since each room now has a docking station, physicians can pull up a patient’s entire record, including radiographic images, at the time of encounter.

So far, Carle Clinic has implemented a number of the EHR’s modules including the full health summary, full clinical messaging and electronic prescriptions with automatic alerts. Pilots for the computerized order entry module and charge capture module are being planned for later in 2007.

Delivering More Than Data
Few specialties can be as rewarding—and risky—as the field of obstetrics. That’s why collecting accurate maternal, fetal and newborn data is critical. To facilitate the collection and transfer of information on both mother and child, NCH Healthcare System in Naples, Fla. selected the Centricity Perinatal Clinical Information System from Milwaukee, Wis.-based GE Healthcare.

According to Donna Hafner, R.N.C., perinatal informatics analyst at NCH Healthcare, the purchase in 2001 of the entry-level surveillance and archive module led to an upgrade a year later to the full perinatal system which includes AirStrip OB, OB Link and Office Client. “We chose Centricity Perinatal because it was configurable,” she explains. “You can configure any documentation on the fly.” Because this CIS is deployed in a high-risk unit, it’s easy to make changes to any documentation should any safety issues arise, she says.

The Web-based system also allows for easy access from outside the hospital through its password-protected OB Link feature, making it possible for clinicians to access maternal data and fetal strips (a record of the fetal heart rate) in near real time. This is especially important for an organization that has multiple locations and is still growing.

A not-for-profit, community-based corporation, NCH Healthcare has both an uptown and downtown campus in Naples that serves more than 550 beds. The growing need for healthcare in this area of Florida also has prompted NCH Healthcare to begin building a new six-story tower. In November 1996, NCH Healthcare System combined its two obstetrical services and opened The Birth Place. Since then, newborn deliveries have increased to more than 4,300 per year.

Separate But Available
Prior to rolling out the Centricity system, all documentation, and even the fetal strips, were on paper. Now, Hafner says, “We are the most paperless unit in the hospital.”

However, given the nature of this specialty, there are still instances when paper records have to be used. For example, not all the data collected goes into the main hospital information system (HIS). “We pretty much keep our records separate,” she says. “We scan delivery information into the HIS, but the official record of the OB stays in the perinatal system. If the patient is moved to another unit, we print out patient information that’s needed by other departments. We want the labor record to be complete from admission to discharge, and we want the record to be as complete as it can be, even though it’s separate from the HIS,” she says.

The system also facilitates the collaboration between nurses and physicians.

“We chart once,” Hafner says. “When a nurse charts a delivery, for example, it flows to the physician. He adds his own documentation and it becomes part of the record. When the chart is signed off, it’s complete.” The system features an audit trail that tracks who charted what and when.

Unlike most clinical information systems, a perinatal system reflects the uniqueness of this specialty. “In no other situation does a patient come in for only nine months, culminating in a delivery,” Hafner says. “So no other system is like this.” Perinatal systems are classified differently than other clinical information systems. “OB documentation systems are regulated as a Class II medical device by the FDA.” she notes. A fetal monitor, for example, is connected to the CIS. But even though the data being collected is going directly into documentation, the fact that this information is coming from a medical device that uses algorithms to display alerts, and is directly attached to the patient, makes the CIS as much of a medical device as the monitor.

Interestingly, the transition from paper to electronic records went smoothly and with minimal resistance, even though some staff members had to take baby steps in the beginning. “We had some people who never used a mouse, and some physicians who didn’t even have e-mail,” Hafner says.

Benefits Accrue
The importance of getting all 26 physicians in the unit comfortable with the new system led to the formation of a six-physician focus group. “We hand-fed them the documentation and worked through the chart so it became their own documentation,” she says. As these doctors came up with their own suggestions to make workflow easier and more efficient, those changes were implemented.

Prior to roll out, four physicians piloted the system for one month. “Within six months, everyone was on,” Hafner says. “And it was not an option. Our administration was very supportive of the transition to electronic charting.”

Since implementing the new perinatal system, NCH Healthcare has realized some remarkable gains in efficiencies, risk management and cost savings. “The return on investment has been phenomenal,” Hafner says. “But there are monetary returns and nonmonetary returns. Our physicians are now more compliant; the system has cut down charting time from 20 minutes to seven minutes; and we are JCAHO-compliant 100 percent of the time”

Because coders, risk managers and attorneys also have remote access to the documentation they need, it takes less time to get reimbursed for services rendered and more risk management issues can be addressed before they become problematic, Hafner says. “This system has caused a whole paradigm shift for us.”

Richard R. Rogoski is a free-lance writer and contributing editor to HMT. Contact him at rogoski@aol.com.

For more information about: The Centricity Perinatal Clinical Information System from GE Healthcare,
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InteGreat’s integrated EHR/PM system,
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Clinician Access and Clinical Workstation from QuadraMed,
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