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For much of the last decade, the health care industry has been criticized for inadequate use of information technology. The inability of health care organizations to apply IT to operational problems is frequently blamed as the root cause of patient safety problems and spiraling operational costs. The underlying processes and activities associated with delivery of health care are complex and interrelated – unlike most industrial work processes that are linear in nature with controllable variables, the healthcare processes are more web-like, with decisions and treatments customized to the patient’s unique considerations.

Up until now, information technology provided only piece-meal solutions to this complex environment. In the early part of the 21st century, dramatic advances have been realized in health care related information technologies such that solutions to many complex healthcare problems are available and becoming more practical. It is critical that the healthcare community and the government explore means to enable and expedite the deployment of advanced health care technology solutions.

The Institute of Medicine reports that every year, tens if not hundreds of thousands of errors occur in the U.S. health care system. Fortunately most of these errors are in the form of "near misses," not resulting in adverse events. An adverse event is one that causes harm to the patient – including injury, disability, and death. The landmark 1999 report, "To Err is Human: Building a Safer Health System," estimated that between 44,000 and 98,000 Americans die each year as the result of preventable medical errors. Additionally, the report estimates the costs of preventable health care errors to be in the tens of billions of dollars. The underlying premise of the report is that mitigating these errors will require "systems [i.e., processes] that make it hard for people to do the wrong thing, and easy to do the right thing."

Yet, in many respects, our health care environment is becoming more complex, not less, and more prone to errors and excess costs. The increasing decentralization of health care systems means it is less likely the physician or clinician will have access to all relevant patient history. The continual flood of new drugs, tests, treatments and images increases the array of options and data points relevant to the clinician. While the volume of relevant clinical information is increasing, only a small percentage of health care organizations have made substantial progress in deploying electronic medical records (EMR) to automate the capture and access of patient data. Clearly the underlying dynamics in the industry are making it easier to do the wrong thing, and harder to do the right thing.

Many, if not most, patient errors can be prevented with better use of information technology to support care delivery. Many errors occur because clinicians do not have ready access to complete, accurate, and legible patient data; paper medical records are poorly organized, are dispersed in many different settings, contain illegible handwriting, and are difficult to locate. (Institute of Medicine, 2001.) Other errors occur because the health system relies on humans to remember large amounts of information (e.g., contraindications and drug-drug interactions for numerous medications) and to make complex decisions that routinely exceed the bounds of the human mind. Some errors occur because the health system relies on clinicians who are often too busy or too tired to accurately perform simple calculations (e.g., determining accurate dosage for a small child).

The foundational building blocks of an effective health care information management system are Electronic Medical Records (EMR) and Computerized Physician Order Entry System (CPOE). The EMR is the repository for relevant patient information including: doctors visits, prescribed medications, medical tests, allergies, blood type, medical images, procedure records, operation reports, family history, etc. Early versions of EMR and CPOE were deployed via bedside point-of-patient devices or terminals. With advances in wireless network capabilities and computing devices, many health care organizations are now deploying EMR and CPOE data via hand-held wireless pen-based computing tablets that enable physicians or staff members to access current patient data anywhere, anytime. When coupled with CPOE, the physician and other caregivers can electronically order tests, diagnostics and record their observations. This dramatically reduces transcription errors and delays in placing the orders on pharmacy, labs, and other operating departments.

The benefits (in terms of patient safety, quality, and cost management) of EMR and CPOE are enhanced the more they are integrated with supporting applications and decision support systems. An example of this is when a physician’s CPOE is integrated with computerized medication decision support so that when orders are placed, the order is assessed against the patients’ EMR so allergies and drug-drug interactions are fully assessed. This "electronic pharmacy" capability eliminates transcription errors and reduces the time to place the order.

Some hospital systems have begun to implement robotics and bar-coding at the point of filling and administering the prescription to further reduce errors. For example, the order is filled through automated dispensing machines (ADMs) and at the point of administration, the nurse scans the patient’s identification bar-code before administering the drug. This type of computer-assisted medication process (from CPOE through ADM and bedside bar-coding) has been shown to reduce medication errors by 86 percent, according to the Kaiser Foundation.

Clinical Decision Support Systems (CDS) are the means by which best clinical practices can be incorporated into patient care. CDS is an integrated set of knowledge-based tools that supplement the clinician’s and physicians diagnosis and treatment recommendations. CDS interact with the clients EMR and can include links to reference databases (such as Physician’s Desk Reference, ePocrates, etc.).

Many healthcare systems are extending the functionality and value of their information systems through interoperability, workflow, and advanced messaging. Interoperability refers to the connection of bio-medical devices and traditional IT. Automated workflow and messaging refers to the capability to monitor data across disparate technical platforms to determine the next required work activity or if an alert should be made, and then transmitting those alerts, reminders and other content to a variety of devices. For example, Meridian Health, Neptune, NJ, is currently pilot testing the capability to integrate data collected from bio-med monitoring into patient EMRs, assess this with CDS functionality, and then based on pre-defined rules and parameters, transmit messages, alerts, and even patient monitoring to wireless devices.

The essence of effective health care is the ability to draw from a wide range of resources, to be tightly coordinated and understand the best treatment options given the patients unique circumstances. The dilemma behind the deployment of advanced health care information systems to support this challenge is that deploying small pieces of the solution do not provide any return and, in fact, may complicated the process more than it is inherently.

Health care systems must think strategically in establishing plans to deploy advanced health care information systems. Deployment needs to follow a building block approach, and focus on cross-functional processes that will yield the highest return in terms of patient safety and cost management. According to Mike McLafferty, (Director, Healthcare Services Group, Amper Politziner & Mattia, LLP) "hospital systems typically have rigid departmental management structures that often impede innovative thinking and action to streamline and simplify work activities that cut-across the business."

Cultural Obstacles: The types of advanced IT applications outlined herein fundamentally alter the health care delivery processes. New management approaches are needed to lay the foundation for this type of change. Solaris Health Care Systems, Edison NJ, has successfully deployed IT to change operational processes by using a process-based approach supported by metrics and process ownership. Solaris has linked many key supporting metrics to patient safety, and then dissected those processes to understand how workflow and supporting information need to align to drive process improvements. Solaris has also assigned accountability to their managers for results of key process metrics that transcend traditional departments. Solaris CIO Lou Hermans indicates that driving improvements to hospital processes is "more of a cultural and people challenge than a technical challenge, …and that metrics are key because they keep everybody focused on what’s important." Solaris has developed a comprehensive measurement approach that links a series of supporting metrics to their overall metric for Patient Safety.

Financial Obstacles: EMR, CPOE and other enabling technologies are very expensive and can be more time consuming for the physician than traditional approaches. Advanced technology patient care systems are very expensive and the benefits do not correspond directly to the source of the investment – including the time required by physicians. Therefore, physicians, health systems and insurers need to collaborate to devise collaborative cost-benefit approaches that enable the deployment of these technologies. The Wall Street Journal recently reported that General Electric, Proctor & Gamble, and Ford Motor are expanding a program that provides financial incentives to physicians for implementing advanced technology-based patient management systems since initial results have shown excellent results in improving patient safety and driving down costs.

Security and privacy: as more information is presented over healthcare systems networks and the Internet, the risks associated with intrusion and malicious viruses and worms increases commensurately. While no security is 100% effective, healthcare systems can achieve reasonable assurance although this will likely require significant commitments of both resources and management rigor.

Dan Schroeder is a Director at Amper, Politziner & Mattia, LLP (AP&M) AP&M provides financial, operational, clinical, and IT services to healthcare organizations. Contact Dan Schroeder dschroeder@amper.com or Mike McLafferty mclafferty@amper.com 732-287-1000 with any questions.