A hospital stay may be intimidating for adults, but it can be downright scary for kids. At Children’s Hospital Boston, Arthur, a cartoon aardvark, helps allay their fears. Available on the hospital’s public Web site, the popular Arthur characters from the Marc Brown books and PBS television series describe in simple terms what children can expect during their stay.
The cartoon is one example of Children’s commitment to using IT to improve pediatric care, say its top executives. It’s part of a comprehensive plan launched several years ago that includes consumer-driven offerings such as Arthur and sophisticated internal clinical and administrative systems designed to help clinicians streamline the delivery of care.
Children’s Boston is the main pediatric teaching facility for Harvard Medical School. It records about 17,000 inpatient admissions and more than 450,000 outpatient and emergency visits annually. Additionally, the hospital performs 22,000 surgical procedures and 170,000 radiological exams each year.
Despite its reputation for clinical excellence, for years the hospital severely underinvested in many aspects of its operations, particularly IT, says James Mandell, M.D., president and CEO of Children’s Boston. It relied on a patchwork of best-of-breed IT systems to meet its needs in different operational areas and found itself at a turning point. “We really had to have a very aggressive plan to completely reinvent where we were,” Mandell says. “My agenda is the physicians’ and clinicians’ agendas. I get battered every day, and IT is the downstream effect of that.”
Three-Phase Overhaul
To help develop and implement a plan, Children’s appointed Daniel Nigrin, M.D., as CIO in 2000. A pediatric endocrinologist and medical informaticist, Nigrin corralled the people and resources the IT department needed to reinvent itself. Using largely homegrown applications, Children’s lab results have been online for 15 years, and electronic documentation from physicians has been increasing incrementally during the past 10 years. But since Nigrin’s appointment, Children’s has launched CHAMPS—Children’s Hospital Applications Maximizing Patient Safety—an ambitious multiyear, multiphase project designed to replace many of the key computer-based systems used to care for patients.
The new systems will provide patient information such as lab results, medication administration records and allergy information to nurses and other clinicians, plus real-time decision support at the point of care. Every clinician will have immediate access to a patient’s entire history, improving communication among the care team and reducing the risk that information will fall through the cracks. The systems will streamline processes, improve patient care and reduce errors, Nigrin says.
“This is a big undertaking simply because it’s dealing with the core set of clinical functions that people do every day, multiple times a day,” he says.
Children’s is rolling out CHAMPS in three phases. The first phase, which wrapped up shortly after the first of the year, involved replacing lab, pharmacy and results reporting systems. New features were added to the lab and pharmacy systems to improve department operations and to position the hospital to implement computerized provider order entry.
The hospital aimed to reduce its best-of-breed and stand-alone systems by selecting two vendors—Epic Systems, Verona, Wis., and Cerner Corp., Kansas City, Mo. Children’s tapped Epic for its ADT, registration and hospital billing applications, as well as patient scheduling, enterprise master patient index and health information management systems. It upgraded its existing laboratory information and pharmacy systems to Cerner’s Millennium products and replaced a homegrown application for viewing lab results and electronic documentation with Cerner’s PowerChart platform.
“Obviously, the Epic applications are clinically related, but I like to think of them as more administrative clinical,” Nigrin says. “The set of Cerner systems we’re putting in now are really the clinical clinical systems.”
During the second phase, Children’s will roll out CPOE and electronic inpatient nursing documentation, and communication among clinicians will be improved through computer-generated rounds and shift reports. That phase—targeted for year-end completion—will have the biggest impact on physicians and nurses, as well as on patient safety, Nigrin says.
A crucial part of the second phase is implementing point-of-care electronic medication administration using handheld, wireless bar-code scanners to identify the patient, the meds and the nurse. The system will generate decision support and drug conflict rules when the physician places the order and again at the time of administration. For pediatric patients, it’s a crucial backstop, Nigrin says.
When a clinician places an order for medication that is sensitive to renal function, for example, the system checks that the dose is appropriate for the patient’s condition. But if the patient’s renal function declines during the following 24 or 48 hours and the medication order is still active, there’s the potential for a serious problem. Nigrin’s staff is working with Cerner to develop alerts that will fire on the handheld device a second time at the point of medication administration if a conflict arises.
It has taken vendors much longer to implement such complexity in the pediatric world, Nigrin says, which is why peds-specific institutions lag in CPOE implementation. “Dose-range checking in pediatrics is a very tricky business,” he says. “That scenario [described above] is potentially a very real one.”
In phase three, Children’s will develop more sophisticated online documentation. Physicians already enter discharge summaries, operative notes and ambulatory clinic notes online, and Nigrin wants them to add daily progress notes for inpatients and histories and physicals as well. The hospital also plans to replace what it calls its periprocedure systems: OR booking, OR room management and integration with materials management systems for the operating and other procedure rooms.
Nigrin also aims to bring online the ability to scan any last bits of the paper medical record that remain and incorporate them into the electronic record. It sounds like a paperless environment, which he admits is unlikely.
“We’re fooling ourselves if we think an inpatient stay or outpatient visit will ever be completely paperless,” he says. “I don’t see the day when a patient won’t have some kind of folder or binder, at least not in the near term. But I do anticipate that folder and binder becoming increasingly small, not like the thick things that you see now.”
PHR on the horizon
Web-based patient-provider communications are an important part of Children’s offerings, especially for patients with chronic diseases like diabetes mellitus. Ten years ago, members of the Children’s Hospital Informatics Program began to discuss a personally controlled health record that would move with the patient and could be considered a lifelong medical record.
“This was at the time when things like personal health records were not being thought about,” Nigrin says, “and doing such a thing on the Web was even less commonly considered.”
The PING (Personal Internetworked Notary and Guardian) system’s premise is that patients control their personal medical records, and they decide whether to grant access to physicians or providers, Nigrin says, not the other way around. PING’s open source software and protocol enable data to migrate to or from the record with few concerns about compatibility.
The concept isn’t quite ready for prime time, Nigrin says, but it will be part of Children’s broader patient portal that’s close to completion. The portal itself will allow secure communication between patients (or their parents and guardians) and clinicians to request prescription refills, validate preregistration information and perform other administrative tasks. E-visits could be in the cards as well.
Via the patient portal, PING will allow patients to specify if they want data to stream into their personal health record from various sources. For example, lab data, X-rays, CT scans and other clinical information from an outpatient visit could automatically flow into the PING record where patients could access it securely.
For tasks such as prescription refills and appointment requests, Nigrin thinks most patients who have computer access will have no trouble dealing with those kinds of interfaces. In fact, the use of an appointment request feature on the hospital’s Web site already is increasing exponentially.
Certain clinical data, however, will require some translation. Nigrin points out that lab test results slightly outside the normal range, for example, would need to be interpreted for the patient.
“That’s our challenge, to make it simple enough and easy enough to use,” he says. “We have to be careful in how we’re putting out some of this data to make sure it’s in an intuitive and easy-to-understand format for the patients.”
These tasks’ complexity is compounded by the fact of being a children’s facility, Nigrin says. Granting proxy access to parents, grandparents or a custodian creates unique challenges: When parents are divorced, who gets access to the personal health record? When the patient is a teenager, should both the teen and the parent get access?
“One of the things that adult places don’t have to worry about for the most part is that when they think of the patient signing on to their personal health record, they think it’s actually the patient that’s signing on,” he says. “Well, a lot of our patients can’t talk or even get on a computer. They’re still in diapers.”
Keeping research viable
As the world’s largest pediatric research facility, the hospital is focusing efforts on promoting its considerable research activities to the public. “Research is a huge portion of what happens here at the hospital, and we’ve now put the emphasis it deserves on our Web site,” Nigrin says. “We have some really excellent interactive features that make the science easy to understand.”
Children’s will also use the Web to manage the pre-award and post-award grant review process for medical research proposals. The facility is ramping up the eResearch Portal developed by Click Commerce, Chicago, which will give it Web-based access to proposal routing and review tools when the National Institutes of Health can process electronic applications. In addition, the hospital will be able to manage research funds once the project is awarded, tracking spending against original budget estimates and combining what had been separate administrative processes.
“Reducing the complexity and review turnaround time for new proposals is crucial when competing for research funding,” says Carleen Brunelli, vice president of research administration at Children’s. “With the steady increases in research volume we’re seeing at Children’s, we need a centralized platform to manage hundreds of proposals and the awards that follow.”
Paying for this ambitious project may be Children’s biggest challenge. Pediatric hospitals rely on Medicaid for as much as half of their revenue. But with states under severe financial pressures and the federal government looking for ways to cut spending, Medicaid is at risk.
Another looming risk is the 2007 federal budget proposed by the Bush administration, which slashes by two-thirds the funding for children’s hospital graduate medical education. Medicaid worries and CHGME cutbacks are a double whammy that keeps CEO Mandell up nights and regularly on a plane to Capitol Hill to lobby.
“We need cash flow and capital to invest in IT, and certainly for other areas,” he says. “We can be OK because we’re not-for-profit and what money we make can be reinvested in IT and infrastructure. But we have to know where we’re going to have shortfalls, and plan for how to make up for that.”
Vital Statistics
Children’s Hospital Boston
President and CEO: James Mandell, M.D.
CIO: Daniel Nigrin, M.D.
Number of beds: 342
Number of employees: Approximately 8,500
Number of IT employees: 278
IT operating budget as percentage of total operating budget: 7%
IT capital budget as percentage of total capital budget: 17%
This article first appeared in the Spring issue of HHN's Most Wired Magazine.
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