Using health-records technology to bring value

The shelves that used to hold Children's Hospital Boston's paper medical records now stand empty.

What does paperlessness mean? It’s about helping patients, says Daniel Nigrin, Chief Information Officer at Children’s Hospital Boston. This approach helps explain why he was named one of the InformationWeek Healthcare 25, a short list of leaders driving the healthcare IT revolution.

“The integration of a patient’s data has to be one of the topmost national priorities,” Nigrin says. “It will eventually lead to better care, and hopefully a reduction in cost.”

This need is becoming critical as healthcare reform rolls out and primary-care practices become patients’ medical homes, integrating information from primary and referral providers, inpatient providers and providers at discharge locations such as rehab facilities.

Not too many years back, Nigrin, a practicing endocrinologist, wrote paper prescriptions for his patients. Now, prescribing electronically, medications can be readily checked against patients’ allergies, adjusted to the appropriate dose and instantly routed to the pharmacy. No one has to struggle to read his handwriting.

The hospital also adopted barcoding of bedside medications, filmless radiology, scanning of paper documents and patient access to their own health records. Within one application, a clinician can see virtually everything there is to see about the patient — ambulatory notes, labs, immunizations, hospitalization data, emergency department visits, imaging studies. This has eliminated redundant tests and reduced medical errors.

Leveraging data

Children’s recently became one of 55 hospitals nationwide, and one of only three children’s hospitals, to be named a Stage 7 hospital by HIMSS Analytics, denoting the highest level of adoption of electronic medical record (EMR) systems. But the biggest return on investment is only starting to be realized: leveraging the information from the electronic records by building in analytics and decision support.

“We can now start to use the computer to support our practice in a way that we weren’t able to do in a paper-based world,” Nigrin said in an online interview with Cerner, the vendor that provides Children’s EMR system. “In some instances, it’s reduced the cost of our care.”

Children’s never set out to be a paperless or “digital” hospital. It became one out of a desire for ready access to large amounts of clinical information. IT was seen as just another clinical tool, Nigrin says, like a new MRI machine, a new surgical robot or a new genetic lab test. In this case, it’s a tool that enables clinicians to examine care practices and outcomes in multiple patients and learn how to deliver better, smarter, more cost-effective care.

Looking externally

"One way of improving access to health information is through personally controlled health records that allow patients and their guardians to become stewards of their own health information," Nigrin says.

But for full integration of care, EMRs have to become a single record, shared seamlessly across institutions. “Although many organizations and healthcare providers have begun or achieved the transition to electronic health records, they are still for the most part disconnected islands of data,” Nigrin says.

Even within one institution, integration isn’t easy to achieve. Flexibility and a willingness to “work within the system” are key. Initially, Nigrin’s team tried to standardize the interface and implementation of the system across the hospital’s inpatient and ambulatory area. But they soon found they could only push so hard.

“When you have a complex, a tertiary-care kind of organization like ours, you can’t actually standardize across the entire place,” Nigrin said in the Cerner blog. “We needed to back off and allow for some flexibility and individual customization depending on the location where the care was being provided. That was a challenge. In some instances it required us to go back and do things over.”

He adds:

“This was at least a 3- to 4-year initiative, and keeping the focus on a project like this over that duration is difficult. Frankly, keeping key staff on your team for that long can sometimes be difficult. And keeping your end users engaged can be tough. The flip side is that if you try and do things too quickly, users basically give you the feedback that it’s too much change too soon, and they can’t absorb that much change in their practice. It’s a delicate balancing act that was difficult and needed a lot of attention over the course of the project.”

Lessons learned:

1. Always keep the patient’s needs and safety at the core of everything you do.
2. Too much change at once can overwhelm users—you must roll it out in stages.
3. Never underestimate the ongoing cost for resources and people to keep EMRs going 24/7.
4. Implementing EMRs takes courage, resilience and support by leadership. If you don’t have a mandate of support from the top and in EVERY level down, it won’t happen.
5. It’s no easier moving from one electronic system to another than it is starting from scratch—in fact, it may be harder.

Next up is maximizing use of mobile devices. Watch for future posts.