Wireless at the Next Level

Vol. 11 •Issue 7 • Page 39
Wireless at the Next Level

Vassar Brothers Medical Center works to achieve positive results with wireless technologies that everyone uses.

Health care leaders are looking for innovative ways to improve patient safety and operational efficiency by giving doctors and nurses the crucial information they need — where and when they need it. Making progress is challenging. Information technology (IT) projects in the health care industry are often costly. They frequently fail to achieve business, clinical and technical goals, and exceed budget and time estimates.

The reasons for these failures are not singular. In many cases, organizations fail to appropriately address social/governance/cultural structures and issues when designing and deploying IT.

Vassar Brothers Medical Center (VBMC), a Health Quest affiliate, located in Poughkeepsie, N.Y., is making impressive progress toward achieving its “digital hospital” vision and becoming a learning institution. The CEO is a pediatrician by training. He is passionate about quality health care for patients and creating a non-punitive learning culture; he also thinks strategically.

As the former CIO at Health Quest IT, I thought not only about what equipment to install, but also about its strategic role. Technology is an enabler and the users at the hospital have to define what’s needed and how to use it.

The challenge

The hospital’s CEO, Daniel Aronzon, MD, still sees patients every Wednesday afternoon. His goal is to provide quality health care for patients and to achieve the best medical outcomes. To achieve this goal, VBMC and all Health Quest affiliated hospitals face six challenges:

1.)Accountability — Hospitals and physicians need to be accountable for their performance and outcomes.

2.)Transparency — The culture of not-reported mistakes by hospitals is a cause of mistrust by patients and their families. Hospitals need to create a more transparent and non-punitive environment so medical mistakes can be analyzed. Hospitals should hardwire the system to prevent errors from happening again.

3.)Safety — More than 97,000 people die annually in U.S. hospitals, according to the Institutes of Medicine “To Err is Human” report, because of mistakes; errors are the sixth leading cause of death in U.S. hospitals.

4.)Capacity — Baby boomers are expected to inundate the health care system in a tidal wave of sheer numbers, longevity and utilization.

5.)Cost — Total U.S. health care spending is greater than $1.5 trillion annually, equal to 16 percent of gross domestic product.

6.)Efficiency — Estimates are that one-third of health care spending, or $500 billion, is wasted annually.

My goals, when I was vice president and CIO at Health Quest IT, were to put together the best technology solution to improve patient outcomes and patient safety, and improve operating efficiency to reduce cost, waste and unproductive time. The biggest challenge to making major progress in such an environment is not to develop the best technology systems but to change behavior and culture, and to redesign processes so they are fortified and supported by technology.

Chief Medical Officer Stephen Katz, MD, is the professional head of all medical staff and has the challenge of helping doctors who are not employees of the hospital build stronger bonds with VBMC. Today many primary care doctors have exceedingly little time to spend with patients. Many have a panel of 3,000 patients and see 30 patients a day. Dr. Katz’s challenge is to find ways to help doctors improve outcomes and give them back the reason they went into medicine — time to spend helping their patients.

Architecting a solution

VBMC explored new ways to take a well-recognized and respected hospital to the next level of medical excellence while increasing profitability and services to its community. The CEO, CMO and I agreed at the time to embrace several areas of improvement centered on patient safety, communications between nurses and physicians, and optimal utilization of valuable resources (i.e., staff and equipment) to improve operations. We determined that by focusing on these areas VBMC could achieve immediate payback through the improvement of patient care, reduction of operating costs and maximization of revenues — which then could open the door to the introduction of new services to its patient community.

VBMC explored these primary themes of safety and resource utilization through grass-roots, cross-functional teams organized to identify top problems and redesign processes, as well as the Health Quest IT and management boards of directors. They identified two common areas that had to be addressed to become successful and to effect real and repeatable change within the organization.

These were process standardization and the use of technology to optimize the process model. These two core concepts, along with the themes of safety and resource utilization, manifested themselves into a vision of the hospital of the future based upon the factory floor model of supply chain management (SCM) aided by the process enablement of key medical staff using a computerized physician/provider order entry (CPOE) system. VBMC first focused on reducing medication errors.

Reducing drug errors

The first step in reducing medication errors was to examine VBMC’s organizational culture/structure and the patient medication process chain and flow. Here’s what we found:

  • Management recognized that Vassar, being a community hospital where physicians are independent and not employees of the hospital, would have a difficult time influencing physicians. Given that computerized order entry takes longer in most cases, the doctors would not use it and therefore would undermine the system. The next big source of drug errors is nurses; the hospital can influence those resources. If a system could be implemented to vastly reduce administration errors by nurses, it would be worthwhile.
  • Patients, doctors, nurses and support staff, and lots of equipment, are in constant motion. A field study of nurses revealed that they walked five miles a day, most of it to deal with non-clinical issues (e.g., answering calls at the nursing station). It became clear that a technical solution that gets all the right resources/information at the right time and place to administer the right care was the right design. Looking at other industries with similar logistics (e.g., airlines) led us to decide the first application to reduce drug errors should be medication barcoding used by nurses wirelessly when administering medications.

    We visited our nearby Home Depot to show the staff how wireless barcoding not only works but can be used by teenagers and others who are not trained professions like the nursing staff.

  • A wireless infrastructure and investment plan was needed. We realized that to achieve real-time communication and to get all the right resources/information at the right time and place in an environment where all the resources (i.e., people and equipment) are in constant motion, a wireless “highway” was an appropriate infrastructure. Applications and information (e.g., medication barcoding and voice over IP) could then be easily plugged into the infrastructure. We did not use a traditional return on investment for financial justification of the wireless infrastructure. Instead, we proposed that the cost of the project would be allocated to initiatives that used the highway. In other words, applications and communications services for the next five years will pay a “toll” to leverage the wireless highway.
  • Business champions who use and benefit from the technology defined the solutions. Often change issues and supporting technologies are defined at the top of an organization. And the expectation is that all users and processes below will align themselves and adjust. Important to success of this undertaking was the realization that the defining, fostering, and ownership of solutions and roadmaps needed to rest with the business stakeholders and be matched with social/organization and governance structures. The social/organizational structures typically define the “culture” of the organization. Is the organization a risk-taker or risk adverse? From a governance structure standpoint, is the organization top-down strategic or bottom-up tactical?

    These nuances will determine the CIO’s ability to gain traction with critical projects. The stakeholders who fully understand and can prioritize projects based upon business needs, would populate the roadmap and lead to the ultimate vision. Only in this way could a direct linkage between business intent and need be adequately addressed and justify moving forward with projects in the hope of reaching the vision’s promise.

    For medication barcoding, the project leaders were the business champions who would benefit — the operations officer of nursing and the director of pharmacy. The business executive (e.g., the overall C-level responsible driver) was Dr. Aronzon, who was passionate about the project. He set targets for the champions, who monitored behavior and understood how culture changed (e.g., workarounds) and why. In addition, through an internal campaign, nurses explained to patients why they were doing medication barcoding and why it was better for the patients. This was key to effecting widespread change and creating medication barcoding zealots.

    The next application to be plugged into the wireless highway was voice over IP, which reduced the non-productive walks nurses took to talk to people and improved communications.

    The third application piloted RFID to track movable assets, such as IV pumps, which were often difficult to locate around the hospital.

    Lessons learned

    Business intent and social structure were probably the most fundamental indicators of project success. Those factors enable a true mapping and understanding of what needs are driving the project to any potential roadblocks and problem areas of implementation and adoption.

    It takes a multilingual approach to understand the three basic elements in building an enterprise solution: business intent, the social/organization and governance structures, and the enabling technology solution.

    Although it is difficult to depict these structures in terms of architectural precepts, the payback is immeasurable since the views produced aid in matching the business needs (or intent) of a project to the actual environment in which the technology operates.

    Connecting those structures to processes and eventually technologies requires a new way of thinking and articulates that it is social-technical in nature. This calls for a method that maps out relationships in a kind of Rosetta Stone approach that can be understood by multiple audiences, both technical and non-technical.

    Business intent, roles, expectations and technologies evolve over time. Keep in mind that a trade-off exists between rigorous understanding and adherence to original business intent, and the forces of evolution that inevitably occur within the history of the application and changes and use of technology in the enterprise.

    It is all the more essential to have multilingual people who can clearly connect the evolving business architecture. Specifically, they must link business intent to human aspects.

    Finally, having an evangelist at the senior management level was critical to the creation and success of the SCM/CPOE initiative.

    Mr. Christiano is the former vice president and CIO at Health Quest IT in Poughkeepsie, N.Y. He is now vice president and CIO at Pocono Health System in East Stroudsburg, PA.

    Renowned Nursing School Mobilizes Learning

    As is the case in so many large urban communities, the Washington Heights and Central Harlem neighborhoods in New York City are populated by thousands of people with limited access to quality health care.

    Increasingly, nurse practitioners find themselves at the forefront of providing quality primary care to individuals in such communities beyond the hospital walls. This trend — and the desire to prepare advanced practice nurses to provide more evidenced-based care and promote patient safety — led the Columbia University School of Nursing to initiate an informatics-based education project using mobile technology.

    The deployment meant a move from paper-based logs, which made it difficult for students to examine their practice over time. In order for faculty to create reports that allowed them to track student progress and ensure patient safety, they needed a mobile data collection system.

    “As part of a federally funded initiative to prepare nurse practitioners to provide more evidence-based care, we decided to create a mobile system that would enable us to promote patient safety through an informatics-based approach to nursing education,” said Suzanne Bakken, alumni professor of nursing and professor of biomedical informatics at Columbia University. “Our strategy was to employ PDAs and other mobile technologies, including Sybase iAnywhere’s OneBridge Mobile Data Suite, to document clinical encounters and retrieve patient safety-related information at the point of care.”

    On a typical day, students visit patients in a variety of settings including the community, ambulatory care clinics and acute care hospitals. They use the PDA system to document their actions and collect patient data, which is de-identified for use as a teaching tool. At least twice per month, they synchronize the data with the system’s central data repository using OneBridge Mobile Data Suite. Once the data is entered into the repository, students and their program directors can access it and generate reports to evaluate the efficacy of the students’ work with their patients, as well as ensure that they are meeting specific criteria required for successful completion of their advanced nursing programs.

    The ability to access and evaluate the detailed information collected during more than 100,000 patient encounters to date clearly highlights the purpose and importance of the mobile data collection system: to provide advanced nursing education in which patient care and safety are paramount and can be monitored and fine-tuned to optimize the students’ educational experiences and their resulting competencies.

    Senthil Krishnapillai is manager of product management at Sybase iAnywhere.

    Tracking the Results

    VBMC achieved the following results through its wireless initiative:

  • Medication barcoding — Prior to this implementation, the manual recording method for tracking adverse drug encounters (ADEs) reported approximately 200 ADEs for 2005. After the implementation of the wireless medication barcoding system, 5,331 ADEs were tracked, of which 12 to 14 would have resulted in a sentinel event. This translated into an $8.5 million cost avoidance for the institution in the first year alone.
  • Voice over IP — Achieved savings results of 85 minutes of wasted nurse travel time/shift; cost avoidance of $995,000.
  • Cellular phone service Ð Established support for Cingular Wireless/AT&T, Verizon and Nextel/Sprint.
  • Re-broadcast capabilities provided through the wireless network.
  • Eliminated the need for physician pagers.
  • Increased physician satisfaction since they were able to use their personal cell phones predictably within the facility.
  • Enabled RFID tracking of movable equipment — Piloted tracking of IV pumps and monitoring software. Eliminated the need to purchase an additional $435,000 of equipment by properly tracking location and condition of pumps for patient use.

    – Nicholas Christiano