Rob Wherry, 06.20.05
Dr. Angela Tiberio used to see more than a dozen patients a day as she made the rounds of the intensive care unit at a hospital in GrandRapids, Mich. But she has had a bigger impact on patients as an unabashed techie. As chief of medical informatics at Spectrum Health, a chain of seven hospitals in western Michigan, Tiberio helps oversee an $80 million computer overhaul to bring Spectrum into the digital age--and save lives and cut costs while doing it.
Tiberio is part of a new breed of tech-savvy doctors on the forefront of using technology to remake hospital practices and cut down on the medical errors that kill 100,000 people every year. Theirs is a quixotic crusade. Hospitals--despite their penchant for magical MRI scanners and other fancy technology that drives revenue--have among the most antiquated and unwired tech in American industry. Health care spends only 5% of revenue on tech, roughly half the level spent by the financial services industry. Only 17% of the nation's hospitals use computerized order-entry systems; a mere 13% have adopted electronic patient health records.
When hospitals do spend on information technology, often they do it poorly. Aging systems can't talk to each other. Business software benefited from the rise of the Microsoft monopoly, letting thousands of developers design programs on a common platform. Medical software has few standards, and wares are as fragmented, dissimilar and incompatible as the dozens of vendors competing to sell them.
That is why Tiberio spends much of her time reining in moves that might add to the mishmash. Spectrum's hospitals used to run dozens of disparate systems that couldn't share crucial patient information. Now its doctors click through the same applications to instantly see lab results and blood work, order X rays and prescribe drugs. But she still runs into obstacles. She recently put off an emergency room physician's plea for a new radiology software system; the new stuff wouldn't be able to link easily to the hospital's backbone software. Another unit wanted to run its own electronic health record for its clinics, but she nixed it because those records wouldn't be accessible to the hospital's ER or intensive care units. "We wanted to have all the vitally important information we needed to take care of you in one place,"says Tiberio, whose Subaru Outback has a license plate that reads GIGADOC. "That is always better than multiple systems you are always trying to keep together with duct tape."
Doctors resist change or refuse to adhere to even simple standards. Physicians who order the routine blood chemistry panel that measures 12 components in your blood call it a "smack12," "sma12," "chem12" or dozens of other nicknames. Cerner, a big seller of physician software, has had to embed into its code a dictionary that runs at times up to five synonyms per term. "It's like the Tower of Babel. Everyone has a different architecture," says Neal Patterson, chief executive of Cerner. "This is a deeply rooted practice in the largest sector of our economy."
At Cedars-Sinai in Los Angeles, doctors rebelled against an order-entry system they said inundated them with things like needless pop-up warnings of unlikely drug side effects, slowing down the entire process. The hospital dismantled it in 2003. At the University of Pennsylvania the hospital's ordering system, which forced doctors to navigate through as many as 20 screens to order one medication, caused 22 types of prescription errors that it was intended to prevent.
Still Tiberio and others hope an overhaul is at hand. Medical ITsystems increasingly emphasize companywide standardization and industrywide portability of patient information. Vendors such as GE, McKesson, Siemens, Cerner, Meditech and IDX are creating smart systems that smoothly combine the intricate work flows of a typical hospital.
Until last year the Susquehanna Health System in central Pennsylvania had a system so balkanized that the surgery and radiology departments had to send a clerk to get a patient file. Siemens just ran a digital conversion of records on 260,000 patients, each with an average of ten years of medical history on file, for a total of 40 million entries, into a format that can be shared by all wards in an instant.
In Spokane, Wash. Inland Northwest Health Services has begun sharing a secure 2.4 million-patient database with 30 health care agencies in Washington and Idaho. Any doctor in the system can get X rays downloaded to a PDA and make diagnoses from home or the office. "The value of all this isn't the technology," says David Brailer, the federal government's point person on health care IT. "It's in how [medical professionals] come and do their work better."
In many hospitals doctors still prescribe drugs by filling out an order sheet in a patient's folder--in their own scratchy scrawl--dog-earing a corner and sliding the file into a rack at the nurse's station. A clerk sees the new order and faxes it to the pharmacy. If a pharmacist can't tell whether a doctor asked for a drug to be administered IV (intravenously) or IM (intramuscularly), he has to chase down the doctor or risk serious patient complications.
Montefiore Medical Center in New York City has spent ten years working to solve these problems. In the old days, depending on which ward you were in, medicine would be given at 9 a.m. and 5 p.m., or 10 a.m. and 6 p.m. Montefiore now runs an IDX drug-order entry system (modified for its own use) for its three hospitals, reducing errors 75% by digitizing choices like IMor IV. (It also made a low-tech fix:All meds are now given at the same times--10 a.m. and/or 6 p.m.) "Getting us to dance and sing together was a tremendous obstacle," says Dr. Matthew Berger, who implemented the drug-ordering software.
Many of Hospital Corporation of America's 190 hospitals are now implementing a system to order meds using pull-down menus at PC stations. An order instantly goes to the nurses and to the pharmacy. When the pharmacist approves the order, a McKesson AcuDose-Rx drawer back at the patient ward clicks open and the nurse pulls out the appropriate bottle of pills. (The computer in the drawer tracks inventory.) With another system, nurses at bedside use a scanner to read the bar code on the pill bottle to confirm it's the right drug and dosage; the nurse then scans a wristband on the patient to ensure it's the right one. Digitizing the old method has cut HCA's drug-dispensing time in half and weeded out 20,000 potential errors in 2004.
WellPoint, the nation's largest insurance carrier, is nudging small private practices into the digital age. Ron J. Ponder, its chief information officer, who designed FedEx's original tracking systems before moving to similar positions at Sprint and AT&T, gave away $40 million worth of Dell PCs and broadband access to doctors last year. The PC comes loaded with a browser that links the practice to WellPoint's servers and those of other health care plans. Instead of mailing claims, doctors fire them off over the Web. Payment is often instant. If one Blue Cross plan wants to call its clients "members" and another to call them "subscribers," WellPoint's translationsoftware recognizes both as patients.
Hope for a revamping of medicine lies in the all-but-impossible dream of an EHR, an electronic health record conforming to a digital standard that will store and display a patient's history in a universally recognizable way for all software systems to use. Vendors and health care providers have fought for years over whether and how to do it.
For parent Peggy C. Frank of Westlake Village, Calif. it couldn't happen soon enough. Her daughter, Ashley, was born with a rare genetic disorder that stunted her growth and caused hearing, heart and lung problems. Ashley, 22, has been admitted to hospitals 35 times, with a resident asking her mom almost every time to go over the details of her pregnancy with Ashley. "I'm literally running interference between the various physicians and health care facilities to ensure that Ashley's medical records get from one place to the next," she says.
An EHR would solve that problem by converting the old manila folder your doctor flips through at your bedside into a safely transferrable digital file. President Bush wants most Americans to have an electronic health record in ten years. An EHR would be far more complex than the standard format banks use to serve anyone with an ATMcard. A health record could contain more than 10,000 data fields, depending on a patient's age and health.
Some hospital chains create their own proprietary EHRs rather than wait for an overarching standard to emerge. Universal Health Services of King of Prussia, Pa., working at the behest of its chief information officer, Linda Reino, created a patient "face sheet" using software from Opus Healthcare Solutions for its 86 medical outlets. It winnowed 220 data fields down to 140, eliminating things like alternate next of kin and multiple address lines. The system tracks admission information and follow-up consults. Reino sits on the Opus board.
By year-end the U.S. government intends to put up for bid a contract for a unique health record that would serve as a model for others. The National Alliance for Health Information Technology, an industry roundtable, is pushing for EHRs that can be shared across the nation. Another trade group will develop an EHR certification process this year, and next year it will begin ruling on EHRformats from IT vendors. "In the past the government has prescribed a standard, and it hasn't always picked the best result," says Michael Leavitt, the new secretary of the U.S. Department of Health & Human Services. "But we can be an early adopter and create some certainty."