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November 24, 2008

A Little Bit Country, a Lot of Technology
By Alice Shepherd
For The Record
Vol. 20 No. 24 P. 14

Despite the need to serve a range of patients spread over miles, rural healthcare organizations are providing shining examples of how health information technology can transform care.

According to the American Hospital Association, only 3% of hospitals with fewer than 50 beds have fully implemented electronic health records (EHRs), and among the smallest hospitals (less than 25 beds), 55% have no EHR. While smaller hospitals in general may not be able to match a large, urban facility’s resources, many forward-thinking rural healthcare organizations are stepping up to the plate and reshaping their missions to embrace technology. They are leveraging cutting-edge EHRs and other innovative health information technologies to deploy high-quality care to geographically dispersed communities—often so efficiently that they can serve as a model for urban facilities.
Elegant Solutions Need Not Be Expensive
In 2001, Citizens Memorial Healthcare in Bolivar, Mo., embarked on a mission to go completely paperless. The organization encompasses a 74-bed hospital, 16 physician offices, a home care agency, and five long-term care facilities. “Our strategic plan called for seamless care across the entire continuum,” says Chief Information Officer Denni McColm, “but as long as our medical records were on paper, that was impossible to achieve.” Lab results, radiology reports, and paper charts were often out of reach when physicians needed them most. Going completely electronic was the only way to provide access anytime, anywhere.

Citizens Memorial’s MEDITECH electronic medical record (EMR) crosses hospital, home care, long-term care, and physician offices to enable the trending of vital statistics and lab results from visit to visit. All facilities use bar coding for medication administration, and a document management system from ImageNow scans paper documents into the system. But the question on everyone’s mind was, what happens when the network goes down or there is a power outage? The solution for Citizens Memorial was scripting technology.

McColm explains: “Although the EMR has its own redundancy and frequent backups, we could not afford additional data centers to preserve our data in the event of downtime or disaster. We asked ourselves, what reports would doctors and nurses need to provide uninterrupted care?” The scripting technology from Boston Software Systems’ WorkStation emulates a user who runs reports on a schedule. But rather than printing the reports, it saves them to an independent computer that can operate on generator power. After a system failure or outage, nurses can access that computer, print reports, and run with the data. “There are multimillion-dollar solutions to the problem of downtime,” says McColm, “but we found an inexpensive, simple, elegant solution.”

The vast majority of Citizens Memorial staff recognized the vast benefits of going paperless from the beginning. “Traditionally, paper has driven the workflow of health information management,” says McColm. “Therefore, some organizations may get defensive at the prospect of giving up their paper. Fortunately, we have a very adaptable group of people who not only participated but helped lead the effort. Many were clamoring to be first. Now, even when we take them offline for only a couple of hours for an upgrade, people act as if we were taking away their firstborn.”

Consensus and buy-in is the first prerequisite for any organization planning to go paperless, says McColm. Everyone has to agree that it’s the right course of action and for the right reasons, such as anytime, anywhere access.

When Citizens Memorial staff educates the public about the benefits of technology during open houses, the reception is invariably positive. This December, the organization’s mission to provide seamless care will take its next step with the deployment of a patient portal. “Patients will be able to access lab results, radiology reports, and appointment schedules and communicate with physicians from home. Although our area is rural and many of our patients are elderly, demand is increasing for online communication,” says McColm.

The power of IT and the Internet to turn the world into a “global village” not only works globally but also closer to home, whether the goal is to bring care to dispersed rural communities or to an urban organization’s continuum of care.

Redesigning the Process of Care
In the sparsely populated plains of northern Iowa, seven hospitals that are part of Mercy Medical Center — North Iowa, Mason City are fortunate to be backed by the resources of Trinity Health. This year, all seven installed an integrated EHR system that transformed the way care is delivered in this rural area. The implementation is part of Genesis, a systemwide initiative uniting state-of-the-art clinical information systems with evidence-based knowledge to ensure patient safety, clinical quality, and financial performance. Although the Genesis model is ideal for uniting communities in areas such as northern Iowa, when complete it will integrate computer systems far beyond a set of rural communities to 24 community hospitals in seven states.

“The mission of Genesis is to transform healthcare from paper-driven, highly variable, and redundant processes that depend on human vigilance to standardized, streamlined, reliable, and safe care,” says J. Michael Kramer, MD, MBA, Trinity’s vice president and chief medical informatics officer. “Our vision was to have a single, consolidated medical record, one in which the partnership with each patient is sustained by accurate knowledge of every encounter we have with that patient, readily available at every point of contact.”
The five key components of Genesis are the following:

• EHR: Patient treatment history will be available at any location, increasing coordination of care, enhancing clinical decisions, and reducing costly duplication of tests when paper records cannot be found. “About 80% of the medical record is electronic, enabling electronically managed care during the hospital stay,” says Kramer. “The remaining 20% of paper that is part of some processes is scanned at the end of the visit, so really nothing goes into the medical record in paper form.”

• Computerized physician order entry (CPOE): Orders are communicated electronically to ancillary departments, eliminating illegible handwritten orders, increasing accuracy, and reducing the potential for errors. “In 1998, the Institute of Medicine stated that CPOE is a major national patient safety initiative,” says Kramer, “and still only a very small percentage of rural organizations have implemented it.”

• Adverse drug event alert system: Orders are automatically cross-checked with a database to help physicians and pharmacists recognize potential drug interactions on the model of a fully electronic, closed-loop medication cycle. For every provider that touches the process, the computer issues alerts, reminders, and constraints to ensure that the patient gets the right drug at the right time in the right dose. This applies to the ordering phase (the physician), the verification phase (the pharmacist), and the administration phase (the nurse). Since 2003, about 50,000 alerts across all Trinity Health facilities have resulted in orders being changed by a physician.

• Revenue management system: Financial, registration, and billing systems are fully integrated and standardized across Trinity Health. “That’s critical,” says Kramer. “If you don’t know who your patients are and can’t register them, then the rest of the clinical systems will not work. One of the reasons clinical systems increase patient safety is that so much vigilance goes into clearly identifying patients for every type of care, whether it be creating a progress note or ordering a medication.”

• Supply chain management system: A common catalog and manner of procuring the equipment needed for care is used across all of Trinity Health.

Trinity Health’s consolidation of all facilities into a single database and a single architecture not only reduces complexity but also ensures that data are protected in the event of system failures and power outages. “For instance, if the system goes down and Novi, Mich., is cut off, we can ‘fail over’ to another location in another city,” Kramer explains. In addition, the system regularly exports the EMR to battery backed-up devices at every facility so that medication lists and current orders and documentation can be re-created immediately after a system failure or power outage.

Kramer emphasizes that computer systems are only a means to an end. It’s not about implementing technology but about fundamentally redesigning the process of care, he says. Whether the mission is to improve care, throughput, quality, or safety, an organization needs leadership, vision, and a business plan to drive technology implementation. When hospitals come to him with problems or enhancement requests, they are not so much about fixing the technology but about understanding and managing the process of care. “The question is not what technology should we use but what should we do with the technology,” says Kramer. “Clinical governance is extremely important in implementing and managing technology.”

As a large organization, Trinity Health has the ability to leverage resources and people from across the country for “big bang” implementations at rural and urban facilities alike. “Over a single weekend, we can bring down all existing clinical systems and bring up the standard Trinity system to make the hospital fully electronic,” says Kramer. “We have demonstrated no increased risk to the patient during that transition.”

Where There’s a Will, There’s a Way
Smaller hospitals and healthcare organizations that do not have the resources of a large parent company have also made progress in closing the gap between providers and dispersed rural communities—with and without grant support. David Collins, MHA, CPHQ, CPHIMS, HIMSS’ director of healthcare information systems who manages the Davies awards and goes on site to facilities around the country, continues to be amazed by the ingenuity and sophistication of rural healthcare organizations.

“Telemedicine is really exploding,” he observes. “Eastern Maine Medical Center in Bangor, for example, has deployed a teletrauma program with the goal to close gaps in care and avoid transfers. Its emergency room is equipped with a large plasma screen and a highly sophisticated video camera that allows the trauma surgeon team to zoom in on a patient and consult with other emergency departments throughout the state in real time.”
This capability saves lives because unstable patients need no longer be transported to other clinics. However, when transport does become necessary, the surgeons can consult with the air transport unit while records are being forwarded electronically, so everything is ready at the receiving facility as soon as the patient arrives.

The hospital has also implemented telemedicine for its three pediatric intensive care units (ICUs). Video equipment lets physicians consult with affiliated or nonaffiliated hospitals throughout the state. Patients even have video equipment set up at their homes for anytime consultations. In addition, Eastern Maine is piloting a virtual ICU that will permit nurses to remotely monitor a patient’s status and speak with him or her. The ICU’s camera is so sophisticated that it can zoom in on a patient’s wrist band and read the name and medical record number, acting as a verification tool for medications or blood transfusions to a floor nurse. Eastern Maine plans to expand the virtual ICU model to provide remote services to outlying hospitals.

In Augusta, Ark., White River Rural Health Center has partnered with the U.S. Department of Agriculture, Rural Development Division, Distance Learning and Telemedicine Office. A grant of $341,297 was the starting capital behind the creation of an EHR for the center’s widely dispersed rural constituency. The clinic’s Web portal allows physicians to reach into the record during off hours for medical authorizations, lab orders, and prescriptions and facilitates the continuity of care during hospital admissions and on-call emergencies. Patients can access their medical records through the portal and get involved with their care.

“Many grants are available for these projects,” says Collins. “For example, from HRSA [Health Resources and Services Administration] and AHRQ [the Agency for Healthcare Research and Quality]. They help, but don’t depend on them because they are temporary solutions.”

Some organizations prefer not to use grants. In Washington state’s Columbia basin, the town of Othello has a population of around 6,000, but its health center serves 30,000 patients from surrounding rural areas, including migrant seasonal farm workers. “Columbia Basin Health Association has a phenomenal EHR system and provides top-rated care,” says Collins. “It also has about 12 clinical minivans that provide care to rural sites. The organization had no choice but to implement cutting-edge technologies because it could not serve its population otherwise.” The clinic forgoes grants to rely on ingenuity, drive, and economies of scale.

Cherokee Indian Hospital Authority in Cherokee, N.C., serves more than 10,000 Cherokees on the reservation. Fourteen county hospitals and a number of outlying clinics are all connected via an EMR system facilitated by a fiber-optic network that reaches all the way to Atlanta and also provides Internet access to area residents. “This rural organization probably has a faster, more efficient network than many urban hospitals,” says Collins. “They also use video teleconferencing for staff training.”

Just as in Othello, necessity was the mother of invention for Cherokee Indian Hospital Authority and other smaller organizations. While some rural hospitals may still be behind the times, many others have found the financial resources and taken the lead with advanced technologies to bridge the gap between patient and provider.

The Transformation Continues
Without a sound governance structure and the entrepreneurial spirit to excel, neither world-renowned urban organizations nor small rural health centers can be successful, Collins says. However, above all, what small, trailblazing organizations have done requires leadership commitment. “What I hear again and again from rural organizations that lead the pack is that they implemented HIT because it was ‘the right thing to do,’” says Collins. “That’s not rhetoric but the truth. Many have taken the financial risk to build these systems because they full-heartedly believed that there is a better way to provide care and that technology makes it possible. Augusta’s White River Rural Health Center is recognized as a leader for its medical outcomes and has been visited by senators and representatives from Johns Hopkins, among others, who wanted to learn about its model practices.”
No matter how advanced an organization’s HIT may be, there are always new developments just around the corner. Trinity Health, for example, expects to have 8 million patients in its system by the end of 2008, but that’s just the beginning. “Our new mission then becomes to mine the data, look at outcomes, and automate quality measures,” says Kramer. “A great deal of refinement in the clinical practice will occur as a consequence of having accessibility to data, and we will continue to enhance the processes of care.”

Trinity Health’s next steps are to extend its reach to ambulatory care clinics and outpatient facilities in a wide-ranging health information exchange. “The regional health information organization is the last leg of our journey,” says Kramer, “and all through this journey, we will continue to use systems and data to improve care.”

— Alice Shepherd is a southern California-based business-to-business journalist specializing in healthcare topics.