A High Dose of Tech
"Some grocery stores have better technology than our hospitals and clinics." Tommy Thompson, secretary of health and human services
Eyebrows shot up at Thompson's uncharacteristically feisty zinger a couple of years ago. Technologically backward? Hospitals, where multimillion-dollar scanners painted finely detailed images of body parts? Where miniature restorative devices were threaded through tiny tubes into ailing vessels? Surely Thompson was engaging in a bit of hyperbole.
Not so--hospital administrators knew he was right on the money. Humble bar-code scanners, ancient technology at neighborhood supermarkets, had barely dented U.S. hospitals. Most patient records were still kept on paper and stuffed in bulging manila folders. Physicians in different parts of the same healthcare system couldn't send clinical data back and forth. Some doctors were technophobes and proud of it, boasting that real docs don't touch a keyboard.
And change was vital. Hospitals were inefficient--but worse, medical mistakes were killing tens of thousands of hospital patients a year. Available technology could slash the toll. Physicians' scrawled prescriptions could be entered directly into a computer, for example, eliminating errors that were causing complications and deaths. Thompson's message to hospitals: Make it happen.
And slowly but surely, hospitals are obeying--junking creaky old computer systems, cabling high-speed networks, and pumping up information-technology budgets that had bumped along hand to mouth for years.
But the few Seabiscuits are being trailed by thousands of also-rans, and last week, Thompson unveiled an ambitious 10-year initiative with a blunt bottom line: You're not wiring up fast enough, so we'll light a fire under you. The plan makes Medicare a vehicle for pilot programs ranging from handling prescriptions electronically to moving patient records online so that caregivers--and patients--can refer to them regardless of time or place. New standards, promised Thompson, will mesh the innovations into a seamless nationwide network.
"In most technology, America is the world leader," declared Thompson. "I can use my bank ATM card in Russia. Your pet has records that are likely kept electronically so you get an automatic E-mail reminder to bring in your dog for a checkup. Don't you think we should do the same in medicine? Isn't it time to bring medicine into the 21st century?"
Even minus a federal push, the number of plugged-in medical centers has climbed. Responses to annual "most-wired hospitals" surveys by Hospitals & Health Networks, an American Hospital Association trade publication, have risen steadily. The latest survey, released last week, represents nearly 1,300 hospitals, almost 20 percent above 2003.
Already, results are evident. Patients in intensive care, who usually are watched over by nurses during off-times, are being monitored by doctors miles away (Page 56). Patients are being armed with more of their own medical information as medical records are converted from paper to digital bits. And the boom is spinning off amenities like bedside Web access and E-mail.
Hospital executives talk about saving lives, not saving money, as the reason to wire up. But the corporate community, pounded by rising healthcare costs, has also been pushing higher tech hard. Four years ago, a group of Fortune 500 companies and other major employers created the Leapfrog Group to reshape the delivery of hospital healthcare in ways that would save lives and reduce complications--and, not coincidentally, drive down costs. The sheer size of Leapfrog's members has given the group unusual muscle in dictating an agenda that includes a laundry list of 27 safety-related practices, computer entry of prescriptions, and improved ICU staffing.
But while hospitals are starting to embrace technology, many are doing so tentatively, having observed the bruises suffered by early adopters. It's not just high cost, or software that needs further tweaking. Old-fashioned stubbornness has been a source of frequent hiccups and occasional debacles. And notwithstanding Thompson's grand plan, a blueprint remains to be drawn up, so wiring up is being done piecemeal. A healthcare system with a number of small or rural hospitals might opt first to fund remote intensive-care monitoring. California hospitals, on the other hand, must submit detailed plans for reducing medication errors by next January, so they might focus on computerized drug orders.
Three features of wired hospitals are especially meaningful to patients: taking the guesswork out of ordering medications, preventing errors when medications are brought to the bedside, and giving patients access to their medical records through a website. For a closer look, read on.
Killer prescription pads
A small piece of paper doesn't look like a deadly weapon, but much of the concern over patient safety and hopes attached to technology have centered on the innocuous prescription pad. No one seriously argues that relying on handwritten drug orders is anything other than antiquated, inefficient, and dangerous. Many of the more than 1 million serious medication errors estimated by Leapfrog to occur in hospitals every year, killing 7,000 patients and driving up healthcare costs by an estimated $2 billion, start with a physician's sloppy scrawl.
The high-tech remedy is computerized physician order entry, or CPOE. Placing orders by computer for medications--and, as a side benefit, for lab tests, special diets, and other procedures--not only eliminates confusion caused by barely legible scrawls but moves medications to patients faster and minimizes the possibility of incorrect dosages and dangerous drug interactions.
In studies, CPOE has cut serious medical errors by 55 percent or more, and Mark Zielazinski, chief information officer for El Camino Hospital in Mountain View, Calif., thinks that may be too conservative. The hospital started using computerized order entry more than 30 years ago--the first in the country to do so, says Zielazinski--working in tandem with Lockheed Martin. Error rates weren't recorded until 1992, but since then, he says, the number of errors per 1,000 patient-days has dropped from approximately 12 to six last year and now stands at four, a decline of 67 percent in a 12-year span.
In a CPOE-equipped hospital, the physician logs in to a computer that might be a terminal in a corridor niche, a laptop on a wheeled cart, or even, as at El Camino, a wireless tablet PC. Depending on the system, the doctor might key in the name of the drug and the dose, or point and click from a list of medications she regularly prescribes. The order is automatically forwarded to the hospital pharmacy and to nurses responsible for administering the medication.
Even a relatively narrow application like CPOE, however, demands a substantial foundation. A database consisting of detailed medical records for each patient in electronic form must be created and scrupulously kept up to the minute. Custom hardware and software packages must be installed. The human beings who will make or break the new system must be trained. Their cooperation is vital, and winning it can be tough.
In 2002, Cedars-Sinai Medical Center in Los Angeles spent millions of dollars on CPOE but quickly scuttled the program because private physicians who sent patients to the hospital rebelled. "It was a noble attempt, but Cedars bit off more than they could chew," says Stephen Uman, an infectious disease specialist who helped organize the movement to dismantle the program, which he believed demanded too much time and attention. Handwritten orders that could be dashed off in a few seconds were taking five to 10 minutes, adding up to hours daily. The system would not allow doctors to prescribe new drugs that hadn't been entered into the computer--and, says Uman, didn't tolerate the smallest misspellings. If a doctor keyed in penicillin with one "l," the computer would respond that no such drug existed. Cedars-Sinai executives did not return repeated requests for details.
"That's the nightmare everybody wants to avoid," says Steve Clark, chief information officer of the University of Colorado Hospital in Denver, which plans to switch to CPOE this fall. "Your success is dependent on the physicians' accepting the technology. It's far easier to just scribble something or tell a nurse what to do." Proper training is a must, says Clark, but it is just as important to demonstrate hospital commitment from the boardroom down.
Clark hopes for a reasonably smooth ride. At a university hospital, the majority of the physicians are on staff, so their choice is to go along or leave. But presumably, as employees they also are more loyal and committed to the hospital than outside physicians typically would be and, Clark agrees, should be easier to persuade. Hospital department heads and other managers also are emphasizing to caregivers the potential for improving patients' safety in ways that will show up in performance numbers.
At Children's Hospital & Regional Medical Center in Seattle, the conversion to CPOE last November was no cakewalk, especially for some older doctors. Tradition was the main obstacle, says Mark Del Beccaro, clinical director of information services--the idea that "I know how to use a pen to write an order--I don't want to spend hours learning a new way and then have to actually get used to doing it." Says Del Beccaro: "I told people, 'This going to be one of the hardest things you're ever going to do, because it really, fundamentally, changes the way we practice medicine, and there aren't too many times when you do that in your career.' "
Children's required private doctors to go through training if they wanted to retain their admitting privileges. "There was a little bit of grumbling," says Del Beccaro. "But now we have some people who didn't even open their own E-mail before; now they're doing their own orders. Once they get used to it, they find that it's actually quicker."
At Children's, the system has halved the time for medications to reach inpatients, meaning that critical drugs are reaching sick kids faster. Pharmacy errors due to hard-to-decipher prescriptions have dropped to zero. And orders for lab tests often move more rapidly, sometimes because of innovations made possible by new features that exploit clinical data. "Last night I was admitting a child with a new diagnosis of leukemia, and there's a bunch of labs we always have to get for those," says Del Beccaro. "Well, I can never remember what they are." The new software, however, displays a list of the required lab tests for new leukemia cases. "I pulled it up and bam, I sent it off. I can write those orders now in under two minutes. If I did it the old way, it would take me forever" --about 20 minutes longer, he says, which now seems like forever.
While adoption of CPOE has been steady, it has a long way to go. Fewer than 5 percent of hospitals in Leapfrog surveys had some form of CPOE in place as of last year. The two biggest barriers are large start-up costs--typically from $3 million to $10 million per hospital--and difficulty in showing bottom-line savings, according to an article last month in the journal Health Affairs. Fewer errors and higher productivity may more than offset the expense, but the savings are largely pocketed by health insurance carriers, not hospitals, because fewer complications and improved efficiency add up to shorter hospital stays.
Hospitals do benefit from increased patient safety, says internist Eric Poon, a coauthor of the article and a researcher at Brigham and Women's Hospital in Boston, but the high expense of CPOE still has to be justified. "Both the government and the insurance companies need to start thinking about providing financial incentives," he says. Part of the new federal program, says Mark McClellan, director of the federal Centers for Medicare and Medicaid Services, would do just that. A new Medicare pilot program will test the effect of higher payments to hospitals that meet various technology requirements.
Taking the long view, Leapfrog CEO Suzanne Delbanco is encouraged. About 16 percent of hospitals have told Leapfrog they plan to have some form of the system fully implemented by the end of 2005--which, she observes, "really is a sea change from where it was four years ago."
One Last Check
About one third of hospital medication errors happen at the front end, according to studies by Lucian Leape of the Harvard School of Public Health, when a doctor prescribes the wrong drug or the wrong dose. Another one third occur in the middle, because a hospital pharmacist misreads the doctor's handwriting or a transcriptionist writing up the doctor's dictated notes fumbles the name of the drug. That two thirds should shrink as hospitals adopt CPOE.
But then there is the back end: a medication administered to the wrong patient or to a patient who has a reaction because allergies, a health condition, potential drug interactions, or other medical information is missing from the record. To reduce those errors, more hospitals are bar-coding not only drugs but patients and nurses.
Before a medication is administered, the nurse scans in the bar codes on her badge, the patient's identification bracelet, and the medication. The computer alerts her to possible conflicts, such as a potentially dangerous interaction with another drug the patient is taking. It can also alert the nurse if the drug isn't being given at the proper time or at the proper dose.
At Eisenhower Medical Center in Rancho Mirage, Calif., 115 beds are wired for bar coding, and an additional 120 are in the works. "It's preventing medication errors daily," says Mary Ann McLaughlin, administrative director for medical-surgical services. Nurses there have come to rely on the system so much, along with pop-up screen alerts like "check blood pressure," says McLaughlin, that they don't "feel as protected" on floors still lacking the system.
All prescription drugs will have to come bar-coded by 2006 under Food and Drug Administration rules, and most likely before then, McClellan said last week, for Medicare patients. To Susan Bumatay, chief nurse at Sutter Delta Medical Center in Antioch, Calif., that's good news. Sutter currently spends millions of dollars to bar-code uncoded medications because keeping medications straight has become critical, says Bumatay. The number of drugs is burgeoning, and many have names that look or sound similar. More than 17,000 medications are currently marketed in Northern California, and processing 30 million prescriptions a year in Sutter Health's system offers plenty of opportunities for error. "We're human," she says. "That's why we need additional layers of safety." The hospital hasn't used the new system long enough to gauge overall results, says Bumatay, but her staff already can see the near misses that would have resulted without it. "We're dealing with lives here," she says emphatically. "We're not flipping hamburgers."
Digital Medical Records
Bruce Freedman was diagnosed with bladder cancer in 1992. Then, in 2001, he had triple coronary artery bypass surgery. He had a mild heart attack last October. And he has kidney problems on top of it all. As the years passed, Freedman, now 62, acquired new doctors with each new ailment. Each one would give him different drugs, and he couldn't keep track of all the instructions and advice.
Then Danny Sands, an internist at Beth Israel Deaconess Medical Center in Boston, became Freedman's primary-care physician. Sands had spent years developing electronic health records that patients could access at any time from home from a secure website.
It was a radical notion. Thanks to bureaucratic obstacles and physician resistance, patients rarely see their medical records. But Sands believed patients could help manage their own care if they felt more connected to information about their health. Besides, he says, studies show that patients forget 30 percent to 50 percent of what a doctor tells them during an office visit almost as soon as they walk out the door. If patients had their information available at a website, he reasoned, and could E-mail follow-up questions, they would be better informed and ultimately healthier.
So in 2000, Sands launched PatientSite on the Web, intended to contain everything that would go into the usual hospital medical record except for doctors' clinical notes (many doctors weren't comfortable including them and the patients weren't asking for them). Patients now could even see results of lab tests, usually as soon as their physicians got them. And patients could share the information with family members at home. As the site has evolved, Sands has added enhancements--such as the ability to schedule appointments and order refills online for maintenance medications. More than 20,000 patients at Beth Israel currently have access to their health records online, he says.
Freedman, a commercial real-estate broker, especially likes the E-mail feature. Before, he had trouble reaching Sands by phone, or they would play phone tag for days. Now he can fire off a message with a question and usually get an answer within a few hours to a day. "It saves me a lot of aggravation and time and effort," he says.
Not all doctors are as enthusiastic. About two thirds of doctors in national surveys would want to participate only if they were compensated, says Sands. The Beth Israel site doesn't charge for messaging capabilities, but that could change. (The Palo Alto Medical Foundation in California charges patients $60 a year for unlimited E-mailing.)
"Consumers have a right to know about their health," says Leapfrog's Delbanco. "That's why we are working so hard to promote a more transparent healthcare system, where we have as much information about our healthcare choices as we do about choosing a car or a dishwasher."
That's a theme heard repeatedly at hospitals that switch to electronic records and open them up to patients. At Palo Alto Medical, more than 25,000 patients now have 24-hour access. "In my mind, it levels the playing field," says Paul Tang, chief medical information officer, "so patients, not just their providers, are armed with information." He plans to launch a disease-management component on his site this fall to give diabetics specialized tools to help them monitor their own progress interactively--by, say, entering their cholesterol and glucose results. "It's one thing to be told your LDL cholesterol is 120," says Tang. "It's another to look at a graph and know what your target is."
Besides involving patients more directly, putting health records in electronic form makes patients safer. At Brigham and Women's Hospital in Boston and its many clinics scattered throughout the area, all patient records are electronic. A patient who comes to one hospital has her record available online at all of them. Perhaps an elderly woman from the suburbs breaks her hip and is taken to Brigham and Women's. The emergency physician calls up her records, says Robert Goldszer, vice chair of medicine, "and sees right away not to give her certain medications because she has a heart condition."
The University of Colorado Hospital in Denver experimented with the ultimate step in 2002, giving 54 regular outpatients at the hospital's heart center full access to their medical records, including clinical notes. Their behavior over the next year was compared with that of 53 other patients matched by age, sex, medical condition, and other qualities. Several physicians resisted, fearing they would have to censor themselves to keep from being E-mailed to death.
"Some of my colleagues may have felt a little threatened," says clinic cardiologist Gene Wolfel. "My philosophy is that these people should know what's going on . . . . If they don't understand something, that's an opportunity for dialogue." Moreover, the feared hounding didn't happen. The 54 patients sent their seven doctors a total of 60 E-mails over the next year, barely more than one per patient. At the end of the study, the 53 other patients got total access, too.
"America's Best" Plugged-in Hospitals
Last week Hospitals & Health Networks, a publication of the American Hospital Association, released its annual list of the "100 most-wired hospitals and health systems." Of the 100, the 38 below have additional appeal: They were also ranked in U.S. News 's "America's Best Hospitals" this year.
Advocate Lutheran General Hospital, Park Ridge, Ill*
Arthur G. James Cancer Hospital, Columbus, Ohio*
Baylor Institute for Rehabilitation, Dallas*
Baylor University Medical Center, Dallas*
Beth Israel Deaconess Medical Center, Boston*
Brigham and Women's Hospital, Boston*
Children's Hospital of Philadelphia
Children's Hospital of Pittsburgh*
Clarian Health Partners (IU and Methodist Hospitals), Indianapolis
Dartmouth-Hitchcock Medical Center, Lebanon, N.H.
Hackensack University Medical Center, Hackensack, N.J.
Hamot Medical Center, Erie, Pa.
Hospital of the University of Pennsylvania, Philadelphia*
Inova Fairfax Hospital, Falls Church, Va.*
Lehigh Valley Hospital, Allentown, Pa.*
Magee-Womens Hospital, Pittsburgh*
Massachusetts General Hospital, Boston*
McLean Hospital, Belmont, Mass.*
Methodist Hospital, Houston
National Rehabilitation Hospital, Washington, D.C.*
New England Baptist Hospital, Boston*
North Carolina Baptist Hospital, Winston-Salem*
Northwestern Memorial Hospital, Chicago
Ochsner Clinic Foundation, New Orleans
Ohio State University Medical Center, Columbus*
Poudre Valley Hospital, Fort Collins, Colo.
Rush-Presbyterian-St. Luke's Medical Center, Chicago
Sentara Norfolk General Hospital, Norfolk, Va.*
Spaulding Rehabilitation Hospital, Boston*
Texas Heart Institute at St. Luke's Episcopal Hospital, Houston
Union Memorial Hospital, Baltimore*
University Hospital of Arkansas, Little Rock
University of Alabama Hospital at Birmingham
University of Pittsburgh Medical Center
University of Utah Hospitals and Clinics, Salt Lake City
University of Wisconsin Hospital and Clinics, Madison
Washington Hospital Center, Washington, D.C.*
Yale-New Haven Hospital, New Haven, Conn.
*In a healthcare system named on the "100 most-wired" list
Scott Greenway--USN&WR
What to Like About Wired Hospitals
A big reason hospitals wire up is to reduce prescription mistakes and other medical errors. But patients benefit in other ways, too, according to Hospitals & Health Networks' yearly surveys.
Wireless prescriptions
The percentage of hospitals where almost all doctors prescribe using wireless devices is rising, and nearly 22 percent of "most wired" hospitals prescribe that way.
[Data is unavailable.]
[Chart labels: 2002, 2003, 2004; 0, 2, 4, 6, 8, 10 pct.]
Matching drug to patient
Hospitals that use information technology to match most medications and doses with patients are increasing: Almost 35 percent of "most wired" hospitals do so.
[Data is unavailable.]
[Chart labels: 2002, 2003, 2004; 0, 4, 8, 12, 16 pct.]
Online scheduling
At a growing number of hospitals, outpatients can book future appointments by logging on to a hospital website. Almost 54 percent of "most wired" hospitals allow it.
[Data is unavailable.]
[Chart labels: 2000, 2001, 2002, 2003, 2004; 0, 5, 15, 25 pct.]
Scott Greenway--USN&WR
This story appears in the August 2, 2004 print edition of U.S. News & World Report.