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Report by – JENNIFER O'BRIEN – 2006 Churchill Fellow The role of

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					              Report by – JENNIFER O’BRIEN – 2006 Churchill Fellow


             The role of bedside computing technology in Healthcare.
   To develop an understanding of how bedside clinical information systems have
        supported improved healthcare quality, efficiency and patient safety.




I understand that the Churchill Trust may publish this Report, either in hard copy or on the
internet or both, and consent to such publication.

I indemnify the Churchill Trust against any loss, costs or damages it may suffer arising out of
any claim or proceedings made against the Trust in respect of or arising out of the publication
of this Report submitted to the Trust and which the Trust places on a website for access over
the internet.

I also warrant that my Final Report is original and does not infringe the copyright of any
person, or contain anything which is, or the incorporation of which into the Final Report is,
actionable for defamation, a breach of any privacy law or obligation, breach of confidence,
contempt of court, passing-off or contravention of any other private right or of any law


Signed:         Jennifer O’Brien          Dated: 27 September, 2007
INDEX
1 Introduction and Acknowledgements ............................................................. 4
2 Executive Summary ......................................................................................... 6
  2.1     Project Description ..................................................................................... 6
  2.2     Fellowship Highlights.................................................................................. 6
  2.3     Major Lessons............................................................................................ 7
  2.4     Dissemination Plan .................................................................................... 7
3 Conclusions...................................................................................................... 8
  3.1     A Chief Medical/Clinical Information Officer Makes It Happen .................... 8
  3.2     Passionate, Visionary Executive & Clinical Leadership is Crucial............... 8
  3.3     Buyer Beware ............................................................................................ 8
  3.4     Funding – There’s No Magic Answer.......................................................... 9
  3.5     Integration is Key ....................................................................................... 9
  3.6     The Single Electronic Medical Record Does Not Exist................................ 9
  3.7     First – Define ‘Quality’ .............................................................................. 10
  3.8     Second – Measure ‘Quality’...................................................................... 10
  3.9     Clinical Systems Often Do Not Support Clinical Workflow ........................ 10
  3.10 Celebrate Research ................................................................................. 11
  3.11 Access Devices – A Matter of Horses for Courses ................................... 11
  3.12 National & Grassroots Initiatives – There’s Room for Both ....................... 11
Recommendations ................................................................................................ 13
4 Programme ..................................................................................................... 14
  4.1     USA ......................................................................................................... 14
    4.1.1 Boston, Massachusetts ........................................................................ 14
    4.1.2 Providence, Rhode Island .................................................................... 14
    4.1.3 New York, New York ............................................................................ 14
    Baltimore, Maryland.......................................................................................... 15
    4.1.4 Durham, North Carolina........................................................................ 15
    4.1.5 Houston, Texas .................................................................................... 15
    4.1.6 Los Angeles, California......................................................................... 15
  4.2     United Kingdom........................................................................................ 15
    4.2.1 London ................................................................................................. 15
  4.3     Denmark .................................................................................................. 16
    4.3.1 Roskilde ............................................................................................... 16
  4.4     Germany .................................................................................................. 16
    4.4.1 Goppingen............................................................................................ 16
    4.4.2 Boblingen ............................................................................................. 16
    4.4.3 Tubingen .............................................................................................. 16
5 Main Body ....................................................................................................... 17
  5.1     Background.............................................................................................. 17
6 US Site Visits - Summary ............................................................................... 19
  6.1     Massachusetts General Hospital (MGH) .................................................. 19
    6.1.1 Hospital Overview ................................................................................ 19
    6.1.2 Clinical Information Systems - MGH Surgical ICU ................................ 19
    6.1.3 Key Observations/Messages................................................................ 21
  6.2     Philips Medical Systems........................................................................... 21
  6.3     Dr David Bates - Brigham & Women’s Hospital ........................................ 22
  6.4     Rhode Island Hospital .............................................................................. 23
    6.4.1 Key Observations/Messages................................................................ 23
  6.5     Memorial Sloan–Kettering Cancer Centre ................................................ 24
    6.5.1 Hospital Overview ................................................................................ 24
    6.5.2 Clinical Systems – Hospital Wide ......................................................... 25
    6.5.3 Key Observations/Messages................................................................ 25
  6.6     New York Presbyterian Hospital............................................................... 26
    6.6.1 Interview – Dr Gilad Kuperman............................................................. 27
  6.7     John Hopkins Hospital.............................................................................. 29
    6.7.1 Hospital Overview ................................................................................ 29
    6.7.2 Clinical Systems – Hospital Wide ......................................................... 30
                                                                                                       Page 2 of 52
    6.7.3 Computerised Physician Order Entry (CPOE) ...................................... 30
    6.7.4 CPOE – A Physician Perspective ......................................................... 31
    6.7.5 CPOE – A Project Implementation Team Experience........................... 31
  6.8    Union Memorial Hospital .......................................................................... 33
    6.8.1 Hospital Overview ................................................................................ 33
    6.8.2 ICU System .......................................................................................... 33
    6.8.3 Visicu Inc.............................................................................................. 34
  6.9    Duke University Hospital .......................................................................... 34
    6.9.1 Hospital Overview ................................................................................ 34
    6.9.2 Clinical Systems ................................................................................... 35
  6.10 MD Anderson Cancer Centre ................................................................... 36
    6.10.1    Hospital Overview............................................................................. 36
    6.10.2    Clinical Systems ............................................................................... 37
    6.10.3    Lessons Learnt................................................................................. 38
  6.11 Cedars Sinai ............................................................................................ 39
    6.11.1    Hospital Overview............................................................................. 39
    6.11.2    Clinical Systems ............................................................................... 39
7 UK Site Visits – Summary .............................................................................. 41
  7.1    St Thomas’ Hospital ................................................................................. 41
    7.1.1 Hospital Overview ................................................................................ 41
    7.1.2 ICU Clinical Systems............................................................................ 41
  7.2    Royal Brompton Hospital.......................................................................... 42
  7.3    NHS - National Information Technology Programme ................................ 44
  7.4    UK Health Funding................................................................................... 45
  7.5    Cerner...................................................................................................... 45
  7.6    London Oncology Clinic ........................................................................... 46
Denmark Site Visit – Summary ............................................................................. 48
  7.7    Roskilde Syghausen (Hospital) ................................................................ 48
8 Germany Site Visits – Summary.................................................................... 50
  8.1    Tubingen University Hospital.................................................................... 50
  8.2    Mainz University Hospital ......................................................................... 50
    8.2.1 Clinical Systems ................................................................................... 50
9 References ...................................................................................................... 51
10 Images............................................................................................................. 52
11 Glossary.......................................................................................................... 52




                                                                                                      Page 3 of 52
1 Introduction and Acknowledgements
This report details the understanding and ‘Lessons Learnt’ from a 2006 Churchill
Scholarship. The Scholarship enabled me to visit centres of health technology
excellence in the USA and Europe. Specific aims were to understand:
• How these countries have used bedside technology to support improved
   healthcare quality, efficiency and safety?
• What types of systems were in use?
• What needs to change in the workplace to leverage the full benefits of these
   clinical bedside systems?
• What studies were conducted to validate the impact of bedside technology on
   improvements in quality of patient care?

International evidence has shown that bedside computing, when implemented
effectively and in conjunction with work flow redesign, is crucial to achieving major
improvements in quality of patient care. In Australia, bedside capture of patient data
(e.g. heart rate, temperature, blood pressure, fluid balance) remains predominantly
manual and paper based. I elected to visit the USA and Europe as the use of bedside
clinical systems is most pervasive. The majority of the literature and experience,
related to technology as a catalyst for improved quality of patient care, also
emanates from these regions.

My passionate belief in the value of clinical bedside technology arises from my
background as a Critical Care Nurse and direct experience using such systems. I
have been a project manager or implementation consultant for bedside systems in
several Australian Intensive Care Units1. I was a member of the Victorian reference
group (2006) to investigate the development and implementation of a state-wide
Intensive Care clinical information system2. In my current role as Chief Information
Officer at St. Vincent’s Health (Melbourne, Victoria), I am an active advocate for
introducing clinical systems on a health service wide basis and for determining and
applying the quality measures to assess the impact of these systems on patient care.

I owe a debt of gratitude to the following, for this ‘once in a lifetime’ and life changing
opportunity of a Churchill Scholarship to study clinical bedside technology:

•   Dr John Santamaria and Dr Bill Kelly, who in 1994 generously gave me my first
    chance to pursue this area of interest, gave me the ‘golden years’ of my career
    and remain great friends and colleagues.

•   Ms Debbie Paltridge (2004 Churchill Scholar) who inspired me to apply for the
    Scholarship, has been a professional mentor and enthusiastic supporter of my
    Churchill experience and whose own Churchill Report on the inadequacies of
    Australian educational support for junior doctors moved me to tears.

•   Ms Denise Bradley, Mr Paul Gladwell, and Dr John Zelcer, friends first and
    foremost, and professional colleagues who humbled me with their references
    supporting my Churchill application.

•   The Winston Churchill Memorial Trust Board, Victorian Regional Committee and
    staff who believed sufficiently in me to award this opportunity and were
    tremendously encouraging throughout the application process and thereafter. The
    Qantas Business Travel Centre for travel advice and a seamless itinerary and
1
  Intensive Care Units of St. Vincent’s Hospital (Melbourne) Ltd; Mater Hospital Brisbane;
Geelong Private Hospital; Royal Melbourne Hospital
2
  Department of Human Services, Victoria’s critical care services, Strategic directions 2007-
12, Background Paper, Melbourne, Pg 27.
                                                                                 Page 4 of 52
    previous Churchill recipients for invaluable survival guides and their infectious
    enthusiasm.

•   The warmly supportive and professionally dedicated Information Services
    management team – my colleagues who kept the ‘ship on course’ in my absence
    and without whom I would not have been able to pursue my ‘holy grail’.

•   St. Vincent’s Heath, its CEO and Executive for endorsing and supporting my
    professional development.

•   The incredibly generous and welcoming clinicians and health system
    professionals in the USA, U.K., Germany and Denmark. Their willingness to
    share their knowledge and expertise, devote precious time and effort to providing
    me a wealth of information, welcome me on their Ward Rounds and into their
    clinical workday, was both overwhelming and humbling. I have established
    professional and personal contacts that will last a lifetime.

•   My wonderful and loving family, who always express their pride in my
    achievements, unstintingly support my every professional and personal
    endeavour and remain my stalwarts no matter what.

•   Sir Winston Churchill, without whom none of this would have been possible.




    Plaque in Mayfair, London on the site of one of Churchill’s former residences.
                 A ‘pilgimage’ site visited whilst on my Fellowship!




                                                                           Page 5 of 52
2 Executive Summary
Name:          Jennifer O’Brien
Position:      Chief Information Officer, St. Vincent’s Health (Melbourne)
Address:       41 Victoria Parade, Fitzroy, Victoria 3065
Contact:       Work: (03) 9288 4000; Fax: (03) 9288 4242

2.1   Project Description

To develop an understanding of how bedside computing technology has supported
improved healthcare quality, efficiency and safety of patient care.

2.2   Fellowship Highlights

The entire experience of the Fellowship has been a highlight. The invaluable
opportunity of dedicated time to learn, think and reflect on my passion for bedside
computing and how to further it in Australia, for the betterment of patient care,
remains overwhelming. To be overseas on my own and to be able to report it as the
best 10 weeks of my life, with every single experience and encounter both fulfilling
and wonderful, is testament to the Fellowship Programme.

Strong recollections of great days include:

1. Meeting a fascinating group of fellow travellers on the first leg of my trip as we
   banded together during a flight delay, including:
        a. Two young Australians heading off to the Virgin Islands to establish the
            first Surf Lifesaving outfit, based on Australian principles, in that region of
            the world.
        b. University of Glasgow Professor of Zoology, David Houston helping bring
            one of the strangest and most endangered birds in the world, the kakapo,
            back from the brink of extinction with dietary supplements.
2. Attending a Ward Round at Massachusetts General Hospital and reflecting on the
   universal ‘sameness’ of clinical care and the dedication of clinicians.
3. Interviewing Dr David Bates, internationally recognised expert and author in the
   application of information technology to achieve major advances in quality of
   patient care.
4. Spending a working day with an extraordinarily dynamic Patricia Skarulis, (Chief
   Information Officer – Memorial Sloan-Kettering Cancer Centre), sharing in
   Memorial’s Clinical Information Technology strategy, and being exposed to the
   benefits of philanthropy on a scale beyond imagining.
5. Witnessing the relatively new role of ‘Chief Medical Information Officer’ (CMIO) in
   action at several US Healthcare institutions and recognising the impressive
   clinical leadership and passion necessary to making effective clinical technology
   a reality.
6. Being hosted at John Hopkins Hospital by a true gentleman, Dr Roy Brower
   (Director, Medical Intensive Care Unit) and marvelling at the dedication and good
   clinical care being provided in extraordinarily difficult physical working
   environments.
7. Experiencing the incredibly caring environment of MD Anderson Cancer Centre
   (Houston, Texas) where cleaners through to clinicians warmly greet visitors and
   staff alike and engender within patients a sense of personal importance, well
   being, and control of their disease and destiny.
8. An enthusiastic meeting with Dr Michael Shabot (Chief Quality Officer, Memorial
   Hermann Healthcare System, Houston, Texas), who shares the passion and is a
   bundle of energy in pursuing evidence based validation of the value of clinical
   information technology.
                                                                             Page 6 of 52
9. A visit to the venerable institution of St. Thomas’ Hospital (London) – founded
    1107 – including a tour of an ‘Ether Dome’ where the the first anaesthetics in
    surgery were administered and the Florence Nightingale Museum next door.
10. Meeting with ‘like minded’ fellow clinical information system campaigners, Dr Cliff
    Morgan (ICU Director, Royal Brompton Hospital, London) and Dr Richard Beale
    (ICU Director, St. Thomas’ Hospital, London).
11. A visit to the Churchill Museum and Cabinet War Rooms in London – a chance to
    pay homage to the man who made this all possible and whose words and
    character are an inspiration to commit and take ‘Action This Day’!


2.3   Major Lessons

1. The newly emerging Chief Medical Information Officer (CMIO)/Chief Clinical
   Information Officer (CCIO) role is pivotal to:
        • Successful implementation of clinical information technology.
        • Leveraging measurable benefits of quality of care.
2. A recurrent theme of all site visits was that the successful integration of bedside
   systems with other hospital systems is highly desirable but made difficult by the
   lack of rigorous technical standards in healthcare computing. Systems integration
   is key to providing a comprehensive and manageable electronic patient record.
3. There is no one single ‘killer’ clinical application that delivers all the necessary
   components of the Electronic Medical Record (EMR) – in all instances, there are
   several different information systems coupled together (amongst them being
   bedside clinical systems), to provide the breadth of functionality necessary.
   Achieving a successful and comprehensive EMR is an evolutionary, long term
   journey that requires all healthcare professionals to be strategic, visionary and
   brave. It also means being prepared to achieve incrementally, with smaller
   bedside systems and projects building towards a comprehensive vision.
4. Clinical leadership requires recruiting passionate clinicians into the organisation,
   driven by a desire to improve quality of care and with a degree of altruism in their
   approach to the organisation and healthcare improvement in general. Strong
   medical leadership is needed to establish the vision and strong nursing
   leadership to make the vision an operational reality.
5. The key to achieving Australia wide implementation of clinical bedside systems is
   embracing the incredibly positive US attitude of ‘give it a go’/’glass almost full’.
   Their approach is to see how it can be done rather than whether or when it
   should be done.
6. Leveraging a capital clinical renovation or new building as the opportunity to
   introduce new systems should not be missed. It is a once in a lifetime opportunity
   to introduce system, process and quality of care improvements.
7. Studies defining measures of quality of care and evaluating the impact of clinical
   systems, other than in the medication area, are largely not being done –
   publication of wider quality of care research is an imperative and would make
   Australia ground breaking.


2.4   Dissemination Plan

1. Speaking presentation at Heads of Department Meeting and Care Forum (St.
   Vincent’s Health).
2. Submission of Paper to Intensive Care Advisory Committee (ICAC) and Office of
   Health Information Systems – Department of Human Services, Victoria.
3. Speaking presentation at Australian National Health Informatics Society
   Conference.
4. Submission of article for publication in International Journal for Quality in Health
   Care.

                                                                          Page 7 of 52
3 Conclusions
Drawing upon:
• the lessons learned from my Fellowship site visits,
• the recurrent themes that emerged across the sites, and
• personal experience in clinical information systems
I have expanded on the ‘Major Lessons’ and conclude the following:


3.1 A Chief Medical/Clinical Information Officer Makes It Happen
The value of the newly emerging CMIO role is pivotal to success in enterprise wide
clinical systems, particularly where data input and system use is predominantly the
responsibility of the medical staff. The role is ideally fulfilled by a senior medical
officer or senior nurse with a passion for quality and who is highly regarded by his/her
peers. The politics and social context of the clinical environment requires a
CMIO/CIO have a strong collaborative relationship with key members of the senior
medical staff and clinical credibility.

I.T. Steering Committees in hospitals are generally ineffective in terms of driving
clinical system strategy or exercising governance and stewardship over I.T. services
in general. At most sites these committees had been disbanded. They are better
replaced by CMIOs/CCIOs and Clinical Advisory or Focus groups which determine
clinical information strategy and are subsequently committed to driving and
implementing individual clinical systems. Once implemented, system usage and the
ability to leverage best value will languish unless the clinical resource(s) are supplied
to maintain the system, keep catalogues and tables updated, train new staff and
continue to investigate new ways of getting value out of the system.

3.2 Passionate, Visionary Executive & Clinical Leadership is Crucial
An environment of tangible and evident Executive and Clinical Leadership is crucial
to clinical system success. This leadership can’t be fostered without recruiting into
the organisation, passionate physicians:
• driven by a desire to improve quality of care, and
• with a degree of altruism in their approach to contributing to the organisation and
    healthcare improvement in general.

Brigham and Women’s provided a tangible example of Executive leadership – the
Chief Executive Officer conducts weekly ‘walk arounds’ of the clinical areas in the
company of the Risk Manager, Quality Manager and CMIO. During the ‘walk
arounds’, Ward based staff are asked for their input on deficiencies in current
process and opportunities to improve patient safety, the occupational environment
and quality of care.

The US attitude towards implementing clinical systems is incredibly positive and the
‘give it a go’/’glass almost full’ focussed approach predominates. The reaction of the
US to clinical systems and their impact on quality of care is to ask how it is to be
done rather than when or whether it should be done.

3.3 Buyer Beware
In the process of acquiring clinical systems it is imperative to know what you are
buying – unless the details of the functionality are understood before purchasing and
the proposed requirements are built into the Agreement, it is likely there will be
disappointment with the delivered system. Clinicians’ expectations often exceed the
capacity and capability of a system to deliver in the first instance. It takes very little
time to lose the hearts and minds of clinicians and, once lost, they are rarely
retrieved.

                                                                             Page 8 of 52
Prior to system selection and implementation, there should be robust discussion
around what information will need to be extracted from the system and the
reports/queries that will be required, as that will impact the database design and table
structures. Often it is too late post implementation and reporting proves to be
inordinately difficult or is time consuming. Invariably, effective reporting requires good
systems analysis and understanding of database design.

3.4 Funding – There’s No Magic Answer
Justifying and subsequently achieving a purely financial return on investment with
clinical information systems is almost impossible. Philanthropy plays an enormous
role in health services and research in the US, but this funding is rarely made
available for clinical systems. Many of the US and European sites visited were not for
profit organisations and the funding for clinical systems was made available as a by
product of capital investment in a building programme. Invariably some of the capital
funds were directed towards making the new facility ‘paperless’ and the workflow
‘efficient’. Leveraging a renovation or new building as the opportunity to introduce
new systems should not be missed. It presents an infrequent opportunity to introduce
process improvement and enhance quality of care.

It is difficult to mount the business case that better acquisition, recording and
management of clinical information will necessarily lead to improved quality of care
as so few projects conduct pre and post implementation studies to demonstrate this
realisation.

3.5 Integration is Key
Integration of systems is key to their clinical success and adoption by the clinical
staff. Electronic Order/Entry systems for medications and tests serve little clinical
value when not integrated with other hospital systems. Integration of disparate
systems together into a single clinical portal is fundamental to achieving a
comprehensive and manageable electronic patient record.

‘Nursing’ specific and ‘Physician’ specific systems should be avoided as this results
in multiple systems with varying subsets of the same information. As a consequence,
different disciplines use different systems to obtain the same information leading to
information inconsistency between care givers.

3.6 The Single Electronic Medical Record Does Not Exist
The term ‘Electronic Medical Record’ (EMR) means different things to different
people. Building an EMR is an evolutionary process – there is no ultimate single
vendor or solution able to provide the breadth of clinical functionality required. Even
in the most financially wealthy US health institutions, progress towards an EMR and
clinical bedside systems is sporadic, variably successful and a long term journey.

There is no one ‘killer’ application for an EMR – it is without exception, an
amalgamation of scanned documents, test result viewers, enterprise wide systems
and specialty/niche department systems tied together in an integration layer or
clinical portal. Where paper documentation remains the most efficient means of care
management, digital scanning of documents plays an important role. Document
scanning is invariably a component of the suite of applications and services forming
an integrated electronic medical record.

Computerised Physician Order Entry (CPOE or Order/Entry) may be implemented in
many US hospitals but the electronic automation and data capture of the bedside
flowsheet and the comprehensive electronic medical record is not. The model of
Order/Entry that would suit the Australian healthcare environment is different to that
of the US. Australia is not so constrained by legalities as the US and is fortunate in
having less professional boundaries around responsibility for performance of

                                                                            Page 9 of 52
individual clinical tasks. As an example, Respiratory Therapists rather than nurses
manage ventilators, and their settings in the US – tasks which the Australian
Intensive Care nurse would consider within their realm of patient care.

3.7 First – Define ‘Quality’
In determining the clinical systems needed by a hospital, it is important to initially
define quality as it relates to that specific organisation. A crisp, explicit definition of
what is meant by quality and how it will be measured will highlight the systems
required and the processes to which it will be applied.

Commercial clinical system design may be targeted at problems that are not relevant
to a particular institution which might have to implement them – they may target the
wrong problem for that hospital. This is reflected in the common experience of my
Fellowship - enterprise wide clinical systems had often been introduced as a knee
jerk reaction to meet legislative standards or impending accreditation requirements.
There was an assumption that as published literature proved the efficacious use of
clinical systems elsewhere, by simply implementing them in other hospitals, the same
quality improvements would be realised. Invariably clinical systems were not
understood as simply providing the initial catalyst for change. Only one of the
institutions visited had formally tackled process re-engineering and associated
change management activities were inconsistent and poorly done at best. ‘Running
out of steam’ after system go live, for any quality process improvements, was a
consistent theme expressed at most sites.

Clinician dissatisfaction with many systems reflected insufficient organisational
forethought in several areas:
• Defining what constitutes quality for an individual organisation.
• Establishing and measuring local indicators of quality pre and post system
    implementation to validate the expected improvements had been realised.
• Appreciating that in addition to implementing the systems, an understanding of
    existing deficiencies in processes of care and a committed program of care
    process redesign and reengineering was necessary to leverage the value out of
    the new systems.
• Engaging clinician buy-in was the single most influential factor in achieving the
    anticipated quality of care outcomes.

3.8 Second – Measure ‘Quality’
Studies of the impact of workflow redesign and clinical information systems on quality
of care are largely not being done, even at the major healthcare institutions. Post
implementation reviews and validation that the expected benefits have been realised
are not built into the project phases up front.

Very few hospitals are defining measures of quality of care and studying and
measuring the impact of clinical systems, outside of medication management. In the
words of Dr Kuperman (New York Presbyterian Hospital), ‘Be careful what you wish
for’. The research findings on which many decisions to implement Order/Entry are
based emerge from the unique and somewhat rarefied environment of Partners
Healthcare. Lessons emerging from Partners studies are not necessarily always
relevant to the rest of the world as their budget is unlimited, their resources and skill
sets extensive and their systems so customised that the majority would be unable to
emulate this unique environment.

3.9 Clinical Systems Often Do Not Support Clinical Workflow
Particularly in the case of clinical systems, there is often a mismatch between system
design and the realities of clinical workflow.



                                                                               Page 10 of 52
Current Clinical Systems are designed to be:
• Objective
• Rationalised
• Linear
• Normalised
• Solitary
• Single minded
Clinical Work is fundamentally:
• Interpretative
• Multitasking
• Collaborative
• Distributed
• Opportunistic
• Reactive
• Interrupted frequently3

3.10 Celebrate Research
The relationship between US research and hospital organisations appears far
healthier and more synergistic than is the case today in Australia. US hospitals view
their affiliation with Research Institutes as a matter of prestige and actively support
research faculty requirements. Research funding is the lifeblood of many hospitals,
who themselves are an ‘on tap’ source of research material and patient study
populations. Patients are major beneficiaries of this arrangement, receiving treatment
at the very forefront of the latest research, particularly in the case of end stage
cancer. They have nothing to lose by committing to ground breaking therapies.

Noted features of US hospital research include:
• All research buildings appear to be donated.
• Benefactors are associated with all major areas of research.
• Research is a notable facet of every major institution.
• A very tangible and celebrated Hospital-University affiliation.
• Hospitals value and leverage the University affiliation.

3.11 Access Devices – A Matter of Horses for Courses
What is suitable for one person, clinical situation or environment is not necessarily
suitable for another. Wireless, laptop or tablet/palm device access to clinical systems
is often thought to be necessary for effective use. However in many of the sites
visited on the Fellowship, wireless, laptop access to clinical systems was poorly
utilised and unwieldy. Insufficient battery life for portable devices remains a major
impediment to their extensive clinical use. The designs of many clinical systems do
not readily lend themselves to use on a small screen.

In the traditional ward based hospital environment a standard personal computer with
a flat screen monitor, located in close proximity to the patient bedside is very
acceptable. Devices with smaller physical dimensions are more suited to situations
such as completing a pre-operative assessment questionnaire, referencing a drug
interaction database or recording care activities based out in the community.
Ensuring effective access to information, especially when many systems are being
accessed concurrently often eliminates the feasibility of portable devices.

3.12 National & Grassroots Initiatives – There’s Room for Both
Local, ‘grassroots’ and national initiatives to introduce clinical systems are not
mutually exclusive. Local, hospital based implementations are valuable as they build:
• Ownership, engagement and responsibility for effecting change.

3
    Wears et al.
                                                                         Page 11 of 52
•  Skills and capabilities to engage in initiatives with a broader health community
   perspective.
• Capabilities that complement national implementations.
They often realise benefits and outcomes more rapidly than would otherwise be
possible.

Concurrent national initiatives have the resources and funding to establish the
backbone on which benefits and outcomes can be extended across the wider clinical
and patient community. State or national clinical system projects are medium to long
term strategies. One of the insights of this Fellowship was recognising that the
current generation of clinicians must be somewhat altruistic and prepared to suffer for
being on the ‘bleeding edge’. This will enable the next generation of clinicians, and
patients to benefit from the infrastructure established, the early lessons and maturing
systems.




                                                                        Page 12 of 52
Recommendations
1. Establish the CMIO/CCIO role in Australian healthcare institutions to drive the
   development of clinical information strategies, champion the implementation of
   key clinical systems and ensure the impact of these systems on quality of care is
   validated in the Australian context.

2. Study, define and adapt the characteristics and attributes that foster
   excellence in clinical leadership and vision. Use the evidence, standards and
   practice from internationally renowned and high performing organisations to
   identify who and what should be emulated and how this is best done. Learn not
   only from within health but also recognise that lessons in excellence from other
   industries are equally applicable to health.

3. Incorporate more specific and mandatory patient safety goals in Australian
   Council of Healthcare Standards (ACHS) accreditation criteria. Establish
   criteria requiring reduction in medication errors, effective handover of patient
   information between caregivers and electronic medical records. Structure the
   criteria to be catalysts for investment in supporting information technology and
   associated quality of care impact studies.

4. Provide local hospital, state and federally funded scholarships/exchange
   programs for Australian clinicians. Enable the opportunity to visit, work at and
   learn from international centres of healthcare excellence. Establish annual
   competitions to compete for the opportunity to be sent overseas on an exchange
   program with a world leading hospital as a great development incentive for
   clinical staff. Actively recruit international, best practice experience into our
   healthcare environment. Send Australians overseas and invite internationally
   recognised clinicians and health administrators/executives to Australia for
   speaking and clinical practice/working engagements.

5. Define quality, study it and publish clinical research measuring it. Establish
   internationally recognised measures of quality against which the impact of clinical
   information systems should be validated to make Australia ground breaking.
   Make quality of care initiatives not only necessary through standards but
   supported by evidence based research at all major healthcare institutions. In the
   words of Sir Winston Churchill ‘However beautiful the strategy, you should
   occasionally look at the results’.

6. Define the approach, implementation and use of Order/Entry tailored to the
   Australian model of clinical care. Establish a different approach than the US
   model to ensure the realisation of benefits from Order/Entry. Design the screen
   based appearance and workflow of Order Entry so that tests and results are
   separated from tasks and the execution of each is tiered according to clinical
   priority.




                                                                        Page 13 of 52
4 Programme
Summary
• USA                              21st May – 27th June, 2007
• United Kingdom (London)          28th June – 15th July, 2007
• Denmark                          11 July – 12th July, 2007
• Germany                          15th July – 26th July, 2007

4.1   USA

4.1.1 Boston, Massachusetts
Massachusetts General Hospital
Hasan B. Alam              Associate Professor of Surgery
Luca Bigatello             Director, Critical Care
Katie Brush                Clinical Nurse Specialist
Philips Medical Systems, Andover, Massachusetts
Sibylle Kessler            Senior Product Manager- Clinical Information Systems
Carole Russel              Research
George Gray                Data Warehousing & Reporting
George Diller              Application Bundles
Dale Wiggins               System Architecture
Brigham and Women's Hospital, Boston, Massachusetts
David W. Bates             Chief, General Medicine Division
                           Medical Director, Clinical and Quality Analysis-
                           Partners HealthCare System, Inc
                           Professor of Medicine, Harvard Medical School

4.1.2 Providence, Rhode Island
Rhode Island Hospital,
Dr Mitchell M. Levy       Director – Medical Intensive Care Unit
Donna Haze                Associate Charge Nurse, Medical Intensive Care Unit

4.1.3 New York, New York
Memorial Sloan–Kettering Cancer Centre
Dr David Artz             Medical Director, Information Systems
MaryAnn Connor            Manager – Nursing Informatics
Gay Bailey                Director of Nursing – Ambulatory Services
Bob Elson                 Chief Medical Officer – Eclipsys
Patricia C. Skarulis      Vice President, Information Systems
                          Chief Information Officer
Carol Gigante             Business Development Manager
                          Intel Americas, Inc.
German Rodriguez          Nurse Leader - GI Service

Cornell University Medical School
Dr Curtis Cole              Clinical I.T. Operations
NewYork - Presbyterian Hospital
Dr Gilad Kuperman           Director, Quality Informatics




                                                                  Page 14 of 52
Baltimore, Maryland
The John Hopkins Hospital
Dr Roy Brower                Director – Medical Intensive Care Unit
Dr Charlie Wiener            Attending Physician – Medical Intensive Care Unit
Stephanie Nonas              Fellow – Pulmonary Medicine
Annette Rawen                Clinical Pharmacist
Leah Trumble                 Point of Care Pharmacist
Dr Christoph Lehmann         Director, Neonatal ICU
James E. Smith               Systems Development Manager
David Li                     Clinical Systems Development Manager
Dr Peter Greene              Chief Medical Information Officer
IBM Corporation
Tony Bosselait               Healthcare Industry Business Unit Executive,
                             Chief Technology Officer
Union Memorial Hospital
Dr Peter Sloane              Director, Intensive Care Unit; Chief of Staff

4.1.4 Durham, North Carolina
Duke University Hospital
Dr Iain Sanderson         Associate Chief Information Officer
Dr Christopher Young      Chief, Division of Critical Care Medicine
Dr Ron Olson              General Practitioner - Pre operative Assessment
                          Clinic

4.1.5 Houston, Texas
MD Anderson Cancer Centre
Jill Roach               Snr Business Process Consultant
Tom Epley                Director – Data Center Operations & Technical
                         Services
Thomas W. Feeley         Vice President, Medical Operations
                         Head, Division of Anesthesiology and Critical Care
Jeanne Fragnoli          Manager, Enterprise Applications
Chuck Suitor             Director - EMR Development
Lynn Vogel               Vice President & Chief Information Officer
Deborah Houston          Area IS Manager

4.1.6 Los Angeles, California
Cedars Sinai
Jeannie Chen               Former ICU Pharmacist
Mark Lobue                 Clinical System Engineer
Memorial Hermann Healthcare System
Dr M. Michael Shabot       Chief Quality Officer - Quality & Patient Safety


4.2   United Kingdom

4.2.1 London
St. Thomas’ Hospital
Dr Richard Beale             Head of Perioperative, Critical Care & Pain Services
Karen Franklin               Project Manager for Clinical Information Systems
Karen Leech                  Application Specialist - Philips Medical Systems
Dave Pierre                  Head of Technical Services for Critical Care
Royal Brompton Hospital
Dr Cliff Morgan              Honorary Consultant Physician

                                                                       Page 15 of 52
                             Honorary Senior Lecturer - National Heart and Lung
                             Institute, Faculty of Medicine, Imperial College of
                             Science, Technology and Medicine
                             Senior Visiting Fellow, Centre for Measurement and
                             Informatics in Medicine, City University
Cerner Corporation
Peter Whatley             Clinical Applications Specialist
The Wandsworth Group Ltd
Richard Mockett           Managing Director
Peter Dunning             Products Manager
The London Oncology Clinic
Marcella O’Brien          Head of Clinical Services


4.3     Denmark

4.3.1    Roskilde
• Roskilde Syghausen (Hospital)
Ulla Mette Nielsen      Applikations Specialist
                        ViCare Medical A/S
Jens Henning            Information Technology
Ole Christensen         Registered Nurse

4.4     Germany

4.4.1 Goppingen
Klinik am Eichert
Dr. Rinderknecht             Director – Intensive Care Unit
Wolfgang Blecher             Intensivist
Timo Baumann                 Chief Information Officer

4.4.2    Boblingen
Philips Medizin Systeme
Dr Chandana                  Manager Market Development & Sales Support
Samaranayake                 (Clinical Information Systems)
Thomas Kerker                Market Development Manager
                             Clinical Information Systems

4.4.3 Tubingen
Tubingen University Hospital
Joachim Hiller             Manager – Biomedical Department




                                                                     Page 16 of 52
5 Main Body
5.1      Background

Bedside clinical care, to a large extent, remains the last bastion to be breached by
technology. Imagine going into a bank these days and depositing some money,
where the bank teller asked for your Bank Book and proceeded to hand write the
deposit amount in the credit column and manually tally up the total. Most people
would be horrified at this ‘dark ages’ approach to accounting, immediately withdraw
all their savings and opt instead for a bank that offered on line banking facilities and
automation. However the manual/hand written recording of information still remains
the norm for the collection of patient information at the bedside. The electronic
capture and handling of financial information is given far more attention and priority
than the collection of health information crucial to quality of care and ultimately, life.

International evidence has shown4 that bedside computing, when implemented in the
right way, and in conjunction with changes in clinical workflow process, is crucial to
achieving major improvements in quality of patient care.

In Australia, other than in a few Intensive Care Units, capture of patient bedside data
(e.g. heart rate, temperature, blood pressure, fluid balance) remains predominantly
manual and paper based. There is a myriad of clinical information that is now able to
be collected from patients including both manual measurements (e,g, blood pressure,
pulse rate) and information from bedside devices such as urimeters, ventilators,
pulse oximeters, patient monitors, infusion pumps, balloon pumps, anaesthesia
machines, and cardiac output monitors. All this information needs to be considered in
the context of the patient’s clinical presentation in order to correctly diagnose and
effectively treat the patient. It is increasingly exceeding the human capacity to collect,
record, collate, synthesize and utilise all the information available.

This Fellowship examined how leading Healthcare institutions are tackling this
information management issue through the use of clinical information systems.

The key areas of investigation included:
1. Understanding how the countries visited have used clinical bedside technology to
   support improved healthcare quality, efficiency and safety.
2. Identifying novel approaches, particularly in the not for profit sector, to funding
   investment in bedside clinical information systems.
3. Exploring the types of bedside systems used.
4. Developing an understanding of the organisational culture and clinical leadership
   that predominates in hospitals with successful implementation of clinical systems.
5. Identifying the process and workflow changes necessary to leverage system
   benefits.
6. Determining how system impacts on quality of care have been measured, and
   validated.

The site visits on my Fellowship focussed on bedside technology in Intensive Care
Units. This reflects the fact that critical care areas have been at the forefront in
development and implementation of bedside systems and are the areas where new
technologies are piloted prior to widespread adoption. The site visits conducted and
the knowledge I gained validated my current understandings. It was reassuring to
recognise that the practice of clinical care and the lessons learnt overseas are for the
most part, applicable in Australia.



4
    M. J. van der Meijden et al
                                                                             Page 17 of 52
Insights in this report are not confined to bedside systems – where there are
unrelated but nevertheless important reflections on quality in healthcare, they have
been included. My Fellowship proved to be a learning experience far beyond the
scope of my intended field of study. It would have been possible to produce a much
more extensive report over many topics in Healthcare.

I have referred to both bedside clinical information systems (CIS) and the Electronic
Medical Record (EMR) in this report. The distinction between these systems, even
amongst clinicians, is not always clear and this was borne out in my site visits. The
definition of a CIS and an EMR for the purpose of this report is as follows:

CIS: a bedside computer which automatically acquires data from patient monitoring
devices, equipment such as ventilators and infusion pumps and displays results from
other hospital information systems such as a Pathology Laboratory system.
Additionally, patient information can be manually entered and the data is visually
displayed, often in a reproduction of the paper chart format and able to be
dynamically graphed and manipulated. It is usually specific in design and use to a
particular clinical department or service. A CIS forms one of the components of an
EMR.

EMR: a comprehensive electronic record of a patient’s clinical history and care
compiled from many different data sources. It is generally a hospital wide system and
contains at least the following patient information:
• Demographics
• Medical history
• Clinical encounters (medical and other)
• Orders and Medications
• Progress notes
• Test results
Often an EMR incorporates interfaces to multiple hospital systems (e.g. digital
radiography, CIS, Patient Administration system etc.) and provides a integrated view
across all the information sources, of the patient’s health history and status.




                                                                        Page 18 of 52
6 US Site Visits - Summary
6.1     Massachusetts General Hospital (MGH)

6.1.1     Hospital Overview

My first site visit was conducted at MGH - the oldest and largest teaching hospital of
Harvard Medical School, with nearly all staff physicians holding Harvard University
faculty appointments. MGH is consistently ranked among the nation’s top five
hospitals by U.S. News and World Report5.

The emphasis and importance of research is evident by the:
• 54,000 square feet of floor space,
• $405 million (U.S.) per annum budget
devoted to research areas.

The scale of MGH (as with most of the US hospitals visited) is staggering, with:
• 940 Beds.
• 131 Intensive Care Unit (ICU) Beds.
• 60 Inpatient Operating Suites.
• 60 Outpatient Operating Suites.

Other key features of the site include:
• Post Anaesthesia Care Unit (PACU) – provides for post anaesthesia overnight
   stay and 24 hour Resident Medical staff cover.
• 15 minute response time goal for a Trauma/Emergency Team to respond to an
   admission to the Emergency Department.
• Robust Nurse Practitioner Program.
• An ‘Ether Dome’
   preserved in the centre
   of the hospital campus
    which was the site in
   1846 for the first
   administration of
   anaesthesia to
   alleviate the pain of
   surgery.
   (Refer to the domed roof of
   the Bulfinch Building pictured
   right). The huge domed
   amphitheatre, allowed
   spectators to watch operations in progress from a tiered gallery. The roof,
   designed with windows around the cupola, allowed natural light to shine down
   into the operating theatre and illuminate the operating table, as there were no
   effective theatre lights available.


6.1.2     Clinical Information Systems - MGH Surgical ICU
•     Alarm Boards (like Flight Schedule Display Boards) are located throughout the
      corridors of the MGH Surgical ICU and display all bedside system alarms,
      irrespective of their priority. The alarms are colour coded into category (red =
      critical, amber = low priority warning). The frequency of the alarm displays
      suggests a tendency to ‘alarm fatigue’ where data overload and false alarms are
      a risk.

5
    http://www.massgeneral.org/news/for_reporters/overview.htm
                                                                         Page 19 of 52
•   A locally developed Computerised Physician Order Entry (CPOE) system is
    hospital wide, but all bedside charting remains paper based. A CPOE or
    Order/Entry system is generally defined as an electronic system that replaces
    hand-written physician or provider orders with a computerised system. These
    orders may include radiology and pathology tests, medication prescriptions,
    procedures and interventions and ideally the incorporation of decision support to
    guide providers in creating these orders.

    A well designed CPOE system identifies and intercepts the most common errors
    during the process of medications ordering. The orders are checked for potential
    drug interactions, allergies, proper dosages, up-to-date information about newly
    developed drugs and avoid the confusion between drugs with similar names.

    Use of CPOE in hospitals is a key standard of the US Leapfrog Group. This is an
    influential standards and benchmarking organisation focussed on improvements
    in the safety, quality and affordability of healthcare. Hospital compliance with
    Leapfrog’s performance measures is increasingly referenced by insurers and
    consumers. Hospitals themselves are voluntarily reporting their performance
    against the measures to establish their marketability and to guarantee
    reimbursement from a quality of care perspective.

    To meet Leapfrog's standard for computerised physician order entry, hospitals
    must:
        o Make sure that doctors enter at least 75% of medication orders on a
           computer system that includes software to prevent drug prescription
           errors.
        o Demonstrate that their computerised order entry system can alert doctors
           of at least 50% of the most common serious prescribing errors.
        o Require that doctors electronically document why they are overriding a
           computer-flagged warning before doing so.
•   Complex algorithms are behind the CPOE screens and require a fair degree of
    maintenance. Pathology and Radiology results are copied from the Laboratory
    system and pasted into the CPOE notes. When asked his opinion of CPOE, Dr
    Hasan Alam, the Surgical Consultant commented it is a ’… cumbersome system
    in some ways but there are trade offs’.
                                     •      Digital radiology (PACS) images are
                                            available in a separate system.
                                     •      Whilst a hospital wide Patient
                                            Administration System exists, a White
                                            Board in the Staff Station displays a hand
                                            written list of all patients and patient
                                            transfers as well as the Team (Red or
                                            Blue) assigned to the patient as
                                            designated by a coloured Post-It tab!
                                     •      A bedside ICU system is to be developed
                                            with a small application development
                                            company. The trade off to the risk of a
                                            small provider is that it offers iterative
                                            software development at a pace and cost
                                            acceptable to the hospital.
                                     •      Ward Rounds are conducted using a cart
                                            mounted wireless laptop. Fundamental
                                            issues such as insufficient battery life and
                                            the fast paced flow of clinical discussion
                                            and rounds preclude the laptops from
                                            being a truly effective tool other than for
                                            access to Pathology and Radiology
           Cart mounted,                    results.
          wireless laptop.                                                   Page 20 of 52
6.1.3 Key Observations/Messages
• Philanthropy is a very strong tradition and benefactors support hospital
    operations so extensively that patients are not actually required to make the
    organisation profitable. This philanthropy however, does not extend to the funding
    of clinical bedside systems. Availability of bedside clinical I.T. systems is growing
    slowly.
• Clinical Leadership is very strong at MGH with surgeons a very influential group.
    As an example, the Partners Healthcare Group, a leading biomedical and clinical
    research group, was started by 4 MGH clinicians who did not seek permission but
    simply decided to form the not for profit organisation. One of Partners joint
    ventures is the Centre for Integration of Medicine and Innovative Technology. The
    technology innovation focuses on robotics, genetics and simulation rather than
    bedside systems. There is however a lot of research conducted out of this group
    around medications, patient safety and use of CPOE.
• Any evaluation of clinical bedside systems at MGH has been performed by the
    Partners Group and the focus has been on CPOE, rather than any other clinical
    bedside system capability.
• Clinical information management in the MGH Surgical ICU does not appear to be
    significantly different from Australian ICUs other than order management being
    conducted electronically.

6.2   Philips Medical Systems

A site visit to the Philips Medical Systems headquarters in Andover, Massachusetts
provided valuable insight into recommended generic features of bedside clinical
systems.

A current platform catering for the full continuum of care would incorporate:
   Specific, customisable documentation for Individuals, Units, Professional Groups
   and Departments.
   Data analysis, querying and reporting providing various, simple through to
   complex, means to mine data and provide information.
   Single user interface to multiple systems (e.g. a web front end or ‘portal’ as a
   single front end to multiple, disparate systems).
   Use of technologies such as web services to overcome the constraints of
   integration with other systems.
   Clinical Decision Support at the point of care (bedside).
   Generation of clinical insights and standard/standards based reports.
   Rules calculation engine which generates alerts when a combination of data
   matches a pre determined set of conditions (e.g. when the combination of low
   blood pressure, fast heart rate and high temperature reaches pre determined
   parameters, an alert is generated advising sepsis, or blood stream infection is a
   possibility and suggesting therapeutic interventions such as blood cultures and
   antibiotics).

The visit also highlighted an emerging trend in the US deemed ‘Pay for Performance’
programs. Most physicians and hospitals are paid the same regardless of the quality
of the health care they provide. This produces no financial incentives and, in some
cases, produces disincentives for quality. Increasingly, insurers are linking payment to
uniform performance measures in the domains of:
• Preventative or chronic care.
• Patient satisfaction/experience.
• Use of Information technology.

The extent of compliance with these measures makes physicians and hospitals
eligible for weighted incentive payments. The Information technology measures are
defined as:
                                                                          Page 21 of 52
•     Support clinical decision making at the point of care (bedside or wherever the
      patient is physically located).
•     Activities including electronic:
               o Prescribing.
               o Drug Interaction.
               o Messaging and retrieval of Laboratory results.
               o Access to clinical notes and findings.
               o Retrieval of patient reminders.6

An important feature of clinical information systems is the ability to incorporate
algorithms which trigger compliance with evidence based, commonly accepted
clinical and patient satisfaction measures. Hospitals are now marketing themselves
based on their compliance with these measures; Clinical system vendors are
differentiating themselves on the capability and capacity of their systems to support
this compliance.

6.3     Dr David Bates - Brigham & Women’s Hospital

Dr Bates holds the positions of:
• Chief, General Medicine Division, Brigham and Women's Hospital.
• Medical Director, Clinical and Quality Analysis, Partners HealthCare System, Inc.
• Professor of Medicine, Harvard Medical School.

His primary research interests have been the use of computer systems to improve
patient care in terms of efficiency, quality and safety. He has published widely on the
application of information technology for clinical decision support, prevention of
adverse drug events, efficiency of diagnostic testing and evidence based guidelines.

An interview with Dr Bates:
• Highlighted the problems in defining the term ‘Electronic Medical Record’ (EMR)
    – it means different things to different people.
• Identified that:
            o President Bush’s 2006 address to the National Economic Council7
                included the statement "We will make wider use of electronic records
                and other health information technology to help control costs and
                reduce dangerous medical errors."
            o There is a US National Coordinator of Health I.T. with a $50 million
                (US) budget.
    Despite this, Dr Bates’ view is that Australia actually has a sounder national
    approach than the USA.
• Elicited his view that the value of digital scanning of clinical paper records is
    ‘questionable and modest at best’ and ‘the resources to support a paper scanning
    solution would be better utilised supporting an electronic system for data capture’.
• Revealed that study methods on the subject of communication during a clinical
    Ward Round involved hand written transcription and analysis of the Ward Round
    conversations, rather than the use of any sophisticated electronic data capture
    tools.
• Confirmed that it would not have been feasible at all to conduct his studies on
    CPOE without the aid of computers, due to the sheer volume of data they are
    able to collect and the capacity they provide to rapidly analyse a vast quantity of
    data.
• Predicted the next major initiatives in clinical computing to be:




6
    Integrated Healthcare Systems
7
    Bush G.W.
                                                                          Page 22 of 52
             o   Patient computing to assist them to manage and update their own
                 health record – allowing two way patient-physician disease
                 management.
             o   Electronic automation of clinical documentation.
             o   Initiatives to support chronic disease management.
             o   Genomics – to help identify ‘at risk’ patients and early onset of
                 disease.
             o   Pharmaco-vigilance, involving contacting patents at home to assess
                 for signs of drug interaction, allergy or under/overdosing.

On the topic of clinical leadership in bedside computing, Dr Bates echoed the
discussion themes of many Fellowship contacts:
• People must be recruited into the organisation who are passionate, experienced
    and enthused about clinical computing.
• In general, clinical leadership is an inherent trait that individuals bring to an
    organisation, rather than something that can be manufactured.
• Effective implementation of clinical systems depends on having clinicians
    involved on the I.T. side.
• A strategic thinking Executive with an appreciation of how quality of care is
    measured and a focus on optimising clinical process, is necessary for success.

6.4     Rhode Island Hospital

The visit to Rhode Island Hospital concentrated on the Medical Intensive Care Unit
(ICU). The hospital operates over 100 ICU beds in the areas of:
• Burns.
• Paediatrics.
• Coronary Care.
• Post Surgery.
• Internal Medicine.
• Coronary Care.
• Cardiothoracics (Heart & Lung).
• Neurosurgery.

•     A Bedside clinical information system was implemented in the Medical ICU in
      1996; a new version was implemented in June 2006.
•     CPOE was implemented in 2000.
•     Numerous cart mounted laptops are available for wireless communication.

6.4.1    Key Observations/Messages

•     Availability of cart mounted computers has resulted in all medical staff bringing
      these devices on the Ward Round and subsequently checking their email, web
      surfing etc. during a consultation, thereby reducing attention and communication.
      It has resulted in an order from the ICU Director that only two laptops to be
      brought on the round – one for the Consultant to record Progress Notes and the
      other to look up Results.
•     Clinical Information System investment was possible as a consequence of a
      building redevelopment project for the ICU.
•     Multiple user names and passwords for many clinical systems remains a problem
      with staff forgetting passwords/system logons.
•     When CPOE is discussed in the US it may mean the clinical portal through which
      all clinical information is accessed (e.g. progress notes, laboratory results) or only
      the system for orders (e.g. radiology, pathology, medications) with bi directional
      interfaces to other hospital systems.
•     CPOE introduction was not the ‘bloodbath’ expected (Dr M. Levy). It was
      introduced sequentially through the Critical Care areas and subsequently
                                                                             Page 23 of 52
      cascaded into the medical/surgical wards. Dr Levy chaired the CPOE introduction
      committee and the CEO mandated its use, which facilitated success. However
      the usual project issues of lack of ‘buy-in’ from several Units, despite a significant
      communication campaign, resulted in many meetings in the CEO’s office with
      angry surgeons and Dr Levy defending the project shortly after Go Live. There is
      no ‘magic’ in introducing CPOE – all the issues are generic to successful project
      management including:
          o Obtaining consensus on system requirements and design.
          o Engaging stakeholders and obtaining their buy in.
          o Not underestimating the magnitude of work involved.
          o Projects such as this expose long standing poor practice and the system
              becomes the ‘scape goat’ when people don’t wish to acknowledge the
              issue or implement change.
•     Dr M. Levy identified that Order Sets make the ‘magic’ of CPOE happen – Order
      Sets are evidence based guidelines in the form of a collection of standardised
      treatment plans, orders and protocols for a particular disease or procedure. For
      example, when a coronary artery bypass surgery patient is admitted, the
      selection of the related ‘Cardiac Surgery’ order set ensures all the relevant pre-
      operative tests and procedures are added in a single action, to their treatment
      plan.
•     Scanning of the existing paper based medical record is not a common interim
      step in the US between paper and electronic data capture. It has been
      leapfrogged as a concept by CPOE.

6.5     Memorial Sloan–Kettering Cancer Centre

6.5.1    Hospital Overview

•     Memorial Sloan-Kettering (Memorial) is one of the leading cancer treatment
      centres in the US with a regional (New York and surrounding states) and
      international referral base.
•     It operates 432 inpatient beds and a large number of regional outpatient sites.
•     Memorial’s success and reputation is achieved by service units that focus on very
      specific tumour sites within tumour streams. For example, within the Upper
      Gastro-Intestinal Unit, a radiation oncologist may focus on only one particular
      type of oesophageal cancer cell type, and one surgeon will focus only on
      performing oesophageal surgeries. Together they accumulate experience with
      approximately 300 resections of the oesophagus performed per annum. Both
      specialists thereby develop expertise by practising in a very narrow field but
      treating a large number of patients with a specific disease type.
•     Philanthropy plays a major role in the existence and continuity of the
      organisation, particularly with respect to research.
•     Clinical informatics has a high profile as evidenced by:
              o A Clinical Informatics department.
              o Various clinical informatics roles including Chief Medical Information
                   Officer, Nurse Informatics Specialists with formal credentialing from
                   New York University, Biostatisticians and other clinical
                   representatives.
•     The sense of clinical leadership is palpable which is explained in a large part by
      the calibre of people in key positions. As an example, the CEO is a Nobel Prize
      Winner in biomedical research, Board members include those with major
      worldwide corporate experience, and the Chief Information Officer is a published
      author in Medical Informatics.




                                                                             Page 24 of 52
6.5.2 Clinical Systems – Hospital Wide
• All Memorial Wards comprise single bed rooms with flat screen televisions and
    computers – the number of computers per Ward floor exceeds the number of
    patients.
• CPOE is a module in an overall hospital system that also incorporates
    Scheduling, Patient Administration System functionality and Results Reporting. A
    pilot of electronic chemotherapy order management is in progress at one of the
    Outpatient Centres.
• A web based PACS (digital imaging for radiology) system is available via
    computer workstations and portable computer carts.
• Scanning of Inpatient Progress Notes and
    other handwritten entries is performed and
    these documents are scanned at
    discharge, or during the patient stay, with
    paper subsequently shredded.
• The Scanning system appears to operate
    on a basis very similar to that seen at
    Casey Hospital in Victoria, Australia.
• Due to exorbitant real estate prices, the
    various hospital Wards and services are
    located across Manhattan Island. The
    multiple locations of the Hospital would
    preclude viable transport of the paper
    record hence the policy is to have an
    electronic record.
• Outpatient Notes are all typed by
    stenographers based on dictation system
    or alternatively entered electronically.
• Infra red devices are being piloted on a
    Ward floor – these display the location of
    key staff on a computer based floor map.
    When combined with a light weight,
    wireless voice activated device they allow
    the identified staff member to be recalled
    based on their geographic location.
• Operating Suites contain a ‘Wall of
    Knowledge’ – two large flat screen plasma
    panels which display patient information
    from various clinical systems.                        Cart mounted, wireless laptop.
• ‘SMART’ infusion pumps are in use with logical dosing rules that warn if an
    infusion exceeds preconfigured standard parameters of rate or dose.
• A ‘Patient Portal’ is in pilot. It allows 250 Breast Cancer patients internet access
    to make and change appointments, view their test results and pay bills on line.
• Every room in each Intensive Care Ward contains:
             o Bar code scanners and printers for Pathology sample tubes.
             o Dual flat screen monitors to display comparative digital x-ray images.
             o Transparent glass walls which can be made to mist over and provide
                 an opaque film for privacy when required.
    However the recording of bedside clinical observations (blood pressure, heart
    rate etc.) remains paper based.
• Bar code scanning of medications and patient ID wrist bands is practised, but
    only in the Outpatient setting.

6.5.3   Key Observations/Messages

•   Memorial’s approach is to ‘buy not build’ in regard to large clinical systems for
    reasons of system support and manageability.
                                                                          Page 25 of 52
•     The role of a Chief Medical Information Officer (CMIO) is key to clinical systems
      success. At Memorial, the CMIO is the communication bridge between the
      clinicians and the I.T. service. The CMIO oversees the selection, development
      and implementation of computerised clinical systems. The CMIO focuses on
      issues of quality, safety, process improvement and is a clinician advocate where
      use of information systems is involved. Memorial’s CMIO is a senior member of
      the Health Service Executive, is MBA qualified and ideally retains a small clinical
      practice (although this is made difficult by hospital meetings and other
      commitments of the role).
•     A Prioritisation Committee determines the benefit versus cost of proposed clinical
      projects for each budgetary cycle. Projects are approved or denied for the
      forthcoming 12 months. The Committee is formed by:
               o Physician In Chief.
               o Chief Medical Information Officer.
               o Chief Operating Officer.
               o Chief Information Officer.
               o Administrators.
•     The Physician in Chief is a very powerful figure in the hospital organisation. The
      CMIO will often ‘word up’ the Physician In Chief in advance, to ensure support for
      key clinical projects.
•     A $20 million (US) spend on clinical systems is planned in 2007 with CPOE
      triggered by the redevelopment of an Outpatients Building on 53rd & 3rd streets in
      Manhattan.
•     The existing CPOE system is deemed to take too many clicks by the physicians
      and requires a large clinical resource group to enter data, develop and maintain
      order sets, quality check entered data and maintain the currency of the system.
•     No studies evaluating the impact of the available clinical systems have been
      conducted. As with most organisations, the clinical systems are implemented on
      the premise that the quality improvements documented in published literature
      from other sites will necessarily be realised, primarily through introduction of the
      system. There is a recognition that local studies would be beneficial but the
      capacity and resources to do this are usually superseded by other operational
      priorities.

6.6     New York Presbyterian Hospital

New York Presbyterian is the result of a
merger between New York Hospital and
Columbia Presbyterian Hospital. One of the
many unresolved issues associated with the
merger is that medical staff contract their
services to the hospital through a Physician
Organisation. This creates the unusual
model where physicians do not necessarily
have their prime allegiance to the hospital
but to their employer Physician organisation
or Columbia/Cornell Universities, where
they hold faculty appointments. In addition,
physicians pay for the provision of the
‘convenience’ of I.T. services within the
hospital. This has ramifications in terms of
inadequate funding for clinical system
projects.

At the time of my visit, the CMIO was
                                                         New York City location of Memorial &
grappling with the impact of a departed
                                                          New York Presbyterian Hospitals
Executive’s decision to switch to a new
organisational clinical system.
                                                                            Page 26 of 52
The ‘one degree of separation’ medical staffing model, the absence of consultation
involved in this decision and a significantly under funded implementation was
causing the expected system acceptance issues.

The contrast between the extent and the success of clinical implementations at
Memorial and New York Presbyterian Hospitals is a salient reminder that those
tasked with the role of a CMIO need to be given the budget, resources and authority
to execute their responsibilities effectively.

6.6.1   Interview – Dr Gilad Kuperman

The visit to New York Presbyterian also involved an interview with Dr Gilad
Kuperman, Director of Quality Informatics. His is an Executive position with a focus
on the application of electronic clinical systems in support of improving patient care.
Dr Kuperman formerly worked with the Boston based Partners Healthcare Group and
is a joint author with Dr. David Bates on many ‘quality of care’ journal articles.
Partners Healthcare was formed when MGH joined with Brigham and Women’s
Hospital in 1994, to establish an integrated health care delivery system. It comprises
the two primary academic hospitals, other specialty and community hospitals, a
network of physician groups and non acute and home health services. It is also a
leading research organisation in the field of clinical informatics and quality of care
and the source of much of the published literature on the efficacy of CPOE.

Dr Kuperman’s view on a strategy for introducing clinical information systems is that
success depends on the capacity to establish a large, complex framework with
multiple components. He commented that this framework is not yet in place at New
York Presbyterian due to the previously identified organisational structure and
cultural issues. Conversely, the Partners Healthcare Group is the result of a merger
between Massachusetts General and Brigham & Women’s Hospitals, but on a
Confederation Model. Where disagreement exists about certain practices or
approaches, those differences are allowed to co-exist, and on consensus issues
there is standardisation across both hospitals. This largely explains the clinical
system success behind the Partners initiatives.

Dr. Kuperman identified the components of success as:

1. Highly configurable or in house built systems
      o Software must be very malleable and able to be adapted to match the
          workflow.
      o Applications need to be designed to tackle the problems specific to an
          institution whereas purchased software usually imposes some workflow
          requirements and may focus on tackling issues that are not a problem in
          that particular institution.
2. Leadership, Vision & Top Level Sponsorship
      o The Partners Healthcare Group provided a culture of strong leadership
          and vision in the clinical systems domain.
3. Domain expertise
      o An understanding of what are the right things to study in relation to a
          particular technology’s impact on quality of care.
4. Documentation
      o Frequent publication of evidence based research and activities that
          demonstrate the link between clinical systems and quality of care.
      o This is dependant on the availability of experienced resources, skill sets,
          and capacity to conduct and publish the research.
5. Availability of high end medical technology
      o The availability of the right technologies also includes the requirement for
          the right people to design, implement and support the same.
6. Appropriate Resourcing
                                                                         Page 27 of 52
       o   Demonstration of success in implementation of clinical systems requires
           resources not often identified.
       o   In addition to the active engagement of bedside clinicians, demonstrating
           success requires resources with expertise in evaluation techniques,
           system design, the technical capability to mine data out of systems,
           conduct research analysis and produce scholarly journal publications.

According to Dr Kuperman, success requires all these factors to be in place and the
absence of even one, inevitably results in significantly slower progress or none at all.
New York Presbyterian’s environment is not optimised for a leading edge role or
major success in clinical informatics as:
• The organisation is the result of a relatively recent merger – not a confederation
   model as practised by Partners. Consequently, both hospitals, their affiliated
   University faculties and Medical Schools feel disenfranchised to a point.
• Legal constraints prevent the two existing faculties from merging.
• Organisational politics are complex and the logistics of achieving change are
   difficult.
• New York City’s environment is financially hard for hospitals with the operating
   margin approximately 0.5%, versus 3-4% elsewhere in the US. The fiscal
   discipline required presents particular challenges.

Dr Kuperman cautioned that the Partners Healthcare is a unique and atypical
environment with vision, leadership and a budget unmatched in any other US
healthcare institution. The lessons learnt and research emanating from Partners is
not always necessarily relevant to the rest of the world. New York Presbyterian’s
experience with clinical systems is more representative of the overall US experience.

In studying the impact of clinical systems on quality of care, Dr Kuperman
emphasised the importance of understanding quality from an individual
organisational perspective. In answering the question ‘What is Quality?’ it is
important to have a crisp, explicit statement/definition of what it is for that
organisation. It is easy for the business goals of the organisation to be different to the
clinical I.T. direction if the vision is not clearly articulated.

For this reason, Dr Kuperman emphasised the importance of I.T. representation at
the highest level in the organisation to enable:
• A response on the technical feasibility of clinical informatics ideas/concepts.
• Effective prioritisation of effort.
• Identification of the capabilities to serve the quality improvement mission and
    vision.
• ‘A continued conversation to evolve the crisp vision’.

Dr Kuperman identified the key factors in obtaining ‘engagement/buy in’ to clinical
information systems have included:

1. Board of Directors with an I.T. Sub Committee
• Has been helpful in setting the stage for I.T. to have a mandate to meet
   requirements.

2. Budgeting Level & Approach
• Partners Healthcare had the Chief Operating Officer own the budget for clinical
   I.T. projects including the Medication Administration Record.
• Operational I.T. infrastructure was budgeted separately from the capital and
   operating requirements for clinical systems.
• This contrasts with the New York Presbyterian experience where the Chief
   Information Officer owns both the I.T. infrastructure and clinical projects budget.
   This often results in a compromise on Projects budget to meet bottom line
   operational infrastructure needs.
                                                                           Page 28 of 52
3. Combined Committee Focussing on Clinical Systems & Quality
• Assists communication across the organisation about what is happening in
   clinical I.T. and why certain initiatives are being done.
• Fosters innovation.
• Ensures patient quality and safety legislative requirements are identified and
   followed through.
• Lifts people out of the day to day tasks and routine to focus on higher order
   things.

4. CMIO Role
• Provides clinical leadership and an important interface between I.T. and
   Clinicians.
• Strategically critical role at a senior management level to initiate and foster
   discussion about the value and impact of clinical systems amongst a politically
   influential group of people – Executives, Board, Senior clinicians, House Staff and
   Nurse Managers.
• Functionally critical role at an operational level to make sure clinical system
   configuration is optimised, clinical users are consulted and catered for, Order
   Sets optimised and work flow supported.
• Strong sponsor and advocate for closing the gap between what is currently
   possible and what is actually required.

5. Clinical Advisory Group
• Creates a vision of I.T. that is important and should replace an I.T. Steering
   Committee.
• Should be purely clinically focused and operate on the assumption that systems
   are able to be engineered to support the quality goals of the organisation.
• Themes that arise provide prioritised responsibilities for the Chief Information
   Officer and Chief Quality Officer.


6.7     John Hopkins Hospital

6.7.1    Hospital Overview

John Hopkins Hospital (JHH) is spread across 4 city blocks and has 48,000
employees. It was a 2004 Finalist in the American Hospital Association ‘Quest for
Quality’ Prize. The patient population is drawn from an area with major socio-
economic issues and there is a high prevalence of heroin addiction and AIDS.

It was JHH’s honesty and candour in identifying their clinical system issues and
deficiencies that made it one of the most rewarding and informative site visits of the
Fellowship.




                                                         Original buildings and
                                                         entrance to
                                                         John Hopkins Hospital.




                                                                         Page 29 of 52
6.7.2   Clinical Systems – Hospital Wide

In spite of a reputation for clinical excellence, by its own admission, JHH is not a
leading edge institution in terms of clinical systems. Multiple systems are in use, each
with their own password. Six enterprise wide systems, with limited integration, cover
different functional requirements. The documentation and flowcharting system has a
very ‘dated’ user interface and does not integrate with the CPOE system, despite
being from the same vendor.

Multiple systems with varying subsets of the same information mean different clinical
professionals use different systems to obtain the same information set – this leads to
knowledge inconsistency. Nurses use electronic flowcharting and documentation;
Physicians remain paper based and their documents are not integrated with the other
professional’s notes.

6.7.3   Computerised Physician Order Entry (CPOE)

From the physician’s perspective, the JHH CPOE experience has been
disappointing. The factors are many and include:
• A fundamental lack of integration with other key clinical systems makes it harder
    to understand the complete clinical picture.
• Significant time/efficiency loss in using the system to perform previously
    handwritten functions.
• Loss of the visual cue of a Physician writing an order now that electronic
    documentation is possible from locations away from the bedside. As a
    consequence, nursing staff often don’t realise a new order has been written and
    communication/discussion about the order that previously occurred between a
    nurse and physician has deteriorated.
• Absence of workflow redesign and resourcing constraints so the system is used
    as the ‘scapegoat’ for outmoded processes and delays in actioning orders.
• Few advantages are evident for the primary order writers (Physicians).
• Attending (senior) clinicians, who rarely use the system, understandably forget
    their access passwords and revert to retrospectively signing off printed orders
    entered by a more junior physician.
• Functional limitation of the system such as:
             o Filtering of Order Sets (by priority) appeared not to be possible.
             o Form design doesn’t alert the prescriber to a problem with an order
                 until the form is completed requiring starting from the beginning – a
                 very time consuming, repetitive and frustrating task for the novice
                 user.
             o Idiosyncrasies and inflexibility in ordering particular sets – e.g. if a
                 daily order is commenced after a certain time of day it doesn’t start
                 until the next day. Overcoming these issues depends on the ordering
                 Physician understanding these nuances and having been properly
                 orientated to the system.
             o Annotating why a medication has been ceased is not possible against
                 the order.
             o Screen font so small to be almost unreadable.
• System training is very haphazard and at busy times, nigh impossible. Frequent
    medical staff rotations through some Units exacerbates the training demand and
    reduces the system familiarity. The effectiveness of the training, where delivered,
    has not been evaluated.
• The flow of an observed Ward Round was too fast for the junior medical staff to
    listen, participate in discussion, look up results and type in system orders
    concurrently – as a consequence, all orders were handwritten for typing into
    CPOE system post Ward Round.

                                                                         Page 30 of 52
The JHH experience with CPOE originated from issues in implementation.
1. Testing was inadequate and very complex, but real life order sets were not
   utilised in testing.
2. Training was insufficient and not sustained for ongoing staff changes; Vendor
   trainers were not all clinically experienced so training was provided without a
   clinical context.
3. Resourcing was inadequate and the major determinant of poor clinician uptake.
4. Integration with other systems was non existent.
5. A clinically competent, specialised Help Desk was not available in the initial Go
   Live term and, in hindsight, was recognised as crucial.
6. Critical system and process issues were not clearly evident until after Go Live.
   Safety issues – particularly inadvertent duplication of medications – whilst
   handled quickly, left a bad impression. There was a measured increase in
   medication errors in the initial Go Live period due to system inflexibility and staff
   unfamiliarity.

6.7.4   CPOE – A Physician Perspective

An interview with Dr Roy Brower, the Director of the Medical ICU, provided the
following medical insights into CPOE:
• A true understanding of product capabilities is crucial prior to signing a contract –
     failure to appreciate what the product is not capable of means:
          o The requirement is not built into delivery under the contract.
          o A mismatch of expectations where the end users have assumed detailed
              functionality that in fact is not possible.
• Clinician assessment of functional efficiency is a necessary step in selecting a
     system as ‘fit for purpose’.
• A CPOE system must display information quickly enough to allow medical staff
     on the Ward Round to stay with the pace of the Ward Round discussion.
• In the absence of system integration, so many disparate pieces of clinical
     information are scattered across multiple systems that a comprehensive and
     summarised clinical view of a patient is not readily accessible with the urgency
     required on a Ward Round.
• Clinical data needs to be managed in a way that is efficient, able to be presented
     with urgency and which copes with complexity.
• Physicians pay the price for the benefits of CPOE, which include:
          o Improved communications to Pharmacy.
          o Reduced transcription errors.
          o Improved Medical Records keeping.
          o A more efficient billing process where an interface to the billing system is
              provided.
• CPOE success is inversely proportional to the time taken to resolve user issues.

6.7.5   CPOE – A Project Implementation Team Experience

Key feedback from the JHH CPOE Project Team included:
• An inundation of requests for system enhancements shortly after Go Live, many
   of which were valid but which the product could not support.
• Vendor’s response very slow (months) for system issues; an hourly rate was
   charged for any changes and new reports; vendor’s team were terrible
   communicators.
• A CPOE implementation must be Physician led to be successful.
• Order sets must not be too numerous or too complex.
• Unsigned verbal orders are an ongoing issue as business rules within the system
   do not allow them to be actioned.


                                                                           Page 31 of 52
Improving the JHH experience with CPOE is a major responsibility of their newly
appointed CMIO – Dr Peter Greene. The following is a summary of an interview with
Dr Greene:

 CPOE & Clinical Systems
• The benefits of CPOE are related to standardisation of process – however this is
   also capable of being achieved via a well organised paper system.
• The Benefits of CPOE remain nebulous and to a large extent, are not being
   measured on a global sense.
• Published studies of the CPOE impact on medication safety have focussed on a
   narrow set of medications or order sets – inadequate evidence exists to validate
   the benefits of CPOE on a broad enough scale.
• Hospitals in the US are usually focussing on addressing specific medication error
   issues and are implementing either:
       o CPOE or,
       o Barcode identification of medications and patients.
   There is not often a simultaneous implementation due to the magnitude of the
   associated project and change management and the inability to successfully
   undertake a project of such combined scope.
• Studying the impact of a clinical system on quality of care requires grant funding
   to conduct the study, expertise in identifying the appropriate measures and
   extensive effort – it is therefore rarely done.
• Commercially available clinical systems usually perform a set ‘repertoire’, which
   they perform very well, but they are usually incapable of performing a different
   repertoire.

CMIO Role
• The CMIO role is considered increasingly important in the US Healthcare system
  in the delivery of clinical I.T. benefits.
• The role is most successful when the appointee :
       o Focuses on smoothing the path to system adoption.
       o Maintains some degree of clinical practice which builds credibility in
          clinical colleagues.
       o Reports to the CEO or Chief Physician, rather than I.T. – which enables
          clinical colleagues to see the role as strategic, influential, objective and
          ‘on their side’.

What’s Next in Clinical Informatics?
• Advanced Decision Support
      o Currently relatively primitive.
      o Form ‘Smarts’ where the recording of a combination of risks, triggers an
         algorithm to recommend an individualised treatment strategy.
      o Need to substantially reducing alerting (screen messages and ‘pop up’
         windows so only critical and meaningful alerts are presented to prevent
         ‘Alert Fatigue’).
      o Opportunities to partner with hospitals using ‘like’ systems, to leverage
         combined resources and standardise on treatment protocols and decision
         support initiatives.
• Enhanced Electronic Workflow
      o Electronic workflow to generate consults, measure the time from issuing
         of consult to patient review, alert if they are not actually performed,
         facilitate the documentation of the consult and subsequent
         recommendations, and finally alert the requesting physician when the
         consult outcomes are available.
• The Shared Electronic Patient Record
      o Currently, upload of information from other hospitals is either delayed or
         impossible. There may be a period of time between one patient episode

                                                                        Page 32 of 52
             and the next where the full information set, despite being somewhere in
             the system, is not yet accessible at another affiliated hospital.
         o   Developing the shared electronic medical record, even within affiliated
             hospitals will go a long way to reducing risk and improving patient care.

6.8     Union Memorial Hospital

6.8.1    Hospital Overview

•     350 bed Hospital in MedStar Group.
•     Single largest Health Care Provider in USA - $2.4 billion (US) in operating
      revenue.
•     World renowned for Hand Plastic Surgery, Orthopaedics and Cardiac Surgery.

6.8.2    ICU System

•     Comprehensive ‘in house’ system built in Microsoft Access, by Dr Peter Sloane
      (Chief of Staff).
•     Comprised of a Medical Form to enter:
         o Patient history, examination, and findings, including test results.
         o Procedures performed and prescribed medications and therapies.
         o Problem oriented list and treatment plan.

The system incorporates a section to comply with JCAHO (Joint Commission on
Accreditation of Healthcare Organisations) audit requirements. JCAHO is the US
equivalent of The Australian Council on Healthcare Standards (ACHS). Both
organisations employ accreditors to evaluate health care organisations, according to
a schedule of pre defined quality standards. Accreditation in the US has become
more daunting as all surveys are unannounced, as opposed to the previous (and
current Australian approach), where scheduled evaluations enabled institutions to
anticipate and prepare for an evaluation. Achieving successful accreditation in both
countries is critical to remaining eligible for funding reimbursement from insurers and
managed care organisations. The ‘unannounced’ model now practiced in the US is
the motivation for a continuous focus on quality standards and improvement, as
hospitals never know when they may be the subject of an accreditation review.

Among the 15 key US accreditation goals there are several that are serving as
specific drivers for investment in information technology. These are:

Goal 1: Improve the accuracy of patient identification.
Goal 2: Improve the effectiveness of communication among caregivers.
Goal 3: Improve the safety of using medications.
Goal 8: Accurately and completely reconcile medications across the continuum of
care to prevent medication errors.

These goals are far more specific than those defined by the ACHS. They are very
effective drivers behind healthcare organisations investing in clinical information
technology which is pivotal to achieving compliance.

Within the Intensive Care community, ‘care bundles’ have been adopted as a means
of grouping elements of care, which individually have a sound research evidence
base for improving patient outcome. As an example, all the Intensive Care units
visited on this Fellowship applied the ventilator care bundle which is targeted at
reducing the risk of complications associated with mechanical ventilation. The
ventilator care bundle involves:
• Prophylaxis against deep vein thrombosis and gastric ulcers with medication and
     feeding.
                                                                          Page 33 of 52
•     Elevation of the head of the bed to 45 degrees to reduce the risk of pneumonia
•     Periods of daily reduction in intravenous sedation. This allows evaluation of
      cognitive status, the minimum effective level of sedation needed and reduces the
      accumulation of drug levels in body tissue. It is intended to reduce the time to
      wean a patient from assisted breathing on a ventilator back to spontaneous, non
      mechanically supported breathing.

The differentiator between sites was that whilst practising the ‘bundles of care’ few of
them were actually measuring and validating compliance with the bundles. The
configurability of Union Memorial’s clinical information system allowed the collection
of vast quantities of data by which to measure compliance and associated patient
outcomes. All the Intensive Care Units visited identified that electronic capture of
patient data was critical – paper based recording of data would have made the data
analysis task impossible, been too time consuming to be effective and the manual
capture of data from other electronic systems would have been haphazard at best.
Despite the presence of electronic information systems in all the Units, very few had
leveraged their capability to analyse the collected data. This was invariably due to the
lack of resources, time or skill sets to do this and the loss of momentum and project
fatigue after system implementation.

This site visit reinforced that no single electronic medical record system exists but is
effectively achieved by the combination and integration of:
• A web based portal allowing patient level access into various systems.
• Digitally scanned paper records where procedures and care are not yet
    supported by electronic data capture.
• Niche departmental systems.
• Clinical and research databases.

It further highlighted that an effective program of developing and/or implementing the
components of an EMR are dependant on the drive of a passionate lead clinician.

6.8.3    Visicu Inc.

Whilst visiting JHH, I was introduced to the concept of remote Critical Care
Management, quirkily titled the ‘Doc in a Box’ concept. This is a private service
established by two intensive care physicians from Johns Hopkins, responding to the
scarcity of Intensive Care resources and the drive to standardise care across multiple
hospitals. ICU patients in numerous small to medium size community hospitals are
monitored via a remote, high bandwidth telemedicine network. Proprietary software
(eICU) is used to collect clinical data at the patient bedside and the video and
database information used to conduct trend analysis and perform predictive
assessment. This forms the basis for treatment recommendations to be provided to
on site clinicians by remote experts. A study of the eICU system published in Critical
Care Medicine8 identified clinical and financial benefits of this model. The availability
of computer-based tools, the 20-30% ICU contribution to hospital operating costs and
increased focus on ICU performance are all drivers for introducing electronic support
to clinical management.


6.9     Duke University Hospital

6.9.1    Hospital Overview

The Duke University Hospital commenced as a Medical school and Hospital with a
$4 million (US) endowment from the Duke ‘tobacco and energy’ family fortune. It


8
    March 2007, Pages 66-76
                                                                           Page 34 of 52
occupies an entire suburb on the outskirts of the city of Durham, North Carolina. The
organisation operates two main multi storey buildings:
• Duke North hosting:
           o 924 inpatient beds.
           o 116 Intensive Care Unit beds.
           o 34 Operating Theatres.
• Duke South hosting:
           o Outpatient and pre-operative Assessment clinics.

The campus is so large that two single carriage tramways operate continuously,
transporting staff, patients and visitors between the North and South buildings. One
of Duke’s fields of expertise is surgery (any specialty) for the obese – Duke’s
surgeons often operate on patients that other professionals have refused and the
institution has developed expertise in managing anaesthesia in the significantly
obese.




         Single carriage tramway between Duke North and South Buildings.

6.9.2   Clinical Systems

The Associate Chief Information Officer, an anaesthetist by background, attributes
the success of clinical informatics at Duke to the evolutionary involvement of more
and more physicians in the I.T. Department. This was made possible in the ‘golden
era’ several years ago when more funding was available and clinical systems began
expanding from departmental to organisational wide access. Despite a more recent
reduction in clinical I.T. funding, there is a sustained presence of clinicians in the
informatics area and they still drive such initiatives at the hospital.

As with Union Memorial, Duke has developed a highly successful in house system
for peri-operative patient management. It incorporates a web based viewer to
integrate different existing peri-operative systems. Like many of the hospitals visited,
Duke has pockets of clinical systems meeting specialty needs and just as many
areas where the paper based chart predominates and electronic access to clinical
information is not available due to the absence of a suitable system.

In the pre-operative Assessment Clinics, Nurse Practitioners conduct the
assessments and the majority of patients are not seen by an anaesthetist until just
prior to surgery. For healthy patients, phone screening is performed, eliminating the
need to attend an on site Assessment Clinic. An electronic tool supports the standard
and quality of assessments conducted. It ensures a consistent set of pre-operative
                                                                          Page 35 of 52
questions, tests and examinations are conducted, the standardised documentation of
information and the categorisation of patients into risk levels based on menu driven
responses. Whilst users reported it takes an extra 5-10 minutes more than the paper
based version, the benefit is a reduction in time to document for re-presentations and
multiple admissions, as much of the static data (demographics, past medical history)
does not need to be rekeyed.

Other key clinical systems in use are:
• eBrowser – provides a common clinical portal for access to applications.
• A CPOE system which despite significant customisation to satisfy clinicians, is
   still the source of much dissatisfaction for House staff (physicians and surgeons
   in speciality training).

Once again, the lack of system integration and the multiplicity of stand alone
applications that must be used for a comprehensive patient view, was a recurring
theme in this site visit. It was to a large extent the reason for dissatisfaction with
current clinical systems.

The CPOE system was also viewed as having been introduced under pressure from
insurers and the National Institutes of Health, rather than for valid local reasons or to
address Duke specific requirements. The predominant clinical view was that there
was little research evidence of the local impact of the system in reducing medication
errors. However there was anecdotal experience that it had overcome handwriting
legibility issues and the automated alerts to drug interactions and incompatibilities
were viewed as a positive.


6.10 MD Anderson Cancer Centre

6.10.1 Hospital Overview

MD Anderson is a not for profit organisation, with an annual operating revenue of
$2.5 billion (US). It occupies 4 million square feet of land, comprises 15 multi storey
buildings and operates 22 Outpatient Clinics, 32 Inpatient and 6 Outpatient Operating
Theatres. George Bush (Snr) is a Member of the Board and reflects the prominent
and influential personages who have contributed to MD Anderson’s position as a
leading US Healthcare institution.




                                                                              MD Anderson
                                                                              Hospital complex




                                                                           Page 36 of 52
MD Anderson was amongst the most impressive of the Fellowship visits. This was
the centre where I witnessed robotic surgery and the ‘Brain Lab’, where a
neurosurgical operating theatre has its own MRI (magnetic resonance imaging)
scanner, allowing brain scans to be conducted during the course of surgery to
confirm complete removal of tiny vestiges of brain tumours. Watching the marvel of
robotic surgery, and travelling through the US at a time when the Iraq conflict was at
the forefront of world news, it was not hard to envisage the future. It is clearly not too
long before specialist surgeons located hundreds of kilometres away from battle
fields, will be able to conduct remote surgery on wounded combatants and offer
expertise to save lives and limit permanent injury.

My outstanding impressions from this visit were:
• MD Anderson not only treats cancer, it beats cancer.
• A striking sense of coordination, control and serenity pervades the organisation.
• The integrity of the people is what makes the difference in this hospital.
• There is an incredible and unquestionable belief that they provide the best cancer
   care in the country.

The motto of the organisation is Caring, Integrity and Discovery. Research is a
mission driven focus of MD Anderson and there is an expectation that every senior
clinician will be a primary or contributing author to research publications on an annual
basis. As clinicians are also researchers, there is an intrinsic understanding of the
value of capturing clinical data electronically and why data needs to be collected in a
particular way to facilitate analysis. Clinical care is research driven with patients
benefiting from the application of trial findings and newly developed treatments even
before they have been published and peer reviewed. In the setting of rapidly
progressive or treatment resistant cancers, patients have nothing to lose by opting for
cutting edge treatments which offer options and hope in an otherwise hopeless
situation.

6.10.2 Clinical Systems

The strategic importance of developing an electronic medical record (EMR) at MD
Anderson is demonstrated in the following ways:
• Of the 600 I.T. staff at MD Anderson, 100 are clinicians.
• Clinical applications are considered the most important institutional systems.
• The Physician In Chief and Research Director are members of an Executive
   Committee governing and driving the EMR strategy.
• An EMR Taskforce and Project office exists, staffed by 100 people, of whom
   more than 40 are software developers.
• Several physicians hold roles devoted solely to communication and liaison
   between clinicians and the I.T. department.
• Strong project governance and a commitment to ensure effectively skilled and
   adequate project resourcing.

Amongst the clinical applications in use are:
• Digital radiology.
• Scanned and electronically generated clinical documents.
• A peri-operative system.
• A locally (in-house) developed, web enabled clinical viewer that references
  numerous clinical databases and displays the data in an integrated view.

Other innovative uses of information technology include:
• A facial photo is displayed on each patient’s ID wristband.
• Each operating theatre contains two 40 inch plasma screens:

                                                                            Page 37 of 52
           o   One displaying colour coded patient information, the status of each
               case, anaesthetic and surgical information.
           o   The second displaying the images from cameras mounted in the
               operating lights and allowing visualisation of the operative field, even
               to those located away from the operating table.

The CPOE experience at MD Anderson mirrors that of the other US sites visited. The
Physician ordering and verification process for medications is long winded and a
source of much frustration. The perceived inadequacies of the system are
exacerbated by the lack of integration with an electronic medication administration
system. Again, like most sites, no studies on the impact on quality of care have been
conducted despite the research orientation of the organisation.

The funding for clinical system projects is primarily generated by clinical billing.
Pharmacy and diagnostic radiological imaging are huge sources of revenue. Other
sources of revenue – philanthropy, research grants and faculty donations – are
channelled primarily to supporting research. The philanthropy practised in the US,
and particularly in oil wealthy Texas, is on a scale that in Australia could not be
envisaged. In the week I arrived at MD Anderson, an individual oil tycoon donated
$50 million (US) and a multi storey building for the purposes of clinical research.




       MD Anderson’s expansive corridors showing golf buggies for transport.

6.10.3 Lessons Learnt

There were some salient lessons from the MD Anderson visit in relation to clinical
information systems:
• Implementation of three commercial EMR products had been attempted and all
    had failed.
• The root cause for these failed projects was believed to be the inability to cater
    for the degree of customisation and varied requirements.
• Clinical project staff identified that commercial companies were not interested in
    developing for large, specialist institutions as the scale of the projects, long
    development lifecycles and associated costs were not financially viable.
• The generally held belief was that commercially available products in the US
    were designed for medium tier general hospitals, not major speciality institutions
    and particularly not for chemotherapy, radiotherapy and surgery.
                                                                          Page 38 of 52
6.11 Cedars Sinai

6.11.1 Hospital Overview

Cedars Sinai is the largest not for profit institution in the Western US and was ranked
by U.S. News & World Report as the 17th-best hospital out of 5,462 medical centers
in the country.




                                 Cedars Sinai Hospital

6.11.2 Clinical Systems

In 2003, Cedars experienced a highly publicised abandonment of a newly
implemented CPOE system, driven by medical staff complaints that it was slow and
inefficient. The demise of the system was inevitable when delays in filling orders and
issues in tracking orders through the system impacted on physician billing revenue.
Cedars reverted to its aged CPOE system which is again planned for replacement
over a 3-5 year period. As an outcome of the lesson learnt from 2003, Cedars new
CPOE replacement project committee is led by a physician and conducts extensive
consultation across professional clinical groups.

It was interesting to observe that despite the current system being intended as a
physician ordering system, all medical orders originate on paper and are later
transcribed into the system by clerical staff. In the ICU, nursing staff also transcribe
these paper based orders into the medication administration module of an electronic
bedside system. The process of medication ordering and administration in the US is
very different to that practised in Australia. The US transcription phase by non clinical
staff introduces overhead and a non value added step into the process. At the sites
visited on the Fellowship, the clerical staff only received limited training in medical
terminology and the risk of transcription errors was often realised due to unfamiliarity
with medications and their associated indications for use.

An interview with Dr Michael Shabot, Cedars former Director of Medical Informatics
(now Chief Quality & Patient Safety Officer, Memorial Hermann Healthcare System)
provided the following insights into CPOE systems, gained from the 2003 experience:
                                                                          Page 39 of 52
•   Training physicians is incredibly difficult as they are notoriously limited in time and
    availability.
•   Complex scenarios are required to test out assumptions about how a system will
    operate – it is very hard to simulate the hectic and fragmented work flow that is
    often a reality of the clinical environment.
•   300-400 changes to the Cedars system were requested shortly after going live,
    overwhelming the capacity of the support team to respond with efficiency and
    effectiveness.
•   Virtually any downtime of a system of this nature is intolerable, so that installing
    upgrades and software patches presents a problem.




                                                                            Page 40 of 52
7 UK Site Visits – Summary
The practice of medicine, hospital operations, models of clinical care and strategies
around clinical systems observed in the following site visits (UK, Germany and
Denmark) more closely resemble those of the Australian experience than was the
case in the US.

7.1     St Thomas’ Hospital

7.1.1    Hospital Overview

St Thomas’ Hospital’s origins date back to the 1100s when a mixed order of
Augustinian monks and nuns, dedicated to Thomas Becket (Archbishop of
Canterbury), provided shelter and treatment for the poor, sick and homeless. St
Thomas’ is situated in London, directly across the Thames River from the Houses of
Parliament and Big Ben. Many of the current buildings are over 100 years old and
include an ‘Ether Dome’ like the Massachusetts General Hospital. The Florence
Nightingale School of Nursing is also located here with a Museum dedicated to her
on the site.




      View form St Thomas’ Hospital across to Houses of Parliament and Big Ben.

A total of 80 Intensive Care Unit beds are available – this site visit involved touring
the two 15 bed adult Intensive Care Units. Other specialty ICUs include a Paediatric
and Cardiothoracic Unit.

7.1.2    ICU Clinical Systems

The clinical system environment of the adult ICUs includes:
•  Wireless and laptop mounted carts available for the Ward Round .
•  A Bedside clinical information system, implemented in 2001, for which no device
   interfaces have been implemented.
• A commercial Cancer Management system incorporating Outpatient Scheduling.
• A digital radiography system – interestingly, the nursing staff do not use this as:
            o Senior/experienced nursing staff are often not available.

                                                                          Page 41 of 52
           o   The daily review of x-rays is conducted away from the clinical area
               which does not facilitate or encourage nurses to attend.
           o   Increasingly, an international and transient nursing population brings
               varying standards of care and knowledge so nursing familiarity with x-
               ray interpretation is variable.

A commercial research group in ICU,
comprising 5 nurses, generates revenue by
testing new critical care equipment and
drugs. The ability to easily and automatically
capture clinical bedside data makes St
Thomas’ highly sought after as the pilot site
for new technologies.

St Thomas is currently piloting an upgraded
version of their ICU specific bedside
system. They have elected to remain with a
specialised system as their observation of
the market place is that larger, hospital wide
systems:
• Don’t cater for the specificity required in
    ICU.
• Have a US or German bias in design.
• Do not have the experience required for
    ICU implementation.
• Do not provide the ‘one stop shop’ to be
    capable of providing both cardiac
    monitoring and clinical bedside charting
    equipment.

The aim is to roll out the product to all acute
beds and eventually general wards as the
NHS has accepted that the full EMR will
require ‘portal’ solutions and an
amalgamation of individual applications
integrated into a seamless view.

The fortunate combination of a small group of physicians and nurses with clinical
leadership and a passion for clinical information systems has been crucial, and the
key to success at St Thomas’.

7.2   Royal Brompton Hospital

The Royal Brompton Heart & Lung Hospital is located in Chelsea and is a nominated
health provider for the British Royal family. It operates 240 beds of which 20 are for
Intensive Care patients.

The Brompton’s Clinical I.T. strategy is a ‘component based’ electronic health record
strategy with multiple applications coupled together to provide a comprehensive
patient view, rather than investment in a single large application. According to Dr Cliff
Morgan, the ICU Director, the Brompton’s investment in electronic clinical
applications is driven by the knowledge that they help eliminate serious clinical
issues and provide information and a record of care in a legible, trendable manner.

The clinical applications available at The Brompton include:
• A digital radiography imaging system.


                                                                          Page 42 of 52
•   A Cardiology digital imaging and archiving system for echocardiograms,
    angiograms and other studies.
•   An ICU bedside clinical information system for patient flowsheets, notes and
    medications. It was interesting to note that use of the medication administration
    component of the application had encountered some resistance from Pharmacy
    until the appointment of an Australian Pharmacist who has enthusiastically
    championed implementation!
•   A web based, Physician specific patient census, and view of Pathology Results
    and radiology images – the functionality and configurability of the current system
    is relatively limited and is scheduled for replacement.

Prospective applications include:
• An operating theatre management system being implemented reluctantly, under
   mandate by the National Health Service. There is significant clinical resistance to
   the system as it is seen to provide only management reports and not be a useful
   contribution to clinical care.
• Rolling out a scaled down version of the ICU bedside clinical information system
   into the general ward areas as the ICU environment is a microcosm of the
   medical/surgical wards. It was interesting to note that this is the same strategy
   planned at St. Thomas’ and the same software application is in use at both
   hospitals.
• Wireless capability and laptop mounted carts are to be implemented for use in the
   ICU Ward Round.
• An electronic communication, results reporting and ordering system is planned to
   address the Order/Entry component of the electronic clinical record. It will only be
   used for physician generated orders for tests and services – not nursing or
   treatment orders such as ‘Start nasogastric feeds’.

Limiting Order/Entry to physician use is in contrast to the US model, where all Health
professionals use the system. The observed down side of the US model is that a
daily list of orders becomes so voluminous that it is very difficult to pinpoint priority
orders. A critical request such as ‘Perform chest x-ray for suspected lung infiltrates’
may be buried deep in a list containing standing orders such as ‘2 hourly mouth
care’, and subsequently not prioritised and expedited. This phenomenon was
observed during one of the visits to a US hospital where a drug order sat latent for 5
days in the Order/Entry system before finally being followed through for dispensing
and administration.




                     Front Entrance to The Royal Brompton Hospital.

                                                                           Page 43 of 52
7.3   NHS - National Information Technology Programme

The site visits to St Thomas and The Royal Brompton Hospitals provided ‘on the
ground’ clinician perspectives of the ambitious 10 year UK program to introduce
electronic health records. Launched in June 2002, and managed by the government
unit ‘NHS (National Health Service) Connecting for Health’, the program aims to
deliver better, safer care to patients. The core of the programme is new computer
systems that hold the electronic patient care record, and services, that link General
Medical Practitioners and community services to hospitals.

The Connecting Health Strategy encompasses the following key systems and
infrastructure:
1. National Data Spine consisting of an integrated communications network and
    electronic clinical record holding summary information for individual patients such
    as NHS number, demographic details, allergies, adverse drug reactions and
    major treatments.
2. Electronic Appointment Booking (‘Choose & Book’).
3. Smart Card (Log In).
4. Digital Radiography System.

Discussions with UK clinicians offered the following insights on the NHS Programme:
• ‘Choose & Book’ appointment booking use was initially limited but good ‘buy-in’
   has now been achieved.
• Development of this concept was hampered by the lack of appreciation of the
   sophistication and diversity of internal hospital systems and the challenges of
   interfacing between external and internal systems.
• UK government chose the ‘Enterprise Model’ for health applications – i.e. to
   implement on a whole of health service basis which reflected the ‘New Labour’,
   top down, centralised/mandated approach.
• Under the strategy, the UK was divided into regions incorporating numerous
   Trusts: in effect public sector corporations.
• There are 5 major types of NHS Trusts carrying out direct services:
           o Primary Care Trusts (General Practitioners, Dentists, Opticians etc.).
           o Hospital Trusts (often referred to as Acute Trusts).
           o Ambulance Services Trusts.
           o Care Trusts (providing community based health and social care).
           o Mental Health Services Trusts.
• Under the NHS Programme various service providers have been awarded
   contracts to supply clinical product and services to the Trusts within a region
• Significant difficulties have arisen as:
           o Companies awarded the opportunities have never done this scope of
               implementation before.
           o Hospitals are separated from direct contact with system suppliers by
               implementation partners, who have immature knowledge of the
               products they are introducing and the workflow of the clinical
               environment.
           o Contractual delivery of some systems was not achieved and delays in
               delivery have occurred with all systems.
           o The involved hospitals have never undergone this degree of
               transformation.
• Communication from the NHS to ‘on the ground’ clinicians is perceived as non
   existent.
• St Thomas’ ICU was to be a recipient of an enterprise clinical system but to date
   the software has not appeared.
• The Patient Administration System applications are poorly integrated modules
   bolted together.

                                                                         Page 44 of 52
•     Bidirectional interfaces to other systems have taken more than one year to deliver
      and in that context, the ability to make hospitals paperless has proven impossible
      for all the vendors.
•     There was an initial hiatus on any new investment in a variety of clinical systems
      as the NHS identified that they would drive and provide all systems. Whilst a
      noble vision, it proved a fractured reality and there is now a pragmatic
      acknowledgement by the NHS that individual Trusts need to get on and invest
      and implement clinical systems on their own, or they will never happen.

In general, the hospital based clinicians’ view of the NHS and the clinical systems
programme is one of disillusionment – a substantial part of this appears to reflect a
mismatch of expectations and the difficulty of communicating and engaging widely
enough across such a substantial national program.

7.4     UK Health Funding

The UK Health funding model is similar to Australia – with the use of HRGs (Health
Related Groups) the equivalent to the Australian DRGs (Diagnostic Related Groups).
HRGs classify hospital cases into one of 100’s of groups based on diagnosis,
procedures, age, sex, and the presence of complications (e.g. infection) or
comorbidities (the effect of other existing conditions, such as heart disease, in
addition to the primary diagnosis such as diabetes). Hospital funding is based on the
number of cases treated in each HRG group and allocated on the premise that the
extent of use of hospital resources is able to be standardised per group and hence a
fixed funding allocation is payable per case, per HRG.

                           Government (National Health Service)

                                       Trusts
                            (Manage HRG Funding Allocations)

                                        Hospitals

Mental Health services operate as separate Trusts – separated from Health Services
in a model similar to the former Victorian (Australian) one. As with Australia, the HRG
funding system does not incorporate a payment component for clinical information
technology (other than pathology and radiology services) in the treatment and so
clinical informatics relies on separate funding initiatives, such as through the NHS
Connecting Health programme.

7.5     Cerner

A visit to the headquarters of Cerner Corporation, one of the clinical system suppliers
to the NHS Programme, provided further insight into the clinical systems strategy and
its implementation in the UK.

Under the programme, the delivery of clinical systems has been awarded to major
consultancy firms who are the prime contractors responsible for training and project
management. This model of having ‘Integration and Delivery partners’ isolates the
software suppliers from:
• Fully appreciating the implementation issues.
• Establishing test scenarios that truly reflect the realities of the clinical
     environment.
• Directly influencing outcomes.
This degree of separation is a significant cause of dissatisfaction from Hospitals and
for the software suppliers themselves.

Cerner’s ‘Powerchart’ is the contracted clinical product and includes:
                                                                          Page 45 of 52
•     Scheduled Appointment Booking.
•     Outpatient and Operating Suite Bookings.
•     Main Patient Administration functionality including Admissions and Waiting List
      Management.
•     Ancillary systems for Operating Theatre, Emergency Department and Pathology
      Laboratory system management.
•     Approximately 57 solutions or modules which will eventually be available under
      the program.

One of the key insights gained on the visit was an understanding of the basis for the
mismatch of expectations about the programme between hospital based clinicians
and the NHS. Under the NHS managed contracts, the software suppliers are
committed to deliver a full suite of products but over several years and release
versions. Many of the UK clinicians I spoke to during the Fellowship have not been
privy to the agreed schedule of staggered functionality releases, and so perceive the
currently available product sets as all that will be delivered and hence inadequate.

There are also some fundamental issues with the available software and its
applicability to the UK environment:
• Order/Entry is based on the US process and designed to meet billing purposes
   with the result that the Order/Entry functionality is overly convoluted and a multi-
   step process.
• Deep functionality has been provided at the sacrifice of useability.
• Users are presented with many icons and they need to recurrently log on to
   access different modules.
• Screen design and language is inconsistent – e.g. a ‘Visit’ on one screen is
   termed an ‘Encounter’ on another screen.

However in spite of the reported and observed challenges associated with the NHS
Programme, the UK’s National Audit Office Parliamentary report in June 2006
identified:
• ‘..substantial progress with the Programme’
• ‘The Programme’s scope, vision and complexity are wider and more extensive
    than any ongoing or planned healthcare IT programme in the world and it
    represents the largest single IT investment in the UK to date. It is designed to
    deliver important financial, patient safety and service benefits’.

At the time of my Fellowship visit:
• The Connecting Health budget was trimmed by then new UK Prime Minister
     (Gordon Brown) from £6.1 billion to £4.2 billion.
• The new Health Minister (Alan Johnson) was considering the options for
     Connecting Health, from continuation as is through to a realignment of the
     strategy.
While a lot of important foundations have indeed been put in place, the delivery of
clinical systems has so far been far slower and less comprehensive than planned
and the realisation of measurable clinical benefits remains intangible. To a large
extent this is for the same reasons as encountered in the US – the focus has been on
system implementation rather than establishing measures of quality of care for which
these systems are to be applied and conducting pre and post evaluation of impact.

7.6     London Oncology Clinic

Part of the Fellowship experience was to examine the bedside infrastructure used for
delivery of clinical applications. In all but one of the sites visited, clinical systems
were being made accessible via a combination of standard desktop computers
installed in close proximity to patient bedsides and to a far lesser extent, through the
use of wireless, cart mounted laptops. The prevailing view was that smaller, more
                                                                          Page 46 of 52
portable devices were not optimal for accessing and capturing clinical bedside data
and existing wireless capabilities are not yet robust, reliable or fast enough to support
clinical computing demands. For those sites using wireless laptops, limited battery
life remained a significant impediment to routine use.

                                          The one exception to the use of standard
                                          PC or laptop infrastructure was observed in
                                          a visit to the London Oncology Clinic,
                                          located in London’s famous Harley Street.
                                          This Clinic offers a full private outpatient
                                          cancer service including radiotherapy,
                                          chemotherapy and specialist oncology
                                          services. Each patient cubicle contains a flat
                                          screen monitor mounted on a flexible,
                                          cantilevered arm. The system, produced by
                                          the UK based Wandsworth Group Ltd,
                                          provides a touch screen patient
                                          entertainment system and provides access
                                          to clinical systems.

                                          Patients are able to access the internet, web
                                          based cancer internet information services,
                                          radio, email, computer games and
                                          television. There is even satellite access to
                                          Arabic channels to meet the needs of the
                                          large clientele who visit the Clinic from the
                                          Gulf States.

                                          Access to clinical applications is enabled by
                                          password controlled entry into a clinical
                                          viewer. Via the same flat screen monitor,
                                          clinicians have access to the pharmacy
                                          system, digital radiography images and a
                                          medical oncology database – ‘MOSAIQ’.
                                          The manufacturer originally responded to
                                          the NHS Patient Bedside Systems tender to
                                          provide the portal for clinical application
                                          access. Dissatisfaction with the
                                          preponderance and lack of opportunity
                                          provided by the NHS, and the inordinate
                                          delays in delivering clinical systems, have
                                          led Wandsworth to focus on overseas
                                          markets.

   Wandsworth bedside terminals




                                                                          Page 47 of 52
Denmark Site Visit – Summary
7.7   Roskilde Syghausen (Hospital)

An overnight visit to Denmark provided the opportunity to visit the 9 bed Intensive
Care Unit in Roskilde Hospital, approximately 30 kilometres west of Copenhagen.
Quaint features of the site include:
• Physicians, surgeons and nurses all dress in white scrubs and coats so individual
   professions are indistinguishable to visitors.
• Staff use foot propelled scooters to travel the hospital corridors and reduce transit
   time.




                            Roskilde Syghausen (Hospital)

In January 2007, Denmark consolidated12 health regions to 5. As a consequence, at
the time of the Fellowship visit, hospital based I.T. services were being amalgamated
into regional Data Centres. This was causing a huge amount of disruption and
reducing the capacity to move forward aggressively on planned clinical application
projects.

The Roskilde ICU has operated a bedside clinical information system since 1992. As
with many other sites visited, the opportunity to introduce the system arose from
funds made available through a capital building project. Other applications in use
across the Roskilde campus include:
• Opusmedicin – a purpose built medication order/entry and administration
    recording system with functionality limited to ‘pills’ administration on the general
    wards.
• A Patient Administration System.
• Digital radiography.
• A Pathology results viewer.

The below diagram depicts the state of bedside clinical applications at Roskilde and
in general, at all the sites visited on the Fellowship. The Roskilde Clinical systems
strategy, is a combination of many systems from multiple vendors, and there has
been limited, if any, opportunity for evidence based validation of the impact on quality
of care. Once again, this was representative of the majority of site visits.

                                                                          Page 48 of 52
                          Patient Administration System
Medications       Digital Xrays     Pathology &       ICU Clinical      Specialised              CURRENT
                                     Radiology          System          Departmental             Available
                                      Results                             Systems                clinical
                                                                                                 solutions.
              Clinical Portal (web based front end for system access)
       Interface Engine (sends some data and messages between systems)
                                                                                                 FUTURE
                                                                                                 Functionality
                                                                                                 necessary to
                                                                                                 achieve a
                                  Integration Tool                                               comprehensive
                                                                                                 EMR.
                           Centralised Data Repository
                                                                                                 POSSIBLE
                                                                                                 FUTURE
                                                                                                 Validation of
Evidence Based Research of Clinical Information Systems Impact on Quality of Care                outcomes &
                                                                                                 success.


               Roskilde Syghausen’s Clinical Information Strategy




                                                                                 Page 49 of 52
8 Germany Site Visits – Summary
8.1     Tubingen University Hospital

Located in Southern Germany, enroute to the Black Forest, Tubingen University
Hospital incorporates 900 beds – 40 of which are Intensive Care beds.

A bedside clinical information system has been in operation since 1993. Success
with the system is attributed to the significant involvement of clinicians in initial
system selection and subsequent system development and support. In fact, one full
time physician and nurse devote 50% of their employed hours to this purpose.

In Germany, ICU bedside systems have proved particularly important in:
• Collecting data and providing performance reporting for insurers. The ability to
    electronically capture patient specific hours of mechanical ventilation has been
    crucial to meeting funding measures.
• Collecting data for research trials.

As was the experience in the UK, and in contrast to the US model, implementation of
Order/Entry at Tubingen has been pragmatic in approach. Only physician generated
orders are entered and captured electronically. Again, the experience of physician
training was a challenge at this site due to the limited availability of doctors to attend
training sessions en masse, at set times and in designated locations.

8.2     Mainz University Hospital

Mainz University Hospital, is close to double the size of Tubingen at 1570 beds and it
operates 45 Intensive Care beds. Post surgical patients occupy 85% of the ICU beds
and one of the ICUs is dedicated to the management of bone marrow transplant
receipients.

8.2.1    Clinical Systems

The following are the key systems at Mainz:
• Organisation wide system for Ward Management, Order/Entry, Discharge
   Summaries and Appointment scheduling.
• The ICU and Anaesthetic services use the same bedside clinical information
   system as Tubingen.
• Pre operative assessment is paper based but subsequently scanned and OCR
   (optical character recognition) technology is used to create an electronic
   database of information for reference.

Like Tubingen, Mainz University Hospital attributes the success of clinical systems to
the active involvement of clinicians – one full time nursing position and a half time
medical position are dedicated to supporting and developing the system configuration
and reporting in the ICU.




                                                                           Page 50 of 52
9 References
Breslow, MJ et al, Effect of a multiple-site intensive care unit telemedicine program
on clinical and economic outcomes: An alternative paradigm for intensivist staffing,
Critical Care Medicine. 32(1):31-38, January 2004.

Bush, G. W. National Economic Council, Reforming Healthcare for the 21st Century,
February 15, 2006

Karsh, B-T, Beyond usability: designing effective technology implementation systems
to promote patient safety, Quality and Safety in Healthcare 2004; 13: 388-394

Fraenkel, D, Clinical Information Systems in Intensive Care, Critical Care and
Resuscitation 1999, 1:173-179

Guidelines for the provision of anaesthetic services, 1999, The Royal College of
Anaesthetists, United Kingdom Pg 32

Integrated Healthcare Systems, Enhancing Quality through Collaboration: The
California Pay for Performance Programs, February 2006

Kaushal, R. and Bates, D.W., Information technology and medication safety: what is
the benefit?, Quality and Safety in Health Care 2002; 11:261-265

Leong, J.R. et al, eICU program favorably affects clinical and economic outcomes,
Critical Care 2005, 9:E22

Peters, S et al, Is the tele-intensive care unit ready for prime time?, Critical Care
Medicine. 32(1):288-290, January 2004.

Physician Leadership in Information Technology, Scottsdale Institute Spring 2006,
Scottsdale Arizona, April 6-8, 2006

Shabot, M. Michael, Ten commandments for implementing clinical information
systems, Boone Powell, Sr., Lectureship at Baylor University Medical Center,
February 25, 2004

The National Programme for IT in the NHS, Report by the Comptroller and Audiotr
General, HC 1173 Session 2005-2006, 16 June 2006

US News & World Report, July 23, 2007

Van der Meijden M. J. et al, Determinants of Success of Inpatient Clinical Information
Systems: A Literature Review, J Am Med Inform Assoc. 2003 May–Jun; 10(3): 235–
243.

Versel, N Positioned for Success: The Rise of the CMIO, For the Record, September
18, 2006 Vol. 18 No. 19 P. 40

Wears RL, Berg M, Computer Technology and Clinical Work Still Waiting for Godot
JAMA. 2005;293:1261-1263.




                                                                            Page 51 of 52
10 Images
Cover photograph courtesy of Philips Medical Systems Nederland B.V.
http://incenter.medical.philips.com/doclib/enc/fetch/2000/4504/577242/577243/57724
7/582646/583147/PM_-_CareVue_Chart.pdf?nodeid=1287802&vernum=1


11 Glossary
ACHS                   Australian Council on Healthcare Standards
Clinical Informatics   The study of information systems (computers and programs)
                       used in the clinical practice of medicine
CPOE                   Computerised Physician Order Entry – refer Order/Entry
EHR                    Electronic Health Record
EMR                    Electronic Medical Record
House Staff            Physicians and surgeons in specialist training
ICU                    Intensive Care Unit
JCAHO                  Joint Commission on Accreditation of Healthcare Organisations
MGH                    Massachusetts General Hospital
NHS                    National Health Service (United Kingdom)
PACS                   Digital Radiology System – both x-ray images and their
                       associated reports
Patient                A hospital computer system which records the patient's
Administration         demographic details and each contact with the outpatient
System (PAS)           department or admission and discharge. The functionality in a
                       PAS may be minimal or extend to clinical practice (e.g Operating
                       Suite Management) depending on individual hospital
                       enhancements
Order/Entry            Process of electronic entry of physician instructions (orders) for
                       tests/services (pharmacy, radiology, pathology) or other health
                       professional (e.g. nurses, physiotherapists) services into an
                       electronic system. CPOE decreases delay in order completion,
                       reduces errors related to handwriting or transcription, allows
                       order entry to occur at the point-of-care (bedside) or off-site,
                       provides error-checking for duplicate or incorrect doses or tests,
                       and simplifies inventory management and billing.
Ward Round             A pivotal and at least daily procedure in hospital-based care.
                       Usually conducted at the patient bedside and led by a senior
                       doctor, the group of clinicians involved in a patient’s care meet
                       and discuss the patient’s condition, test results and progress and
                       determine an integrated plan of care.




                                                                         Page 52 of 52

				
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