Healthcare’s ‘Most Wired’ Transforming Workflow and Patient Care

By Debra Wood, RN, contributor

August 1, 2013 - While healthcare once lagged other industries in embracing technology, a push from the federal government has changed things dramatically. The Health Information Technology for Economic and Clinical Health Act of 2009’s push for meaningful use of electronic health records (EHRs) and the need to streamline operations has hospitals and health systems swiftly catching up.

Providers are now an integral part of the movement to change how care is delivered and documented, with nearly 300 hospitals making Hospitals & Health Networks' 2013 Most Wired list.

“We had so many things on our roadmap, and meaningful use was a catalyst to getting these things done,” said Bonnie Kierstead, director of clinical IT strategy in management information systems at Florida Hospital in Orlando, who attributes earning a spot on the list to its integrated clinical systems and pervasive wireless networks that let clinicians be more mobile. “It puts the tools in the hands of the clinicians at the bedside.”

North Shore-LIJ Health System in New York also has provided clinician-ready access to electronic decision-support tools and guidelines, and nurses use evidence-based charting as patients are assessed or care provided.

“It has helped our nurses and our patients,” said Susan Robertson, RN, vice president of clinical information systems at North Shore-LIJ. “Our model is to look at best practice and design technology to support the process.”

North Shore-LIJ is utilizing the EHR to help nurses eliminate redundant questions to inpatients and outpatients, and simplify updates regardomg medications, diet and other changes.

“It saves time for the nurses, and they have more time to connect with the patient and develop the relationship,” said Marianna Vazquez, RN, associate executive director of patient care services at Syosset Hospital, a North Shore-LIJ hospital. “We build on a plan based on good historical information.”

Hospitals & Health Networks’ 15th annual Health Care's Most Wired Survey focused on four areas: (1) infrastructure; (2) business and administrative management; (3) clinical quality and safety in both the inpatient and outpatient settings; and (4) clinical integration. About 30 percent of U.S. hospitals responded to the survey, and 289 made the list.

Texas Children’s Hospital in Houston received a 2013 Innovator Award for its rapid communication system. Nurses carry special iPhones that make and receive voice and text messages with colleagues, physicians and families, and receive monitor and other alerts.

Shannon Holland: rapid communication system helped make Texas Children's Most Wired.
Shannon Holland, MSN, RN, NEA-BC, reports a rapid communication system has improved patient satisfaction at Texas Children’s Hospital.

“It’s changed the way [nurses] do business, and they like it,” said Shannon Holland, MSN, RN, NEA-BC, assistant director of the newborn center at Texas Children’s, adding that it has improved response time, communication, and patient and family satisfaction.

All of the Most Wired facilities document at least 80 percent of patient care as structured data, including a problem list of current and active diagnoses.

“It goes beyond having an electronic medical record,” said Ana M. Rodriguez, PharmD, PMP, clinical informatics/IT administrative director at Memorial Healthcare System in Hollywood, Fla., an early pioneer of barcode drug administration. Nurses found barcoding so helpful in eliminating medication errors that they pushed the IT department to expand barcoding to breast milk, vital sign transmission and specimen collection, including pathology specimens in the operating room with labeling at the bedside. 

Gaining efficiencies

Many facilities are focusing on enhancing the record system or developing other technologies to enhance quality of care or restructure in preparation for reimbursement changes.

Florida Hospital electronically tracks supplies, equipment and nurses’ workflow, aiming to learn more about how many times they go to a drug-dispensing machine or to gather IV equipment, so the hospital can determine where to most appropriately locate those items to save time.

“Good process is enabled by technology,” Kierstead said. “If we can make it simpler for the clinicians, then patients will benefit by increased safety and clinicians with greater productivity.”

Nurses welcomed the workflow analysis, assured efficiencies gained would be applied to time with patients and not eliminating staff, she said.

Donna McDonough EHR decision-support tools improve patient care.
Donna MacDonough credited decision-support tools and access to data across settings with improving patient care.

Donna MacDonough, administrative director of information systems at Memorial Hermann in Houston, credited clinical decision-support tools with improving safety and quality. Their system has more than 150 rules, reminders and alerts. Closed-loop patient identification also has improved patient safety, and the health system uses barcoding for blood and breast milk as well as medications.

Carolinas Medical Center in Charlotte, N.C., uses decision support to prompt physicians to assess thrombosis risk and order prophylaxis. The health system uses palm readers to access patient records and can call up records across the continuum, reported Grace Sotomayor, chief nursing officer at Carolinas Medical.

Interoperability and data warehousing of inpatient and outpatient records at NorthShore University HealthSystem in Evanston, Ill., allows providers to share information across settings. Now emergency department physicians can call up 60 percent of arriving patients’ records, reported Steven Smith, chief information officer at NorthShore.

“This gets to the national movement of sharing data to improve quality and reduce cost,” Smith said.

The University of Pennsylvania Health System in Philadelphia also has focused on seamless integration of records from the outpatient to inpatient setting, said Bruce Boxer, PhD, MBA, MSSN, RN, CPHQ, director of professional development, education and quality at Pennsylvania Hospital. Penn uses simulation technology for interdisciplinary training of its clinicians, particularly for rare adverse events and to boost teamwork, Boxer said.

Technologies to benefit workflow and patient care

Penn technology increases adherence with evidence-based guidelines. It has incorporated vaccine screening in its EHR, flagging the nurses to assess the patient’s pneumococcal and flu status, check the outpatient record and administer if needed.

“It’s improved compliance to get vaccinations,” said Colleen Mallozzi, BSN, RN, BSIS, manager of informatics at the Hospital of the University of Pennsylvania. Based on the success of that protocol, the health system is working on a nurse-driven heparin protocol and a Foley removal protocol.

“It would allow the nurses to work more independently,” Mallozzi said.

Carolinas Medical already uses a nurse-driven Foley protocol and has found it reduces urinary tract infections.

Lori Fowler-Gagliardi: vital sign flow to electronic medical records saves nurses time.
Lori Fowler-Gagliardi, RN, MBA, CNOR, cites the automatic flow of vital signs to the medical record as a time saver for PACU nurses.

The Penn Health System also recently switched to a perioperative electronic documentation and scheduling system. Lori Fowler-Gagliardi, RN, MBA, CNOR, director of perioperative services at Penn Presbyterian Medical Center, reported that it has helped nurses make sure everything is on the chart before the procedure and allows them to pull in lab reports from the outpatient setting.

“The PACU nurses love it, because vital signs flow into the chart, with all of the monitors interfaced,” Fowler-Gagliardi said. “It’s definitely an improvement.”

Device integration in NorthShore’s anesthesia and intensive units captures information and automatically enters it in the EHR system. The hospital uses advanced analytics in the EHR to help find patients with undiagnosed hypertension and begin treatment sooner.

The University of Virginia Health System in Charlottesville has embedded a validated nutrition-screening tool into its admission process. All patients are screened and the system will alert a dietician if the patient scores as “at risk.”

Beth Quarara: electronic malnutrition screening finds at-risk patients.
Beth Quatrara, DNP, RN, ACNS-BC, reports an electronic malnutrition-screening tool helps in identifying at-risk patients.

“We have seen an increase in the amount of patients identified as malnourished with the implementation of the screening tool, and its also helped with communication, making referrals more efficient,” said Beth Quatrara, DNP, RN, ACNS-BC, a clinical nurse specialist with the digestive health department at the University of Virginia and a representative of the Alliance to Advance Patient Nutrition.

Patient engagement

Sixty-four percent of Most Wired hospitals have established a personal health record program, a goal of meaningful use. Thousands of Memorial Healthcare’s patients participate online, but the health system is making an effort to encourage its use.

Loyola University Medical Center, named a Most Wired hospital for 11 out of the past 13 years, began using myLoyola, a patient portal, four years ago. Nurses sign up patients during a clinic visit. Patients then can contact their physician or provider and receive information back. Nurses screen the notes and often can handle the question, such as a referral, and ensure it’s a non-urgent message.

“It’s made it easier, because there aren’t people waiting on hold, and patients don’t get frustrated,” said Nora Primiano, RN, a triage nurse in Loyola’s Burr Ridge primary care clinic. She reported it has resulted in a change in workflow, but it has eliminated leaving telephone messages. She added that the system has encouraged patient engagement.

Lehigh Valley Health Network in Allentown, Pa., prints a daily “Road Map” from the EHR for patients with lists of pending test results, medications, activities for that day and other things they and their families may want to know about the plan of care. The nurse invites discussion about the plan and also gives the patient a pen to mark up the report and list questions for the physician.

“It’s to help clear up the care plan and make sure patients are part of their health and wellness,” said Michele Wagaman, director of information services at Lehigh Valley.

The Road Map has resulted in improved patient satisfaction scores, including a boost in pain management, something Janice Wilson, RN, MS, CPHIMS, manager of nurse informatics at Lehigh Valley, attributes to patients knowing they have something ordered for pain and how often they can receive it.

Lehigh Valley nurses record the patients’ discharge instructions on an iPod and upload them to a secure website where the patient or family members can listen again, helping to engage them in their care and prevent hospital readmissions.

Implementation issues

Nurses and hospital IT staff agree that changing processes and systems involving technology can be difficult or complicated. Yet once staff members begin using it, they will miss it when it’s offline, because it’s faster and more efficient, Kierstead said.

Memorial Hermann is working toward getting all of its systems on a single platform, since some software ideal for one setting will not integrate well with other systems. It also has enhanced information so physicians can readily find it.

The nursing, pharmacy and medical informatics teams at Memorial Healthcare come up with ideas about how to better use technology, such as a brief summary about the patient with hyperlinks to more data, later incorporated by the vendor into its core product.

“They come to us to use technology in more creative ways,” Rodriguez said.

Colleen Mallozzi: EHRs have improved vaccine compliance.
Colleen Mallozzi, BSN, RN, BSIS, indicates that online documentation of vaccine screening has improved compliance.

Penn’s team of corporate IT nurses works to let the computer system become an advisor, suggesting actions when certain criteria are met. For instance, the sepsis early warning system alerts the nurse and provider when a patient’s vital signs and labs have changed, indicating a possible sepsis. The team then huddles and comes up with a plan.

“This will help with mortality, because we are getting ahead of it,” Mallozzi said.

Other Most Wired hospitals, including Memorial Hermann and North Shore-LIJ, are pulling data for similar alerts.

Most Wired facilities are streamlining operations and improving outcomes by carefully implementing technology. Sotomayor cautions that every time something new is added, things can change, so Carolinas Medical watches for unintended consequences. She added that the investment is worth it.

“It’s an exciting time to be giving care,” Sotomayor concluded. “We are consciously looking to make sure it’s working the way it should.”

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