No place for paper at new Children's Hospital
After examining a patient Dr. Sylvia Choi, center, talks with intern Ruchika Goel at Children's Hospital of Pittsburgh of UPMC. To the right are two of the computers used for record keeping.
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In this growing age of electronic record-keeping, hospitals have lagged behind in computerizing patient records, and for notable reasons.
Every step of a patient's journey through a hospital must be documented in detail -- prescriptions, blood-pressure readings, temperatures, and every procedure along with the results. Add to that every visit from doctors, therapists, counselors and nurses.
Electronic documentation requires time, money, training and a large battery of computers. So going electronic can be a time-consuming, frustrating and expensive nightmare.
Despite the obstacles, Children's Hospital of Pittsburgh of UPMC will have 95 percent of the process completed by year's end, and the switchover is expected to be 100 percent when the hospital moves next spring to its new Lawrenceville facility, where no space has been allocated for paper-record storage.
"The drive is that there's no place to put paper, so they've had to get this done -- and they've done a good job with it," said Dr. Robert Bart, chief medical officer of pediatrics and academics for Cerner Corp., the Kansas City company that provided the systems software for Children's electronic records.
Reaching this level of transition required "very forward thinking" by hospital administrators, he said.
Children's is one of the first freestanding children's hospitals in the nation to reach "stage 6" of eight stages in going electronic. It's one of only 24 of the 5,700 hospitals nationwide that have reached that stage, with no hospital yet to reach the highest level. The Monroe Carell Jr. Children's Hospital at Vanderbilt in Nashville, Tenn., is the only other children's hospital at stage 6, according to Healthcare Information and Management Systems Society, which scores hospitals based on their progress in completing all eight stages. Its studies show improvements in health-care quality with use of electronic records.
HIMSS recently recognized Children's and UPMC Presbyterian for reaching stage 6 in the transition.
"Stage 6 hospitals are shining examples for our industry of what can be achieved with electronic medical records information technologies," said Mike Davis, executive vice president of HIMSS Analystics. "These facilities demonstrate best practices for using electronic medical records to improve care delivery, clinical outcomes and patient safety."
But the ordeal of reaching stage 6 explains why it's taken seven grueling years.
Treatment for a patient at Children's involves 60 people, on average, but often more than 100, with each step documented in medical records.
Paper records were handed off from one department and caregiver to the next, limiting access to the one person with the record in hand. Legibility, including poor physician penmanship, has been a historic problem, sometimes forcing people to recopy information. Once the process was complete, the entire record had to be transcribed to establish a permanent record.
"There was an opportunity for errors and inevitable delays," said Dr. James E. Levin, Children's chief medical information officer.
In October 2002, hospital officials documented a medication error rate at Children's of one in every 1,000 medical doses, with one in every 10,000 cases creating a "medical safety event" that reached or had potential impact on the patient and could require corrective action.
Studying the source of errors, hospital officials found that wrong dosage or wrong routes of treatment, such as by mouth rather than intravenously, were key causes, with a misplaced decimal leading to the wrong dose. Transcription errors were another common cause.
From the start, hospital officials knew electronic records would reduce errors and improve safety, if only installation challenges could be overcome.
But electronic records require a culture change for the entire hospital. Some install systems, then make the switchover all at once, in a process called "the big bang."
Children's officials, however, decided to usher in electronic records one step at a time. To study the process, they traveled to other hospitals with electronic systems to note their successes and avoid their failures. The hospital also redesigned workflow through the hospital so electronic recordkeeping could be implemented in more logical stages.
"They've done an incredible job there," Dr. Bart said. "When you visit children's hospitals across the country, two things differentiate Pittsburgh from other children's hospitals. One is the quality and detail of the executive leadership."
He said Children's executives were invested from the start in making the hospital paperless. While some hospitals design their systems in a vacuum, Children's involved the people early on who would be most affected by the changeover, including bedside clinicians.
"I can't stress how different that is from many institutions," Dr. Bart said.
In yet another difference, Children's Hospital in Pittsburgh focused throughout the transition on improving the quality of patient care as a key reason for the changeover.
Another goal was to standardize records, so Children's can send information to other University of Pittsburgh Medical Center hospitals and, in time, all hospitals and medical centers. Some initial steps are in place for that process.
As Children's installed the system one department at a time, doctors had to begin using computers rather than pens and paper. That required computers in each hospital room. Nurses push carts bearing computers room to room to document every treatment, procedure and medication.
That required installation of more than 4,000 computers hospital-wide. Children's spokesman Marc Lukasiak listed the total cost of going electronic in excess of $10 million.
But the biggest concern was whether doctors would embrace drastic change.
"As we look back, the physicians have been remarkably cooperative and enthusiastic because we sold this to the physicians for all the right reasons -- safety at every step. That's why this is better," said Dr. Steve G. Docimo, professor and director of pediatric urology at Children's.
With no place for paper, the medical records department has scanned existing paper documents, including referrals from other doctors and medical centers, into the computer system.
And those errors?
Officials said the hospital has reduced the number drastically, from one per 10,000 medication doses to 0.4 errors per 10,000 doses, for a 60 percent decline. "We want it to be zero," said Jocelyn Benes-Stickle, vice president of quality and performance improvements.
The error rate is expected to drop lower once people get used to it. The system also offers a way to track errors to their source, leading to easier correction.
Physicians still must take time to type detailed orders and prescriptions into the computer, which can take longer than writing them on paper. But many procedures involve a simple click on the correct box on the computer screen.
Doctors also save time with immediate access to X-rays and imaging results on any computer rather than having to traipse to the lab or radiology room. Any number of doctors and health officials can view records simultaneously from different computers, while doctors also can retrieve information from a secure link at home. Every access is logged and tracked by computer, which helps to assure approprate access and respect for patient confidentiality.
Ultimately, Dr. Levin said, many children will have their full medical record on computer by the time they reach adulthood. He calls it "the secret weapon" of the Children's system.
"Each step was approached as a quality improvement," he said, noting improvements in communications. "That's what is best for the child, and it allows us to take advantage of technology."
So, in just months everyone at Children's will be on the same page -- albeit a virtual rather than paper one.
"We're ahead of virtually everyone in the country, and it gives us further opportunity to increase safety and improve care," Dr. Levin said.
First Published December 31, 2008 12:00 am