Medical Device Daily Washington Editor

WASHINGTON – Healthcare information technology (HIT) issues are drawing a lot of ink and, according to one official at the Agency for Healthcare Research and Quality (AHRQ; Washington), also a lot of capital investment. However, building a fully functional HIT infrastructure is proving to be no cakewalk for either government or the private sector.

The Patient Safety & Health IT conference, sponsored by AHRQ, on Tuesday included a town hall meeting offering a review of HIT systems implemented by three healthcare groups.

Denni McColm, chief information officer for Citizen's Memorial Health (CMH; Bolivar, Missouri), described her organization as including a public hospital and a 501 (c) (3) corporation jointly operating 44 acute care beds, five long-term care facilities and a level III trauma center. McColm said that none of the 98 physicians employed by CMH use paper charts, but that verbal orders and telephone orders are still accepted and entered directly into the organization's electronic system.

One of the difficulties encountered in the electronic transition was the traditional hang-up incurred any time drastic changes to daily routine are imposed: organizational culture. McColm said that “the teams working on patient safety did not initially see the value in the new system,” but that over time, the vendors and those in the organization championing the change won over resisters.

Another difficulty was encountered in the effort to develop a tracking system for medication errors.

“We don't have good measures of medication errors” from the years before going electronic, partly because the information in question was not parsed into data the same way it is now, she said.

CMH also had to “take a proactive approach” to communicating the new system's strengths and weaknesses to those dealing with the new system. One of the features of the system was that it prompts physicians to place certain orders for tests and so on, based on the diagnosis, a feature that annoyed some for a time before they became accustomed to dealing with that function.

James Ralston, MD, an internist and an assistant investigator at the Center for Health Studies Group Health Cooperative (GHC; Seattle), described the function of GHC's patient portal, MyGroupHealth.

Ralston insisted that where electronic health is concerned, such a portal is “low-hanging fruit” that can improve patient outcomes in part by providing secure electronic messaging (as opposed to e-mail) and “limited access” to patient records (results not available online include results of HIV tests and radiographic and pathology results).

He said that other institutions with portals include Beth Israel Deaconess Hospital (Boston) and Kaiser Permanente (Oakland, California), although his slide did not state whether all Permanente units have built such portals.

GHC serves more than half a million patients in Washington and Idaho with a staff of 860 doctors as well as an unspecified number of out-of-network providers. In addition to the limited access to medical records and the secure messaging between patient and provider, the GHC portal provides subscribers after-visit summaries and allows patients to order refills and book appointments.

Enrollment in the portal has risen from 5% of patients in September 2002 to 35% in November 2005, with the most common uses to obtain test results and to order refills. Women make up about 56% of the users, a ratio that Ralston said roughly parallels the overall healthcare utilization pattern in the U.S.

Brian Strom, MD, associate vice dean at the University of Pennsylvania School of Medicine (U-Penn; Philadelphia) offered a flurry of facts and figures from his slide show and remarked that a review of drug use patterns and adverse events “in the late 1980s” prompted U-Penn to assemble a data collection and analysis effort.

Prior to that effort, U-Penn had reported about 10 adverse reactions per year, but that the count came to number in the vicinity of 600 annually. Of these, he said, 37% were serious, dose-related problems and 14% were serious problems of “idiosyncratic” origin. The downside to this effort was that the institution's effort to track medication errors took four years to yield fruit in the form of useful data.

Strom commented that one of the areas in which he is very interested is the impact of work schedule and workplace stress on medication errors but that “errors were also caused” by the IT system itself – though not specifying the nature of those errors.

Also, resistance to the electronic drug error system did not come strictly from the medical staff.

“To our surprise,” Strom noted, “one of the people who objected to a trial” for the medication error system was a member of the institutional review board at U-Penn that was charged with oversight of the study.

In the Q&A that followed the presentations, one attendee asked why there was so much emphasis on technology when “careless physicians and nurses” can create problems so readily.

Strom replied that while “its nice to think that [an HIT safety system] will automatically work” to reduce or eliminate medication errors, such systems are really designed only to facilitate the effort to reduce errors and that other factors, such as workloads, also must come under the microscope in order to cut errors to the absolute minimum.

Another participant asked whether recruiting would not become a problem if studies indicated that doctors and nurses are overworked and the numbers of graduates from medical school and nursing programs were not sufficient to cover the gap.

Strom said that his facility did not have a recruiting problem for MDs, but that “nurses are an issue.” He also reiterated that in some instances, an HIT system “is now part ofthe stress” encountered by some, but not all, providers. How-ever, McColm remarked that she had not seen a similar problem at CMH.

A third audience member asked Ralston what sort of training GHC offered physicians on when to turn an e-query into an office visit.

He replied that this was something of a dilemma for many doctors, especially those for whom “messaging is intimidating,” and that the issue is the focus of an ongoing effort. Patients cannot as yet contact a contract provider working outside the GHC system via the portal, but Ralston said that GHC “would like to be able to do that.”

Bill Munier of the AHRQ informed attendees in closing that from his view, “the amount of capital that is going into this field is impressive.”

And with the prediction that dramatic change is on the way, he urged attendees to “hold on to your seat.”