Sunday, December 25, 2005

We have to take you in

On rounds this morning, I witnessed the life of our hospital as always. Nurses attended their patients. Doctors were at the bedside and at the charts. A technologist pushed a bed toward Radiology. The Emergency Department accepted its next patient. A maternity patient went upstairs for evaluation. The laboratory staff was busy testing fluids. In the kitchen, breakfast trays were being prepared for upstairs. Security was on alert.

It is a holiday, and our patients need us.

There is no elective surgery, and all our patients are those who cannot be anywhere else. As a hospital, we care for the acutely ill every day and all night.
There is an often quoted line of poetry by Robert Frost:
Home is where, when you go there,/ They have to take you in.[1]
The line applies to hospitals too – “we have to take you in.” What a responsibility we have, and what a privilege!

[1] “The Death of the Hired Man,” North of Boston, New York: Henry Holt, 1915

Saturday, September 3, 2005

A most difficult heroism

In the aftermath of Hurricane Katrina, words fail. The scale of the Gulf Coast disaster is truly massive, and the situation in New Orleans is a natural disaster compounded by a human one.

I have been thinking about those New Orleans hospital workers who left their families last Sunday, fully expecting to ride out the approaching hurricane while caring for the patients who needed them. By week’s end, however, the patients and caregivers of one hospital had become “almost indistinguishable,” according to the Los Angeles Times. [1] The newspaper reported the hospital had become “a chamber of horrors” with sewage backed up in sinks, its basement morgue under water, and a body bag in the ED. One employee was quoted as saying, “Workers are to the point of collapse.”

When the hurricane intensified Sunday night, hospital staff moved patients into hallways to protect them from the shattering windows. When the power failed, the hospital’s generators came on, but the rising water stopped the generators, and the hospital was without the electricity that runs ventilators, CT scanners, computers and air conditioning. Patients used 02 tanks to smash windows for fresh air. An internal evacuation moved patients to an upper floor. By Thursday hospital staff were in the third day of hand-ventilating patients. The National Guard started, then stopped an external evacuation because of sniper fire. Other rescue workers eventually followed, and aluminum boats were packed with patient stretchers and IVs as nurses accompanied patients to the Superdome and to the airport, which served as staging areas for evacuation out of the area. By Thursday 1,800 patients had been evacuated from New Orleans hospitals – with another 3,000 waiting for evacuation.

Hospital staff have families too – were they safe? With so many communications problems, the hospital staff were unable to talk with their loved ones. What must have been the worry, the fatigue, and the demands on doctors and hospital employees as they remained with the sick in those wasted facilities without the ability to provide sanitary or adequate care?

There have been many dramatic photos of the Coast Guard rescuing hundreds of people from rooftops and attic windows. The helicopters worked, allowing such heroic action. But medical equipment did not work. Indeed, the buildings themselves failed. That required a different kind of heroism by the caregivers of New Orleans. They struggled without rest to keep patients as safe as possible without equipment that is basic to proper care.

I have not seen any dramatic photos of life saving within the hospitals, comparable to the photos of Coast Guard rescuers. But the work of hospital people represented a different kind of heroism, one of the most difficult kind.

[1] “Hospital Descends into Misery,” Los Angeles Times, September 2, 2005.

Saturday, June 4, 2005

EMR promise and reality

It was standing room only in the POB-South classroom at Community General Hospital on May 27 when several presenters discussed the promise – and the reality – of electronic medical records (EMRs). The forum was organized by health care advisers to New York State Assembly Member Jeff Brown (121st Assembly District).

Dr. David Wormuth, a thoracic surgeon, opened the discussion by reviewing office-based medical record systems, such as the one he uses. This was followed by a discussion of hospital EMRs by Mitch Rozonkiewiecz, CGH vice president of information technology, and Chuck Fennel who has the same position at St. Joseph’s Hospital.

Mitch talked about the importance of linking separate CGH systems (such as radiology, pharmacy, and patient access) through a common “portal” that is easier for clinicians to use and that improves patient safety by reducing multiple data entries and patient look-ups. He also talked about a discussion by the Manufacturers’ Association of Central New York (MACNY) about possibly forming a regional health information network (RHIO). A RHIO would permit physician offices and hospitals with EMRs to exchange test results and other patient information, no matter where in our region a patient had tests.

Such connectivity is the promise of electronic medical records, although the discussion quickly focused on some barriers to that promise.

Several physicians in attendance talked about the difficulty of using EMRs that include lengthy narrations or formulaic sentences, making it time consuming to locate relevant information about a patient. Chuck Fennell said that, despite all the talk about records portability, “the health care industry is underserved because commercial products are not readily available for implementation in community hospitals.” There are some 300 vendors who provide systems with differing components, making it difficult for medical practices to select a vendor or commit to the cost of a system that might not survive all the market and regulatroy changes to come.

Mitch Rozonkiewiecz said that forming a local RHIO would be a formidable undertaking requiring the community to provide the “brains, the investment, and the standards for use.” Where, he asked, would the necessary resources come from?

One person attending the forum was Nasir Ali, the Chamber of Commerce vice president responsible for new venture development. He said the health care system is not a single process – it acts more like an ecosystem. He speculated the lack of a single, large customer makes it difficult for the information technology industry to focus on a single standard for connectivity. Mr. Ali suggested that the formation of RHIOs might provide a sufficiently large customer base to help the information technology industry develop the systems and standards necessary for connectivity, similar to that of the internet.

It was a fascinating discussion, full of promise and caution in equal measure.

Assemblyman Brown deserves thanks for arranging such a briefing on this important subject, and CGH was pleased to serve as host for the meeting.

Saturday, May 21, 2005

Motality & hospital report cards

Two years ago I was concerned about pneumonia cases. A large insurance company released an updated version of its report card on hospitals, and for the second year in a row CGH statistics were good in all areas – except pneumonia. According to the insurer, the death rate from pneumonia at CGH was more than it should be when compared with the Central New York region.

What was the cause? Were CGH patient records properly coded?[1] An outside review of our records showed that we were accurately coding them.

Was CGH care being provided properly? Yes, it was. We reviewed every single case.

Were pneumonia patients at CGH somehow different from those at other hospitals? We looked at the numbers of patients transferred to CGH from nursing homes. We looked at the average age of pneumonia patients. CGH pneumonia patients were somewhat older than those in other hospitals. On average the CGH patients were 75 years old. The average age of pneumonia patients at other hospitals ranged from 50 to 69 years. Still, age alone did not explain it. We were puzzled.

The quality committee that was reviewing our pneumonia care focused its attention on advance directives.[2] One form of advance directive is a DNR order (“do no resuscitate” order). Patients with DNR orders request not to have cardiopulmonary resuscitation (CPR) under certain circumstances.

When we examined the records of patients with pneumonia who died at CGH, we found that that 90% of them had DNR orders. In other words, most deaths were by patients who did not want aggressive efforts to resuscitate them if their conditions seriously deteriorated. Of the hundreds of non-DNR pneumonia patients cared for at CGH, the death rate was less than one percent.

This distinction was apparently not reflected in the analysis used by the insurance company for its hospital report card. This point was clearly demonstrated last year when Dr. Dan Carlson, Vice President – Medical Affairs, and I attended a meeting on hospital report cards with about a dozen upstate hospitals. The large insurance company showed pneumonia mortality rates that it prepared for hospitals attending the session – and, sure enough, CGH appeared to have an above average mortality rate. Next to present was a national company that also produced quality comparison data. In this case, however, CGH was shown to have a lower mortality rate than the other hospitals when adjusted for more patient risk factors. Both presentations used the same data to generate different hospital rankings, based on their different statistical methods.

I was reminded of our pneumonia investigation when I read “Informed Choices For Better Care,” a recent story in the Post-Standard. The story said that for many years patients and families were “kept in the dark” about hospital comparison information, but report cards are now letting “consumers shop for health care much the same way they do for cars.”[3] The article also quoted the publisher of one hospital report card as saying that “hospital special interests” may no longer claim that “those poor dumb yokels (the general public) couldn’t possibly decipher how to use hospital data.”[4]

That report card publisher apparently sees hospitals as an adversary, but CGH has supported the development of report cards for many years (and we never disparaged the public as “dumb yokels”). In the 1990’s CGH was the first and only upstate hospital to publish its own comparative quality report card.[5] In doing so, CGH consulted the literature on quality reporting, used available data from national studies, and conferred with state government, local health maintenance organizations, and national organizations on the design and data used in the CGH report. This was before insurance companies and the federal government developed their hospital comparison websites.

Hospitals are not perfect, and neither are report cards, as the above pneumonia example suggests. I would argue, however, that website report cards educate both the public and providers, and they encourage competitive hospitals to get better. These are important tools in helping the health care industry make continuous improvements in quality management.

The pneumonia example demonstrates how seriously CGH investigates itself. I believe all hospitals take variations in quality seriously, and as the tools for measurement get better, hospital results will improve too.

[1] The government and payers look at the disease codes assigned to each patient record – this forms the basis for analysis.
[2] Advance directives are the written instructions patients give to doctors and hospitals specifying the type of care the patients want to receive (or don’t want to deceive) in the event they cannot make future medical decisions for themselves.
[3] “Informed Choices for Better Care,” Post-Standard, May 9, 2005.

[4] Post-Standard, May 9, 2005
[5] CGH’s self-published Quality Report Card started in 1996. It was posted on the CGH website and was issued annually until 2000, when the internally-prepared documents ceased when CGH joined the Health Alliance of CNY. In 1999 CGH’s report card cited with approval the Report of the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry (1998): “A widespread and ongoing consumer education strategy should be developed to deliver accurate and reliable information on quality when choosing health plans, providers, and treatments.”

Saturday, February 12, 2005

Passport to the Future

On the evening of May 19 last year, representatives from CGH and other Syracuse hospitals gathered in an auditorium on University Hill as a Harvard physician gave us a glimpse of the future.

Dr. John Halamka, the Harvard physician, operates the information systems that link the medical records of all patients in a 21-hospital system in the Boston area. We watched as he connected into his system, and the image from his computer was projected on a screen. He showed us how a doctor can sit at a computer anywhere and, through the internet, see the list of his hospitalized patients. Some patient names have flags indicating new test results or highlighting abnormal tests that need the doctor’s attention. The physician can click on each patient name and see each patient’s information. The doctor can easily change a patient’s medications or write notes in the chart, all from the computer. The system automatically reminds the doctor of care standards and potential drug interactions.

Dr. Halamka showed us the future.

At most hospitals patient information is still very much a paper process. Hospitals may have advanced clinical equipment, but when it comes to information management, most of us still use paper technologies that have more in common with the 19th than the 21st Century.

Even when we have computerized information, it is usually in stand-alone systems that are not easily linked. For example, the CGH radiology system is separate from the CGH pharmacy system, and each is separate from the CGH patient registration system. With isolated systems, it is very difficult for doctors to check on their patients. With isolated systems, patient information and identification numbers are entered manually on multiple occasions, increasing the opportunity for error. To review patient information, CGH doctors currently use multiple passwords and different codes to get into these separate systems, each with its own report on the same patient.

Two weeks ago President Bush was in Ohio[1] to highlight health care information technology as “essential to improving America's health care system.” The White House news release said that, although information technology has transformed industry, hospitals have yet to realize the full benefits of the digital age. As a result, it said there are
serious concerns about high costs, avoidable medical errors, administrative inefficiencies, and poor coordination – all of which are closely connected to the failure to incorporate health information technology into our health care system.
CGH is about to take one giant step into the next generation of information technology. Next week our Board of Directors will review new technology to link our stand-alone systems. This will be a major advance, and the changes in the coming months and years will affect many areas of our hospital.

CGH was the first hospital in Syracuse (and one of the first nationwide) to implement a pharmacy robot some ten years ago. Since then we’ve seen the addition of computerized drug-dispensing units in patient care areas, new x-ray and pharmacy systems, a speech-recognition dictation system – and this year we will add a new surgery system.

What is the new technology being planned? CGH will begin to develop an electronic medical record, and we will install a new “portal” to allow physicians to see on computer the list of their hospitalized patients. CGH doctors, using a single password and code, will be able to see patient test results, to readily identify abnormal values, and to enter orders directly into the system, even from their offices or homes. When these changes are complete, doctors on our medical staff will be able to do many of the things we saw demonstrated last May.

Linking CGH’s stand-alone systems through the “portal” will go a long way to making patient information more available and easier to use. And the true beneficiaries will be our patients. These systems will improve patient safety because they reduce the risk of misidentification and the risk of medication error.[2]

President Bush has set a ten-year goal to assure that most Americans have electronic health records. The electronic records would be able to share information privately and securely among health care providers. There’s a lot of work to achieve that national goal. Even the Boston system we saw in demonstration links providers within a single hospital system and cannot communicate with outside doctors or hospitals.

The review with our Board next week will be a first step. Acquiring these systems represents a commitment of millions of dollars over several years, a significant investment for our hospital.

The new technology will represent more than a “portal” for physicians and additional safety protection for patients. The new technology will be CGH’s passport to the future: when the nation is ready to share medical information among hospitals and doctors as the President has proposed, CGH will be prepared.

[1] On January 27, 2005, the President appeared at the Cleveland Clinic.
[2] “CPOE systems can be remarkably effective in reducing the rate of serious medications errors,” according to The Leapfrog Group, which is made up of more than 160 companies that buy health care services. The Leapfrog Group seeks to reduce preventable medical mistakes and improve the quality.