While some talk about it, and others wonder who will pay for it, the Detroit Medical Center has taken a leading role in adopting a complete electronic medical record
Written and produced by James Buchanan & Thomas Venturo
According to a study by the Institute of Medicine (IOM) issued in July of 2006, there are between 380,000 and 450,000 medication errors made in U.S. hospitals each year.
Further, the IOM estimates that these errors cost the healthcare system and patients approximately $3.5 billion each year.
In both human and financial terms, the costs of these errors are staggering. Making matters worse, the IOM goes on to state that it is possible for hospitals to institute changes to prevent many of these errors.
Among the IOM’s suggestions are increasing the role that patients play in their own care to include better efforts to educate them on the medications they are taking, and by improving the labeling and packaging of medications.
Perhaps the most important change hospitals could make, though, is to integrate information technologies into their systems so that prescriptions are handled electronically. In fact, moving to an electronic medical records system at the nation’s hospitals would go a long way toward preventing all sorts of medical errors.
However, while some hospitals have adopted electronic medical records systems, the vast majority have not.
“We are one of a very few hospitals in the country — less than one percent — that has a fully electronic medical records system, which is currently being used and embraced by our staff and clinicians,” says David Ellis, corporate director of planning and future studies at the Detroit Medical Center.
The Detroit Medical Center, or DMC as it is commonly known, is an academically integrated system of eight hospitals and a handful of associated facilities located in the metro Detroit area. The DMC is allied with the Wayne State University medical school and has more than 2,000 licensed beds and approximately 3,000 affiliated clinicians, some of whom are residents of the medical school program completing their medical studies.
The DMC’s history goes back to the Civil War and includes a number of medical breakthroughs, such as developing the first successful heart pump in the world — which allowed for surgery to be done to the heart and the vessels immediately surrounding it; and synthesizing the first effective AIDS drug (AZT) which has helped prolong the lives of AIDS sufferers around the world.
However, despite these major break-throughs, Ellis says the really important technological story is the DMC’s organization-wide adoption of an electronic medical record system (EMR). Other technologies, such as the heart pump, “Will save precious lives, but the EMR will save so many more lives by preventing [medical] errors and improving the care we provide,” he says.
According to Michael LeRoy, SVP and CIO of the DMC, the organization initiated the design phase of the project in June of 2005 and began implementing it in April of 2006. The last of the DMC’s eight hospitals was brought online in May of this year.
What this time frame means, says Pat Natale, chief nursing officer for the DMC, is that after the first hospital was brought online, the rest of the organization’s hospitals were able to localize the EMR as well as build, train staff and implement the system in approximately 13 months.
“We moved at the speed of light,” says Natale.
LeRoy adds that the system is much more than just an electronically stored and presented record of the patient’s health history and treatment. It also includes processes to speed the delivery of care as well as to enact suggestions made by the IOM to reduce the risk of medical errors — particularly in the area of medications.
Medicines are no longer ordered via a paper-based process, where everything from the physician’s handwriting to labeling to when and how the drugs are administered could be open to possible errors. Rather, doctors order medicines electronically from the hospital’s pharmacy and a number of redundant safety measures are in place to make sure there is little chance a mistake could be made.
The basis of this ordering and delivery system is the use of barcodes that can be scanned at each step in the process. The medicine is ordered via an electronic form, which reduces the possibility that a pharmacist could misread the order. The medication order is filled and a barcode is included on the packaging. When the medication arrives on the floor, the nurse uses a wireless barcode scanner to scan the patient’s wrist band, the medicine’s packaging, and the nurse’s ID badge.
These steps are designed to ensure that each hospital is practicing what LeRoy describes as the Five Rights: the right patient, the right dose, the right medicine, the right time, and the right route when administering the medicine. Throughout these checks the system will alert the clinician to any inconsistencies as well as if the medication may have a negative interaction with another medicine the patient is taking.
According to Natale, this element of the EMR is designed to close the medication loop — physician ordered, pharmacy verified, and nurse administration with barcode verification — which should greatly reduce the number and potential for error.
In all, the EMR will enable electronic ordering of tests, therapies and medications; receipt and logging of test results; physician and nurse documentation of the patient’s care; drug administration; and the patient’s previous medical history. The net result being that, with an average of 93,000 admissions per year to the DMC’s hospitals, error potential is reduced and care is provided quickly and efficiently — which reduces costs to the hospital, insurers and patients.
LeRoy notes that the EMR drives out some of the randomness of patient care that is endemic in the healthcare industry, yet would not be tolerated in other industries such as with automotive manufacturers and airlines.
“Quality is the mantra in these other industries,” he says.
What LeRoy, Natale and Ellis all say, is that the EMR is bringing that same culture of accountability to quality standards to medical care. In a sense, the DMC’s electronic medical records system is a step toward integrating lean and continuous improvement strategies into a healthcare setting.
Further, in much the same way a manufacturer would convene a lean manufacturing cell to look for ways to make processes more efficient, the DMC brought in groups of physicians prior to implementing the EMR system to discuss their workflow. The intent was to look at what the EMR would mean to these physicians on a day-to-day basis.
In particular, says LeRoy, discussions centered on processes that could be eliminated, such as submitting orders on paper forms; what could remain the same, physicians are still in charge of making these orders and providing necessary information; and what could be improved/altered, such as orders being sent electronically with a system to check for possible errors.
Before conversion at the first hospital, the DMC involved the staff in determining how their workflow would change, while also demonstrating how it would improve patient care and safety, and trained them on the new system. This led the organization to identify approximately 60 people they would designate as super-users, says Natale.
These people were trained to navigate the system as experts, in order to train their peers at the other hospitals and act as problem solvers within their home hospital. In a sense, they could be thought of as in-house EMR support, as well as clinical experts.
“We are pleased at how our staff rose to the top,” she says. “They developed expertise that they didn’t know they have.”
This internal resource is also helping to nurture and support continued improve-ments and additions to the system as they are integrated.
“We have elevated the standard of care in a way that everyone takes ownership of it, and that is adoption,” says Natale.
LeRoy, Natale, and Ellis also stress that while the DMC gained financially from these changes, the intent and driving force behind the investment was to improve patient care. In a sense, they are saying that healthcare is not the same as manufacturing cars or running an airline, because the ultimate goal is not profit — it’s providing better outcomes and improving the health of patients.
That said, there are lessons to be learned from how other profit-based industries improve how they operate and improve the end product.
“We don’t look at this as an ROI initiative,” says LeRoy. “This represents an investment and a lot of work all dedicated to improving patient care and outcomes, but by doing that we also add to the financial status of the organization.”
Ellis adds that these changes were, in a sense, done in isolation, because the DMC is so far ahead of the curve. Only approximately one-half of one percent of hospitals in the country have made the move to a complete electronic medical records system.
Further, says Natale, adoption of the EMR system represented a massive, total and complete change for the organization.
“This was like going from the days of horseback to automobiles. It was that significant and dramatic a change for us,” she says.
Asked if the hospital has data showing discernable benefits of the new system, LeRoy says the hospital does have metrics it is developing data for, but it is too soon to speak with any specificity.
That said, he notes that the level of documentation generated by the system as it relates to the capturing of data has greatly improved.
Early anecdotal data, based on just two months’ experience at just two of DMC’s eight hospitals (as shown in the following tables), pointed to likely substantial cost savings and patient safety/care quality improvements over time, he says.
Looking to the future, LeRoy says the DMC will continue to implement new technologies, which it sees as offering the potential to improve the care its patients receive. The DMC will also continue to bring its EMR system to its associated clinics and offices beyond the hospitals.
Ellis adds, though, that the biggest next step is a national electronic medical record system. The DMC has been very active in helping to bring this about by working with various government agencies to act as advocates and advisors.
A national system is still a long way off, he says, because EMR systems are expensive investments for individual hospitals and healthcare organizations to make. Further, not all hospitals see an EMR as the best way to improve patient outcomes.
“They have to see this as a strong investment and embrace it,” he says.