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Going 100 Percent Online – What It Means for Quality Cardiac Care

With its multicultural patient population, it's fitting that the Bronx-based Montefiore Medical Center is one of 10 hospitals selected to develop best practices to reduce racial and ethnic disparities as part of Expecting Success. And with its reputation as an early adopter of information technology, it makes sense that doctors and nurses at Montefiore will use cutting-edge technology to provide the right care to patients of all races and ethnicities.

Hospitals have been extremely slow to adopt information technology systems. According to the Leapfrog Group, fewer than six percent of hospitals and health systems nationwide have computerized physician order entry systems – Montefiore is among them. Currently, its pharmacy records, laboratory tests, radiology department results and other record elements are online. In addition, Montefiore will soon have a fully computerized electronic medical record for its patients.

"In those hospitals meeting Leapfrog criteria for computerized physician order entry, at least 75 percent of orders are entered via a computerized system," said Rohit Bhalla, M.D., M.P.H., medical director of quality management at Montefiore Medical Center and one of the leaders of the hospital's Expecting Success program. "Here at Montefiore, we're close to 100 percent of orders entered online."

Equalizing Care: Putting Information Technology to Work for Patients

Through its significant investments in health information technology and the Expecting Success grant, Montefiore is moving toward what they call 'electronic equalization' – where consistent, known interventions are provided to all patients, regardless of race or ethnicity.

"Most quality experts agree that systems can be put into place to equalize health care disparities, and at Montefiore, we view our information technology as a system. If systems can be used to help equalize care, electronic systems can be used to do this consistently," said Dr. Bhalla.

Montefiore's Expecting Success cardiac care project has a particular focus on patients with heart failure. In a paper world, health care providers sometimes rely on printed order sets or their memory to recall everything that should be done for a heart failure patient. In an environment without a fully integrated electronic information system that prompts the clinician with treatment options and provides real-time patient data, it's possible that something gets missed and the best care is not given.

"Providers are relying on their smarts and their memory, which are affected by how many things are demanding their attention as they sit down with a patient," said Dr. Bhalla. "There are many interventions that should be put into place for a heart failure patient. In a paper system, staff may only immediately remember a few. At Montefiore, our goal is to provide decision support electronically and in real-time – such as disease profiles and treatment summaries – that will guide the physician."

The Ideal Continuum of Care

Essential to the ongoing management of heart failure patients is access to care beyond the four walls of the hospital. Montefiore is working to optimize the sharing of patient health information across the continuum of care and it starts with the electronic medical record. Each time a cardiac patient arrives at one of Montefiore Medical Center's facilities, the care the patient receives is electronically recorded. The record is accessible to staff throughout the Medical Center and 'follows' the patient in the weeks to come – after he has checked out of the hospital and is visiting one of Montefiore's clinics for follow-up care. The goal is to soon have all of the ambulatory sites across the Montefiore system fully online.

By using such integrated information technology, the care and medical advice provided to the patient at all points across the continuum can be tracked. For example, when a patient leaves the hospital and goes for his or her first follow-up visit, the outpatient health care provider will be able to electronically review all of the care the patient received when in the hospital. The outpatient care provider can then add to the electronic record any interventions provided in the outpatient setting. All of this valuable information will then be accessible in the inpatient setting, should the patient be hospitalized again.

Montefiore's eventual goal is to develop a system that can prompt physicians and nurses to consider targeted interventions for patients with specific conditions. These include providing smoking cessation advice and counseling, exercise recommendations, information on diet restrictions and the prescription of recommended medications, before the patient leaves the hospital.

"If we implemented a quality improvement initiative in a paper system, the improvement achieved is likely to fall off – even if there was significant staff enthusiasm surrounding the initiative," said Dr. Bhalla. "Hardwiring the quality improvements into our electronic system is a more sustainable approach. Alignment of improvements with operational workflows promotes their durability."

When 'Minority' Patients are the Hospital's Majority

One of the key factors that will determine Montefiore's success in electronic equalization will be its ability to uniformly capture detailed demographic data – race, ethnicity and primary language – for all cardiac patients and to use the information to ensure that the right care is provided.

The Bronx has more than 1.3 million residents, 52 percent of whom are Hispanic, while 34 percent are African American. Thus, nearly every cardiac patient who walks through the door of a Montefiore hospital or clinic belongs to a racial or ethnic minority group.

"New York really is the great melting pot, and that is especially true of the Bronx. More than 30 percent of Bronx residents are foreign-born, and more than half speak a language other than English. A number of patients identify themselves as multi-racial," said Dr. Bhalla. "Montefiore is already capturing demographic data in its electronic system, but there's room for improvement. We will be focusing on how to capture this information more completely, how to better define multi-racial patients, and how to best train staff to do this effectively."

While many hospitals in America are asking themselves how to convert to a completely online system, Montefiore is facing the next question – how to redesign or refine its existing information technology system to provide better patient care.

Investing in Information Technology

Implementing a complex information technology system is neither quick nor easy. Montefiore has invested $140 million to establish electronic medical records for all patients systemwide during the past decade. More than $55 million has been spent on clinical applications – such as a radiology system that allows staff to look at digitized images, as well as a fully computerized laboratory system. Another $30 million has gone toward financial and business applications, including an electronic system for purchasing materials and supplies.

While Montefiore's investment may sound daunting to smaller institutions, it was invested slowly with clear strategic objectives in mind, over a 10-year period. "Some hospitals will say that we've spent a lot, but it is likely that all health care institutions are making some investments in information systems," said Dr. Bhalla.

Take-Away Lessons

The staff is quick to point out, however, that it's not as easy as spending the money, and then simply pushing the 'on' button. It takes time.

"I liken the process of moving a medical system online to turning a giant oil tanker," said Brian Currie, M.D., M.P.H., vice president and senior medical director at Montefiore Medical Center and Montefiore's Expecting Success project director. "The captain of an oil tanker starts making a turn nearly six miles in advance of when the ship actually needs to turn. We cannot be in a rush if we want to do this right."

It also takes extensive staff involvement. "We cannot take a 'Paul Revere-style' approach to implementing new initiatives. That is, we can't put someone on a horse and within a matter of minutes inform all of our staff of a change," said Dr. Bhalla. "As one of the largest health care systems in the country, it takes time for us to communicate information technology changes to all of our staff. It was also very important that we didn't just inform staff, but that we engaged them in the process. While information systems have the potential to improve provider care, providers can and should improve the way information systems are deployed."

Both physicians stress that other hospitals looking to adopt a similar online system should spend time carefully reviewing and selecting the hardware and software tools that will help them to tailor the system for the hospital's own specific needs.

"The notion of providing disease-specific care, such as cardiac care, across the continuum is one of quality management's Holy Grails," said Dr. Currie. "A medical system of our size must have advanced information technology in order to do something like this, but the lack of such a system should not dissuade smaller hospitals and health systems."

The doctors believe that the lesson for any institution, regardless of size, is that 'slow and steady' truly does win the race. "There's no sense doing it quickly only to find out that it wasn't fully thought out and it fails," said Dr. Bhalla. "You will just end up spending more to fix it. Whatever electronic information system your institution can afford to implement, do it slowly, and do it strategically."

Spotlight On...

Located in New York City, Montefiore provides medical care to the more than 1.3 million residents of the Bronx, as well as from nearby Westchester County and patients referred from across the nation and around the world.

At-a-Glance:

• Number of staffed beds: 1,023
• Hospital type: Large academic medical center
• Community location: Urban
• Number of myocardial infarction and heart failure patients annually: 4,000
• Number of cardiac catheterizations annually: 6,500

 

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