The role of information technology is not to replace clinicians, but to change their work environment to provide better job satisfaction and better patient care. By redesigning clinical processes and automating them with enabling technologies often through innovative outsourcing arrangements health care providers transform themselves into competitive enterprises that better serve their communities.
The health care industry is experiencing a worsening shortage of health care
professionals. Though the national shortage of nurses is the most recognized
crisis, a recent report from the American Hospital Association shows that 89
percent of hospital chief executives report significant personnel shortages
in nearly every type of hospital job. If current trends continue, the United
States will employ about 1 million fewer nurses than it needs by 2020 (see Figure
1).
Figure 1: National Supply and Demand Projections for FTE Registered Nurses:
2000 to 2020 Source: Bureau of Health Professions, R.N. Supply and Demand Projections
As the crisis worsens, people who remain in the workforce are becoming progressively
overworked and demoralized, often more focused on administrative tasks than
on the delivery of patient care. Mistakes are likely to become more frequent
and widespread as job stress and dissatisfaction increase. Job satisfaction
among health care professionals is dropping, and staff turnover, especially
among nurses, is rising. Clearly, the health care industry’s status quo has
a discouraging prognosis. Fortunately, there’s a cure. It’s called clinical
transformation.
IT: From High-Tech to the Right Tech
For decades, health care organizations sought to develop information technology
systems to improve efficiencies in delivering patient care, and to relieve clinicians’
administrative duties in order to increase “patient time.” For the most part,
their IT investments failed to deliver on even these limited goals. What they
created is a patchwork of disparate systems that partially automate non-core
functions and generate more overhead work than they displace. These so-called
“best-of-breed” proprietary systems generally lack the ability to integrate
the minimal data they exchange. These disjointed systems fail to deliver efficiencies
that justify their cost. More importantly, isolated applications may pose a
significant threat to patient safety due to “siloing” of critical patient information
and system alerts. By contributing to the fragmentation of information and the
inflexibility of processes, these systems have become part of the problem.
Health care providers are seeking examples and advice from other industries,
which long ago began developing reliable information management systems and
networks that can transparently and seamlessly integrate information across
an entire organization and beyond. They’re learning new concepts like “workflow
automation” and “enabling technologies.” They’re seeking more integrated IT
systems that can collect enormous quantities of patient information, including
a patient’s medical history, results of radiology or lab tests and other diagnostic
procedures, records of medications ordered and dispensed, and other relevant
data. The goal is to make patient data available wherever needed across organizations
and systems.
The object of this quest is not a technology enhancement or an IT architecture
overhaul, but a clinical transformation that results from redesigning clinical
processes, then integrating and automating them through an advanced clinical
information system (CIS). When leading clinical practices are implemented through
a CIS, clinicians will be able to access this information in the pharmacy, in
the lab, at the patient’s bedside, at the nurses’ station, or in the physicians’
office. Patients will be able to access their own medical information from home.
Physicians will be able to order tests or medications from their offices and
review the test results and confirmation of medication administration via the
Internet. Nurses, unburdened from the tedious collating of charts, recopying
of physician orders, and administrative tasks that currently occupy one-third
to one-half of their time, will spend more time in the role that best serves
both nurse and patient: caregiver.
It is this kind of reliable, integrated, and transparently networked information
system that the Institute of Medicine of the National Academies had in mind
when it said:
“The committee believes information technology must play a central role
in the re-design of the health care system if a substantial improvement in
quality is to be achieved over the coming decade …. re-organization and
reform are urgently needed to fix what is now a disjointed and inefficient
[health care] system.”1
No Margin, No Mission
Change, especially the fundamental changes needed to transform today’s health
care provider into a competitive enterprise, is seldom simple or pleasant. It
involves disruption of work routines; new, more collaborative relationships
among clinicians; and re-evaluation by each clinician about his or her professional
priorities.
Effective strategies exist for dealing with these well-understood factors,
but the health care industry has been slow to adopt new business models for
an additional reason unique to the industry: the perception that health care
providers have a higher purpose than profitability. An academic or teaching
institution serves the medical community through the “three-legged stool” of
clinical care, teaching, and research. A community-based hospital contributes
to the health and well being of its community by seeking to provide excellent
care through top-notch facilities and talent, often regardless of a patient’s
ability to pay.
Surely, staying true to these missions is more important that being competitive,
isn’t it? Yes and no. The reality is that the health care organization that
utilizes its resources most effectively will join more health plans and attract
more patients. This organization can afford better facilities and working conditions,
and so will attract the best talent. It will better retain the staff it must
have to provide first-class health care. The “competitive” academic teaching
hospital will attract the most accomplished specialists and the most qualified
students. It will get more research grants.
In short, health care organizations that undergo the rigorous transformation
process to become more competitive will better serve their missions to their
communities. Studies have shown a direct link between delivering better care
and maintaining solid margins. When addressed through a comprehensive program,
quality of care, margins, and clinician satisfaction all improve.
The New Role for IT
The purpose of an advanced CIS is not to reduce the number of nurses or other
clinicians required to staff a hospital. Organizations looking to technology
to reduce full-time equivalents of nurses and other scarce personnel operate
under a dangerous misconception. Experience has shown that the real benefit
of a CIS is better patient care through more-informed decisions by less-distracted
and more-collaborative caregivers. This benefit is realized only when physicians,
nurses, radiologists, lab techs, pharmacists — the entire health care delivery
chain — all exchange information and collaborate over a reliable and ubiquitous
network. Such a system greatly reduces medical errors by eliminating the tiresome
and error-prone tasks of transcribing, collecting, finding, or reviewing patient
charts, lab reports, medication orders, or any of a multitude of paper documents.
Advanced clinical information systems enable knowledge-driven care. They remind
clinicians of the treatment options that have resulted in the best outcomes
for a specific diagnosis.
This guidance can be valuable in reducing costly and dangerous medical errors,
particularly with drug therapies. A physician may not be aware of interfering
medications or medical conditions that would preclude the use of a particular
drug or require adjusted dosing. Many drugs require adjusted doses, for example,
if the patient has impaired renal function. An advanced CIS alerts the physician
to avoid overdosing the patient. Reducing the incidence of adverse drug events
(ADEs) results from combining complete knowledge of a patient’s medical state
with knowledge-based “triggers” that look for drug interactions and drug-disease
and drug-allergy contraindications .
An advanced CIS manages and processes this kind of information. Hospitals where
an advanced CIS is in widespread use by physicians and other clinicians have
experienced dramatic reductions in ADEs and in the unnecessary hospitalization
costs that often result. Relieved of tasks associated with remedying medical
errors, clinicians find their workloads more manageable.
Getting the Pharmacist Out of the Basement (Changing the Roles of Clinicians)
An advanced CIS puts comprehensive information about the patient throughout
the hospital and, via the Internet, into the physician’s office. Patient data
include both historical and up-to-the-minute information such as the results
of diagnostic tests and current vital signs. Information is always where it
is needed. Wherever they are, clinicians always have access to comprehensive
patient information. Pharmacists can practice their profession while engaged
in direct patient contact. Pharmacy information is just as available on the
patient floor as in the main pharmacy. Pharmacists are free to accompany physicians
on rounds, becoming more collaborative health care partners. Caregivers and
patients both benefit from such an arrangement.
Nurses, radiologists, and other clinicians, benefiting from a decreased clerical
workload and increased availability of clinical information, can spend more
time with patients. Patients receive better, more responsive care, and clinicians
benefit from a more satisfying professional experience.
Maximizing the Impact of IT: Outsourcing
One of the lessons learned through clinical transformation is that the most
significant benefits are realized only when core business processes — the
delivery of patient care — are consistent with the proven best practices
in the industry. Often, health care organizations possess neither the IT expertise
nor the computing environment to support these best practices. In such a case,
it is useful to remember that if IT isn’t your core business, someone else can
probably do it better, faster, and cheaper.
A growing number of hospital groups are outsourcing their entire information
systems departments to companies such as Cap Gemini Ernst & Young to take advantage
of the experience, resources, and successful track record these companies provide.
Outsourcing providers can leverage a business model across several clients,
resulting in a more economical implementation. They have the flexibility and
breadth of resources to call upon experts as needed. They can more easily invest
in the best hardware and software tools and share them among multiple clients.
They develop proven methodologies and bring lessons-learned experience to multiple
engagements. They can provide services like a help desk, available to users
at any time, which might not be practical for a single client to staff.
Traditional outsourcing arrangements aren’t enough. The confluence of redesigned
processes with enabling technologies makes a clinical transformation initiative
worthwhile. Outsourcing partnerships must be focused on collaborations that
give each track the attention and resources it merits.
Outsourcing Options
A successful outsourcing relationship must recognize that technology is valuable
only if it enables better clinical and business processes. An outsourcing partner
should be prepared to offer a flexible array of options (see Figure 2) that
goes beyond traditional infrastructure and applications management to involve
the technology-enabled transformation of the entire clinical enterprise. While
cost-savings and quality improvements will likely be achieved in Tiers 1 and
2, their ability to support operational change in Tier 3 will determine the
real value.
Figure 2: Outsourcing Options
In-house IS departments face accelerating change. They lack the resources to
handle change effectively. In general, they fail to deliver high levels of service
even for the applications they currently support. Most health care executives
feel their non-core activities are not cost-effective. CEOs and board members
interviewed for the 2001 VHA Annual Strategic Study on Sourcing Options said
they would be prepared to outsource non-core activities such as IS if they could
be assured of high performance at low cost, and would have the capability to
easily bring services back in-house if the outsourcing provider fails to meet
expectations.
An outsourcing arrangement can bring to a health care organization both clinical
expertise and implementation experience. Some outsourcing providers are confident
enough to risk part of their fees on their ability to meet agreed-upon performance
measures. That’s a tough combination for an in-house department to beat. For
most organizations, outsourcing should be considered as a way of increasing
the impact of IT on the workforce while mitigating the risks of transformation
on the enterprise.
Summary
By engaging in clinical transformation, health care organizations can design
and build systems to match their clinical processes. Benefits include more flexible
information technology support, improved ability to deal with labor shortage
issues, enhanced clinician satisfaction, and support for newer models of care.
The end result is a renewed focus on the core business: delivering quality patient
care.