February 01, 2011
Children's Hospital Boston: Supporting Clinical Excellence with Technology
In December 2010, Children’s Hospital Boston achieved HIMSS Stage 7. We had the pleasure of interviewing Daniel Nigrin, MD, MS, Senior VP for Information Services & Chief Information Officer Division of Endocrinology & Informatics Program at Children's Hospital Boston to learn more about Boston Children's success as one of healthcare IT’s early adopters.
How would you describe Children's Hospital Boston prior to the decision to become a digital hospital?
We never really set out to become a “digital hospital.” It never was a goal of ours to do so. We just wanted to use automation and IT to improve patient care. As many people know, Children’s Boston is a world-renowned institution for the clinical care we provide. And I’d like to think that we were still providing excellent patient care prior to our decision to automate a lot of our clinical care processes. What I will say is that subsequent to our implementation of a lot of these systems, that care has been enhanced quite a bit. Now, in addition to having top-notch clinicians who’ve always worked collaboratively to deliver great patient care, they have an additional layer of support and technology that helps them provide even better care. That was always sort of the driving force behind why we did what we did. Back in 2001, when we decided to go ahead with this project, there was not the emphasis on reducing health care costs we have today. Another benefit of IT is ready access to large amounts of clinical information which enables Children’s clinicians to study care practices and outcomes and determine how to deliver better, smarter care at a lower cost — where it’s safe and appropriate, of course
What made you decide to move toward automation and IT?
We recognized that IT was becoming more and more of a clinical tool that we could use - just like if there was advancement in a newfangled MRI machine, or a new surgical robot, or a new sophisticated genetic lab test. We would evaluate any of those new technologies and if we thought they would enhance patient care, we would implement them. So we saw IT and EMR systems as another one of those new technologies. When the evidence was growing that these technologies could really help to provide better patient care and safer patient care, we decided as an institution that we should go ahead and implement them.
How did you get internal buy-in from leadership to clinicians?
We’re lucky at our organization because many of our administrative leaders, including our CEO, Chief Nursing Officer who is also the Senior VP for Patient Care Services, Chief Quality and Patient Safety Officer, and Chief Medical Information Officer, were or are still practicing clinicians themselves - me included. I think because the message to our staff came from some of these individuals that definitely helped to deliver some credibility. It was definitely a top down approach, but that in and of itself would not have been enough. I think what really helped was that we were able to point to some of those examples in industry publications and even some anecdotal evidence that these systems really do improve the care of our patients.
We’re in a little bit of a bubble here in the Boston area simply because we are surrounded by many leading edge clinical organizations - Mass General Hospital, Brigham & Women’s Hospital, Dana-Farber Cancer Institute, etc. But many of those institutions, in addition to being top notch clinical places, have also been leaders with respect to advancing the state of information technology. So literally across the street or across town, we’ve got lots of evidence that some of the earliest incarnations of these IT systems, especially ones that included decision support, were really beneficial and could be used effectively to improve the care of our patients. That went a long way in convincing our clinical staff of the importance to do this.
What were the challenges you faced throughout the implementation process and what did you do to overcome these challenges?
So, obviously there are lots of challenges when you try and do big initiatives like this that span many years. One of the high level challenges was the tension that we experienced between the desire to standardize care practices and user interface and approaches to care guidelines - basically just a generalized standardization of the implementation of the system across our entire scope of practice in our organization, which we were deploying not just to our inpatient areas, but also to our ambulatory areas as well. There is benefit that comes with standardization. You standardize practice, clinical care practice, which often is helpful, but also from maintenance and support perspective from a technological point of view. With that said, when you have a complex organization… a tertiary care kind of organization like ours, you can’t actually standardize across the entire place. So there was tension that emerged where we needed to try and push standardization, but we needed to recognize when we couldn’t push it to a certain degree and when we needed to back off and allow for some flexibility and essentially individual customization depending on the location where the care was being provided. That was a challenge. I won’t say that we did that perfectly on the first go around. And, in some instances it required us to go back and do things over where we didn’t do quite well on the first time around.
Another challenge was simply reflective of the complex care that we provide here, especially in a pediatric organization that has its own unique challenges. In some instances, the technology was just not where it needed to be to support the clinical care. In that instance, we worked collaboratively with Cerner to point out why the technology as it was currently developed wasn’t meeting our needs. To Cerner’s credit, they collaborated closely with us on lots of things and improved the product.
I think it was Boston Children’s together with Pittsburgh Children’s and probably a handful of other Cerner clients that started to recognize this need to get a more global view of the patient information as it was stored in Millennium, what we called here a gestalt view about the patient, especially in our critical care environment. I think Cerner heard that feedback and in turn developed iAware, and now we’re all fortunate to have the iAware product. That was a good example where we initially saw kind of a lack of functionality in the product and through iteration and working collaboratively we addressed that.
The length of the implementation for a big project like this is another challenge. This was not a 6 month or 1 year initiative. This was at least a 3 to 4 year initiative and keeping the focus on a project like this over that duration is difficult. Frankly, keeping key staff on your team for that long can sometimes be difficult. And most importantly, perhaps, is keeping your end users engaged over that period of time can be tough. The flip side is that if you try and do things too quickly to try and compress a timeline to do it over a shorter span, you end up having users who basically give you the feedback that it’s too much change too soon and they can’t absorb that much change in their practice. It’s a delicate balancing act that was difficult and needed a lot of attention over the course of the project.
What were some of your successes during the automation process?
I think probably the biggest success that we see now is the integration of all of the patient’s data into a single place that clinicians can access it. As I mentioned, we didn’t limit the scope to just inpatients or just ambulatory. So now within one application, a clinician can see essentially everything there is to see about the patient, from ambulatory notes, to ambulatory labs and immunizations, to inpatient hospitalizations, emergency department visits, operative documentation, diagnostic studies that are done including seeing the images as well. Everything is available in a single location. That’s really incredibly useful and valuable to clinicians who used to have to either hunt down things in different systems or even worse try and thumb through patient charts in a futile attempt to find the little bit of information they need. They can now access it very easily within the electronic record.
The second major success is now that we’ve got all this information in digital form and now that we’ve automated many of our clinical processes, we can start to use the computer basically to support our practice in a way that we weren’t able to do in a paper-based world, specifically supporting the clinicians with decision support, helping them to follow clinical guidelines for best practices, and basically adding an extra layer of safety support that wasn’t there before. That’s a big win. It translates to wins for the patient too because it means safer care and, in some instances, it’s reduced the cost of our care which is an important strategic direction as well.
How did working to achieve Meaningful Use assist Children's Hospital Boston in reaching HIMSS Level 7 status?
It’s funny - we’ve never had specific projects that were focused on achieving either Meaningful Use or level 7 recognition. We started our initiative so many years back. I think the decision was made in 2001 or 2002 to move forward with this project and we didn’t start until 2003 or so. All of those things pre-dated Meaningful Use and HIMSS Analytics. We were just basically following our roadmap as we had originally laid it out - focusing on improving clinical care and enhancing patient safety. We continued to use that as our driving strategic goal.
Is that roadmap something that you worked on within your organization or jointly with the Cerner team?
I think that the patient safety and the clinical optimization were developed jointly with Cerner. We never went specifically after achieving the level 7 recognition or specifically things for Meaningful Use. Those have come as by-products of our initial goals, which is nice. It meant that our initial goals were probably on the money and led us down a path that others have now seen is the appropriate one.
What advantages would a patient have in selecting Children's Hospital Boston over a hospital that is not automated?
We’re an institution that’s always been all about clinical excellence and we’re well recognized for that. But I think we now have clinicians and clinical practices that are even better supported by technology - technology with decision support and templating and so on - that have enhanced the care that we provide even that much more. I think patients that come here are going to experience clinical excellence that’s also supported by technical excellence. Our emphasis has always been on the patient. We try and also implement systems that are going to facilitate the provision of care for our providers as well, but when we come to decision making points that are sometimes tough, we always return to this notion of what’s best for the patient and that’s what leads us to the answer. I think patients are going to be the beneficiaries of that kind of thought process.
Daniel Nigrin, MD, MS is Chief Information Officer and a practicing endocrinologist at Children's Hospital Boston. He is also a senior staff member of the Children's Hospital Informatics Program and an assistant professor of Pediatrics at Harvard Medical School. His IT research interests include large-scale clinical data mining and electronic patient-physician communication systems.
You can read more about Dr. Nigrin’s perspective on the intersection of medicine and IT on Vector, Children’s Hospital Boston’s science and innovation blog.