Tuesday, October 20, 2009

NU501 Assignment 3

This one took a bit longer than I had planned, but I'm glad that I took the time.

Some personal context

I work as a staff nurse in the neurosciences intensive care unit at the Brigham and Women's Hospital (BWH) in Boston. My primary clinical interest is caring for patients and families at end of life. I am also very interested in how information technology can be used to support patient care and nursing education.

My professional experience is split between my clinical work, which has been spent practicing in a range of critical care settings, and with patients receiving hemodialysis for end stage renal disease; and my work with patient care information systems, and with systems used more broadly as tools for individuals and organizations.

Many key advances in health care information technology occurred in the Boston-area. I've met and worked with some of the people who have played important roles in this industry, and I have incorporated a few personal recollections and observations in this assignment.

Brigham and Women's Hospital (BWH)

BWH is a 747-bed nonprofit teaching affiliate of Harvard Medical School, and one of the two founding member of Partners HealthCare System (Partners), an integrated health care delivery network.

source 2008 AnnualReport, Partners HealthCare (pdf)

BWH provides medical and surgical services, and has established clinical centers of excellence for oncology, and women's and reproductive health, cardiovascular/thoracic, neurosciences, orthopedics, and arthritis.

BWH has over thirteen thousand (13,000+) employees, of which over two thousand (2,000+) are staff physicians, and over twenty-eight hundred (2,800+) are registered nurses.

According to the most recent data from the American Hospital Directory, Partners member hospitals account for over sixteen percent (16%) of staffed beds, and over twenty-seven percent (27%) of gross patient revenue in Massachusetts.

BWH accounts for approximately 5 percent (5%) of the staffed beds, and approximately 8 and a half percent (8.5%) of gross patient revenue.

The foundation for information technology at BWH

This paper does not consider BWH's use of information technology prior to the formation of Partners in 1994.

Massachusetts General Hospital (MGH) has a notable history of computerization dating back over 40 years, which directly influenced the implementation and use of information teachnology at BWH. When Partners was established, the department responsible for developing and supporting information systems at MGH was reorganized as a corporate service to meet the needs the new organization's member hospitals. The core systems currently in use at BWH were developed and are maintained by this corporate services group, Partners/IT.

The systems currently in use at BWH can be appreciated in the context of the history of computerization at MGH. The impact of this history is most clearly seen in the development of the Massachusetts General Hospital Utility Multi-Programming System (MUMPS) by Neil Pappalardo and Kurt Marble, working under under G. Octo Barnett at the MGH Laboratory of Computer Sciences.

Pappalardo and colleagues developed MUMPS in 1966 and 1967 specifically to provide a set of programming and data management tools best suited for patient care computer systems. MUMPS was developed as an alternative to the tools and systems then in use to support commercial and scientific organizations.

As Henry Heffernan noted in his presentation at the 1980 meeting of the MUMPS Users Group (MUG) in Washington, DC:
“The data management and communications needs of clinical care and health care management were quite different from the business batch processing and large scale scientific computation tasks that had dominated the software system design thinking of the previous decade. The lesson…was that software systems should be designed to fit the paradigms of information usage in medical applications, instead of medical applications being twisted and stretched to fit batch processing paradigms.”

Pappalardo later founded MEDITECH, a company that continues to sell and support a wide range of integrated applications for hospitals and other health care organizations. He still heads the company as chairman. One industry observer has noted:
"...the talent involved in the founding of MEDITECH is astronomical. These are some very, very smart and successful people who made extensive contributions...I'm in awe of the influence these pioneers have had, not only in healthcare automation, but in healthcare in general...the story of MEDITECH and its founders is, to me, the most fascinating and awe-inspiring of any firm in our industry. Someone should write a book."

I worked at MEDITECH from January to October, 1986, and though I probably won't be the one to write that book, I did gain some insights into the company, its values, and its leadership role in the industry. There were about 350 people working at MEDITECH while I was there. The current count likely exceeds 3,500, just one indication of the company's steady growth.

I personally found MEDITECH's management culture too restrictive, which prompted my decision to leave. But nothing succeeds like success.

I left MEDITECH for a sales position at Collaborative Medical Systems (CoMED), where I worked for the next 8 years selling CoPATH, the best-of-breed anatomic pathology system. My customers included MGH, the Lahey Clinic, the University of Kentucky Medical Center, the University of Tennessee Medical Center, the University of Maryland Medical System, the Cleveland Clinic Foundation, University Hospitals of Cleveland, the Toledo Hospital, Children’s Hospital of Columbus, Mercy Health System, and other leading institutions throughout the country. I also sold a copy of CoMED's clinical laboratory system, CoLAB, to MGH as a replacement for an internally developed system used by the hematology and chemistry departments there.

CoPATH and CoLAB were written in MUMPS, and three of CoMED’s four founders had worked at MEDITECH earlier in their careers. One of CoMED's founders had developed MEDITECH's first commercial clinical laboratory system, and was responsible for hiring Howard Messing, who now serves as MEDITECH's president. All four CoMED founders were graduates of the Massachusetts Institute of Technology (MIT), as were Neil Pappalardo and Kurt Marble.

Another company bought CoMED shortly after I left in 1995. That company was, in turn, later acquired by Cerner Corp. CoPATH is still in wide use, including at U.S. Military hospitals around the world. That sale of CoPath to the U.S. Department of Defense was my final contribution and the company's largest sale ever.

It was a nice way to go out.

Information technology at BWH

The patient care systems currently deployed at the Brigham and Women’s Hospital include a mix of applications developed by Partners/IT, along with applications obtained from vendors.

The core inpatient care system is called BICSBrigham Integrated Computer System. It supports key administrative and patient demographic functions to support inpatient admissions and includes a master patient index (MPI), a permanent repository of information associated all admitted inpatients and registered outpatients.

BICS is also the mechanism for provider order entry (POE), where physicians and advanced practice nurses request a range of ancillary services including clinical lab tests and medications; and through which clinical staff access findings and results. Though POE does not provide all of the elements for a fully automated patient electronic medical record (EMR), it serves as an important component of the base from which an EMR is built.

Finally, BICS supports the complex needs of the BWH clinical laboratory and pharmacy departments, including the full range of each department’s functional processing and internal control requirements.

BICS was developed and is supported by Partners/IT using a toolset called Cache, provided by InterSystems of Cambridge, Massachusetts. Like MEDITECH, InterSystems is a leading vendor still headed by its founder, and whose history can be traced directly back to the initial development of MUMPS; though InterSystems evolved into a developer and provider of programming tools for others to use when building application systems.

This illustration shows the patient care applications most frequently used by clinicians and ancillary personnel at the Brigham and Women’s Hospital, and indicates the central role played by BICS.

Partners/IT has also developed an inpatient system for nurses and house staff called eMAR – the Electronic Medication Administration Record – though its capabilities go beyond administering and recording inpatient medications. eMAR is the main system used by staff nurses with mobile notebook computers during the course of most patient care, and is the conduit for access to other systems that include word processing and email, web browsing, facility and departmental policies and procedures, and BICS.

The following illustration depicts core eMAR functions, along with the interaction between BICS and eMAR.

Inpatient medication ordering and administration at BWH is controlled by several interacting information systems
  • BICS OE subsystem for provider order entry
  • BICS Pharmacy subsystem for pharmacy staff review/approval, drug-interaction and formulary check, and other internal controls
  • eMAR for scheduling medications
  • Omnicell for medication inventory management
  • Omnicell for medication access by nursing staff
  • BICS results reporting for nursing staff to review pertinent laboratory and related patient data
  • eMAR for patient/medication reconciliation by nursing staff using handheld scanner to identify the patient and the medication
  • eMAR for quick communication between nursing and pharmacy staff
Partners/IT has also developed a system for outpatient care called LMR – the Longitudinal Medical Record – which has been deployed throughout the Partners network at outpatient clinics and in provider offices. LMR supports continuity of care with access for authorized users, incuding primary care providers, to the full range of an individual’s inpatient and outpatient data.

The combination of systems developed by Partners/IT and obtained from vendors places BWH firmly within the very small minority of institutions found by reserachers to have comprehensive systems.
“On the basis of responses from 63.1% of hospitals surveyed, only 1.5% of U.S. hospitals have a comprehensive electronic-records system (i.e., present in all clinical units), and an additional 7.6% have a basic system (i.e., present in at least one clinical unit). Computerized provider-order entry for medications has been implemented in only 17% of hospitals.”

from Use of Electronic Health Records in U.S. Hospitals

Similarly, the widespread application of information technology to support patient care establishes the Partners network as well along towards meeting national goals.

source 2008 AnnualReport, Partners HealthCare (pdf)

Other considerations

BWH house staff independently acquire and use their preferred personal digital assistant (PDA). These devices can be synchronized with various medical department schedules, as well as provide access to the Partners email system through Microsoft Exchange Server.

Partners attending physicians and house staff use online telehealth to review radiology images at affiliated sites, an application I’m personally familiar with as a member of an accredited stroke center.

Finally, the near-term system development objectives for BWH includes replacing the current paper chart used for written inpatient progress notes and other patient care charting with a fully computerized electronic medical record.

BWH is the most fully automated patient care setting I have ever worked in. The systems here meet my professional needs and support quality patient care.

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