American College of Physicians: Internal Medicine — Doctors for Adults ®

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Is there a computer in the house?

At Utah's LDS Hospital, information systems help call the shots

From the June 1997 ACP Observer, copyright © 1997 by the American College of Physicians.

By Edward Doyle

SALT LAKE CITY—If you walk around LDS Hospital, you can't miss the computers. They're in nearly every patient room and at nursing stations and cubicles throughout the building.

But these aren't like the computers in your hospital. The LDS computers not only track and store patient information, but also use protocols and guidelines written by the hospital's clinicians to suggest the best antibiotic treatment for patients fighting infection—and adjust the drug dosage when the patient's renal function changes. And when patients take a turn for the worse—they show a dangerously low creatinine level, for example—the system will page, beep or fax the appropriate clinician.

Although you may now be convinced your hospital should purchase an LDS-type inpatient electronic record system, don't look for it on a sales shelf—for any price. Every piece of the system, which has been in the works since the 1960s, has been customized for both LDS and its parent company, Intermountain Healthcare. The system would require major modifications to work anywhere else.

However, LDS offers valuable lessons in how to build an electronic patient record, from the way the system collects its vast sums of patient information to the way physicians have embraced computerized tools. As anyone who has even toyed with the notion of installing a computerized record system knows, these are huge barriers indeed.

The data-entry dilemma

One of the first lessons that LDS has to offer is how to enter information into the computer, a problem that can cripple even the best-laid electronic record plans. As David C. Classen, ACP Member, a member of the clinical epidemiology task force at Intermountain who also helps develop infectious disease management software for LDS, likes to emphasize, the onus to enter data is not on physicians.

Instead, employees throughout the hospital keyboard data at the point of care. Microbiology technicians, for example, enter microbiology and culture results from the lab, while nurses enter their own blood pressure readings. Physicians merely dictate their notes as they would at other hospitals, and transcriptionists enter the text into the system in less than two hours.

In part, LDS can keep its physicians from having to type in patient data due to some homegrown technology. In each patient room, a little black box with slots for five cables is mounted on the wall above patient beds. The device, known as a medical information bus, was invented by staff at the hospital to take measurements from the various machines—the infusion pumps and mechanical ventilators, for example—and enter that information into the patient record. All patient information that is collected automatically—vital signs, body temperature, heart rate, urine volume, respirator data—goes into the system automatically. This information is updated in the system every 15 minutes, and every five minutes for patients in the intensive care unit.

To demonstrate the system's thoroughness, Dr. Classen called up a patient record on a computer terminal in a vacant patient room. In a matter of seconds, he has access to patient information collected earlier that day like the patient's blood pressure, body temperature, medication lists, lab results and hemodynamics.

While collecting so much information is quite a feat, it's what LDS does with those data that has attracted attention from hospitals around the world. Within LDS, various departments have created programs and tools that help physicians do a better job. In infectious disease, Dr. Classen's specialty, the clinicians have created a program called the Antibiotic Assistant. Its purpose is to help physicians choose the most effective antibiotic—and in the right doses.

The program starts by collecting data from various components of the LDS information system. From the lab, it retrieves data on patients' white blood cell counts from the previous 24 hours, creating a chart of the highs and lows. The program also collects a range of other information like body temperature, body weight, admission date, drug allergies and current medicines and their start dates.

The program then gets to work. Because it maintains detailed lists of organisms that have appeared in the hospital and notes which antibiotics have worked and which have failed, it gives physicians the data they need to best treat infections. When Dr. Classen queries the system for information on staphylococcus aureus, the computer indicates that in the shock trauma unit alone, 286 strains were detected in the last year. It tells him that the only drug that effectively treated all cases was the antibiotic vancomycin, and it also gives efficacy rates for other antibiotics in case the patient is allergic to the first choice. The program then determines the right dosage of the drug that is chosen. And if the patient's condition changes—his renal function deteriorates, for example—the system will automatically adjust the drug dose.

Emphasis on the basics

The Antibiotic Assistant program offers another important lesson: Physicians need help in putting some of the agreed-upon basics of medicine into practice.

In creating the antibiotics program, for example, the department simply computerized some basic infectious disease principles. "All we did was apply the principles that we are all taught," explained Dr. John P. Burke, FACP, chief of clinical epidemiology and infectious disease for LDS and chair of the clinical epidemiology task force at Intermountain. "That you should base your decisions on the most active antibiotic among the choices available for a specific pathogen, that you should look for the drug that's the least toxic among those available, that if you have drugs that are equally active and equally toxic, you should look for the lowest cost as a third level of function," he said.

Improving patient care through programs like the Antibiotic Assistant is a top priority for LDS, in part because it is owned by Intermountain, a system that owns 24 hospitals and more than 100 outpatient centers throughout the midwest. Intermountain has identified 24 areas of care—areas like antibiotic management, ventilator management, anticoagulation protocols—that account for roughly 80% of the services it provides.

Intermountain has already taken the LDS system—as well as components that have been developed at its other hospitals—and implemented it in five of its hospitals and more than 100 outpatient clinics. Intermountain next plans to introduce the system to the rest of its hospitals, with the goal of improving patient care, reducing costs and keeping purchasers of health care happy.

Intermountain's quality initiative is typical of the work that LDS has been doing for years. The LDS emphasis on the basics of medical practice led to another computer program, one that helps make sure that prophylactic antibiotics are being used properly before surgery. While most surgeons agree that prophylactic antibiotics should be given within two hours before surgery, Dr. Burke said, that doesn't always happen. When LDS studied the issue using information from its computer system, it found that patients were receiving antibiotics in that two-hour window only about half the time. The hospital also found that infection rates rose when antibiotics were not given in the right time frame.

Based on that information, the clinical epidemiology/infectious disease department created a list of surgical procedures and the appropriate antibiotics; the computer generates a checklist for nurses in the surgical holding area to make sure that patients receive the right antibiotic at the right time.

Getting physicians aboard

While these examples illustrate the strides that LDS has made in improving patient care, Drs. Burke and Classen say they also shed some light on the most important lesson they have learned: Building a computer system that physicians will use has more to do with interpersonal issues than matters of hardware and software.

In the late 1980s, for example, when the hospital began examining the use of antibiotics before surgery, Dr. Burke said that it took physicians a while to even agree that this was a problem. First, LDS's massive computing power generated the data. Next, informaticians like Drs. Burke and Classen met with surgeons to determine which antibiotics should be used with which patients. Only when a consensus was formed and a list of drugs was drawn up—the truly hard work in the process—was a computer program created.

To give clinicians a voice in how technology is used at the hospital, LDS has formed clinical groups in areas like infectious disease, pulmonology, cardiology, bone marrow and women's and children's services. Like the infectious disease group, they are all busy creating their own computer programs to help clinicians practice more efficiently—and working with end-users so there are no surprises.

"One of the things we don't do here is take the big bang approach and develop an application off-site and then make everybody use it," Dr. Classen said. "We show it to the clinicians early on in the development and get their feedback."

This flexibility is built into the finished products as well. When physicians don't want the antibiotic that the computer recommends, for example, they are free to choose another one—provided that they give the system an explanation. "You can override the computer's choice," Dr. Classen explained, "but you're going to have to justify it."

This give and take helps improve both the computer system and the way physicians practice. The Antibiotic Assistant program, for example, didn't initially calculate doses; everyone assumed that physicians would want to do it themselves. However, many patients were being overdosed because physicians weren't correctly calculating their renal function. Adding automatic dosing to the program helped the hospital cut its use of some expensive drugs by as much as 30%, Dr. Classen said. The hospital has also noticed a decrease in side effects of up to 75% in some cases. For example, seizures from the drug imipenem, which used to occur in about 4% of patients, have become virtually nonexistent.

Too much power?

While the LDS system clearly helps physicians better manage patient care, it also raises questions about the roles of physicians. As Dr. Burke explained, infectious disease specialists who watch the Antibiotic Assistant program often have one question: What is left for me to do?

"The program clearly changes the focus of what we do," Dr. Burke explained. "So much of what we have done in the past has been focused on information gathering activities and around mundane sorts of calculations, figuring doses, figuring blood levels, getting calculations on things like creatinine clearance. If you eliminate all these little jobs, it frees you up to spend more time taking care of the patients' real problems, like whether they really need the drug in the first place."

The LDS system raises other professional and ethical questions. For one, how much power over patients' lives is the hospital willing to give to a machine? And when do physicians stop making decisions about their patients—and when does the computer take over?

Consider again the information bus—the little black box that collects information from the automatic drip machines in each patient room—that lets the computer system control the flow of drugs to patients. Nurses simply tell the computer what drug is in the bag and how much medicine the patient should receive, and the computer automatically calculates the formula according to body weight. When a patient's renal function changes, it is the medical information bus—not humans—that automatically adjust the dose.

The computer has similarly been used in limited studies to control mechanical ventilators in patients with severe lung disease. The LDS system can use ventilator management protocols that the hospital's doctors created and artificial intelligence technology to decide how ventilators should be adjusted. One study showed that allowing the computer system to adjust patient ventilators improved overall survival by 30%.

In most instances, however, the computer system does not have direct control over patient care. While it regularly controls automatic drip machines, the computer system does not regularly control the settings on mechanical ventilators. Instead, the system keeps physicians in the decision-making loop by forwarding its recommendations to physicians, who then make the final call on whether to change the settings.

One of the system's most powerful roles, in fact, is as a consultant to clinicians at the hospital. It constantly screens volumes of patient information, looking for problems that it may have missed or conditions that have just developed. If a patient develops a condition that resembles a nosocomial pneumonia, for example, the system notifies both a nurse and an infection control physician so they can examine the patient.

If the computer encounters a life-threatening condition—a deadly drug interaction, for example—it will page the attending physician. If the condition is more minor, the computer may send a fax to the nursing station responsible for that patient. In either case, the computer will keep sending the alert until a human being responds. Dr. Classen said one key to the alerts is that they are never sent via e-mail, requiring clinicians to use the computer to use the system. Alerts are instead sent via technology that clinicians are already used to-pagers, for example-and will use.

Overcoming resistance

The time that LDS has invested in honing the interaction between machine and human beings has helped the system overcome the single biggest barrier in medical computing: physician resistance. By tailoring the system to fit the needs of its clinicians, LDS has created a system that is largely invisible to its users, that thinks the way they think and communicates the way they communicate.

Ironically, however, the system's close fit with clinicians at the hospital makes it less useful for hospitals that are not part of LDS or Intermountain. To implement the LDS system in another hospital with different practice patterns would require huge revisions. Adapting the Antibiotic Assistant program, for example, would require access to that hospital's information about efficacy rates of antibiotics and lists of common infections, something that is not readily available at most institutions.

This often frustrates physicians. "People always seem to think that LDS is so different and so far ahead that no one else can catch us," Dr. Burke said.

That may be true. Dr. Burke acknowledges that it is already too late for most hospitals to build their own version of the LDS system. "We have clearly reached a stage where other institutions can't develop a medical record from the ground up," he said. "They have to deal with existing computer systems and find some way to stitch them together."

Even so, the LDS system offers lessons for physicians and health care systems interested in building a top-notch clinical information system. Visitors from countries like Japan and Germany frequent the hospital. In Japan, a hospital coalition has been formed to create an electronic record system. They all are studying the LDS system carefully, learning from the hospital's mistakes and triumphs.

Even in LDS's backyard, there are signs that physician resistance is waning. When Dr. Classen helps install parts of the LDS system in other Intermountain hospitals, for example, he still encounters some physicians—typically older practitioners—who refuse to use the system. Some have nurses print the contents of the record and staple it to the chart so they don't have to use the record.

But Dr. Classen said that resistance is disappearing as older physicians retire or leave practice. And there are signs that physicians finally want the help that computers can provide.

While showing the Antibiotic Assistant program to physicians at one of Intermountain's smaller hospitals, for example, Dr. Classen was surprised by the reaction. "A physician got up at a medical staff meeting and asked how I could ethically deny him this tool," Dr. Classen said. "That's a complete change of direction from a physician saying, 'Stay away.' "

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