Imagine 30% fewer deaths in intensive-care units and half the medication errors in hospitals IT is poised to deliver improved patient care May 19th, 2003 By Marianne Kolbasuk McGee It's a bit after 10 p.m., and a patient is in the intensive-care unit of Sutter General Hospital in Sacramento, Calif., following surgery to remove a section of dead bowel tissue. The patient's vital signs are deteriorating, which, given the surgery, probably means a section of dead tissue remains or, worse, the patient is septic, a potentially deadly blood and tissue infection. Dr. Daniel Ikeda is about two miles away, trying to monitor the well-being of more than two dozen patients, including the one in trouble. Ikeda and a registered nurse sit at workstations, scanning several computer displays of information, including real-time vital signs in what's called the electronic intensive-care unit. An alert sounds, signaling that the patient's vital signs have changed. Ikeda checks what surgery has been done and can even look at the patient using a Webcam in the room. He calls a nurse on the floor to start intravenous fluids and a stronger antibiotic, and he tells an assistant to call a surgeon. Emergency surgery begins around midnight. The Sutter Health hospital network in Northern California is testing an electronic intensive-care unit that lets one doctor and one nurse remotely monitor dozens of patients at once. Without the system, the pressure would've been entirely on the nursing staff to spot the pattern of weakening vital signs and make the call that it's worth rousting a doctor and a surgeon about a possible midnight operation. Ikeda says the remote center removes him from the distractions and pressures of the intensive-care floor to scan all the patients at once for signs of trouble. "When I'm in the eICU®, I'm a lifeguard," says Ikeda, director of Sutter Health's new online intensive-care system. "I use the technology to look for troubling trends," before they become serious complications. "A critically ill patient can turn sour in a matter of minutes." IT is poised to change dramatically how patients are cared for, and in the process possibly save tens of thousands of lives a year. How? Sutter expects death rates in intensive care to drop a stunning 30% by 2006 when the electronic-monitoring system will be in place across all its hospitals, tracking more than 460 patients. That's right--three out of 10 patients who die today in intensive care would not. Stunning, but also realistic. Sentara Norfolk General Hospital in Virginia, the first hospital in the country to test the system, saw a 25% drop in mortality rates in the first six months of use compared with the previous 12 months, according to a report commissioned by Cap Gemini Ernst & Young. So far, much of the IT spending in health care has been tied to transactions--creating electronic health records or improving payment efficiency. The next great leap will come from tools that save lives by improving patient safety, boosting quality of care, and reducing errors. That's important. The National Academy of Science's Institute of Medicine estimated in 1999 that 44,000 to 98,000 people die from medical errors each year--greater than the number of people who die anually in automobile accidents. Many efforts are just getting started. Visicu Inc., the company founded by two doctors from Johns Hopkins University to create the electronic ICU system Sutter Health and Sentara use, is working with several other hospital chains on similar projects. The Sutter hospitals also are among several hundred in the country deploying computerized, bar-coded drug systems that let nurses scan drugs at patients' bedsides, receiving alerts if they're giving the wrong medication. At Erlanger Medical Center, a 22-building complex in Chattanooga, Tenn., wireless technologies help nurses eliminate hours of paperwork and miles of running around, freeing them to provide more hands-on care. At Memorial Health University Medical Center in Savannah, Ga., a Web portal and computer order-entry system give doctors access to real-time patient information, lab results, X-rays, and other materials, so physicians can make better decisions, either remotely or at the patient's bedside. Add to this a broad, though slow, movement toward digital medical records and electronic information-sharing among doctors, nurses, and hospitals, and the potential exists to give health-care workers more accurate and timely information that will let them deliver better care. "In five or 10 years, patients will be amazed when they enter a hospital and don't see bar-coded drug systems, electronic medical records, and technologies like that," Sutter CIO John Hummel predicts. "Those that don't have the technology will be at a great competitive disadvantage--on the business side and especially in patient safety." In addition to saving lives, there's a growing money motive for health-care providers to buy IT systems that improve patient care. Malpractice insurance premiums are skyrocketing, so technologies that reduce the chance for medical errors are attractive. There's also a shortage of people with many health-care skills, including intensive-care physicians and registered nurses. Plus, hospitals are just beginning to be judged--and paid--based on quality. Influential organizations such as the Leapfrog Group, a nonprofit company founded by businesses and other big health-care buyers to improve quality, rate hospitals on whether they employ certain practices to reduce errors and improve care, including computerized drug systems. For example, Leapfrog advocates that a hospital always have a doctor specializing in urgent care in the intensive-care unit. But many hospitals can't afford that or can't find the people, since there's a national shortage. Leapfrog has blessed the eICU® units at Sutter and Sentara. "What's lacking in the on-site presence of an intensivist in the unit is made up with the smart software," Leapfrog executive director Suzanne Delbanco says. "It's fine-tuning of information that's not even available at the actual bedside." Insurance companies also hold hospitals more accountable. Some insurance networks provide payment incentives to health-care providers that rate higher on quality standards. Cigna HealthCare gives members detailed online reports on mortality and complication rates for more than 50 diagnoses and surgeries. But money is also the reason many companies haven't yet invested in promising technologies. Erlanger Medical Center, for example, expects to lose at least $9 million this year. It's a leap of faith that the $1.5 million it's spending on wireless connectivity will improve the nursing staff's productivity and performance enough to justify the expense. Some barriers are beginning to fall. In March, the U.S. Food and Drug Administration proposed a rule to require bar codes on all individual doses of over-the-counter or prescription drugs, vaccines, blood products, or intravenous medications dispensed in hospitals or other care settings. The rule, which is expected to be finalized this year, would require a bar code that includes the drug's National Drug Code number, a unique identification of the drug, its strength, and its dosage form. If drugmakers put bar codes on single-unit medicines, it would make it cheaper and easier for hospitals to deploy computer drug systems that use bar codes. Some medical-supply and drug distributors such as McKesson Corp., as well as IT-services firms such as EDS, can help build bar-code systems, including those for use at the patient bedside, and robotic systems to improve efficiency at hospital pharmacies. The Institute of Medicine estimates 770,000 adverse drug events a year lead to injury or death in U.S. hospitals. It estimates 28% to as many as 95% result from preventable errors. It was this 1999 research that prompted the FDA to investigate ways of reducing errors. Only about 300 of the nation's 6,600 hospitals have bar-code drug systems, of which about 130 are Department of Veterans Affairs facilities, estimates Jeff Schou, director of worldwide health-care markets at Symbol Technologies Inc., a maker of bar-code devices. The success of the VA's bar-code drug system was a big factor in the FDA's deciding that such systems could deliver major reductions in medication mistakes. The FDA rule would mandate only that drug companies add the bar codes within three years. It would not force hospitals to deploy computerized systems. But that's the FDA's goal. Hospitals have been reluctant to invest in the systems because many single-dose drugs don't come with bar codes, and drugmakers have been reluctant to use bar codes until there's demand. Once drug companies are mandated to include the single-dose bar codes, "the hope is it will get hospitals to deploy the systems," says Jerry Phillips, associate director of the FDA's office of drug safety. The FDA estimates the bar-code rule would cut in half the number of medication errors at the point of dispensing drugs, translating to more than 400,000 fewer adverse events per year--and savings of more than $41 billion over the next 20 years because of shorter hospital stays. Some health-care companies already have computerized order-entry systems that replace handwritten prescriptions with electronic orders, eliminating errors caused by doctors' messy handwriting. Most of those systems check patients' electronic medical records and red-flag possible allergies and suggest alternative treatments. CareGroup Healthcare System, a network of Boston hospitals and doctors, has cut drug-related errors at least in half in the two years since it deployed electronic prescriptions. However, CareGroup hasn't yet deployed a bar-code system for use when medications are dispensed to patients. When that happens, "that will close another big loop" where mistakes occur, CareGroup CIO John Halamka says. A bar-coded drug system could greatly reduce one category of mistakes, but there are other, broader IT developments aimed at improving care by providing more real-time information with which to make decisions and to make time-pressed nurses and doctors more efficient. One is converting more information into digital format for delivery through portals to Internet-connected devices. Digitization is making the rounds at hospitals, starting in labs and X-ray and imaging centers, where information that needs to be shared widely is generated. "What drives our technology strategy is getting more information into the hands of clinicians so they can make better clinical decisions and act on the most timely information," says Steven Stanic, CIO of Memorial Health University Medical Center in Georgia. In what's becoming an increasingly common platform, Memorial's doctors can access a physician portal for patient medicine, health records, and lab results. A Web-based order-entry system also lets doctors order tests and drugs from their offices or via tablet PCs at the hospital. As more information becomes available digitally, the value of accessing it wirelessly grows. And once wireless networks are in place in hospitals, they may have even broader uses, such as tracking equipment and patients using radio-frequency ID tags. The savings in terms of financial costs and lives are stacked in favor of these technologies. In addition to a 25% drop in mortality rates, the Cap Gemini Ernst & Young study of two Sentara Health eICU® units in Norfolk found that people had a 17% shorter stay in ICUs, letting the units treat 20% more patients. The study calculated a $3 million-a-year net gain for the 16 ICU beds. Sutter's Hummel sees possible business opportunities in providing remote ICU services to non-Sutter hospitals in rural areas that have difficulty recruiting ICU physicians. But are patients--and doctors and nurses--ready for this kind of technology-enabled delivery of health care? Patients might need to give up the idea that a doctor is physically down the hall. Doctors and nurses will have to overcome the idea that bar-code and other alert systems question their competence. And they'll have to decide if checking vital signs on computers and remote cameras still feels like practicing medicine. Yet this brave new world is nothing close to automating the practice of medicine. Software is still somewhat dumb--all it can do is recognize changes and trends in vital signs and send up alerts. "For every 50 to 100 alerts, maybe one is important," Sutter Health's Ikeda says. "It's my job to investigate if vital signs are changing because the patient is eating his breakfast or because something more serious is happening." Mary Beth Navarra is a former practicing registered nurse who, as director of automation planning at McKesson, has brought technologies such as bar-code drug-readers into hospitals. She's seen the resentment when they're first installed. "But the minute a nurse sees the system catch an error before she's about to administer a drug, she never wants to go back to not having that extra level of security," Navarra says. Given the chance, patients will almost certainly feel the same way.