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Serious Medicine. Extraordinary Care.

Defining Quality

In the 1970s, an average patient was touched by approximately 2.5 health care professionals during an inpatient visit in the hospital. Today, that same patient is seen by an average of 17 health care professionals.

“Medicine has become much more specialized so there are multiple providers seeing each patient,” says Julie Fedderson, MD, an internal medicine specialist and chief quality/outcomes officer at The Nebraska Medical Center. “It’s a reflection of how complex health care has become today. While specialization is good, it also requires the need to collaborate and make sure everyone has the same information and is working toward the same goal.”

The complexity of our health care system combined with communication breakdowns are sometimes the biggest barriers in achieving these goals. These shortfalls come with a price. Not only has health care become exceedingly expensive, but the safety of our health care has also been under fire. For example, health expenditures in the United States neared $2.6 trillion in 2010, over 10 times the $256 billion spent in 1980 (Henry Kaiser Family Foundation), while health insurance premiums for families have risen 131 percent since 1999 (Kaiser Family Foundation and Health Research & Educational Trust survey, 2012). Today there are also an estimated 200,000 preventable medical errors each year in the United States (Healthgrades, 2004).

The Nebraska Medical Center is committed to improving the delivery of health care now and in the future. With this goal in mind, the medical center recently partnered with the University of Nebraska Medical Center (UNMC), UNMC Physicians and Bellevue Medical Center to introduce One Chart, an electronic health record (EHR) system to eliminate communication barriers and make health care safer and more efficient.

One Chart is a secure online web portal that allows health care professionals to enter and track a patient’s medical information in real time providing accurate, provider-friendly, easily accessible and up-to-date records that follow a patient from birth to death and across all episodes of health care use.

The Nebraska Medical Center and its partners recently completed the implementation of One Chart throughout the entire campus. The hospital used the software program called EPIC, the most successful and widely used EHR software in the industry. It was a massive undertaking that took 629 days, hundreds of employees and an $87 million investment. The initial rollout began in the spring of 2012 and was completed by fall. However, improvements and additional features continue to be added to the system.

“One Chart provides total transparency across an entire continuum of care and throughout the patient’s entire life,” says Dr. Fedderson. “It was a huge undertaking that in the end will improve the efficiency, safety and quality of patient care, produce better outcomes and reduce costs.”

JULIE FEDDERSON, MD

A hospitalist at The Nebraska Medical Center since 2003, Dr. Fedderson says patient safety and quality improvement have become her greatest passions. She believes that maintaining quality will be a top priority and challenge as hospitals nationwide are faced with finding ways to cut costs. “It’s been said that if you reduce waste and inefficiency in a system, you can reduce health care costs by 40 percent,” says Dr. Fedderson. “We think this system is one of the tools that will help us achieve cost savings while providing better care.”

It is also a system that is helping the hospital prepare for new health care mandates and governmental regulations.

“Health care reform now requires us to demonstrate that we offer value to those purchasing our services,” says James Canedy, MD, president of Clarkson Regional Health Services. “We will need to measure cost, standardization, efficiency of care and results of clinical services. If we can’t measure it, we can’t improve it. As One Chart evolves, we expect it to provide many benefits to our system.”

While change in any industry can be difficult, sometimes we must look beyond the short-term challenges of adjusting to a new way of doing things to the end result, notes Dr. Canedy.

“There is no doubt that this is one of the biggest changes physicians and patients will ever experience in the practice of medicine,” agrees Stanley Schack, MD, chief of staff at The Nebraska Medical Center. “I compare it to the introduction of cell phones. When I started practice, we did not have cell phones. The new generation of doctors couldn’t imagine practicing without cell phones. Ten years from now, doctors are going to look back and ask how we practiced with paper charts. Already, we are beginning to realize the benefits of a seamless flow of information and communication that is giving us the ability to manage our patients more effectively whether we are in the hospital, our office or at home. Overall, I believe the efficiencies it will provide us over time will be well worth it.”

“Up until the implementation of One Chart, many of our staff had been working in silos,” says Carisa Masek, executive director for Enterprise Applications at The Nebraska Medical Center. “We did not have a common platform for all health care personnel to work from. As a patient transitioned from different areas of the hospital, we relied on verbal handoffs in which health care staff relayed patient information to each other and took notes. This provided too many opportunities for breakdowns in communication and/or loss of information. With One Chart, patient information is entered directly into the patient’s online medical record by care providers and is immediately accessible to other staff eliminating the possibility of miscommunication or losing data.”

CARISA MASEK, PHARMD
“What makes this system even more unique
is that it was designed in part by our
clinical staff.”

Masek provides this example. A patient comes to a physician clinic with a health complaint. The physician sends the patient to the Emergency Room for further evaluation. The patient is then transferred to another area for diagnostic tests. Based on these results, the patient is admitted for inpatient care. Through each of these “handoffs” or transitions of care, there are opportunities for miscommunication. One Chart eliminates these potential communication breakdowns.

“What makes this system even more unique is that it was designed in part by our clinical staff,” notes Masek. “We recruited doctors, nurses and other clinicians and trained them to be technical builders of the applications for One Chart,” says Masek. “So instead of technology developing and driving the processes, clinical care has driven the processes and then we have developed the technology to support these processes.”

MARIVIC MEEGAN, MEDICAL ASSISTANT

One Chart also includes a decision support element that analyzes data to help health care providers make clinical decisions. Through the use of data mining — the process of sorting through information to identify patterns and establish relationships — the system examines the patient’s medical history in conjunction with relevant clinical research. Such analysis can help predict potential events, which can range from drug interactions to disease symptoms. Health care staff may be prompted to perform certain tasks based on this data. For instance, it may prompt health care staff to screen a patient for things like diabetes or depression, remind them when the patient is due for certain preventive screenings or alert staff when certain indicators point toward more critical conditions like septic shock.

“While your doctor will ultimately make patient care decisions, this serves as a great back-up and screening tool,” says Dr. Fedderson. “It is also designed to keep us up-to-date with the latest regulations, guidelines and newest evidence-based practices. There are 30,000 medical journal articles published each week worldwide. A study from 2004 showed it would require 600 hours of reading a month for a physician just to stay current on medical epidemiology. We need to help support our clinicians as information increases exponentially.”

Data mining will become increasingly more beneficial and necessary as medicine continues to become more detailed and complicated, notes Toby Free, MD, medical director of Bellevue Medical Center Family Medicine Clinic. “Electronic medical records allows us to access all of a patient’s data in real time and because of the way the information is presented, it will aid us in the management of the patient and in providing the best practices.”

Dr. Free believes it will also provide benefits beyond the management of single-patient care. “There is a fundamental change in the way medicine is being practiced with a shift from managing acute-care problems to managing a patient’s overall wellness, as well as addressing common health problems that occur in populations as a whole,” says Dr. Free. “One Chart will give us the ability to analyze data in population groups so that we can address common health problems that may be caused by behavioral or environmental factors.”

“One Chart will give us the ability to analyze data in population groups so that we can address common health problems that may be caused by behavioral or environmental factors.”
Toby Free, MD

Looking to the future, The Nebraska Medical Center would like to see EHR available on a larger scale. “As an enterprise, we want to support the exchange of patient information and lead the development of a national health information exchange system,” says Masek. “Ultimately, a patient’s information will be accessible to his or her health care providers no matter where he or she is in this country or the world.”

But the benefits of One Chart don’t stop here. In addition to sharing of patient information, The Nebraska Medical Center plans to use One Chart as a tool in helping it define quality health care here and on a national scale. “There are hundreds of quality measures out there among hospitals and states,” says Dr. Fedderson. “We want to be the leader in defining quality. This system will allow us to compare data related to patient outcomes, research and quality indicators in real time, eliminate inappropriate variations and continuously improve by applying best practices to our own patients.”

“We truly want to push the clinical quality envelope,” says Dr. Fedderson. “True clinical quality is derived when you have data and you can compare processes and analyze why we do certain things. This inspires efficiency and consistency of practices and arrives at the best way to do things. For years, we have always told our doctors to work harder. One Chart will help us work smarter.”

Another important element of One Chart includes the patient portal called One Chart l Patient. One Chart l Patient is a secure, online web portal that offers personalized access to parts of a patient’s medical records. When fully implemented, a patient will be able to review his/her medical records; review a family’s medical records; schedule, request or cancel a doctor’s appointment; refill a prescription; review insurance information; pay bills online and access patient information on common conditions.

One Chart also serves as an educational forum that provides useful health information to help prevent patients from having to come to the hospital in the first place, notes Masek. “It helps the patient make good decisions along the way,” says Masek, “and if they do need health care, how to manage their condition at home to prevent another incident. Reducing the need to come to the hospital is the ultimate goal.”

“Implementing the EHR was a large leap in the right direction,” says Chad Vokoun, MD, director of Consultative Medicine and an associate program director for the internal medicine residency program at UNMC. “I believe the patient portal has been one of the most valuable aspects of the system as it gives patients the ability to have access to their own records, which allows them to be more proactive in their care. It’s been exciting to see patients get more involved. In the end, this should result in better outcomes.”

While One Chart has been in place for just a year, its benefits and impact on the delivery of quality health care will continue to evolve.

“One Chart is a living, breathing thing,” says Dr. Fedderson. “It has limitless possibilities in how we can use it.”