The expansion of information technology (IT) in U.S. hospitals is an evolutionary process. Billing, collections, and admission and discharge records have long been computerized, but now electronic medical administration records, patient electronic health records, and computerized physician order entry (CPOE) systems are joining the ranks.
Hospitalists are more likely to encounter sophisticated IT systems in larger, urban, or teaching hospitals, according to a 2005 survey by the American Hospital Association.1
The Hospitalist’s first installment about hospital informatics (“Charts to Screens,” January 2007, p. 25) focused on the challenges of health IT and the barriers to effective adoption of computer-based documentation systems. This installment explores the potentially rich vein of data available to hospitalists from those information systems and the opportunities for research and QI applications.
The mechanics of conducting clinical research and QI projects will depend to a large extent on the progress each hospital medical group’s institution has made in the IT adoption process. Some say hospitalists have powerful contributions to make in influencing how the IT process evolves so their research opportunities will also improve.
Data in information systems differ from hospital to hospital, says Tejal K. Gandhi, MD, MPH, director of patient safety at Boston’s Brigham and Women’s Hospital (BWH) and assistant professor of medicine in the Department of Medicine at Harvard Medical School in Boston.
Dr. Gandhi’s research focuses on redesigning hospital and outpatient processes to improve patient safety. She notes that hospitalists can take advantage of data the hospital is collecting to satisfy its reporting requirements to spearhead more quality-improvement efforts.
“For example,” says Dr. Gandhi, “the hospital has to document how it’s doing on pneumonia measures, acute myocardial infarction measures (was the patient having a heart attack given aspirin and a beta-blocker?), and others. These are fruitful topics for quality-improvement projects.”
Hospitalist Andrew Karson, MD, MPH, associate director of the Decision Support and Quality Management Unit and associate program director for the Internal Medicine Residency Program at Massachusetts General Hospital, Boston, also focuses on patient safety issues in his research. Given hospitalists’ knowledge of decision-making systems in the hospital, they are in a unique situation to initiate such projects, he believes.
For example, Dr. Karson participated in a study initiated by colleague Christopher L. Roy, MD, associate director of the hospitalist program at BWH.2 Dr. Roy posited that pending test results could be an important patient safety issue and, at the very least, might affect continuity of care. The researchers identified 2,644 consecutive patients discharged from BWH and Massachusetts General between February and June 2004. During that time, a mixture of hospitalists and non-hospitalists were responsible for discharging patients on house staff and non-house-staff services. Using a Results Manager application integrated into each patient’s electronic medical record (EMR) at the hospitals, the team identified and tracked pending laboratory and/or radiologic test results that had been returned after the patients were discharged.
The team used physician reviewers to determine whether the pending test results were potentially actionable. They found that 41% (1,095) of the discharged patients had a total of 2,033 test results return after their discharge. Of those tests, the physician reviewer determined that 9.4% (191) were potentially actionable. Examples of actionable results of which discharging physicians had been unaware included a levofloxacin-resistant Klebsiella infection in a patient being treated with levofloxacin, and a thyroid-stimulating hormone level that was dangerously low in a patient with rapid atrial fibrillation. A coauthor of the study, Eric G. Poon, MD, MPH, Division of General Medicine and Primary Care at BWH, is working on a results-management system that will automatically alert hospitalists and other physicians in the process of discharging patients when those patients are awaiting test results.