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Health Care System "In Pursuit of Excellence" Case Example

        

Texas Health Resources

December 2009

The Organization

Texas Health Resources (THR) is one of the largest faith-based, not-for-profit health care delivery systems in the United States, and the largest in North Texas in terms of patients served. The system's primary service area consists of 16 counties in North Central Texas. Texas Health Resources was formed in 1997 with the assets of Fort Worth-based Harris Methodist Health System and Dallas-based Presbyterian Healthcare Resources. Later that year, Arlington Memorial Hospital joined the THR system.
Today the system has 13 acute-care hospitals and one long-term care hospital with 3,355 licensed hospital beds, almost 19,000 employees, and more than 3,600 physicians with active staff privileges at its hospitals. Texas Health Resources is also a corporate member or partner in six additional hospitals and surgery centers. The mission of Texas Health Resources is “to improve the health of the people in the communities we serve.”

The Initiative

Texas Health Resources has been using health information technology to transform the way care is delivered and reduce waste in the system for over ten years.  The organization began with the development of information “portals” for three primary groups: physicians, employees and board members.  Initially, the system was designed as a secure one-way communication portal to allow users to access information, such as physicians accessing patient information and basic electronic health records; board members viewing newsletters, calendars and online video education; and employees accessing benefit information and weekly salary statements. 
THR’s use of technology has now evolved to a more comprehensive two-way communication approach, using a combination of an integrated electronic health record system, a variety of leading information technology resources, and social media networking. The health system has a financial and business commitment to use technology to help streamline communications and ensure that the most appropriate and necessary information is available to people when and how they need it.

THR’s Organizational Commitment to Technology.  THR’s strategic focus is comprised of five primary transformational themes:  strengthening its culture, adopting a comprehensive view of quality, ensuring a cost-effective system, serving as a provider and coordinator of care, and engaging physicians.  A focus on information technology helps achieve all five of these themes.  The organization made a conscious decision in 2006 to embark on a 10-year plan encompassing all five themes, which continued the commitment to maximize the use of leading information technology.  The plan gave organizational leaders and employees the courage and enthusiasm to move forward and think more creatively about ways to use technology throughout the health system’s operations.  It also created an opportunity to connect and partner with physicians and strengthen market differentiation.

Transitioning From One-Way to Two-Way Communication.  Although physician portals affording one-way information had been available at Texas Health Resources for some time, in recent years THR began the implementation of CareConnect, the organization’s comprehensive electronic health records (EHR) system utilizing Epic software. 
CareConnect was established to improve clinical outcomes, strengthen patient safety, and increase cost-effectiveness by not only providing real-time information but also by allowing more interactivity between clinicians.  For example, physicians may send comments through the system to other physicians or hospital leaders, allowing them to easily interact about a patient or process, and making hospital leaders more available and accessible to physicians.  Today the majority of THR clinicians use the CareGate system to connect with the organization’s information system, and interface with the health system, other providers within the system, and hospital employees and leaders.

The transition to a real-time, interactive system allows physicians to be more connected to THR, and aids in their ability to provide top-notch patient care in a variety of ways.  For example, one physician reported that a life was saved because he was able to use the CareConnect application to get the patient information he needed to make rapid clinical decisions on-site, where he was treating the patient.  With the ability to access CareConnect remotely via any Internet connection, he did not have to find a location to connect to the CareConnect network before providing further patient treatment or making a decision without all of the necessary information.  In addition, THR utilizes an iPhone application for OB physicians that provides them with remote fetal monitoring information for patients in labor.  The application helps physicians determine how their patients are progressing, if they are nearing time for delivery, and if there are other issues that need to be addressed in-person.

Texas Health Resources has committed approximately $250,000,000 over a multi-year period for the transition to a comprehensive electronic health record system.  Although the system is not fully implemented yet, THR has been recognized nationally for its innovation and for being one of Hospitals and Health Networks magazine’s “Most Wired” hospitals in 10 of the last 11 years.

Maximizing Social Media Opportunities.  In addition to a comprehensive information technology system, Texas Health Resources is in the beginning stages of utilizing a variety of social media to leverage coordination and collaboration internally within its workforce and clinicians, as well as to reach out to the community.  The THR Facebook and Twitter pages provide ongoing information about THR activities and local resources, and its YouTube page provides informational videos on timely topics, such as hand hygiene. 

Internally, the organization uses a system called Yammer, a concept similar to Twitter, for employees to provide updates, share information, track conversations, and maintain a company directory with employee profiles.  Yammer aids in quick, real-time communication between key stakeholders.  For example, one of the system’s hospital emergency departments was recently overcrowded with flu patients.  The organization’s Chief Nursing Officer sent a message on Yammer about the problem, and another hospital responded with an offer to share resources to meet the emergency department need. 

Board of Trustees Involvement.  The Texas Health Resources board of trustees has played an integral role in the organization’s ability to stay ahead of the information technology curve.  The board believes that automating and using information technology is critical to improving care delivery, and it includes technology as a key strategic imperative for high-level decision making.  The current initiative is based on a board-level decision to fund and support the effort, and the board continues to receive periodic updates at board and subcommittee meetings.

Factors Critical to Success.  Success in achieving the implementation and use of the technology is reliant on people and processes.  It requires involvement from physicians, organizational leaders and employees throughout the organization; and it requires an understanding that there will be a learning curve, as the transition from a traditional system relying on written and informal personal communication to an electronic environment can be disruptive to physician practices. 

Because of the sharp learning curve and the need for physician buy-in, physicians should be intimately involved in technology development and implementation.  For example, THR’s EHR system includes decision-support capabilities to help facilitate the adoption of evidence-based practices.  THR worked with physicians to develop the content, using the transition as an opportunity to re-engineer the health care process.

The leadership of physicians and senior leaders must be highly visible.  In addition, organizational leaders should evaluate whether new ventures coincide with the organization’s long-term vision and plan and should continually look for opportunities for improvement.  The ultimate measurement of success should be whether new technology, systems and processes advance the organization’s quality and patient safety agenda.

Based on feedback from employees and physicians throughout the organization, the THR Chief Information Officer identified 21 factors as critical to successful implementation of organization-changing technology:

  • Project team: The majority of project teams should be clinicians and at least ninety percent of the team must be actively engaged.  The road is long with many winding curves and requires building up staying power.
  • Senior leadership engagement: The CEO must actively promote and reinforce the initiative and receive regular reports. In addition, enterprise incentives should be based on technology adoption levels.
  • Hospital leadership engagement: Presidents of individual facilities need to be very visible and articulate.
  • Chief Medical Information Officer (CMIO): This rare individual can bridge the gap between information technology and medical staff.  For larger systems or integrated delivery networks, multiple CMIOs may be necessary.
  • Project leadership: Project leaders must be leaders and be clinicians. They are the face and brains of the operation and should be surrounded with grace and all the resources they ask for.
  • Project team: The majority of project teams should be clinicians and at least ninety percent of the team must be actively engaged.  The road is long with many winding curves and requires building up staying power.
  • Clinical staff: No project will be successful without engaged physicians and nurses. Sometimes organizational leaders must facilitate their engagement if they are initially resistant.
  • Culture: Organizational culture eats strategy every day. Set up literal shared incentives for success. In systems, the overarching organizational culture must transcend individual hospitals. 
  • Relationships: Relationships cover a multitude of sins. Develop relationships with everyone from clinicians to support staff to leadership.
  • Visibility:  Key leaders must be visible during the new system go-live and after. Most of the THR leaders participate in go-live support, even if just to answer phones.
  • Agility and velocity: The organization should have a pool of highly trained staff who can respond to crises at a moment's notice. The team should report to the CMIO.
  • Build: Lay a solid foundation from the onset to withstand the continual storms. The design must include clinical staff for usability and acceptance.
  • Standardized order sets: Present computerized physician order entry as the ultimate tool to drive transformation and clinical quality and to drive out costs.
  • Governance: Set up an effective decision-making body on two levels: a senior executive team for strategy and a larger team for tactics and operations. Ensure that clinicians are assigned to key roles.
  • Change control process: Control application evolution at a rate that introduces new features while maintaining an acceptable learning adaptation curve.
  • Implementation: Ensure the organization is keenly organized, with additional staffing at the physician’s elbow.
  • Marketing and communication: Employ a multi-dimensional, targeted strategy including actual customers. Do not limit yourself to traditional media -- be innovative and leverage social networks.
  • Training: Use multiple venues for training, blending traditional methods with modern methods, such as our video vignettes.  Make access to applications dependent upon completion of training.
  • Support: Post-implementation support must be impeccable and ubiquitous.
  • Vendor connections: The best relationships start at the top, with C-level executives exchanging strategy and vision. Establish escalation paths to solve issues quickly.
  • Infrastructure: Monitor and tune the infrastructure to ensure optimal uptime and response speed.
  • Software: Select a seasoned application. Test and retest enhancements and patches prior to releasing to clinicians.

Unique Advantage as a System.  Being a large system provides the organization with easier access to capital, and access to more resources, such as the ability to call on a wide-ranging talent pool of both information technology experts and community physicians. When THR was first implementing its new EHR system, it held demonstrations and invited clinicians to participate in the decision-making to innovate a custom-created technology solution.  Over 100 physicians participated in the feedback process, providing comprehensive and wide-ranging ideas that influenced the development of the EHR system.

The organization’s size also dictates a great need for connectivity.  Health systems often tend to have many “silos,” and information technology is the glue that connects the silos together.  A comprehensive information technology solution implemented in a large system has the ability to significantly impact the quality and efficiency of care provided in an entire geographic area.

In addition, because it has multiple physical locations, THR was able to implement a new technology concept at one or two locations, and then make adjustments based on lessons learned.  This allows for the long-term development of a better system and a smoother implementation at the other system facilities.

Long-Term Strategy for Connecting Health through Technology.  THR’s long-term strategy is a “Connected Health Strategy,” with the goal of linking all patient points of care into one seamless system.  Texas Health Resources understands that health care has moved away from traditional settings to not only ambulatory settings, but also into patients’ homes.  Developing a social networking strategy is part of addressing this trend, but THR is also in the process of developing personal health records and the ability to conduct patient diagnostics from patients’ homes.  Providing routine care such as blood pressure and weight measurements, medication reminders and blood glucose tests from home allows patients to minimize physician office visits while still remaining connected with their clinician through other communication channels, such as face-to-face video calls and online messaging.

In addition, Texas Health Resources continues to look outside of health care for “clinical business intelligence” ideas.  The organization leverages board member expertise from outside of health care settings and looks to leading-edge industries for technology utilization concepts that can be adapted to the health care environment.

Impact

Texas Health Resources’ EHR has achieved over 80 percent adoption of computerized physician order entry from all voluntary medical staff.  Although it is too early to calculate specific measurements to demonstrate the impact, THR believes that its comprehensive system and widespread adoption is driving waste and redundancy out of the system while simultaneously making care more timely, efficient and effective.  The system allows providers to communicate more effectively and have access to real-time information, which improves quality and safety and reduces re-work.  Physicians working with Texas Health Resources universally agree that the electronic process is better than the traditional paper process used in the past.

In addition to the impacts on costs and quality of care, the combination of using cutting-edge information technology and social networking helps Texas Health Resources in its recruitment and marketing efforts. 

Value

Texas Health Resources has undertaken a “value realization effort” to determine the value derived from its electronic health information efforts.  The organization recognizes that significant tangible and non-tangible benefits will be realized as a result of the system.  To measure the impact, THR conducts baseline measurements before the system is implemented and then similar measurements after the system is in place to determine its impact, measuring areas such as at-risk drug events, length of stay, specific medication safety parameters, and the storage cost of paper versus electronic medical records. THR also measures efficiency, such as the length of time required to conduct basic documentation on paper using the old system, versus online using the new system.  Initial measurements have demonstrated that the electronic health record system has resulted in improved costs and improved nursing and physician efficiency.

THR uses a similar process for all projects it funds, expecting each project to stand on its own merit.  The organization has a transparent and accountable return on investment measurement process for all new projects, requiring the facility or department that implemented the project to compare the original estimated impact to the actual impact.  The health system’s goal is to continue to grow the discipline of measurement, ensuring transparency and accountability throughout the organization.

Contact Name:  Steve Hanson
Title: Senior Executive Vice President
Email: c/o kaylinburgess@texashealth.org
Tel:  (817) 462-7922
Fax:  (817) 462-7881

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