1. Rufo, Rebecca DNSc, RN, CCRN


Interfacing an EHR to an existing tele-ICU can leverage care delivery. What considerations are necessary to allow for seamless data transfer?


Article Content

67-year-old man presents to the ED with "stroke-like symptoms." He rapidly deteriorates neurologically. The stroke neurologist performs remote monitoring using audio-video capabilities, allowing for immediate intervention.


This is integrated care delivery through telemedicine at its best.


Ever wonder what integration looks like behind the scenes? What factors lead to successful integration? Resurrection Health Care, Chicago, Ill., is in a rapid transformation of clinical and technological advancements in support of healthcare reform and national patient safety initiatives. Movement toward becoming an accountable care organization and value-based purchasing initiatives are driving quality endeavors within the organization.


The call for transformation

Patient safety experts cite outmoded systems of work as the reason for healthcare related errors and quality problems a decade ago. At that time, the Institute of Medicine (IOM) called for national efforts to address the problem of patient safety and the impact on quality. Patient safety initiatives escalated over the past decade but errors in healthcare continue at alarming rates despite proliferative efforts.


Recommendations from the IOM suggest that redesigned systems will yield better, safer care. The IOM's groundbreaking report in 1999 estimated that as many as one million people were injured and approximately 100,000 died annually as a result of medical error.1 The Agency for Healthcare Research and Quality (2001) and the Leapfrog Group estimated that more than 4 million patients are admitted to the Intensive Care Units (ICU), and approximately 500,000 die annually.2 Another estimate shows that critical care costs account for approximately 4.1% of the nations' $2.6 trillion in annual health care expenditure.3 By 2015, the IOM predicts that healthcare expenditure will account for 20% of the nation's gross national product.4 In 2007, the Congressional Budget Office reported long-term budget projections in which the total healthcare spending would rise to 25% of gross domestic product in 2025, 37% in 2050, and 49% in 2082 if the federal law remains static.5


The U.S. population growth trends further compound the barrier to care access. By 2050, the population is projected to increase to 392 million, (50% more than in 1990), according to the U.S. Census Bureau.5 Of particular interest with population growth is the number of persons aged 65 years or older. The Department of Health and Human Services Administration predicts that by 2030 the total population will be comprised of 72.1 million older persons in that age group (19% of the population).5 This increase is already negatively impacting the healthcare system, as the elderly have more chronic conditions that predispose them to increased needs for medical intervention. The current healthcare delivery system is strained to support an increased number of patients, primarily elderly, with chronic illness.


Healthcare Reform involving the passage of the American Recovery and Reinvest Acts (HITECH Act) in 2009 and the Patient Protection and Affordable Care Act (PPACA) of 2010 will drive adoption of technology in the hope of a more efficient and safer environment. Implementation of EHRs is anticipated to foster better clinical outcomes, lower costs, decrease medical errors, and drive higher quality care. Increased use of telemedicine and mobile devices will leverage access to care. Those in underserved areas and highest risk for complications will particularly benefit from greater access to critical resources. A challenge to both integration of EHRs and use of telemedicine is the cultural change of doing care differently. Expanding care coordination to accommodate more patients through the use of technology is a global challenge. Care coordination and real-time gaps in care are well documented. Since the 2001 release of the IOM's Crossing the Quality Chasm, care coordination, infrastructures, and access to technology remain a challenge.


In response to long-standing patient safety and quality concerns "The Lucian Leape Institute" was created. The Lucian Leape Institute was established by the U.S. National Patient Safety Foundation to provide vision and strategic direction for safety initiatives. Five transforming concepts (transparency, integrated care platform, consumer engagement, joy and meaning in work, medical education reform) were identified as fundamental to the endeavor of achieving significant improvement in healthcare system safety. These strategic concepts are to transform organizational culture, behavior, and ultimately patient care quality. Healthcare systems must transform the culture not just selectively improve aspects of safe care. Often hierarchical organizational structures, labor intense processes, egotistical attitudes and "working in silos" inhibit true collaboration that directly impacts patient care. Fragmentation, inefficient processes, redundancies in workflows, and rigid practices increase vulnerabilities and place the organization at risk for increased errors. When system processes, inefficient operational workflows and lack of teamwork are present, patients suffer the consequences of unsafe care. The Lucian Leape Institute's transforming concepts move beyond the IOM recommendations to radically change the way healthcare systems, view and provide patient care.6


Building blocks of integration

Three major technological and clinical initiatives are transforming previous methods of care delivery. Advancements in healthcare IT (HIT) through integration of Tele-Stroke, EHR, and leveraging current Tele-ICU to skilled nursing facilities will improve access to quality care.



Resurrection Health Care leveraged its existing Tele-ICU Program to incorporate remote Tele-Stroke monitoring in March 2011. The RHC Tele-Stroke Program incorporates mobile technology that's based from the existing Tele-ICU infrastructure. Stroke neurologists use the same audio-video capabilities, software application, and diagnostics available to the Tele-ICU team. Stroke neurologists are able to access patients remotely within RHC and external locations such as in the office, clinic, and home.


True collaboration is at the core of the Tele-Stroke Program at RHC. The 2005 AACN Standards for Establishing and Sustaining Health Work Environments states that "true collaboration" is a process, not an event. True collaboration respects the unique knowledge and abilities of each professional to achieve safe, quality patient care.7 A multi-disciplinary collaborative approach including the EDs, ICUs, Tele-ICU, stroke neurologists, neurointerventional physicians, administrators, educators, stroke coordinators, and Information Services participated in development of an innovative model of practice. Early program performance demonstrates improved physician response time, early intravenous thrombolytics, and care collaboration. Patients, physicians, and staff are experiencing greater satisfaction with the use of mobile technology to access stroke resources when timing is critical.


Key aspects of integration of the RHC Tele-Stroke Program:


* Base the foundation on established organizational Primary Stroke Certification and existing Tele-ICU Program.


* Leverage existing resources in the Tele-ICU for system-wide program integration.


* Designate a source of funding for mobile carts, physician laptops, and associated infrastructure/technical requirements and upgrades.


* Provide on-site training of staff to demonstrate functionality of technology and workflow processes.


* Extensively test with physicians to ensure consistent connectivity of remote presence monitoring.


* Consider the speed and broadband width of home internet provider, which is important to connectivity for remote presence monitoring.


* Conduct daily assessment of mobile cart for functioning audio-video capabilities.


* Establish performance metrics to evaluate outcomes of program.


* Keep in mind that development of system-wide Tele-Stroke Program provides the foundation to other disciplines of remote monitoring, such as Tele-Pysch.



EHR integration

Healthcare Information Technology (HIT) is revolutionizing operational and clinical performance. It's the intent that HIT systems such as EHRs will achieve improved efficiencies, safety and overall quality care. Integration of an electronic health record vs. support of "best-in-breed technology" is a real issue in transforming the face of healthcare. Integration of these technological advancements involves numerous and complicated clinical transactions to achieve behavioral changes in patients, clinicians and organizations. Healthcare leaders must appreciate and acknowledge the complexity surrounding EHR design, implementation and utilization. The level of leadership involvement with areas such as build-out, interfacing, workflow design, and integration is highly variable. Integration of interfaces to support functionality of multiple applications is a current challenging in care delivery.


Many aspects related to the technical functions are designed by people who don't fully understand the complex interaction of human technology interfacing and ramifications that impact patient safety.8 End users must ask questions that impact clinical care, documentation and information transfer. However, end users may lack knowledge of standardized dictionaries, processes, principles, human computer interactions and flow of data entries. The end user then becomes dependent upon the technical and vendor experts during decision making involving various care aspects. For example, the Food and Drug Administration acknowledged that insufficient design and testing of software products could result in errors and patient harm.9


The IOM's (2000) article To Err is Human: Building a Safer Health System discussed that latent error such as, those hidden in complex health information technology applications (poor design, misperceptions in decision making, faulty implementation programs, complicated flows) pose increased risk of errors leading to patient harm.10 Experts coined the term "e-iatrogenesis" to represent the potential risks associated with HIT, including EHRs, computerized physicians order entry, and clinical decision support systems and bar coded medication administration. The Joint Commission echoed this concern by citing that healthcare providers must be alert to technology-related adverse events contributing to unintentional patient harm.11 Examples of EHR technology-related safety issues include:


* insufficient interface design.


* fragmented screen displays.


* difficulty viewing the flow of data, increased need to toggle between multiple screens.


* limited time available to train and test application/workflows.


* unclear alert information or a lack of notification prompts.


* less time with patient due to increased computer time.



Authentic leaders needed

The building blocks of integration are many. Healthcare is at an exciting time for technological advancements that enhance care delivery. Clinicians have waited for these advancements to become possible for years. In light of these historic innovations, patient safety and quality must be at the forefront of every effort to advance care. Leaders are challenged by deadlines, legislative requirements, financial performance, and outcome measurements associated with technological advancements. We must ask the difficult and challenging questions to drive patient safety. The need for authentic leadership is greater than ever to promote an integrative, highly efficient, outcome driven environment. Leaders must be engaged, courageous, and thoroughly understand operational functions to make informed decisions related to technological advancements. At the end of the day, a patient's life depends on the decisions we make as leaders.




1. Kohn LT, Corrigan, J., Donald MS, eds. (1999). To Err is Human: Building a Safer Health System. Washington, DC: National Academics Press. [Context Link]


2. The Leapfrog Group about Us. 2009. Accessed May 24, 2011. [Context Link]


3. Fifer S, Everrett W, Adams M, Vincequere J. Critical Care Choices: The Case for Tele-ICUs in Intensive Care. Cambridge, MA: Massachusetts Technology Collaborative and New England Healthcare Institute. [Context Link]


4. Institute of Medicine. (2008). Knowing What Works in Health Care: A Roadmap for the Nation. Washington, D.C: National Academics Press [Context Link]


5. Dishman, E. (2011). Reimagining the U.S. Healthcare System: Investing in Innovative Health IT to Support the 21st Century Personal Health Model. The 4Cs of Global Healthcare Reform. [Context Link]


6. Leape, L., Berwick, D., Clancy, C., Conway, J., Gluck, P., Guest, J., Lawrence, D., Morath, J., O'Leary, D., O'Neill, P., Pinakiewicz, D., Isaac, T. (2009). Transforming Healthcare: a Safety Imperative. Quality Safety Healthcare. 18:424-428. Downloaded from[Context Link]


7. AACN. [Context Link]


8. Harrington, L., Kennerly, D., & Johnson, C. (2011). Safety Issues Related to the Electronic Medical Record (EMR): Synthesis of the Literature from the Last Decade, 2000-2009. Journal of Healthcare Management. 56(1), pp 31-43. [Context Link]


9. Burlington, D.B. (1996). Human Factors and FDA's Goals: Improved Medical Device Design. Biomedical Instrumentation & Technology. 30(2): 107-109. [Context Link]


10. Institute of Medicine. (2001). Crossing the Quality Chasm. Washington, D.C. National Academy Press [Context Link]


11. Palmieri, P.A., Peterson, L.T. & Ford, E.W. (2007). Technological Iatrogenesis: New Risks Necessitate heightened Management Awareness. Journal of Healthcare Risk Management. 27(4). 540-53. [Context Link]