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Electronic Records Reduce Errors, Increase Safety at Lenox Hill
By Barbara Kirchheimer
Monday October 19, 2009



From left, Mia Patunas-Rubin, RN; Joanne Fullerton, RN; Laura Shahim, RN; and Maureen Early-Donohue, RN

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Four years after Lenox Hill Hospital adopted a technology-based documentation and clinical decision support system for obstetrics, the nurses on the labor and delivery unit rave about how it has streamlined their workflow, increased documentation, and reduced the number of potential errors. But it wasn’t always that way. Their story illustrates how successful clinical decision support is more complicated than plugging in a new software system.

In 2005, the New York City hospital partnered with a company then called E&C Medical Intelligence Inc. — since renamed PeriGen Inc. — to implement an intelligent electronic medical record for obstetrics that would provide real-time feedback and guidance to doctors and nurses and help the hospital with risk management in the OB arena.

The system, called PeriBirth, is used by about 34 hospitals nationwide, according to PeriGen. Caregivers enter information into an electronic medical record that is measured in real time against some 6,500 built-in protocols and best practices. Not only are nurses and physicians alerted when there might be a potential error, medication contraindication or risk they hadn’t thought of, but they also are required to document their decisions along the way, which enhances risk management as well as follow-up data analysis.

“It’s like having an expert, if you will, in the room, tapping you on the shoulder,” says Sandra Taylor, PhD, PeriGen’s chief marketing officer. It also allows the caregivers “complete transparency,” she explains. “They can see how they compare to national standards in an objective manner.”

From the first quarter of 2008 to the fourth quarter of 2008, the results of the system were impressive, says Joanne Fullerton, RN, MSN, clinical systems administrator at Lenox Hill. For example, documentation of pelvic adequacy during labor inductions rose 47.34%, while documentation of pelvic adequacy when there were labor abnormalities rose 29.41%. Moreover, for the fourth quarter of 2008 the hospital avoided potential errors in 7.13% of births thanks to an alert from the system that the order should be canceled because of a change in the patient’s condition. In 7.58% of births, potential errors were avoided because an order was canceled thanks to a contraindication alert from the system.

“It’s constantly updating and going over the protocols and works in real time,” Fullerton says. So medication that might have been fine at one point in the labor and delivery might become dangerous as more information is put into the system, and the system will alert the caregiver to that change in status immediately, potentially preventing errors.

Bumps Along the Way

In order to achieve these kinds of results, nurses and doctors have to use the tools properly and make changes in their behaviors. When the CDS system was first implemented at Lenox Hill, there was a lack of buy-in from the hospital’s OB/GYN department and the physicians and nurses who used the system, say Fullerton and other nurses who now wholeheartedly embrace it. As Fullerton noted in a written summary of the hospital’s experience, “the perceived consequences of using the IPR (Intelligent Patient Record) also inhibited the use of the IPR.” The prompts to input information became stressful for doctors and nurses, and the protocols embedded in the system were not always in synch with the hospital’s own protocols, which slowed workflow and created frustration.

Experts in clinical decision support say this is not uncommon. Dr. Jerry Osheroff, MD, chief clinical informatics officer for the Healthcare and Science business of Thomson Reuters, is chairman of the Clinical Decision Support Task Force at the Healthcare Information Management and Systems Society, and authored a book on how CDS can help improve healthcare outcomes. Data shows more than 90% of potential drug interactions are ignored because caregivers stop paying attention to warning messages that pop up in their faces all the time, Osheroff says.

At Lenox Hill, where there were some 3,900 deliveries last year, the hospital made a concerted effort to go back and retool the system with PeriGen’s help so it would be more compatible with the hospital’s own protocols and more helpful to those who used it every day, Fullerton says.

Maureen Early-Donohue, RN, MSN, nurse manager of labor and delivery, says Lenox Hill went back to the vendor and asked for help re-launching PeriBirth to overcome the backlash. PeriGen worked with the hospital to customize the record to better reflect Lenox Hill’s own protocols and improve workflow. PeriGen also offered to assist the hospital with more customization hours and training on PeriBirth. PeriGen learned users need to be included up front, even in the design phase of a new information technology system, Fullerton says.

New and Improved

So far, the re-launched version has led to a decrease in adverse events, improved clinical documentation, and improved communication among staff, Fullerton says. Mia Patunas-Rubin, RN, a perinatal safety nurse at Lenox Hill, says PeriBirth allows her to quickly identify patients who are at risk for adverse events and follow those patients more closely. “The system actually provides us with a way to receive adverse outcome event reports daily,” she says. Residents doing research on conditions such as postpartum depression also are able to retrieve data more easily and quickly than if they had to pull handwritten charts, the Lenox Hill nurses say.

The federal government also is expected to offer financial incentives to hospitals that are able to demonstrate “meaningful use” of health-related information technology, another incentive for adopting IT-based CDS systems.

The PeriBirth system is working for Lenox Hill because the hospital has succeeded in what Osheroff refers to as “the five rights.” The hospital is getting the right information to the right people, in the right format, through the right channels at the right point in workflow. If any one of these “rights” is wrong, success with clinical decision support is hampered, he says.

Evidence that Lenox Hill’s PeriBirth system has been accepted by staff came when the hospital recently had to go offline for two days. “It was eye-opening to see people begging for the computer to go back into function,” Patunas-Rubin says. “Doctors and nurses couldn’t wait for the system to come back up. In my personal opinion, that spoke volumes about how the system has helped us.”

Barbara Kirchheimer is a freelance writer. To comment, e-mail editorNY@nursingspectrum.com.

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