Kaiser-Permanente Improves Perinatal Chart Access with QS® Perinatal Clinical Information System
Kaiser-Permanente Medical Center
Santa Clara, California
Solution in Action:
Inefficiencies in its paper records system for perinatal patients led Kaiser-Permanente
Santa Clara Medical Center to convert to the first ever electronic system
for this patient population, developed in collaboration with GE Medical Systems Information Technologies. This system now serves as a model for other medical centers
nationwide.
Because expectant mothers are among the most prolific consumers of outpatient healthcare, Kaiser-Permanente Medical Center, Santa Clara, began seven years ago to search for a way to more efficiently track these patients - and their charts - as pregnancy progressed. The problem was simple: When a patient went to one of four Kaiser-Permanente sites for an appointment
- unscheduled or otherwise - the patient's chart was invariably at one of the other sites, requiring time-consuming faxing or delivery by messenger service.
An electronic database of patient records, networked between the sites, would be the ideal solution, according to Deborah Ray, M.D., director of
maternal-fetal medicine at the Kaiser-Permanente Santa Clara site.
"Our short-term goal was to provide a computerized record that would allow the main hospital and each of our satellite clinics in Milpitas, Mountain View and Marina Playa to have immediate access to patient records, without records always being in transit between sites," she says.
In 1991, however, there weren't any vendors dedicated to perinatal records projects, according to Donald Dyson, M.D., assistant physician-in-chief.
"So, Kaiser-Permanente entered into an agreement with a current vendor, Corometrics - now part of GE Medical Systems Information Technologies - to develop jointly the prenatal component of a perinatal records system," he says.
Cooperation Yields First Ever Electronic Prenatal Records System
Because the Santa Clara medical center served as the hub of the four-site system, with its labor and delivery facilities, it was the first site to
install the QS Perinatal (Quantitative Sentinel) Clinical Information System, in June 1995. The project included distributing workstations in doctors' offices
throughout the hospital and placing one terminal in Labor & Delivery.
"With the QS Perinatal CIS terminal in Labor & Delivery, I can pull up the patient's prenatal record from the computer instead of calling the chart room to
request it," Dr. Ray explains.
Kaiser-Permanente Medical Center
Upon completion of this phase, Kaiser-Permanente linked the first of three satellite locations, the clinic in Marina Playa, in December 1995. By October 1996, the two remaining clinics in Milpitas and Mountain View had been brought on-line. Among the four sites there now are approximately 100 QS Perinatal workstations, from which users can download patient records.
Dr. Deborah Ray, M.D.,
Director of Maternal-Fetal Medicine.
Because this was a pioneering effort, Kaiser-Permanente information technology staff and GE Medical Systems Information Technologies engineers worked together to accomplish the challenging task of linking four sites which had disparate communication configurations.
"We had to lay down the physical links in terms of cabling and communication links - such as T1 and T3 lines - and hardware, such as hubs and routers,
and then we tested the required applications to make sure the mainframe interface and the QS Perinatal system were communicating with each other," says Karen Danbe, service director for the Regional Perinatal Service Center at Kaiser-Permanente. "It was a very detail-oriented process that required a great deal of trouble-shooting, but in the end we were successful."
The method of conversion to the electronic record occurred in phases. All existing pregnancies remained in the paper system, and all new expectant
mothers were entered into the electronic system as they were identified - a process that unfolded over an eight-month period.
"We manage 95 percent of our prenatal patients on computer with about 3,000 active records on the system at any one time," Dr. Dyson notes.
Labor & Delivery Records System Established
Shortly after the Santa Clara site went on-line, the hospital began to remodel its Labor & Delivery facilities, installing new monitors and equipment. Kaiser-Permanente decided to expand its investment to include an L&D component to its new electronic records system. The system included fetal surveillance and central monitoring, and eventually forms related
to the L&D process were designed and added.
"We manage 95 percent of our prenatal patients on computer with about 3,000 active records on the system at any one time."
"We opened the new Labor & Delivery unit in April 1996, and used the newly developed L&D component for central monitoring and archiving of fetal heart rate tracings," says Dr. Dyson. In 1997, we phased in, over a period of months, all of the nursing charting forms, as well as physicians' history and labor & delivery summary."
"Now the patient has a complete record that starts from prenatal and continues to post-delivery," he says. "I estimate that 85 percent of the L&D
charting is now done on this system, which has virtually eliminated paper charting."
With the addition of L&D data, and before the satellite centers were added, so much data began to accumulate that Kaiser-Permanente eventually
needed to add a new file server to share data archiving duties and to prevent
downtime.
"We have two file servers with built-in redundancy," Dr. Ray says. "Each file server is equipped with a RAID Level 5 disk array, so we've had virtually
no downtime."
Dr. Donald Dyson, M.D., Assistant Physician-in-Chief
QS Perinatal Benefits Outweigh Growing Pains at Kaiser-Permanente
Adjusting to a predominantly computer-based system has been difficult for some Kaiser-Permanente staff, despite the benefits the system promises. Kaiser-Permanente acknowledges that such change can be challenging, but affirms that the new technology is here to stay.
"Medicine can't continue to archive paper medical records forever," Dr. Ray says. "When we have the capability to put data that would fill a warehouse on a couple of laser disks, it's ridiculous to store records the way we've done."
Despite that fact, using a computer to do charting is a foreign experience for many Kaiser-Permanente providers, some of whom believe it takes them
longer to chart electronically, Dr. Ray notes. She emphasizes, however, that as providers become accustomed to using the QS Perinatal system, the result
will be more complete charting. Major advantages of the system include availability of the chart to multiple users at a single moment in time,
100 percent legibility and forms in the same consistent order.
Continuing Successes:
Access to Ultrasound and Lab Data
Kaiser-Permanente's current procedure for providing ultrasound data - such as fetal measurements, placenta location, amniotic fluid volume, and estimation
of fetal age - is to enter that data into a separate computer, which generates an obstetrical ultrasound report. This report is given to a clerk who,
in turn, enters it into the records system - a process which is both time-consuming and prone to transcription errors.
"We're talking about entering ultrasound data for 3,000 patients a year, which translates into 4,500 ultrasounds on average," Dr. Ray says. "There's
lot a of potential for error there."
Access to ultrasound data on the QS Perinatal system can be delayed by several days. Dr. Ray says, because the process requires a physician to review the initial
ultrasound data before it is entered into the computer for reading and report generation. Subsequently, more time is consumed as the report data is entered into the QS Perinatal system.
"We've implemented a parallel program in the QS Perinatal system which assumed the function of the computer that generates reports," she says. "As the technologist performs the ultrasound test, he or she will enter the
preliminary data into the QS Perinatal system, which will conduct all ultrasound reading and report generation. The benefit is that the minute the preliminary
data is entered in the QS Perinatal system it will be available for the primary provider to review."
Kaiser-Permanente, Santa Clara, is exploring how to gain electronic access to its parent company's main laboratory. The most challenging aspect, according to Dr. Dyson, is not interfacing the QS Perinatal system with the laboratory system, but being able to "pick off the small fraction of data we need."
"The regional laboratory system supports all of Kaiser-Permanente's hospitals and clinics, and with about 2.7 million members in Northern California, there is an enormous amount of data on the shared system," he notes. "But we're in the final phases of developing some options that will allow Kaiser-Permanente
to make our data available to us in a format acceptable to the QS Perinatal system."
Current Challenges
Providing more data
Getting communication networks between different clinical sites to work together was a challenge that Kaiser-Permanente staff and GE Medical Systems Information Technologies engineers
met with success.
Now, the Santa Clara network wants to increase the functionality of its records systems to provide even more useful data, while limiting data entry and delays in receiving information. Specifically, Kaiser-Permanente wants its electronic records systems to allow immediate access to obstetrical
ultrasound and laboratory data (see sidebar).
Long-term Goals
The natural extension of Kaiser-Permanente's QS CIS project at the Santa Clara site is to link all Kaiser-Permanente sites in Northern California. Drs. Ray and Dyson envision the regional healthcare provider united under one electronic prenatal form, instantly accessible at any of its satellites.
"It would be ideal to have a consistent prenatal record that would be available to the Kaiser-Permanente system, which includes 11 medical centers
and 32 medical offices throughout Northern California," Dr. Ray says. "In this way, a patient who usually goes to the Oakland Medical Center would
come here and we could still get instant access to their prenatal records. The way we do it now requires us to call Oakland and have them find and fax the record to us."
The sheer volume of data that could be collected in a multi-site prenatal, post-natal clinical information network would be immensely valuable in observing trends in child-birth in Northern California, Dr. Ray adds.
"We could potentially track outcomes on nearly 30,000 deliveries a year," she says. "We could analyze more complex issues than C-section rates, which is something we do already without a computer. Rather, we could track patients with hypertension or diabetes, and determine how a particular intervention
changes their outcome."
Kaiser-Permanente, Santa Clara, has taken its first step in that direction by collaborating with other Kaiser sites on a study which examines prenatal
staffing requirements based on the patient population. These other sites proposed placing an ASPEN (computer database) workstation at all Northern
California Kaiser sites, including the Kaiser-Permanente, Santa Clara QS CIS network. GE Medical Systems Information Technologies worked with the Santa Clara site to
develop information export functionality that allows the QS CIS prenatal and labor and delivery data to be imported into ASPEN without data re-entry.
"What we're doing with our four-site network, with Kaiser-Permanente, Santa Clara at the hub, is just the tip of the iceberg," Dr. Dyson says. "The efficiencies we've gained with just four sites sharing information
could be multiplied many times by linking the entire Kaiser-Permanente network to prenatal and post-natal databases."
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Kaiser-Permanente Medical Center
Dr. Deborah Ray, M.D.,
Dr. Donald Dyson, M.D.,