15
Nursing Adoption of IT I 1
PAGE SECTION
3 EXECUTIVE OVERVIEW
Introduction Vendor Performance Overviews
15 INTRODUCTION
Nursing Study Reporting Team
Author’s Notes: Market Overview
Study Overview
25 MARKET REALITIES: AN EXPANDED SUMMARY
Report Overview
Lessons Learned
Provider Checklist
Benefits & ROI
Comparative Technical Assessment
45 VENDOR BRIEFS (IN ALPHABETICAL ORDER)
Cerner McKesson
Eclipsys Meditech
Epic Misys
GE Siemens
89 ADDITIONAL RESOURCES
Common Vocabulary Definitions
Additional Nursing Resources
Vendor Range of Product Offerings
Vendor Directory List
T A B L E O F C O N T E N T S
Nursing Adoption of IT
2 I Nursing Adoption of IT
PAGE SECTION
95 APPENDICES A–H: VENDOR APPENDICES (PROVIDER COMMENTARY, SPECIAL
QUESTIONS COMMENTARY, VENDOR REPORTED OVERVIEW, TECHNICAL
ASSESSMENT)
Cerner McKesson
Eclipsys Meditech
Epic Misys
GE Siemens
409 APPENDIX I: RAW DATA – VENDOR PERFORMANCE
411 APPENDIX J: RAW DATA – SPECIAL QUESTIONS
452 ADDENDUM
Table of Figures
Sponsor/Advocate Provider Profiles
Sharp Healthcare
Poudre Valley Health System
Penobscot Bay Medical Center
St. Joseph’s/Candler Health System
The TIGER Initiative
Scoring Methodology
Study Survey Document
KLAS Vendor Performance Evaluation
About KLAS
Nursing Adoption of IT I 3
Cerner
Eclipsys
Epic
GE
McKesson
Meditech
Misys
Siemens PRODUCED BY: 630 East Technology Avenue Orem, Utah 84097 801.226.5120 www.healthcomputing.com Study Contacts Kent Gale, [email protected] Adam Gale, [email protected]
Sponsors/Advocates Sharp Healthcare San Diego, CA
Poudre Valley Health System Fort Collins, CO
Penobscot Bay Medical Center Rockport, ME
St. Joseph’s/Candler Health System Savannah, GA
The TIGER Initiative 05 July 2007
N U R S I N G A D O P T I O N O F I T
Executive Overview
4 I Nursing Adoption of IT
Figure 1
Figure 2
Figure 1:
Overall Adoption Scores Reflects Product Usage and Functional Satisfaction
VENDOR
ADOPTION SCORE (OUT OF 40)
Cerner 23.3 McKesson 22.3 Meditech 22.0
Epic 20.2 Eclipsys 19.6
Misys 19.5 Siemens 17.4
GE 14.9
INTRODUCTION: Eighty-eight percent of acute organizations investing in nursing solutions report nursing
adoption—but how much more than basic functions are they using? And what about the
real tough stuff? Which vendors lead client adoption? What unique challenges do nurses
face? And just how satisfied are nurses with their patient care IT solutions?
KLAS set out to find the answers to these and other questions regarding Nursing
Adoption in this landmark study. And, while we were prepared to quantify and report
results, we were not prepared for the overwhelming energy and attention the subject
received from those who care most about it: Nurses.
Of the 251 study participants, 68 percent were nurses. As they shared their impassioned feedback with us, each one of them demonstrated a lively interest in guiding vendors to improve nursing solutions. A number spent an hour or more on the phone with us, with two to three nurses in conference—frequently including the CNO. Their feedback was invaluable, and repeatedly highlighted this common theme: “It’s about time attention is given to the challenge nurses face with technology adoption.” The
Figure 2: Overall Adoption Scores
Nursing Adoption of IT I 5
Executive Overview
study findings that follow come directly from their candid, exhaustive feedback.
STUDY BACKGROUND: This nursing study, sponsored by four provider organizations, was designed with two goals in mind. First, interview nurses for their candid feedback. Second, find out how many of each vendor’s CIS sites had actual nurse adoption—and how deep was that adoption. To accomplish the first goal, we contacted nurses at 243 organizations. Nursing interviews were given highest priority, followed by IT management. These priorities are reflected in the study participant make up (See Figure 2), with nursing at 68 percent, and other IT management at 32 percent. Achieving the second goal required close cooperation with the clinical information system (CIS) vendors. We asked each of them for a list of their 50 best live nursing clients. Most vendors were happy to oblige and were helpful in answering our questions. Every vendor except Cerner provided a list that had at least one client that was not yet live—in their 50 best clients, indicating how difficult it is to know the actual client status. The vendor lists revealed other useful findings:
Three of the eight vendors (Epic, GE, and Misys) did not yet have 50 live CIS organizations. In those cases, KLAS
contacted a majority of customers who had contracted with the vendor before year-end 2004.
While nursing automation is in its infancy across the industry, our estimates indicate that Meditech, Cerner, and McKesson (in that order) lead out in the number of live sites over 200 beds using some nursing tools.
We calculated a vendor’s overall adoption score based on provider adoption and satisfaction in six key areas: Vitals, eMAR, care plans, orders/results, ICU, and “other caregiver usage” (PT, OT, RT, etc.). Extra points were awarded if they went live on time, had alerts in place, were doing barcode scanning, or had patient monitors interfaced. Other factors were included as well.
OVERALL NURSING ADOPTION RESULTS: Of study participants with a live CIS, 88 percent report some level of adoption. (See Figure 3 on p. 6) But what does “some level of adoption” mean?
Nursing Sponsors/Advocates
Sharp Healthcare San Diego, CA
Poudre Valley Health System Fort Collins, CO
Penobscot Bay Medical Center Rockport, ME
St. Joseph’s/Candler Health System Savannah, GA
The TIGER Initiative
6 I Nursing Adoption of IT
Figure 3 Study findings show that most adopting organizations are doing basic nursing functions, such as reviewing results and inputting orders. Beyond that, deeper functional nursing use varied. The good news was that less than five-percent of organizations were using only the basic functions. More common was for an organization to do the basics plus one or two deeper functions (i.e.: vitals, eMAR, care plans, ICU, etc). Functional uses varied widely by organization and many of the more advanced nursing tools have yet to be adopted. We also expected to find that adoption rates would increase with time as
organizations phased in nursing functionality. While this was true in a few cases, it was not true across the board. For some vendors, such as Misys and Cerner, the longer an organization had the product, the more functionality they had implemented. For other vendors (Epic, Meditech) newer customers were implementing significant portions immediately. For most vendors, however, adoption levels among newer customers and older customers are almost equal.
VENDORS LEADING IN ADOPTION: To date, overall adoption scores (see Figure 1 on p. 4) leave room for improvement, though the scores vary widely by vendor and by area measured.
Figure 3: Nursing Adoption* Among CIS Clients *Estimate based on sample, over 200 beds
126
55
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38
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13
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86
0
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Cerner Eclipsys Epic GE McKesson Meditech Misys Siemens
Live with Nursing
Total CIS Clients
Nursing Adoption of IT I 7
Executive Overview
Figure 4
It’s likely that in the future, vendors will continue to differentiate themselves by their successes with advanced functionality.
Cerner is leading overall, with several other vendors leading in adoption and satisfaction in the six specific areas measured:
Vitals: Cerner and Epic lead in adoption; Epic and McKesson lead in satisfaction. The Epic/Epic combination is a win for customers.
eMAR: The combination of meds-meets-IT at the bedside is proving difficult—(the confluence of nursing, pharmacy, barcodes, and order entry/CPOE). Cerner leads in adoption; Epic leads in satisfaction. Meditech, though integrated, had the lowest adoption at less than 30 percent.
Care Plans: The field as a whole has low adoption, though Meditech leads all others. McKesson leads in satisfaction.
Orders/Results: An overall mature adoption area, led by Cerner, Epic, McKesson, and Meditech; McKesson leads in satisfaction. The McKesson combination is a plus.
ICU: A very challenging area in adoption, led by Epic and McKesson; Cerner leads in satisfaction with today’s product, even before the iNet deployment. The near term displacement of a best-of-breed solution by an enterprise solution vendor may prove difficult.
Other caregiver usage: McKesson leads in adoption; McKesson, Meditech and Cerner lead in satisfaction.
23.3
Adoption Score for
Cerner—the Highest in this
Study
Figure 4: Client Satisfaction vs. Number of Clients Live organizations are estimates only. performance score is the standard KLAS performance score (nurses only)
60
65
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80
85
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95
100
0 20 40 60 80 100 120 140
Nu
rse
Sa
tisfa
cti
on
Estimated Live Organizations
Siemens
Average
Fewer Live Organizations/
Higher Client Satisfaction
More Live Organizations/
Higher Client Satisfaction
Fewer Live Organizations/
Lower Client Satisfaction
More Live Organizations/
Lower Client Satisfaction
Epic
Eclipsys
GE
Meditech
CernerMcKesson
8 I Nursing Adoption of IT
Figure 5 CHALLENGES TO ADOPTION: Findings from the Nursing Study confirm that challenges with nurse automation run deep. Nothing demonstrates this more clearly than vendor scores from the “Nurse Adoption” rating, where even the best vendor (Cerner) scored only 23.3 out of 40 possible. Scores like that beg the question: Why have so few sites arrived? Or, in other words: why is adoption so low? The long answer lies in the 450 pages that follow in this report. The short answer is this: there is a lot of complex workflow in a nurse’s day, and it is difficult to automate all of it. While there are providers who have embraced the entire suite of nursing technology, they are few.
Virtually all of them comment on the dream of transparent IT solutions enhancing workflow. When providers were asked to share their own hurdles to adoption the answers were varied. There were, however, several consistent themes (see Figure 4): (1) missing functionality and/or software quality; (2) the struggle for software to support processes and workflow; (3) problems with data entry devices and human behavior; and (4) the lack of basic computer skills for first time adopters along with associated training challenges.
Figure 5: Overall: Challenges to Adoption (n=143)
5%
6%
6%
7%
8%
8%
8%
9%
10%
14%
24%
31%
31%
0% 5% 10% 15% 20% 25% 30% 35%
Interfaces/Integration Issues
Learning Curve/Computer Skills
IF Monitors, Pumps, BPOC issues
Printing (Labels, reports, stds, etc)
Vendor- Imp., Staff, Tech Challenges
Increased effort/time/cost
Communication Nurse to Nurse/MD/RX
Nurse Involvement in File Build/Maint.
User Adoption/Commitment
Training Challenges
Devices Issues (wireless, bedside, etc.)
Process Change, Inflexible/Workflow
Missing Functions and/or SW Quality
Nursing Adoption of IT I 9
Executive Overview
Figure 6
NURSING CHALLENGES: WHERE TO
INVEST R&D DOLLARS
As orders and results become ubiquitous, providers report a need for increased emphasis on the “tough stuff”—namely interdisciplinary care plans, ICU, and interfacing of patient monitors to the CIS. As the focus on nursing shifts towards ironing out advanced functionality, vendors may differentiate themselves by doing just that—but is that all they have to do? Not according to nurses interviewed for this study.
Nurses eager to share their suggestions on improving nursing technology had a lot to say on where vendors should invest R&D dollars. (See Figure 6) Overwhelmingly they want greater support in workflow and ease of use—
specifically, the ergonomics of patient care. How does a hard, obtuse piece of technology realistically fit into a nurse’s workflow?
Nurses offered a multitude of suggestions on what vendors can work on. The following helpful suggestions were derived from thousands of nurse comments pointing to specific issues vendors and providers alike should be aware of:
The visuals that replace a nursing cardex and reviewing medication orders seem to get lost. For some reason, it is harder for nurses to perform on-screen reviews. Nurses repeatedly mentioned the need for an online cardex, or at least a viable substitute.
Nurses reported several problems
Figure 6: Where to Invest R&D Dollars (n=156)
5%
5%
9%
9%
10%
12%
13%
15%
16%
17%
17%
46%
0% 10% 20% 30% 40% 50%
Voice Recognition
Nurse Dashboard
Med Reconciliation
BPOC
Bedside Devices, Wireless Reliability
Integration
IF Monitors, Pumps, etc
Alerts, Best Practice, Content
Reporting (Mgmt,Reg,Clin Outcomes)
Improved SW (Biometric,RFID,ED,L&D,ICU,Video,Acuity,Image)
Care Plans & Interdisciplinary CP
Workflow, Ease of Use
10 I Nursing Adoption of IT
Figure 7
with wireless devices. Wireless “dead zones” seriously deter system confidence—making many caregivers reluctant to proceed.
Nursing devices, while great in theory, are often the cause of many headaches. The bottom line is that pushing, pulling, or dragging anything is not fun for a nurse. Finding a device that is truly user-friendly will facilitate nurse documentation at the bedside.
Nurses need a system that helps them retrieve data in a timely manner; running reports without a request for help to IT.
Regarding the buzz on whether a solution is interfaced, interoperable, or integrated: the reality is that nurses often do not know and more often do not care—unless the solution doesn’t work. The lack of a connected solution
can be the source of irritating problems.
NURSE SATISFACTION:
Perhaps the most important positive, though surprising, study finding was that nurses overall proved happier than their IT colleagues do. With the exception of Meditech, nurses were more satisfied & rated their vendors higher than did their IT counterparts. (See Figure 7)
The study also revealed that vendors with a greater client base did not satisfy clients any better than vendors with a smaller client base did. (See Figure 4) The outliers in this picture frame the discussion—Epic elevates itself from the average but with fewer live organizations, suggesting that the jury is still out. GE, on the other hand,
Figure 7: Vendor Performance Scores: Nursing vs. IT Score out of 100.
* does not meet minimum KLAS standards for statistical confidence
80.581.6
90.8*
67.8*
80.2
75.576.4*
74.2
77.0
87.8
67.0*
79.480.2
74.7
50
55
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70
75
80
85
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100
Cerner Eclipsys Epic GE McKesson Meditech Siemens
Nursing IT
Nursing Adoption of IT I 11
Executive Overview
Figure 8
has something to prove with the lowest client satisfaction, and a lower number of live organizations.
ADDITIONAL FINDINGS—PHYSICIAN
ADOPTION VS. NURSING ADOPTION
With all the attention given to physician order entry and physician adoption, one might wonder how nursing adoption compares. The comparison is tricky—a bit like comparing apples to oranges, though it does give some perspective. Study results comparing live nursing organizations against live CPOE organizations showed that nursing comes out ahead. (See Figure 8) Eclipsys was the only vendor with greater physician adoption than nursing adoption. One key factor in the doctor versus nurse discussion is that nurses are employees of
the hospital; doctors are not. Nursing adoption reflects the will and authority of management while physician adoption is generally more voluntary (except where employed) and the response to indirect pressures.
Nurses and physicians face different automation challenges. In many ways, the focus on physician order entry was a distraction for nursing technology goals. Study findings clearly revealed that physician functionality and flow does not work for nursing. Nurses need their own functionality, their own workflow, their own automation.
In reality, nursing and physician automation is highly interdependent. Real success happens only when they work together.
Figure 8: Estimated Number of Nursing Orgs Live vs. Live CPOE
0
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Cerner Eclipsys Epic GE McKesson Meditech Misys Siemens
Estimated Live Nursing Organizations
Live CPOE Organizations
12 I Nursing Adoption of IT
Figure 9
VENDOR PERFORMANCE OVERVIEWS The vendor overviews below provide a vendor position (based on adoption
scores) and briefly summarize provider feedback collected during this nursing study.
Vendor Performance Overviews: All Vendors
Vendor/ Product
Provider Feedback
BRAVO: Highest average adoption by any vendor. Integration is referred to as the real win by nurses and is reflected in the highest eMAR adoption score. Nurses see improving flexibility and maturing of the product visible in the end-user interface. Upcoming iNet and iView release seen as positive ICU updates adding benefits to nurses, the current highest client satisfaction for ICU flow sheets. OUCH: Requires an intense process to get live and fully engaged. Nurses report difficulty getting to the stored data for reporting. Voluminous data needs a dashboard or summary. Challenging care plan functionality. BOTTOM LINE: A significant number of Cerner hospitals have gone live in the last two years. With adoption solid, satisfaction is above average and the overall value Cerner clients are getting scored the highest of all vendors.
Adoption Score
Position
1st
Figure 9: Satisfaction Score by Function and Vendor Absence of a vendor plot indicates insufficient data
6.00
6.50
7.00
7.50
8.00
8.50
Vitals & I/O eMAR Care Plans Orders & Results ICU Flowsheets Other Caregivers
Overall Cerner Eclipsys
Epic GE McKesson
Meditech Misys Siemens
Nursing Adoption of IT I 13
Executive Overview
Vendor Performance Overviews: All Vendors
Vendor/ Product
Provider Feedback
BRAVO: Rated highest in nursing satisfaction among fully rated vendors. Solid end user response times in light of the high number of nurse users. Nurses forecast KBC will be the best knowledge-based toolset in the industry. Emtek clients are now moving to SCM successfully for the complex ICU environment. Eclipsys’ deepest sites compare favorably with any in the country. OUCH: The surgery partnership and a newly launched ED solution create nurse challenges, tied to integration. Lack of a barcoding solution is an impediment for deep nurse usage (low percent doing eMAR or BPOC). Non-Emtek clients are slow to adopt SCM in the ICU. KBC requires more work than expected to utilize. BOTTOM LINE: Eclipsys products are built for clinicians—physicians and nurses are typically satisfied with the solution. Integration challenges and new modules (ED, Rx, Ambulatory EMR) are having an impact on adoption and satisfaction.
Adoption Score
Position
5th
BRAVO: Proactive approach demonstrated by listening well to nurses regarding requirements and needs. Providers report fast delivery, strong software, and strong partnership experience showing up in high satisfaction rating relative to sample size. Quick product development and improvement. Work well with third-parties. Good interfacing capability.
OUCH: Lack of deep inpatient experience. Young and green installation team members. Product gaps. Shallow clinical team.
BOTTOM LINE: Some modules considered immature (e.g. ICU, interdisciplinary care plans).Design, develop and implement new products in a comparatively short time. Providers are pleased with the client focus giving high ratings for keeping promises and delivering above expectations. Providers applaud Epic’s approach in bringing development teams to client sites to see and hear what users need.
Adoption Score
Position
4th
BRAVO: GE has the largest number of nurses per organization using a solution. Clients speak of groundbreaking development work with Intermountain Healthcare leading to an advanced solution (client forecasted 2009–2010).
OUCH: Lowest nursing satisfaction. Response times are often a challenge, even with NonStop platform. Nursing adoption is low in nearly every area, especially care plans and ICU.
BOTTOM LINE: Many LastWord customers have migrated to Centricity Enterprise (previously called Carecast). The transition has been a struggle for many. The new GE leadership team is working to gain buy-in from clients and prospects alike. Clients and buyers declare the jury is out regarding their future with GE.
Adoption Score
Position
8th
14 I Nursing Adoption of IT
Vendor Performance Overviews: All Vendors
Vendor/ Product
Provider Feedback
BRAVO: Legacy Clin Doc to HED transition is cost effective versus replacement. Knowledgeable nursing team helps engage client nurses. Strong relationship with client nurse executives. BPOC, patient monitor interfaces (highest) and overall orders and results review area strengths. Very likely to hit live date. Clients see a stronger partnership.
OUCH: Lack of integration especially with Surgery and ED. Solution requires use of multiple McKesson products with variable end user interfaces. Workflow issues. Shallow use in alerts and best practice guidelines. Timely bug free software delivery needs improvement.
BOTTOM LINE: HED clients migrating from HCD achieve desired benefits avoiding a complete replacement experience with a competitive vendor. Integration both within McKesson products and to foreign systems is a common challenge. Strong nursing team helps clients readily adapt achieving go live goals.
Adoption Score
Position
2nd
BRAVO: Software support is strong while support of nursing issues is weak. New status board for nurses is valuable. Integration is solid and effective. Systems are reliable with fast end user response times. Strongest adoption of care planning solution.
OUCH: Lack of interfaces to patient monitors and other third-party solutions. Lack of transferable nursing knowledge – providers must figure out how to build, implement and engage process change on their own. Problematic end user interface w/MAGIC yet better with C/S. Overall nursing satisfaction lowest of fully rated vendors.
BOTTOM LINE: Meditech is not a relationship company. Meditech provides reliable, solid software. The solution is generally lower cost and very predictable. Nurses use the software having built needed capabilities with their own heavy investment. Iatric and others are contracted by some hospitals to install a more desirable end user interface.
Adoption Score
Position
3rd
BRAVO: Nearly all sites using basic nursing functionality. Care plans are also used in 60 percent of the Misys sites. Response time satisfaction is above average.
OUCH: Clients report little R&D blaming it on the few new sales of the Misys CPR system. Most clients are long-term users, accustomed to the older looking interface. A BPOC solution is being implemented at the first sites. The new client installs typically go live late.
BOTTOM LINE: Vendor announced focus on ambulatory is resulting in client concerns about the future of this product (including future ownership). Misys CPR has deep clinician adoption. Older customers are more satisfied than newer customers.
Adoption Score
Position
6th
BRAVO: Soarian touted for ease of use and workflow potential. Recent Siemens executive commitment and willingness to listen a positive. After live support is strong. Workflow and BPOC with MAK is part of desired new technology. Invision continuation until Soarian live is a welcome safety net. MedSeries4 in a beta environment for community hospitals.
OUCH: Building templates from scratch is a painful memory for Soarian clients (mostly from early adopters). Lack of integration between MAK and Soarian. Lack of integration noted with other critical solutions. Green Soarian installation staff. Soarian delays. Invision rating by nurses is lowest in industry.
BOTTOM LINE: Soarian is live with some deeper use at early adopters. Ease of use (GUI) approach gets high praise. Transition from Unity and Invision is taking place, though clumsy. MedSeries4 clients have a recommended clinical route outside Soarian. Reported delays artificially reflect a second wave of dates, ignoring initial forecasted live dates in most cases.
Adoption Score
Position
7th
