University of Iowa links rural providers.

Wagner started in 1971 as a computer operator during his graduate school days at the University of Iowa. Now he heads an Information Systems department of 113 people, manages a complex system that handles 1.7 million transactions every day and shepherds an annual I/S budget of $7.5 million.

He's now preparing for the roll out of a newly won $7.3 million contract from the National Library of Medicine that, among other things, is set to establish UIHC as one of the nation's premiere "laboratories" for the study of rural telemedicine via a statewide fiberoptic communication network.

Wagner's I/S department is organized well enough to now devote 70 percent of its time to developing new applications, with only 30 percent of its time required to service current implementations. He also says he has excellent support from both staff and top management. In fact, Wagner says the UIHC has stable leadership who share a vision for what technology can do within the healthcare delivery process.

"I'm seeing here at the UIHC now in that even when we're making cutbacks in other departmental areas throughout the hospital, top administration is recognizing that the best investment of their limited resources is in the information systems area. And so we're seeing additional staff being allocated to us in times when other departmental areas are facing some cutbacks," says Wagner.

Evidently, Jim Wagner has a few reasons to smile.

Wagner has both mastered and guided the almost exclusively homegrown INFORMM system that has expanded to more than 2,000 terminals hanging off an IBM 3090-500J mainframe. The system now boasts 2,000 unique application functions. "INFORMM" is an acronym for Information Network for Online Retrieval and Medical Management, according to Wagner.

Although he virtually grew up with the system--he has worked at UIHC for 23 years, 11 of them as I/S director--Wagner still faces enormous management challenges.

"I say that serving as a health-care CIO in today's environment is a little like the task in that 'I Love Lucy' segment," Wagner explains. "Remember where she's trying to box up the pies as they roll off the assembly line? It seems to me that if everything goes perfectly, then it's theoretically possible to do the job. But as new demands, such as healthcare reform and technological advances, come at you so fast, if you have even one little misstep, then you can quickly have a major disaster on your hands."

Wringing every last drop

The University of Iowa Hospitals and Clinics is a comprehensive tertiary healthcare center and teaching institution with 891 beds, 234 specialty clinics, 597 staff physicians, 681 residents and fellow physicians, 1,562 professional nurses, 1,504 other professional staff and 3,244 other supporting staff. Nearly six million laboratory procedures and more than 200,000 radiographic examinations are performed at UIHC each year. In 1993, UIHC physicians treated more than 466,000 ambulatory clinic patients.

Such a large, complex healthcare organization has a large and complex information system to match. In fact, as director of UIHC's Information Systems department, Jim Wagner is known among some of his peers for his ability to wring the ultimate capability out of his mainframe shop of thousands of homegrown application functions. He's particularly proud that they all have a singlesystem feel to them.

His INFORMM system applications are set up in four separate divisions: administrative, clinical, financial and technical. The idea is to collect information about patients when they first encounter the hospital. That information is stored in a central database repository and shared with authorized users via the fiber-optic net.

The INFORMM system is so well entrenched that Wagner and his I/S staff have been able to implement refinements that assess performance, incentivize productivity and encourage user feedback. Wagner says his goal is for staffers to want to use the system.

During the past year, he has developed what he calls a "Hospital Information System Performance Score Card," which he has modeled after the graphically colorful USA Today weather map. It's a layered, colored presentation posting the various components of his system operations--for example, subsecond response time, promptness in producing reports, tracking the availability of the training network and development network--and monitoring those against what the department has set as acceptable performance levels. Acceptable levels appear as green. Any deviations are red. Productivity and compliance can be taken in at a glance.

These Performance Score Cards are posted in several strategic areas throughout the hospital to let everyone know that the I/S department is going to adhere to certain standards of quality in terms of the services it provides. "And we're going to be accountable for those," Wagner says.

Although Wagner does not characterize hospitals in general as leaders in quality improvement, he says he has a strong personal commitment to that area in terms of information systems. Wagner's team has reached out to its vast user community with what amounts to an electronic suggestion box, called "INFORMM US." It's an online function ready to accept user notes and comments. The notes flow to an electronic mailbox checked daily by one of Wagner's project assistants.

"I put in place a protocol that we will follow up within 24 hours to anyone who makes a suggestion to us to give them a personalized reply," he says. "That's a technique that has worked very well for us in terms of keeping my Information Systems staff in tune with the users of the system."

Suggestions are taken seriously. In a two-year period, the INFORMM US application received 460 unsolicited messages. Of those, 8 percent were comments, 12 percent reported system problems, 25 percent were training questions and 27 percent were questions about why the system operates in a certain way. Twenty-eight percent of the responses suggested enhancements to the system. Wagner's team has implemented about a third of those suggestions.

Strategic I/S goals

Now well into their five-year Information Systems Strategic Plan and Profile, Wagner and his I/S steering committee have three strategic goals still before them. First, they plan to sustain and enhance their already rich portfolio of 2,000-plus applications. They will expand their electronic physician network by capitalizing on the availability of Iowa's statewide fiber-optic network, and they will aggressively address the issue of physicians interfacing to the hospital information system.

Wagner has a lot of statistics on how the system is used. For example, he knows that 1,800 nurses perform 130,000 transactions every day on the nursing system. Physicians perform 42,000 transactions per day on the system. "Interestingly enough, most of the things [the physicians] do are retrieval functions," says Wagner. "In other words, they're very good at getting information out of the system. What we want to do is to find ways to provide incentives for them to put data into the system."

Toward that goal, Wagner has recruited a full-time physician to work with his department on developing a physician interface. James R. Flanagan, M.D., Ph.D., assistant professor of internal medicine and chairman of UIHC's Electronic Medical Record Task Force, is providing insights on the physician interface presentation and enhanced system functionality to incentivize physicians to do more than "look-ups."

Flanagan says physicians represent 5 percent of all system users. "These clinicians, of course, have always had an interest in getting information," he says. "But what has been missing is the desire to spend any time interacting with these information systems and put information into them. And that lack of desire to do that is going to continue. But I think that what clinicians have never realized is how much they can get out of it if the information they generate--the clinical notes and the physician orders and their impressions--is available within the information system."

Management challenges

Wagner has identified three primary management issues in his role as director of Information Systems. The concept of system security and confidentiality is paramount. He says he has heard many healthcare CIOs give in to the notion that hackers are going to break into confidential clinical records. "That's a cop out," he says. Wagner and his team have already implemented electronic and managerial measures to control the security of their system.

Of course, enticing physicians to interact directly with the system is also a top priority for Wagner, but making the most out of the resources available to I/S managers is his passion. He says, "In times like this when the resources are more precious than ever, to have your CEO entrust you with very precious resources at a time that they're pulling them away from other folks, I think that involves a huge responsibility."

$7.3 million NLM grant

A big part of Jim Wagner's job in the coming years will be to help implement the many projects planned under the National Library of Medicine grant for the study of rural telemedicine.

The fact that the state of Iowa is building a fiber-optic network to link 99 county seats, coupled with UIHC's demonstrated technological expertise, has helped the organization win the $7.3 million contract from the National Library of Medicine, announced in late March.

The three-year grant may eventually help link hospitals and physicians throughout Iowa in support of enhanced healthcare services in rural areas. The NLM grant establishes the National Laboratory for the Study of Rural Telemedicine at the University of Iowa. The laboratory will enable healthcare providers and researchers to share medical data and imaging technology, according to Jim Wagner. Clinics, medical schools, physicians' offices, medical libraries and universities will be linked.

The grant contract establishes three Iowa hospitals as test sites that link to UIHC Laboratory for the Study of Rural Telemedicine: Van Buren County Hospital in Keosauqua, Ottumwa Regional Medical Center and Genesis Health System in the Quad Cities. These three institutions were selected to represent small, medium and larger rural-based hospitals, says Michael G. Kienzle, M.D., UIHC's interim associate vice president for Clinical Affairs and the university's principal investigator for the NLM grant. "In that way we can look at applications and try to figure out whether applications are appropriate for all types of hospitals or whether there are certain characteristics of hospitals that make certain applications more valuable," Kienzle explains.

Kienzle says UIHC saw its opportunity with the NLM grant and seized it. "We at Iowa have had a relatively limited experience with telemedicine services up until recently, and that mostly consisted of doing teleradiology network electrocardiographic interpretation," he explains. "We also utilized a satellite network for selected health-education kinds of applications. With the advent of the Iowa Communications Network, which is a 2,800-mile fiber-optic network connecting the entire state, and the federal emphasis on advanced telecommunications to support primary care and rural healthcare, we saw the opportunity to put something together that was of a more programmatic nature, rather than just single projects. We thought that there was an opportunity to build a real infrastructure for the study of telemedicine as it might apply to a rural state."

Virtual Hospital

Perhaps one of the strongest hooks that helped secure the NLM grant was the Virtual Hospital project, already in place at UIHC. The idea started three years ago, according to Jeffrey R. Galvin, M.D., a professor of radiology and director of the Virtual Hospital project. Three UIHC professors realized they needed a way of providing information to medical students that could answer their questions at the time they were doing their work.

Galvin says he began to understand that physicians need to work the way an airplane pilot works, with information coming to them constantly via information systems. Very few human beings are capable of retaining all that they read or hear in lectures, Galvin observes.

"All of this information--whether it's the latest article on how to cure somebody in heart failure, or what's the anatomy of a certain blood vessel that I'm about to put a needle into--should be sitting there, either in my hand, through the network, at the patient's bedside." Galvin says. "I should be able to 'go to the library' through this kind of system and acquire information on demand. It's really sort of a 'just-in-time' learning process, because I think that's the way all of us work."

Galvin and his colleagues began to develop multimedia medical education content to share throughout the UIHC complex, and even began to upload this information to the Internet. He views the Virtual Hospital as the "tele-education" portion of the NLM grant for linking rural healthcare providers to the UIHC resources. In fact, the project success became a strong factor in the overall success of the grant.

Galvin reports that the Virtual Hospital's Internet exposure has been far more explosive than he could ever have imagined. He says his usage estimates were off by a factor of 100. In the last three months alone, 279,000 users all over the world have tapped into the Virtual Hospital via the Internet.

As to what Internet users or Iowa healthcare providers can expect from the Virtual Hospital, Galvin says the plans are just starting and will expand beyond textual educational material to multimedia forms like video presentations of specific surgical procedures, X-rays, MRI scans, CT scans and teleconsultation capabilities between physicians. "In other words, you will be able to send an actual picture of your particular patient," Galvin adds.

Much multimedia information related to the chest--its anatomy and disease information--is now on the system, Galvin says. "But eventually the whole body will be in there."