2CPOE/EMRIn the Oct of 2009 we are planning a large expansion of the use of the Electronic Medical Record (EMR) for our inpatients at UNMH.The two major outcomes of the expansion will be that1) except some physician documentation all other patient care documentation (nursing, RT, social work, OT, PT) will be done electronically2) CPOE all inpatient orders will be entered electronically by the providersThe expansion of the EMR will change the way we take care of patients at UNMH.
3Who is making this all happen? 5 major teamsProvider teamCPOE development of order setsClinical teamClinical documentationInformation Technology teamApplication design and buildSupport teamEquipment and infrastructureWorkflow teamsWork redesign
4Provider Team Nancy Alton, NICU Carlos Argulles Emergency Medicine Paul Echols OrthopedicsRao Deepti Internal MedicineWilliam Dodson Family MedicineScott Forman, Resident, EDGary Iwamoto, MICU, LeaderAaron Jacobs, PediatricsSteven Jenkusky PsychiatryRobert Katz, Pediatrics Clinical LeadershipMatthew Luke, PathologyMarc Malkoff Neurosurgery/NeurologyJohn Marinaro, SurgeryGary Mlady RadiologyAndrew Paterson OrthopedicsSharon Phelan ObstetricsSarah Pirio Richardson NeurologyKendall Rogers, MedicineTrevor Rohm InformaticsJess Schwartz, SurgeryRandall Stewart Psychiatry
5Clinical (aka PULSE) Team Steve Bass-ICUBrian Carter-PedsKim Heinen-Med/SurgDeirdre Kearney-NeuroCarrie Khalsa-EDMary Laflin-PT/OT/SpeechKim McKinley-Senior DirectorMelanie Morris-HUCIda Placencio-RTJames Simpson-PharmacyAmanda Sorio-NICUSue Titsworth-Case ManagementBridget Yarrington-Pharmacy
6IT Team Neil Alessio Karen Day Glen Jornigan-Exec. Director Diane KostagJan Krell-IT Project ManagerKellie MoudyLisa QuintanaShari ShafferDavid TurnerMargaret Wallhagen
7Support Team Tim Suchla, Clinical Engineering Mary Rivera, Equipment Project LeaderOn Site Cerner Support:Hillary Biskner, Executive LeaderKarmen Gilbert, RN Solution ArchitectLori Raynaud, RN Workflow RedesignDon Kane, MDPhysician Liaison
8The expansion of the EMR will allow all care providers equal access to patient information, and improve the ability to access information and document care for all care providers.The present electronic medical record is based on paper records that are scanned into the computer. What we are moving to is an interactive system that will allow for real-time charting on all aspects of patient care, from vital signs to medication administration.
9CPOE (Computerized Provider Order Entry): Handwritten orders can often be difficult to read, and often result in errors. Orders will continue to be reviewed by pharmacists and nursing staff, but potential errors due to handwriting are eliminated. Also, since providers will enter orders directly, tests and medications can be processed much more quickly, enhancing our current process.
10Advantages of CPOE Systems Compared With Paper-Based System Free of handwriting identification problems (time, date, person ordering all part of order)Faster to reach the pharmacyLess subject to error associated with similar drug namesMore easily integrated into medical records and decision-support systemsLess subject to errors caused by use of apothecary measuresEasily linked to drug-drug interaction warningsAble to link to ADE reporting systemsAble to avoid specification errors, such as trailing zerosAvailable for immediate data analysisClaimed to generate significant economic savingsOrder Sets may standardize care
11CPOEOrder sets~200 power plans covering admission, post op, specific diseases CHF, ACSSingle orders order sentencesChoices frequency, type (Stat, ASAP, Routine)For a medication dose, frequency, route,For diagnostic type test reason for exam other areas prefilled in by location and other data already in the systemEvaluate work flow in each process admitting transferring discharge, daily care of patient, post op, level of careDose range checkingFolders of common orders
12Orders from order folders, favorites and by searching
20Electronic Medical Record Documentationwill be easier findmultiple users can access of data at the same timestandardization of documentationlegibilitydata analysisHIPPA complianceViewing data. Patient data can be viewed on any computerEMAR can view both what patient on but also view when meds given will have one MAR.Vital signs, I&O, nursing tasksDocumentation by all services
26Changes that have occurred Development of the order sets and the expanded EMR have standardized many practices.Ordering of daily labs, repeating labs. Old way was the daily labs had to be entered each day by the HUC who kept track of this on a cardStandardized documentation by nursing, RT, etc.Urgent clinical documentsWill pull in Code status note, advanced directives, POA, medication contractDaily Rounds Summary
30Rev 17 Training Starts Time line Rev 17 June 21, RHO Sept 27, Go Live Oct 25Training 6 weeks before go live SuperUsers 8 weeks before go liveJune 2009July 2009August 2009MTWTFSRev 17SMTWTFSSMTWTFSS1234567293012345272829303112891011121314678910111234567891516171819202113141516171819101112131415162223242526272820212223242526171819202122232930123452728293031122425262728293031123456Superuser TrainingSeptember 2009October 2009MTWTFSSMTWTFSSGo Live31123456282930123478910111213RHO5678910111415161718192012131415161718212223242526271920212223242528293012342627282930311Training Starts
31Training needs to cover New functions such as adding orders and powerplansProcessesAdmit with med recTransfer with med recDischarge with med recFinding data in the chartDocumentation nursing, RT, H&P, etc; vital signs, I&O, medications and ordersCommunication
32Training2 hour classroom to cover basic ordering, processes admission, transfer, discharge, where to find the dataThe classes will assume that everyone has a basic understanding in using Power Chart can log in, find lab values, read and find documentation, write prescriptions.Would ideally like to teach in groups ie by division or department so that core processes are covered and then at the end processes specific to that area can also be addressedIn addition to the classroom training web based training, videos and tip sheets will be available
35Go LiveWhen we go live we will have superusers available on the floors to help with problemsA process in place to make changes needed as we find themThe tip sheets, web videos and training are all available by clicking the “How to ?” button in power chart at the topThe development of new order sets, changes to improve work flow, etc. will be an ongoing process.
36Summary CPOE will improve legibility, date and time The enhanced EMR will have all the information on the patient in one place and improve standardization of many processes.The change is coming we need to prepare everyone for it .Superuser Training starts Sept 1Training starts Sept 15Go live set for Oct 25Training on the EMR for the hospital, lead superusers (45) 40 hrs training, super users (243) 20 hours training, users (~2000) 12 hours trainingProviders ~ 1500 superusers (~ 40 residents, ~15 attendings)To train everyone scheduling needs to be done as early as possibleAs much as possible we would like to train in groups to help emphasize areas specific to that group for example for surgery cover post op compared to admission what part of the process is different,The training plan has a basic core of what we are going to teach ordering, processes admit, transfer, discharge, med rec, and how to find data if we can teach in groups we can then emphasize specific areas that they will be doing. Some groups have already scheduled as a division meeting.
37Tasks to performLet everyone know it is coming (talks with faculty and residents)Schedule training times nowDevelop training material (ongoing)Super user training (starts Sept 1)Schedule training sessionsTraining sessions (starts Sept 15)Go live Oct 25
38Where we areAnesthesia contact Dr Arndt and Dr Chapman, talk presented 7/10/09, schedule training timeEmergency Medicine contact Dr Arguelles talk scheduled, working on scheduling training timeFamily Medicine need contact; need to schedule talks; need to schedule training timeMedicine contacts Dr Rogers, Dr Rao, Dr. Garcia CRTC; need to schedule talks to divisions; need to schedule training timePulmonary and Heme Onc have scheduled training timeNeurology need a contact; would like to schedule talk; schedule training timeNeurosurgery need contact; scheduling talk; need to schedule training timeOb/Gyn contact Dr Phalen; scheduling talks and training timeOrthopedics talk contacts Dr Paterson and Dr Echols; talk 7/15/09; need to schedule training timePathology contact Dr Luke need to assess what trainingPediatrics contact Dr Jacobs; scheduling talks; need to schedule training timesNeonatal contact Nancy Alton, has scheduled training timesPsychiatry Adult need contact; need to schedule talks; need to schedule training time.Psychiatry Peds contact Dr Mancuso need to schedule talk and training timeRadiology contact Dr Mlady need to assess what trainingSurgery contacts Dr. Howdishell and Dr. Schwartz; 3 talks scheduled first 7/15/09, will see if divisions want talks; need to schedule training timesResidents recruiting super users to help in training and when we go live would like to present to talk to let them know whats coming, also schedule training
39CPOE Expected Out Comes Improved legibilitydate, time, person ordering defined easy to find, reason for test requiredOrder sets may improve uniformity of careImproved turn around timesWill not be faster for provider or nurse writing the order
46Communication A major concern is how communication will change. Electronic order entry and charting does not replace effective communication between clinicians.How do we safeguard effective communication?
48CPOE- Computerized Physician Order Entry Power Plansa set of orders for admission, post op, specific diseases ie acute coronary syndrome.Single Orderssentences fill in the necessary details needed for that order including reason for test, STAT, routine, ASAP
49CPOEOrder sets~200 so far covering admission, post op, specific diseases CHF, ACSSingle orders order sentencesChoices frequency, type (Stat, Now Routine)For a medication dose, frequency, route,For diagnostic type test reason for exam other areas prefilled in by location and other data already in the systemEvaluate work flow in each process admitting transferring discharge, daily care of patient, post op, level of careMedications correct dosing eliminate fields that will cause confusionPediatrics order as they are used to, dose range checkingTraining on each process
50Urgent Clinical Documents tab Will pull in Code status note, advanced directives, POA, medication contract,
54USP MEDMARX Computer Technology-Related Harmful Errors (2006) Cause Number %Barcode, medication mislabeled 20 5Information management system 1,176 2Computer screen display unclear/ confusing Dispensing device involved 3, Barcode, failure to scan <1Computer entry (general, other than CPOE) 24,715 <1CPOE 10,752 <1Barcode, override warning Total 43,372* * From a total of 176,409 medication error records.
55Joint Commission suggested actions Below are suggested actions to help prevent patient harm related to the implementation and use of HIT and converging technologies. (Summary)Examine workflow processes and procedures for risks and inefficiencies and resolve these issues prior to any technology implementation.Actively involve clinicians and staff who will ultimately use or be affected by the technology, along with IT staff with strong clinical experience, in the planning, selection, design, reassessment and ongoing quality improvement of technology solutions--- Involve a pharmacist in the planning and implementation of any technology that involves medication.Assess your organization’s technology needs beforehand (e.g., supporting infrastructure; communication of admissions, discharges, transfers, etc.).
56During the introduction of new technology, continuously monitor for problems and address any issues as quickly as possible, particularly problems obscured by workarounds or incomplete error reporting.Establish a training program for all types of clinicians and operations staff who will be using the technology and provide frequent refresher courses. Evaluate order sets safety alerts, review new drugsAfter implementation, continually reassess and enhance safety effectiveness and error-detection capability, including the use of error tracking tools and the evaluation of near-miss events.After implementation, continually monitor and report errors and near misses or close calls caused by technology through manual or automated surveillance techniques.Re-evaluate the applicability of security and confidentiality protocols as more medical devices interface with the IT network. Reassess HIPAA compliance on a periodic basis to ensure that the addition of medical devices to your IT network and the growing responsibilities of the IT department haven’t introduced new security and compliance risks.
57CPOE- Computerized Physician Order Entry Power Plansa set of orders for admission, post op, specific diseases ie acute coronary syndrome.Single Orderssentences fill in the necessary details needed for that order including reason for test, STAT, routine, ASAP
58CPOEMay decrease medication errors may introduce new types of medication errorsSeveral studies have looked at changes brought about by CPOEOne study stated 22 new types of errors were introduced with CPOE a second study using an updated version same software saw 4 types of new errorsThere will be anticipated results and unanticipated results both good and bad.To prepare for we are using the experience of others, literature and training
60Identified problems examples Initial set up for iNET standardization of practices in the ICUs improved overall practice and careHUCs have done a lot of translation of orders we will need to teach what really is orderedDaily labs can be written not have to be written each day by HUCCulturessite drawn from not known at time of order placement can write where culture drawn on order sheet will be input in lab
61CPOEOrder sets~190 so far covering admission, post op, specific diseases CHF, ACSSingle orders order sentencesChoices frequency, type (Stat, ASAP, Routine)For a medication dose, frequency, route,For diagnostic type test reason for exam other areas prefilled in by location and other data already in the systemEvaluate work flow in each process admitting transferring discharge, daily care of patient, post op, level of careMedications correct dosing eliminate fields that will cause confusionPediatrics order as they are used to, dose range checkingTraining on each process
62Physician Team Nancy Alton, NICU Carlos Argulles Emergency Medicine Paul Echols OrthopedicsRao Deepti Internal MedicineWilliam Dodson Family MedicineScott Forman, Resident, EDGary Iwamoto, MICU, LeaderAaron Jacobs, PediatricsSteven Jenkusky PsychiatryRobert Katz, Pediatrics Clinical LeadershipMatthew Luke, PathologyMarc Malkoff Neurosurgery/NeurologyJohn Marinaro, SurgeryGary Mlady RadiologyAndrew Paterson OrthopedicsSharon Phelan ObstetricsSarah Pirio Richardson NeurologyKendall Rogers, MedicineTrevor Rohm InformaticsJess Schwartz, SurgeryRandall Stewart Psychiatry
63Purpose of Workflow Analysis: Define the new process that will support the future stateIdentify what processes will START, STOP & CONTINUECreate/modify policies and procedures based on the new processesDefine how employee roles will changePlan for the organizational impactIdentify the benefits for patient, clinicians and the organizationIdentify the training requirementsRecommendations for Downtime