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SynergE3 CPOE/EMR CPOE/EMR In the Oct of 2009 we are planning a large expansion of the use of the Electronic Medical Record (EMR) for our inpatients.

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Presentation on theme: "SynergE3 CPOE/EMR CPOE/EMR In the Oct of 2009 we are planning a large expansion of the use of the Electronic Medical Record (EMR) for our inpatients."— Presentation transcript:

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2 SynergE3 CPOE/EMR

3 CPOE/EMR In 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 that 1) except some physician documentation all other patient care documentation (nursing, RT, social work, OT, PT) will be done electronically 2) CPOE all inpatient orders will be entered electronically by the providers The expansion of the EMR will change the way we take care of patients at UNMH.

4 Who is making this all happen? 5 major teams – Provider team CPOE development of order sets – Clinical team Clinical documentation – Information Technology team Application design and build – Support team Equipment and infrastructure – Workflow teams Work redesign

5 Provider Team Nancy Alton, NICU Carlos Argulles Emergency Medicine Paul Echols Orthopedics Rao Deepti Internal Medicine William Dodson Family Medicine Scott Forman, Resident, ED Gary Iwamoto, MICU, Leader Aaron Jacobs, Pediatrics Steven Jenkusky Psychiatry Robert Katz, Pediatrics Clinical Leadership Matthew Luke, Pathology Marc Malkoff Neurosurgery/Neurology John Marinaro, Surgery Gary Mlady Radiology Andrew Paterson Orthopedics Sharon Phelan Obstetrics Sarah Pirio Richardson Neurology Kendall Rogers, Medicine Trevor Rohm Informatics Jess Schwartz, Surgery Randall Stewart Psychiatry

6 Clinical (aka PULSE) Team Steve Bass- ICU Brian Carter- Peds Kim Heinen- Med/Surg Deirdre Kearney- Neuro Carrie Khalsa- ED Mary Laflin- PT/OT/Speech Kim McKinley-Senior Director Melanie Morris- HUC Ida Placencio- RT James Simpson- Pharmacy Amanda Sorio- NICU Sue Titsworth -Case Management Bridget Yarrington- Pharmacy

7 IT Team Neil Alessio Karen Day Glen Jornigan-Exec. Director Diane Kostag Jan Krell-IT Project Manager Kellie Moudy Lisa Quintana Shari Shaffer David Turner Margaret Wallhagen

8 Support Team Tim Suchla, Clinical Engineering Mary Rivera, Equipment Project Leader On Site Cerner Support: – Hillary Biskner, Executive Leader – Karmen Gilbert, RN Solution Architect – Lori Raynaud, RN Workflow Redesign – Don Kane, MD Physician Liaison

9 The 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.

10 CPOE (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.

11 Advantages 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 pharmacy Less subject to error associated with similar drug names More easily integrated into medical records and decision-support systems Less subject to errors caused by use of apothecary measures Easily linked to drug-drug interaction warnings Able to link to ADE reporting systems Able to avoid specification errors, such as trailing zeros Available for immediate data analysis Claimed to generate significant economic savings Order Sets may standardize care

12 CPOE Order sets – ~200 power plans covering admission, post op, specific diseases CHF, ACS – Single orders order sentences Choices 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 system Evaluate work flow in each process admitting transferring discharge, daily care of patient, post op, level of care Dose range checking Folders of common orders

13 Orders from order folders, favorites and by searching

14 Searching start first few letters

15 Order sentences have details of dose, frequency, route options

16 Power Plans are groups of orders

17 Arranged in a standard way

18 Common values are available as drop down boxes

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21 Electronic Medical Record Documentation – will be easier find – multiple users can access of data at the same time – standardization of documentation – legibility – data analysis – HIPPA compliance Viewing data. Patient data can be viewed on any computer EMAR can view both what patient on but also view when meds given will have one MAR. Vital signs, I&O, nursing tasks Documentation by all services

22 Vital signs

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27 Changes 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 card Standardized documentation by nursing, RT, etc. Urgent clinical documents – Will pull in Code status note, advanced directives, POA, medication contract Daily Rounds Summary

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30 Rounding Summary

31 Time line Rev 17 June 21, RHO Sept 27, Go Live Oct 25 Training 6 weeks before go live SuperUsers 8 weeks before go live SSFTWTM October SSFTWTM SSFTWTM SSFTWTM September 2009 August 2009 July SSFTWTM June 2009 Rev 17 Go Live RHO Superuser Training Training Starts

32 Training needs to cover – New functions such as adding orders and powerplans – Processes Admit with med rec Transfer with med rec Discharge with med rec – Finding data in the chart Documentation nursing, RT, H&P, etc; vital signs, I&O, medications and orders Communication

33 Training 2 hour classroom to cover basic ordering, processes admission, transfer, discharge, where to find the data The 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 addressed In addition to the classroom training web based training, videos and tip sheets will be available

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36 Go Live When we go live we will have superusers available on the floors to help with problems A process in place to make changes needed as we find them The tip sheets, web videos and training are all available by clicking the “How to ?” button in power chart at the top The development of new order sets, changes to improve work flow, etc. will be an ongoing process.

37 Summary 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 1 Training starts Sept 15 Go live set for Oct 25 Training on the EMR for the hospital, lead superusers (45) 40 hrs training, super users (243) 20 hours training, users (~2000) 12 hours training Providers ~ 1500 superusers (~ 40 residents, ~15 attendings) To train everyone scheduling needs to be done as early as possible As 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.

38 Tasks to perform Let everyone know it is coming (talks with faculty and residents) Schedule training times now Develop training material (ongoing) Super user training (starts Sept 1) Schedule training sessions Training sessions (starts Sept 15) Go live Oct 25

39 Where we are Anesthesia contact Dr Arndt and Dr Chapman, talk presented 7/10/09, schedule training time Emergency Medicine contact Dr Arguelles talk scheduled, working on scheduling training time Family Medicine need contact; need to schedule talks; need to schedule training time Medicine contacts Dr Rogers, Dr Rao, Dr. Garcia CRTC; need to schedule talks to divisions; need to schedule training time –Pulmonary and Heme Onc have scheduled training time Neurology need a contact; would like to schedule talk; schedule training time Neurosurgery need contact; scheduling talk; need to schedule training time Ob/Gyn contact Dr Phalen; scheduling talks and training time Orthopedics talk contacts Dr Paterson and Dr Echols; talk 7/15/09; need to schedule training time Pathology contact Dr Luke need to assess what training Pediatrics contact Dr Jacobs; scheduling talks; need to schedule training times –Neonatal contact Nancy Alton, has scheduled training times Psychiatry Adult need contact; need to schedule talks; need to schedule training time. Psychiatry Peds contact Dr Mancuso need to schedule talk and training time Radiology contact Dr Mlady need to assess what training Surgery contacts Dr. Howdishell and Dr. Schwartz; 3 talks scheduled first 7/15/09, will see if divisions want talks; need to schedule training times Residents 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

40 CPOE Expected Out Comes Improved legibility date, time, person ordering defined easy to find, reason for test required Order sets may improve uniformity of care Improved turn around times Will not be faster for provider or nurse writing the order

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47 Communication 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?

48 Hardware

49 CPOE- Computerized Physician Order Entry – Power Plans a set of orders for admission, post op, specific diseases ie acute coronary syndrome. – Single Orders sentences fill in the necessary details needed for that order including reason for test, STAT, routine, ASAP

50 CPOE Order sets – ~200 so far covering admission, post op, specific diseases CHF, ACS – Single orders order sentences Choices 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 system Evaluate work flow in each process admitting transferring discharge, daily care of patient, post op, level of care Medications correct dosing eliminate fields that will cause confusion Pediatrics order as they are used to, dose range checking Training on each process

51 Urgent Clinical Documents tab – Will pull in Code status note, advanced directives, POA, medication contract,

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55 USP MEDMARX Computer Technology-Related Harmful Errors (2006) Cause Number % Barcode, medication mislabeled 20 5 Information management system 1,176 2 Computer screen display unclear/ confusing Dispensing device involved 3, Barcode, failure to scan 114 <1 Computer entry (general, other than CPOE) 24,715<1 CPOE 10,752 <1 Barcode, override warning 41 0 Total 43,372* * From a total of 176,409 medication error records.

56 Joint 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.).

57 During 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 drugs After 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.

58 CPOE- Computerized Physician Order Entry – Power Plans a set of orders for admission, post op, specific diseases ie acute coronary syndrome. – Single Orders sentences fill in the necessary details needed for that order including reason for test, STAT, routine, ASAP

59 CPOE May decrease medication errors may introduce new types of medication errors Several studies have looked at changes brought about by CPOE One 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 errors There will be anticipated results and unanticipated results both good and bad. To prepare for we are using the experience of others, literature and training

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61 Identified problems examples Initial set up for iNET standardization of practices in the ICUs improved overall practice and care HUCs have done a lot of translation of orders we will need to teach what really is ordered Daily labs can be written not have to be written each day by HUC Cultures – site drawn from not known at time of order placement can write where culture drawn on order sheet will be input in lab

62 CPOE Order sets – ~190 so far covering admission, post op, specific diseases CHF, ACS – Single orders order sentences Choices 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 system Evaluate work flow in each process admitting transferring discharge, daily care of patient, post op, level of care Medications correct dosing eliminate fields that will cause confusion Pediatrics order as they are used to, dose range checking Training on each process

63 Physician Team Nancy Alton, NICU Carlos Argulles Emergency Medicine Paul Echols Orthopedics Rao Deepti Internal Medicine William Dodson Family Medicine Scott Forman, Resident, ED Gary Iwamoto, MICU, Leader Aaron Jacobs, Pediatrics Steven Jenkusky Psychiatry Robert Katz, Pediatrics Clinical Leadership Matthew Luke, Pathology Marc Malkoff Neurosurgery/Neurology John Marinaro, Surgery Gary Mlady Radiology Andrew Paterson Orthopedics Sharon Phelan Obstetrics Sarah Pirio Richardson Neurology Kendall Rogers, Medicine Trevor Rohm Informatics Jess Schwartz, Surgery Randall Stewart Psychiatry

64 Purpose of Workflow Analysis : – Define the new process that will support the future state – Identify what processes will START, STOP & CONTINUE – Create/modify policies and procedures based on the new processes – Define how employee roles will change – Plan for the organizational impact – Identify the benefits for patient, clinicians and the organization – Identify the training requirements – Recommendations for Downtime


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