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Stage 6 and Beyond St. Michael’s Hospital Michael Freeman MD Medical Director Heart and Vascular Program Director of Medical Informatics Director of Nuclear.

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Presentation on theme: "Stage 6 and Beyond St. Michael’s Hospital Michael Freeman MD Medical Director Heart and Vascular Program Director of Medical Informatics Director of Nuclear."— Presentation transcript:

1 Stage 6 and Beyond St. Michael’s Hospital Michael Freeman MD Medical Director Heart and Vascular Program Director of Medical Informatics Director of Nuclear Cardiology St. Michael’s Hospital Associate Professor of Medicine University of Toronto

2 Stage 6 and Beyond Where we have travelled Structure Case study of CPOE What follows after Stage 6

3 St. Michael’s Hospital: Toronto’s Urban Angel A leading academic health sciences centre, fully affiliated with the University of Toronto Recognized as a provider of compassionate care Provide primary and secondary care to the region’s largest homeless and inner city health population Major tertiary referral and regional trauma centre Strong focus on research and education

4 Innovations 2011 – Clinical Solutions 3 - Session # 5 – IT Adoption Hat Trick Phase 1 Master Plan Limitations

5 St. Michael’s: An Academic Health Sciences Centre Li Ka Shing Knowledge Institute Education Patient Care Research Keenan Research Centre Li Ka Shing International Healthcare Education Centre Bridge to St. Michael’s Hospital Knowledge Translation

6 Information Management Vision Recognizing: Health care is knowledge based Extends beyond the boundaries of the hospital Information Systems: Patient-focused Enabler for quality and safety Support business processes through information access and flow Enable process improvement through inquiry and change Enable practice excellence Delivering the right information, right person, right time

7 A History Lesson 2001- SMH has new IM strategic plan that sets the stage for an integrated clinical system Perceived to be behind peers Clinical results viewing available; no other legacy applications except in diagnostic departments (Lab, DI, Cardiology) Siemens contract signed 2002

8 Project Gemini Twinning of transformation and technology Clinical transformation as the underpinning to the project Harness power of workflow technology to enable practice and process change

9 Project Gemini Goals Improve access to health services Improve clinical outcomes for patients Increase patient safety; reduce risk of error Improve coordination of care Increase patient satisfaction Improve the quality of worklife Reduce overall delivery costs

10 And the best laid plans…. SARS Immature product Expansive scope and short timeline Unprepared clinicians

11 How will we achieve adoption? 1.Build and Demonstrate Value 2.Build Partnerships to engage clinical leadership 3.Innovation- leverage technology and tools with an emphasis on workflow enabled process

12 Articulate a Shared Vision The vision for clinical transformation at SMH is about much more than simply automating our existing paper systems. It is about carefully designing a patient centered, best- practice framework for implementation. –That is based on a model of interprofessional practice –Includes the use of evidence based care processes and decision-support systems to achieve the best outcomes for our patients.

13 1. Value Understand the needs of clinicians Clinical user group Push the envelope with the design teams Participation in validation sessions Engagement with the vendor Define benefits and share with clinicians

14 2. Delivery Provide stability Act, respond Thoughtful, detailed planning for implementations Understand, anticipate and redesign the workflow Active and visible issues management

15 3. Innovation Be creative NO is not in our vocabulary..

16 Enabling Infrastructure for Adoption People / Processes –Interdisciplinary culture / model –Workflow redesign expertise Technology –Design of technological tools –Access devices to bring technology to the point of care –Software - user centric design with clinical decision support

17 Results of Demonstrating Value


19 CPOE Project Scope Electronic ordering of all diagnostics, medications, treatments and care orders for Inpatient units Electronic MAR with bar code closed loop administration

20 5 Learning's From our Launching of CPOE 1 Governance and organizational models are required to support complex clinical system implementations 2 Enabling roles, processes and evaluation necessary to successfully promote clinician adoption of CPOE/eMAR 3 Strategies are required for a phased-in implementation approach for CPOE/eMAR and the successful transformation of a patient centered care delivery model

21 6 CPOE/eMAR & MAK Scope All patient care orders, non-medication orders and medication orders are placed by an MD or resident To dispense medications, Pharmacists validate all electronic medication orders Nurses chart all medications administration electronically All providers can view medication history

22 7 CPOE/eMAR Committee & Team Structure - Planning Content Development Subcommittee eMAR Subcommittee Design/Build Subcommittee Change Management / Education Subcommittee Design/Build Team Education/Support Team Operations Committee eHealth Executive Committee CPOE/eMAR Advisory Committee Physician Leads

23 8 Moving from Planning to Implementation Planning structure created ‘Silos’ that challenged the teams working relationships Implementation required greater co-operation and ownership between these ‘Silos’ Performed an analysis of project structure and identified the needs for implementation Conclusion: The CPOE/eMAR Project Structure needed to CHANGE

24 9 CPOE/eMAR Project Team Structure - Implementation Operations Committee Soarian Development Education & Support Unit Engagement Technical CPOE Leadership Team Professional Practice Pharmacy Information Technology Medical Informatics Clinical Informatics Project Management CPOE Project Team Project Management Change Management Clinical Informatics Clinicians including RNs, Pharmacists and Others Communication Content Development Order Sets Medications Non-medication CPOE Advisory Design Build Test & UAT Workflow & Practice Change Management Impl. Scoping Workstreams Project Structure & Committees Devices Release Management Interfaces Content SubCommitee Medication Management CPOE Project Sponsor CIO & CMO Metrics & Evaluation Rx Team Clinical Unit Team Physician Leads ICT Team Key Partners eHealth Executive

25 10 Our Implementation Approach – How? Demonstration Unit 12 bed Medical Unit Validation Unit 1 30 bed Medical Unit Validation Unit 2 36 bed Surgical Unit Go-Live Day 1 & MAK LiveSoarian CPOE Go-Live Day 1 MAK Go-Live Day 1 Soarian CPOE MAK Go-Live Day 10Go-Live Day 14

26 11 Implications of Different Day 1 Go-Lives Big Bang – CPOE & MAK on Day 1 Initial chaos on the unit; complete transfer from paper to electronic environment Many different users to support (i.e. MDs, RNs, HDs, etc); fewer support team members to users Move directly from current state workflows into future state workflows Phased Approach – CPOE or MAK on Day 1 Focus the changes on one key process (order entry/management vs. medication administration) Support team members can focus “at the elbow” training with key users of the process Users must adapt to interim processes before fully transitioning into future state processes Significant workload impact on pharmacy to bring MAK live first pre- CPOE.

27 13 What was included with each implementation? Scoping & Engagement Design, Build & Testing Education & Training Post Live Support Key Activities: On unit observations and interviews with key stakeholders Understanding patient/information flow and unique workflows (i.e. self medication program) 7 week engagement sessions focusing on processes, changes, Soarian/MAK functionality, considerations for clinical team, etc.

28 14 What was included with each implementation? Scoping & Engagement Design, Build & Testing Education & Training Post Live Support Key Activities: Collection of unique content (i.e. care orders, predefined medications, etc.) Analysis of content and order sets Design and development of new electronic orders and orders sets Testing of new electronic content Migration from DEV to TRAIN to PROD

29 15 What was included with each implementation? Scoping & Engagement Design, Build & Testing Education & Training Post Live Support Key Activities: Documentation of unique workflows 7.5 hour RN training session (in classroom) 2 hour MD/resident training (in classroom) 2 hour HD training (in classroom)

30 16 What was included with each implementation? Scoping & Engagement Design, Build & Testing Education & Training Post Live Support Key Activities: 24/7 on unit support for 4 to 5 weeks Command centre to log, triage and resolve issues Daily status meeting with Project Leadership, Team, Unit leaderships and end users

31 17 Driving Clinical Adoption – Physician Perspective Ensuring future state process fit with physician workflow Clear and consistent communication regarding the benefits of the changes Engaging physicians to develop orders sets which incorporate evidence-based, best practice guidelines Providing flexibility for training sessions Leveraging Physician Leads role in key clinical areas as champions Enabling multiple Soarian access points – remotely from home and through various devices (iPhones, blackberries, computers on wheels, iPads, etc.) Leveraging existing structures for communication, input into key decision points and project updates (i.e. Medical Advisory Committee)

32 18 Driving Clinical Adoption – Staff/Unit Perspective Understanding a clinical unit’s culture, practices and flow to define an implementation scope that most appropriate for the unit Ensuring transitions function as smoothly as possible (i.e. OR transfer workflow, ED admissions, etc.) Focus on creating shared ownership of the project between the project team, stakeholders and clinical unit Tackling less than desirable practices and processes; Frequency of telephone and verbal orders Using physician order sheets as a communication tool Minimizing incomplete orders

33 19 Driving Clinical Adoption – Challenging Processes Consult Orders Suggest orders from a consulting MD that require review and acceptance from the MRP Transfers of Care From service to service or one level of care to another Increased complexity when transferring from paper based area to electronic unit Supporting SMH’s educational mandate Organization trains over 300 nursing students, 150 medical students and 400 residents Currently, no safe electronic solution is available to support medical student workflows Enhancement Requests/Content Change Requests Clear downtime procedures

34 20 Where we are today…..all med/surg beds are live! All staff physicians,nurse practitioner’s and residents enter orders electronically 215 physicians, 650 residents have been trained –>2,500,000 medication, investigations, diagnostics and care orders have been placed

35 21 Right Drug = Drug Type + Dose + Route + Frequency Each alert (incorrect drug, dose, or route) helps avoid a potential medication error * Reporting period: March 9, 2010 to March 31, 2011, Source: Siemens MAK Our 360 CPOE Trained RNs received 3694 Medication Alerts

36 22 Pre-CPOEPost-CPOE # of Biochemistry Tests Ordering efficiencies are improving lab test utilization Comparison of Biochemistry Lab Test Volumes – Pre & Post CPOE

37 The real value has been on the integration of the process analysis methodology with the implementation. We have uncovered many “hidden gems” in the implementation

38 Unanticipated Workflow Changes Self administration policy on CF unit. Partnership of RN and patient Eliminated “take own meds” Standardized transfer order sets from critical care to floor Nurse patient assignments changed to geographic MDs have changed their rounding practices And we have over 95% orders entered directly by MDs

39 Implications Engaging clinicians is about driving value. Workflow can be a key asset in demonstrating early wins. Workflow analysis and technology, combined with advanced clinical information systems can be a mechanism to: Deliver information to the clinician desktop Assist organizations to transform practice Facilitate knowledge translation from bench to bedside

40 The Result – SMH is now a leader in EMR deployment Over 30% of Ontario hospitals are between Stage 0 and 2 Only TWO Ontario Hospitals have reached Stage 6.

41 What’s Next? Enabling the Emergency Department and Critical Care Adoption Sustainability Strategy & Optimization Implementation of Embedded Analytics (business analytics tool)

42 Road to Stage 7

43 Challenges to Attaining HIMSS 7 Physician Documentation Interoperability Changing technologies Financial Pressures People Competing organizational priorities

44 23 Questions Michael Freeman, MD Director, Medical Informatics St. Michael‘s Hospital Purvi Desai, MBA Senior Clinical Project Manager St. Michael‘s Hospital Anne Trafford, BSc. RN Vice President, Information Management, St. Michael’s Hospital

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