1. Implementing a Clinical Information System – The Role of Informatics Nurses Helen Edwards RN MN Carol Warren RN November 24, 2009

2. Outline Evolution of Computerization at SickKids Building a Nursing Informatics Portfolio Implementing a Clinical Information System o Design o Communication o Education o Go-Live o Post Go-Live Key Success Factors Lessons Learned

3. SickKids Hospital Grand Total Planned Beds 274 Clinic Visits 73,907 Medical Day Care Visits 28,971 Day Surgery Visits 5,146 Inpatient Surgical Visits 6,238 Emergency Visits 54,580 Discharges 13,803 Average LOS 7.3 Patient Days 100,332 Average Daily Census 274.9

4. Evolution of Computerization Complex infrastructure - comprises diverse platforms, applications, client devices Complex and dynamic technological environment with >140 information technology systems/applications in use 44 main clinical applications 12 patient management 5 decision support 3 interface technology 15 scheduling and departmental 14 personal productivity 23 business services 18 network/computing infrastructure 6 communications

5. Evolution of Computerization cont’d 1980s first clinical information system – home grown system (functionalities included laboratory order entry / results retrieval and dietary order entry) 1989 Poison Control Centre switches from microfiche to electronic database (electronic charting 1997)

6. Evolution of Computerization cont’d 1992/1993 DOS based system (Kidcom) – ADT, CPOE, eMAR, some clinical documentation 1996 Telemedicine launched 2000 - ICUs – all clinical documentation except CPOE

7. Evolution of Computerization cont’d Other common systems o PACS o Scanned historical paper chart o Schedule Book o Transcription and Dictation System o Ambulatory Referral Management System o eCHN – EHR o Surgical Information System o Emergency Department Information System

8. Evolution of Computerization cont’d 2005 –KidCare Phase I (transitioning Kidcom to Windows based system) o Patient Lists o Results retrieval 2008 – KidCare Phase II (transitioning remaining functions) o CPOE o eMAR o Clinical Documentation (e.g. Admission Assessment, LOA, Discharge Summary)

9. Our Vision Fully electronic patient chart across the inpatient and ambulatory areas o Progress Notes o Flow Sheets o Consents o Diagrams/Photographs, etc. Universal Workstations o Single Sign-on o Multiple form factors

10. Building a Nursing Informatics Portfolio Prior to 2003 o Variety of titles o Variety of responsibilities o Variety of compensation strategies o Little opportunity for specialist-specific professional development 2003 o First Director of Nursing Informatics o Mandate – build a portfolio

11. Building a Nursing Informatics Portfolio 2007/2008 o Informatics Nurse – common job description and ranking  Informatics Nurse – Application Specialist  Informatics Nurse – Education Specialist  Informatics Nurse – Workload Specialist Currently o Monthly business/professional development meetings o Bi-monthly hospital CIT Forum

12. C.I.T. Matrix Organizational Chart Chief – Inter-Professional Practice and Chief Nurse Executive Director – Clinical Informatics and Technology Chief Information Officer Directors – Clinical Programs Centre for Nursing IN – Workload Specialists IN – Application Specialists Clinical Technology PM Clinical Programs IN – Application Specialists IS Mgr – Informatics Education IN – Application Specialists IN – Education Specialists Directors/Managers - IS Managers – Clinical Programs Direct Reports Matrix Reports

13. Implementing a Clinical Information System Design Communication Education Go-Live o Command Centre o Support Post Go-Live

14. Design Application and Education Specialists o Knowledge of practices and processes o Consultation with clinical departments/ areas and IS staff o Advocacy / Liaison o Theoretical perspectives o Testing – unit, functional, integrated o Reports

15. Communication Hospital-wide engagement/profile Steering Committee o Executive Sponsor o Physician Leadership o Nursing Leadership o Professional Services Project Team o Diverse membership - Application and Education Specialists – IS and Clinical Programs

16. Communication cont’d Built off of successes of KidCare Phase I User Groups o Nursing, Professional Services, Physicians, Others Super Users o Meetings o Emails

17. Communication cont’d Hospital publications o This Week (print) o Daily News (homepage) Website o KidCare o Countdown

18. Communication cont’d Clinical Program Director meetings Clinical Program Manager meetings Nurse Educator meetings Division/Department meetings o Medical o Professional Services

19. Informatics Education 3500+ staff 8 Weeks

20. Education Design 3 team leads o Nursing o Physician o Professional Services and Administration Instructor led class curriculum Reference material

21. Education

22. Pre - Education

23. Pre – Education Open Forums

24. Pre – Education Open House

26. Communication and Advertising

31. Leadership Nursing Physician Professional Services and Administration Communication and Advertising

33. Blended Learning Approach Computer-based Tutorials (CBTs) o Mandatory pre-requisite o General/Basic information o Decreased in-classroom time o Staff themselves decided when and where Instructor Lead Classes (ILC) o Complex process or changes in process/ concepts o To anchor knowledge – provide hands-on training

34. CBTs 5 modules o General Overview o Order Entry o Documentation o eMAR o Task Viewer

35. CBT Agreement Form

36. Super User Education Job Description o proficient at all functionality on legacy system and KidCare Phase I o recognized ability to lead and support all health care colleagues o availability to act as a SU during implementation Attend Super User training

37. 3500+ staff 8 Weeks Original Goal Outcome: o Between Sep 4th and Nov 4th 3083 staff were trained 585 classes were held 88% of staff were trained by go-live

38. Go-Live Education continued through go-live o 3 Informatics Educators  Scheduled and adhoc training  Ongoing education for existing clinical systems o 4 Informatics Educators  Go-live support Reference material

41. Go-Live Command Centre

42. Command Center Help Desk

43. Informatics Nurses

44. Communication tools

45. External Support Staff and Super Users

46. Go-Live cont’d Daily meetings at 1300 with all clinical managers – get a sense of how staff were doing Tips and Tricks

47. Post Go-Live Ongoing education Clinical Applications Resources and Education Support (CARES) Ongoing communication o Tips and Tricks o Website updates KidCare Duty Officer (KDO) Stabilize the system for a period of time before making any revisions

48. Key Success Factors Hospital engagement o Hospital-wide project – ownership o Go-live day was a “marked event” Communication mechanisms o Countdown o Posters o Clinical Managers, Directors, VPs Education o Model o Daily communication o CME Credits

49. Key Success Factors Go-Live Support Model o Command centre o Super Users o Informatics nurses o Hiring skilled activation support resources helped the front-line users tremendously throughout the activation process. Post Go-Live Support Model o Continuing training session o CARES

50. Lessons Learned Application Ensure sufficient resources for both the project team and support staff Cross-train more of the project team members on system configuration Having one consistent vendor project manager is necessary for continuity

51. Lessons Learned Application o Changes to a legacy system should be restricted to only those that are critical o Printing should be tested earlier in the Project

52. Lessons Learned Training Ensure you have sufficient technical expertise to support training No grab bags Have an admin assistant An LMS would help! Regular debrief sessions

53. Lessons Learned Training Create a mock training environment for educators to practice Create a practice database for staff to practice after attending training

54. Lessons Learned Communication Communicate project scope to the users – functionality Communication mechanism to all relevant project team members re changes and decisions

55. Lessons Learned Support o Extended activation support should be planned for and acquired (for example, contracted project team members should not be released shortly after activation)

56. Helen Edwards RN MN Director – Clinical Informatics and Technology Centre for Nursing Hospital for Sick Children (SickKids) helen.edwards@sickkids.ca Carol Warren RN Manager – Informatics Education Information Services carol.warren@sickkids.ca Contact Information