hospitals and health systems: nurses and physicians in the implementation of the emr at nyc health...
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Hospitals and Health SystemsHospitals and Health Systems::Nurses and Physicians in the Nurses and Physicians in the
Implementation of the EMR at NYC Implementation of the EMR at NYC Health & Hospitals CorporationHealth & Hospitals Corporation
Marie Ankner, RN, MS, CNAA, HHCMarie Ankner, RN, MS, CNAA, HHCAbha Agrawal, MD, Kings County Abha Agrawal, MD, Kings County Hospital/HHCHospital/HHCLouis Capponi, MD, HHCLouis Capponi, MD, HHCGlenn Martin, MD, Queens Health Glenn Martin, MD, Queens Health Network/HHCNetwork/HHCNadia Sultana, MBA, RN, BC, HHCNadia Sultana, MBA, RN, BC, HHC
HHC Mission StatementHHC Mission Statement To extend equally to all New Yorkers, To extend equally to all New Yorkers,
regardless of their ability to payregardless of their ability to pay, , comprehensive health services of the highest comprehensive health services of the highest quality in an atmosphere of human care, quality in an atmosphere of human care, dignity and respect; dignity and respect;
To promote and protect, as both innovator To promote and protect, as both innovator and advocate, the health, welfare and safety and advocate, the health, welfare and safety of the people of the City of New York; of the people of the City of New York;
To join with other health workers and with To join with other health workers and with communities in a partnership which will communities in a partnership which will enable each of our institutions to promote and enable each of our institutions to promote and protect health in its fullest sense -- the total protect health in its fullest sense -- the total physical, mental and social well-being of the physical, mental and social well-being of the people we serve. people we serve.
11 11 HospitalsHospitals
5 DTC’s5 DTC’s 4 LTC’s4 LTC’s 100 Clinics100 Clinics
Home CareHome Care MetroPlusMetroPlus
www.nyc.gov/HHC
•Revenues totaled approximately $4.3 billion.
•Nearly one million ER visits.
•Five million outpatient visits including 2 million primary care visits.
•210,000 Hospital Discharges
•The single largest provider of psychiatric services in New York City
•23,000 births
HHCHHC
HHC Organization HHC Organization ChartChart
Board of Directors
Benjamin Chu, MD, MPHPresident
SVP SVP SVP SVP SVP(7) Networks
Facilities
Mayor Appoints
Mayor Appoints
HHC EMR TimelineHHC EMR Timeline1991 / 1997 2000 2002 2004 2005
HDS Pilot, Jacobi Medical CenterLabs, CPOE, Documentation
Installation throughout HHCLab, Lab Consolidation
CPOE
OPD Documentation/Coding
DC Summaries
Smart Cards
Disease/Pt. Registries
Medication Admin.
LTC
Portals
Vision for HHC Clinical Vision for HHC Clinical SystemsSystems
Leaders in Clinical OutcomesLeaders in Clinical Outcomes Reliably Support the Care Reliably Support the Care
TeamTeam Complete Information Complete Information
AvailabilityAvailability Positive Fiscal ImpactPositive Fiscal Impact
Critical Success FactorsCritical Success Factors
Increase the Speed of InnovationIncrease the Speed of Innovation Complete ProjectsComplete Projects Facilitate System ConsistencyFacilitate System Consistency
Enhance Clinical Information AccessEnhance Clinical Information Access RegistriesRegistries Close the Data Warehouse LoopClose the Data Warehouse Loop EMPIEMPI
Successful 4.1/4.2 GUI implementedSuccessful 4.1/4.2 GUI implemented
Critical Success FactorsCritical Success Factors
Continuous EngagementContinuous Engagement SVP IT Steering CommitteeSVP IT Steering Committee NISA, PISA, DW Users GroupNISA, PISA, DW Users Group IT Senior StaffIT Senior Staff Front Line StaffFront Line Staff
Provide Support, Resources & Provide Support, Resources & LeadershipLeadership
Improve Management of our PartnersImprove Management of our Partners
Using IT to Improve Using IT to Improve Patient SafetyPatient Safety
Abha Agrawal, MDAbha Agrawal, MD
Chief Medical Informatics OfficerChief Medical Informatics Officer
Associate Medical DirectorAssociate Medical Director
Kings County Hospital, Brooklyn, Kings County Hospital, Brooklyn, NYNY
HIT Summit, Oct. 2004. Washington, DC
Medication ErrorsMedication Errors
One million serious One million serious medicationmedication errors every errors every year.year.
20% are life-threatening.20% are life-threatening. 7000 deaths annually.7000 deaths annually. $2 billion nationwide in $2 billion nationwide in
hospital costs alone.hospital costs alone.
IT to Reduce Med. ErrorsIT to Reduce Med. Errors
Information Information Technology is a critical Technology is a critical
ingredient to reduce ingredient to reduce medication errors.medication errors.
Medication ProcessMedication Process
Medication OrderCPOE
PharmacyPharmacy
Review
Dispensing
Nurse E- Med AdminAdministration
Physician
CPOE with Decision CPOE with Decision SupportSupport
Electronic prescribing – eliminates Electronic prescribing – eliminates illegibility issue.illegibility issue.
Drug-allergy checking.Drug-allergy checking. Drug-drug interaction checking.Drug-drug interaction checking. Coming up - Drug-lab checking.Coming up - Drug-lab checking. Pharmacy review of meds – matched Pharmacy review of meds – matched
against an electronic profile.against an electronic profile.
CPOE: Incorrect dose CPOE: Incorrect dose warningwarning
CPOE: Drug-drug CPOE: Drug-drug interaction warninginteraction warning
Electronic Medication Electronic Medication Administration Administration
Wireless network and mobile carts on Wireless network and mobile carts on wardswards
Real-time data entryReal-time data entry Decision support e.g. delayed med Decision support e.g. delayed med
admin, too high dose etc.admin, too high dose etc. Error reportingError reporting No errors during transcription from No errors during transcription from
paper to MAR sheetpaper to MAR sheet Next steps: Bar-coded matching of Next steps: Bar-coded matching of
patient and of medicationpatient and of medication
Med Admin: Info. available Med Admin: Info. available to RNto RN
Med Admin: Pharmacy Med Admin: Pharmacy Review WarningReview Warning
Med Admin: Incorrect Med Admin: Incorrect Time WarningTime Warning
Challenges in Challenges in ImplementationImplementation
Complexity – interdisciplinaryComplexity – interdisciplinary Clinician buy-in – MD, RN, PharmacyClinician buy-in – MD, RN, Pharmacy Cost of the software, even more – Cost of the software, even more –
the cost of the implementationthe cost of the implementation
Putting this in Putting this in perspectiveperspective
5-10% hospitals have adequate CPOE.5-10% hospitals have adequate CPOE. <10% hospitals have Electronic Med. <10% hospitals have Electronic Med.
Admin.Admin. 2003 HIMSS Patient Safety Survey2003 HIMSS Patient Safety Survey
Issues that IT can addressIssues that IT can address Top issue - Medication errors – 93% Top issue - Medication errors – 93%
respondents.respondents. 1414thth annual HIMSS leadership survey annual HIMSS leadership survey
Projected IT prioritiesProjected IT priorities Top issue – Reduce medical errors, promote pt Top issue – Reduce medical errors, promote pt
safety – 59% respondents.safety – 59% respondents.
It’s All About ResultsIt’s All About Results
12-month Evaluation of CPOE at 12-month Evaluation of CPOE at Metropolitan HospitalMetropolitan Hospital
Overall Med. Error rate down by 40%Overall Med. Error rate down by 40% Incomplete orders down by 70%Incomplete orders down by 70% Incorrect orders down by 45%Incorrect orders down by 45% Illegible orders virtually eliminatedIllegible orders virtually eliminated Errors due to drug therapy problems - Errors due to drug therapy problems -
unchangedunchanged
Igboechi et al. Hospital Pharmacy 2003
Nursing at New York City Nursing at New York City Health and Hospitals Health and Hospitals
CorporationCorporation
Scope and Scope and InformaticsInformatics
Marie Ankner, RN,MS,CNAAMarie Ankner, RN,MS,CNAAAssistant Vice President , Assistant Vice President ,
Nursing Services Nursing Services
New York City Nursing New York City Nursing ServicesServices
Each facility led by a Chief Nurse Each facility led by a Chief Nurse ExecutiveExecutive
6600 RNs located throughout the five 6600 RNs located throughout the five boroughsboroughs
Nursing teams include ancillary Nursing teams include ancillary personnelpersonnel
Interdisciplinary approach to patient careInterdisciplinary approach to patient care Unionized environment Unionized environment
NYSNA, 1199, DC 37NYSNA, 1199, DC 37
Nursing Nursing Presence:Presence:
7 Networks7 Networks 11 Acute 11 Acute
Care Care Facilities Facilities
4 Long Term 4 Long Term Care Care FacilitiesFacilities
Diagnostic Diagnostic and and Treatment Treatment Centers Centers
Ambulatory Ambulatory Care SitesCare Sites
Home CareHome CareTelemedicineTelemedicine
MetroPlusMetroPlus Child Health Child Health
ClinicsClinics
In the beginning …In the beginning …
RFP was developed and reviewed by RFP was developed and reviewed by an interdisciplinary team an interdisciplinary team representing all facilities (90’s)representing all facilities (90’s)
Pilot developed at Jacobi Medical Pilot developed at Jacobi Medical CenterCenter Initiative led by nursing and fostered Initiative led by nursing and fostered
interdisciplinary screen building interdisciplinary screen building Individualized Network /Facility Individualized Network /Facility
expansionexpansion
Nursing ClimateNursing Climate
National Nursing ShortageNational Nursing Shortage Average age of the RN in NYS is 48 yrs.Average age of the RN in NYS is 48 yrs.
Knowledgeable, aging workforceKnowledgeable, aging workforce Workplace DriversWorkplace Drivers
Increased patient complexityIncreased patient complexity Decreased length of stayDecreased length of stay NYS regulatory requirementsNYS regulatory requirements Focus on access, health promotion and Focus on access, health promotion and
preventionprevention
HHC EnvironmentHHC Environment HHC RNs average age 48 yrs HHC RNs average age 48 yrs
- 60 % direct care providers have > 10 yrs of - 60 % direct care providers have > 10 yrs of serviceservice
Nursing and the Electronic RecordNursing and the Electronic Record
- variation in templates and terminology- variation in templates and terminology Initiation of the NISA committeeInitiation of the NISA committee Identification of Nursing Informatics Educational Identification of Nursing Informatics Educational
NeedsNeeds Nursing Conference incorporated Nursing InformaticsNursing Conference incorporated Nursing Informatics Pre hire assessment of computer skills Pre hire assessment of computer skills
NISA GoalsNISA Goals
Identification and adoption of Best Identification and adoption of Best Nursing PracticesNursing Practices
Collaboration of knowledge, expertise Collaboration of knowledge, expertise Work smarter not necessarily harderWork smarter not necessarily harder Safeguard patient care Safeguard patient care Assure professional practiceAssure professional practice Support Nursing and ITSupport Nursing and IT Maximize IT utilization to support Maximize IT utilization to support
patient carepatient care
Driving Force is Patient Driving Force is Patient CareCare
Cost effective, quality, safe patient Cost effective, quality, safe patient carecare
Provide IT support for all health care Provide IT support for all health care providers, including nursingproviders, including nursing
Computerize Nursing ProcessComputerize Nursing Process Literature reports that Nursing Literature reports that Nursing
DocumentationDocumentation
Utilize13-28 % RN time Utilize13-28 % RN time
AchievementsAchievements Online electronic medical recordsOnline electronic medical records
Pharmacy, lab and radiologyPharmacy, lab and radiology Medication administration pilotsMedication administration pilots Patient educationPatient education Health Promotion Health Promotion Immunization screensImmunization screens Home Care telemedicine programHome Care telemedicine program Paperless NICU at Jacobi Medical CenterPaperless NICU at Jacobi Medical Center Smart CardsSmart Cards
The Nursing and Technology LinkThe Nursing and Technology Link
Nadia Sultana Nadia Sultana MBA RN,BCMBA RN,BC
Senior Director, Clinical Information SystemsSenior Director, Clinical Information Systems
NYC Health & Hospital’s Corporation NYC Health & Hospital’s Corporation
October 23,2004October 23,2004
Historically Historically
User Groups developed data collection screens User Groups developed data collection screens separately to meet their immediate needs:separately to meet their immediate needs: Physician Documentation screens Physician Documentation screens Physician Order Entry Physician Order Entry Nursing Assessments and Flow sheets Nursing Assessments and Flow sheets
Data collection screens lack Data collection screens lack standardization …standardization …impacting impacting Data Warehouse initiative andData Warehouse initiative andability to implement timely changesability to implement timely changesto CPR to CPR
Action Plan Action Plan
Formation of …Formation of …
NISANISA = Nursing Information System = Nursing Information System
Advisory Group Advisory Group
… …to promote dialogue, share best to promote dialogue, share best practices andpractices and
foster Nursing Informatic education foster Nursing Informatic education
NISA Framework NISA Framework
Network Nursing Service Network Nursing Service RepresentationRepresentation
Regular Monthly meetingsRegular Monthly meetings Co-chaired by Corporate Nursing and Co-chaired by Corporate Nursing and
IT IT Specific AgendaSpecific Agenda Initiation of an Issues List with Follow-Initiation of an Issues List with Follow-
upup Guest SpeakersGuest Speakers
Current ConceptsCurrent Concepts in in discussiondiscussion……
Development of standardized data collection Development of standardized data collection screens with data element identificationscreens with data element identification
Establishment of Change Control Establishment of Change Control Procedures Procedures
Identification of Educational NeedsIdentification of Educational Needs
Planning next modules incorporatingPlanning next modules incorporating “ “best practice”best practice”
StandardizationStandardization
First attempt - First attempt - Development of the Development of the VISTA Desktop Nursing StandardVISTA Desktop Nursing Standard
Outcome – some variation continued Outcome – some variation continued post implementation …emphasized post implementation …emphasized the need for change control the need for change control process…and need to process…and need to
continue to Standardizecontinue to Standardize
CONEY
• High Issue - Block functions should appear as tabs. Substantial deviation from NISA standards.
• Recommendation – Align desktop with NISA standards.
•Response – Rebuilding new desktop for April 18th.
•Status –verify with Misys analyst if this issue will be fixed on new desktop
•Next Steps – Re-audit desktops when desktop build is complete.
CONEY
• Medium Issue - Redundant icon function
• Recommendation – Remove icon
• Response – Rebuilding new desktop by April 18th
• Status - verify with Misys analyst if this issue will be fixed on new desktop
• Next Steps - Re-audit desktops when desktop build is complete.
Non-Compliance IP Nursing Issues
WOODHULL
• Medium Issue – Duplicate review queue functionality
• Recommendation – Remove desktop shortcut
• Status – IT rep will not sign off change control form or make changes until audit has been reviewed with NISA rep.
• Next Steps – Review audit results with NISA Rep and IT.
Non-Compliance IP Nursing Issues
Change Control Procedures Change Control Procedures
……Experience with VISTA Desktop Experience with VISTA Desktop Standardization and Phase I Standardization and Phase I Development of Data Warehouse Development of Data Warehouse Reports highlighted need for Change Reports highlighted need for Change Control Procedures to Decrease Control Procedures to Decrease variation of key data elements and variation of key data elements and terminology terminology
Change Control Process -CPR /DATA WAREHOUSE
Education efforts Education efforts
Development of Survey to assess needs Development of Survey to assess needs
Standardized CPR Modules Training and Standardized CPR Modules Training and
issue CEUsissue CEUs
Perform “Gap Analysis” – focus on Perform “Gap Analysis” – focus on
Nursing Documentation and CPR usageNursing Documentation and CPR usage
to determine “best practice”to determine “best practice”
Medication Administration Medication Administration ExpansionExpansion
Interdisciplinary Documentation Interdisciplinary Documentation Clinical Pathways Clinical Pathways SMART CARDSSMART CARDS
Planning next modules incorporating “best practice”…
Glenn Martin, MDGlenn Martin, MDDirector, Medical Director, Medical
InformaticsInformaticsQueens Health NetworkQueens Health Network
Now that we have an EHR how do we use the data it generates?
Shift focus from process to outcomesShift focus from process to outcomes
Create clinical data repository and Create clinical data repository and management registriesmanagement registries
Convert data into useful information Convert data into useful information Use data to segment patient populations according Use data to segment patient populations according
to condition and acuityto condition and acuity
Draw on clinical repository to measure indicators Draw on clinical repository to measure indicators and track improvement in patient health outcomesand track improvement in patient health outcomes
Report writer sits on QHN Intranet and Report writer sits on QHN Intranet and provides user-friendly query access:provides user-friendly query access:
• Provides flexible parameters for Provides flexible parameters for key indicatorskey indicators• Output can be saved for Output can be saved for retrospective review retrospective review • Can sort data to facilitate patient Can sort data to facilitate patient segmentationsegmentation• Includes patient telephone numbers Includes patient telephone numbers and primary care provider nameand primary care provider name
Diabetes Diabetes
Community providers can forward consultation requests and receive reports on-line quickly confidentially
And information needs to be coordinated and flow seamlessly to community providers who serve our patients outside the hospital
How do we plan to ensure that patients drive How do we plan to ensure that patients drive our services and make decisions about where our services and make decisions about where to get their care?to get their care?
Effectively make patients the owner of their information
Provide patients the opportunity to carry their medical information at all times
Offers patient a vehicle for communicating current information to their provider of choice
Smart cards empower patients and connect empower patients and connect providers across communities and health systemsproviders across communities and health systems
Health Connection CardHealth Connection Card Functions as Patient Functions as Patient
ID ID Includes 64K chipIncludes 64K chip Patient summary Patient summary
updated at each updated at each encounter with:encounter with: Patient informationPatient information Emergency contactEmergency contact Problem List and AllergiesProblem List and Allergies Active MedicationsActive Medications Complete, relevant lab resultsComplete, relevant lab results
6,000 patients own the Health Connection Card
Patients Name
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