electronic communication across provider settings:
DESCRIPTION
TRANSCRIPT
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Electronic Communication Across Provider Settings:Connecting NH Providers
June 10, 2005
Wendy Angelo, MD
Dan Venecek, PMP
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Objectives
• Discuss Existing Systems
• Clinical Workflow Examples
• Gaps in clinical handoffs
• Proposed plan to address clinical information sharing
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Concord HospitalLead Partner in AHRQ Grant
• Second busiest acute care hospital in NH• 205 beds• Regional referral area 275,000• 15,500 admissions in 2004
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Capital Region HealthCare• More than 2,600 employees
• 300+ physicians on medical staff
• 75+ employed physicians
• Serves 5 counties in central New Hampshire
• Approx. 750,000 patient contacts/visits per year
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Located in Central NH
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Concord Area Partner Organizations
• Concord Hospital• Concord Hospital Primary Care Practices• Concord Hospital Family Health Center• Dartmouth Hitchcock-Concord Clinic• Concord Regional VNA• Riverbend Mental Health Services
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Concord Hospital Technology• Over 10 years experience with
barcoded medication administration
• A decade of EMR experience• PACS Medical Imaging System• Physician Portal• > 25 systems communicating via
Interface Engine technology• Implementing Electronic Patient
Record (Document Imaging)
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Concord Regional Visiting Nurse Association
• Horizon Homecare - McKesson• Clinicians maintain coded medication lists• Medications reconciled from patient home• Centralized database updated with clinical
information entered remotely• Shared clinical information
electronically (Physician Portal)• Implementing Telehealth technology
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Riverbend CommunityMental Health
• TIER - Sequest technologies• Communication tool for multi-disciplinary team• Document visits• Tracking federal and state required forms
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Over 170 providers accessing more than 125,000 electronic patient records
90% Primary Care Breast Care Center
100% Pulmonary Lipid Management
40% Surgery Diabetes Education
50% Gastroenterology Wound Healing Center
66% Dermatology Nutrition Counseling
60% OB/Gyn Sleep Center
75% Pediatrics Family Dental Center
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3
8
6
55 147HillsboroHillsboro
70LaconiaLaconia
53
EMR in the Concord Area
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For a rural community we are fortunate to have a
depth of EMR penetration and a culture of
collaborative practice that enhances our ability to take on quality improvement at
a community level.
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Current Electronic Communications
• Communication between hospital services and the practices– HL7 interfaces between lab, radiology, hospital
transcription, and the outpatient EMR– Secure messaging of rehab progress notes to PCP
• Primary care to specialty care– electronic outbound referrals from ambulatory EMR – Secure messaging between providers
• Specialty care consult notes to primary care– interfaced directly into ambulatory EMR
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Current Electronic Communications
• Providing the “right” information at the “right” time– ED granted access to EMR– Physician Portal brings together hospital
experience (EKG’s, images)– Clinical data gathered by VNA can be viewed
via Physician Portal
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Communication Between Inpatient and Outpatient
• “Wrap-around” EMR• Using tools that directly pull information from the
outpatient to the inpatient environment• Discharge processes that facilitate the maintenance
of the outpatient record• Tools and processes used by hospitalists to smooth
transition points
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Clinical Handoff Scenario Hospital Admission Orders
• Hospital admission template in EMR
• Order sheet auto-populates with problems, allergies, and medications
• Decreases transcription errors
• Creating hospital admit orders within EMR
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Clinical Handoff Scenario Hospital Discharge
Dictation Placeholder for Hospital Course
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Clinical Handoff Scenario
Hospital Discharge
Easy to read patient
discharge instructions
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Even with our current technologies and collaborative environment there are many
examples of difficult transitions
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The Biggest Risk at Any Transition Point is Medication
Error
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Our Current PilotPre-op Medication Reconciliation
• Pt is pre-op for lung surgery• Surgery about to be canceled because of elevated
liver functions of unknown etiology• Going through pre-op process• Clearance nurse realized that he was on two meds
that PCP did not know about• Letter faxed to PCP• PCP had him discontinue meds• Liver functions improved
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Barriers to Medication Reconciliation
• Varying Accuracy of Medication Lists• Often does not represent what the patient is actually taking
– OTC, herbs, vitamins, meds stopped or started by patient
• Difficult, if not impossible, to share discrete data electronically
• Information not shared between episodes of care in different settings
• Provider push back on any workflow that increases their workload
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How do we overcome these barriers…
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It’s NOT about the technologyIt is about getting the right people
at the table
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Leadership
• Recognized Challenges– A sense of urgency that this issue needs to be
addressed– Financial Match Commitment and Fair
Distribution of Shared Costs– Support for needed changes at each
organization– Liability concerns among partners– Governance Structure
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Collaboration of the Clinical Community
• Clinical and Frontline Staff from each partner to address– How to keep the project patient centered– Patient Privacy & Confidentiality Concerns
(HIPAA Standards)
– Sensitivity to provider workload and Clinical Workflow Changes
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Our Vision of Success
• Organizational Success Defined by:– A cultural change has occurred– Actively seeking collaboration between
partners– Workflows re- engineered to be more Patient-
centric
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Our Vision of Success
• Technological Success Defined by:– All partner EMRs store medications in a discrete
format– Able to share the same medication list across
provider settings– Use Automated Technology to Broadcast
Updates/Changes to all of a patient’s providers– Measure number of updates/changes broadcast
and number accepted
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Our Proposed Technological solution
The creation of a community wide grid
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Technology SolutionNovo Innovations, Inc
• Information captured in local EMR
• Continuity of Care (CCR) record updated
• Changes securely broadcast to all nodes on the grid
• Provider notified of change and allowed to update EMR
EHR 2
CCRCCR
CCRCCRCCRCCR
CCRCCR
EHR 3EHR 1
EHR 4
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Development Considerations• Events – when is the information acquired and
distributed?• Extraction – how is the data acquired from the
local EMR?• Patient matching – who is the patient, who has
interest in the patient?• Intervention – how do providers receive and
accept data?• Insertion – how is data input into the local EMR?
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Why we will succeed
• Collaborative environment established
• Record of successfully implementing clinical info systems
• Focused on quality and patient safety
• Partner clinicians and IT
• Patient safety demands that we succeed