emr adoption: benefits realization - aventri · 2,0% 4,0% 6,0% 8,0% stage 0 stage 1 stage 2 stage 3...
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EMR Adoption: Benefits Realization
John H. Daniels, CNM, FACHE, FHIMSS, CPHIMS
Global Vice President, HIMSS Analytics
Pre
ss
urrin
g /
O
ve
rlo
ad
Medical Knowledge
Automate to optimize clinical decision making
Ultimate Goal
Ensure the most relevant information
is available to the decision maker at the
right place and at the right time
HOW CAN WE DO THIS?
EMR Adoption Model (EMRAM)
A progressively
sophisticated
roadmap that
enables …
Quality, safety,
and
Operations
efficiencies
Physician Documentation with CDS
• Progress notes
• H&P
• Consult notes
• Problem / Diagnosis list
• Discharge summary
CDS Examples
• VTE risk assessment, “Order this prophylaxis”
• Asthma dx, “Start Asthma Action Plan at discharge”
• Certain antibiotic orders, “Order infectious disease consult”
• CHF diagnosis, “Want to order ACE or ARB?”
• Stroke diagnosis, “Want to order a statin?”
• Diabetes diagnosis, “Follow ADA rule for diabetes orders”
Before the bedside
• Step 1: Physician enters order via CPOE w/CDS
NOTE: At Stage 7, ≥90% of all orders via CPOE for ≥ 4 months
• Step 2: Pharmacist (or other qualified & authorized
professional, e.g., senior physician) verifies the
order in system w/CDS
• Step 3: Pharmacy dispenses barcoded medication
Closed-Loop Medication Administration
At the bedside
NOTE: At Stage 7, ≥ 95% of pts/meds scanned for ≥ 4 months
• Step 4: Nurse scans patient
• Step 5: Nurse scans medication
• Step 6: System verifies ‘5 Rights’ – Patient, Medication,
Route, Dose, Time – with alerts
• Step 7: Nurse administers medication
• Step 8: Nurse verifies / documents administration in EMR
Closed-Loop Medication Administration
0,0%
2,0%
4,0%
6,0%
8,0%
10,0%
12,0%
14,0%
16,0%
18,0%
Timing related errors Non-timing related errors Errors with ADE potential Transcription errors in medadmin documentation
eMAR Manual
Source: Effect of Bar-Code Technology on the Safety of Medication Administration;
Poon, Keohane, Bates, Lipsitz, et al, New England Journal of Medicine, 2010;362:1698-707,
May 6, 2010
Closed-Loop Medication Administration:
A Key Element of Patient Safety
0
0,05
0,1
0,15
0,2
0,25
0,3
0,35
0,4
0,45
0,5
Jan 2011 Jan 2013 Jun 2013
710
Pt Scan: 96%
Med Scan 93%
Pt Scan: 79%
Med Scan: 76%
44%
62%
19
Medication Administration Errors per 1000
CMI-Adjusted Patient Days
• Use data to drive improved outcomes related to …
– Process, Financial, Clinical, Quality & Safety
• Are paperless, or near paperless (create no paper)
– All clinically relevant data is in the EMR
• Are fully committed to continuous process improvement
through collaboration
– Strong IT leadership and executive champions
– Clinician / end-user champions
Profile of a Stage 6 & 7 Organization
BENEFITS REALIZATION FROM IT
HIMSS Analytics LOGIC® correlation studies with other
comprehensive data sources.
Top Performing Hospitals By Number of Quality Metrics
Excelling In By EMRAM Stage
Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 Stage 7
4 or more 0,4% 1,8% 6,2% 10,0% 6,4% 6,4% 12,8% 30,1%
3 or less 1,9% 4,8% 10,0% 8,1% 4,2% 6,5% 7,9% 9,7%
0%
10%
20%
30%
40%
50%
All
ho
spit
als
wit
hin
eac
h
EM
RA
M S
tag
e
Source: HIMSS Analytics
2.3%
6.5%
16.3%18.1%
10.6%12.9%
20.7%
39.8%
Hospitals with an "A" Leapfrog Hospital Safety Grade By
EMRAM Stage
0,0% 5,9%12,8% 14,3%
20,1% 21,8%30,8%
62,6%
0%
10%
20%
30%
40%
50%
60%
70%
Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 Stage 7
All
ho
spit
als
wit
hin
eac
h
EM
RA
M S
tag
e
Source: HIMSS Analytics
Tipping Point
38,9
45,5 44,645,9 45,9
42,7
49,0
64,3
30
40
50
60
70
Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 Stage 7
AV
G P
roje
cte
d V
BP
C
lin
ical S
co
re
Tipping Point
Tipping Point
Clinical Performance Scores
Source: HIMSS Analytics
Mortality Rates
0%
10%
20%
30%
Heart Atack RespiratoryTherapy
Actual MortalityLow EMRAM
Actual MortalityHigh EMRAM
Source: HIMSS Analytics
-1,52%
4,91%
-0,43%
6,19%
2,77%
7,95%
-2,0%
0,0%
2,0%
4,0%
6,0%
8,0%
Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 Stage 7
Av
era
ge O
pera
tin
g
Marg
in
In 2011 In 2013 In 2015Source: HIMSS Analytics® Logic™
Financial Performance (Profitability)
Source: HIMSS Analytics
STAGE 7 CASE STUDIES
Actual case studies from validated Stage 7 hospitals
Annual Incident Reports 2009 – 2013*
per 1000 CMI-Adjusted Pt Days
0
0,5
1
1,5
2
2,5
0
5
10
15
20
25
2009 2010 2011 2012 2013*
Med
icati
on
Even
ts
Oth
er
Incid
en
t R
ep
ort
sOther Incident Reports Medication Events
30
20
4 0
5,34
4,47
1,08
0,000
10
20
30
40
50
60
0,00
1,00
2,00
3,00
4,00
5,00
6,00
Jul 10 to Jun 11 Jul 11 to Jun 12 Jul 12 to Jun 13 Jul 13 to Sep 13 (3 months)
# C
AU
TI
Rate
per
1000 c
ath
ete
r-days
Catheter-Associated Urinary Tract Infection (CAUTI)rate per 1000 catheter-days
# CAUTI CAUTI rate per 1000 catheter-days
Central Line-associated bloodstream infection (CLABSI)
Human (breast) milk administration through CLMA process
Attention to detail
Some changes in the pharmacy
Reduction in the number of
unnecessary STAT orders
Great communication by the team
• Grid / Order Set Form Approach for Chemotherapy
• Reduced CPOE from 90 Minutes to 15 Minutes per Patient
Order Sets Process Improvement
50
55
60
65
70
75
80
85
90
95
100
Jan2013
Feb2013
Mar2013
Oct2013
Nov2013
Dec2013
Jan2014
Feb2014
Mar2014
Oct2014
Nov2014
Dec2014
Jan2015
Feb2015
Mar2015
Oct2015
Nov2015
Dec2015
Jan2016
Feb2016
Mar2016
Influenza Immunization Screening/Vaccination Compliance
How did they do this?
Hard Stop at Patient Discharge
• Upon discharge, if the vaccine has
not been addressed the system will
not allow the AVS to be printed
• The nurse will have to click on the
hyperlink → this will take the nurse
to the Core Measures activity →
the nurse will need to answer the
Vaccine Administration question
Breast Milk Process
0
Breast Milk Error Rate
0,00021
0 0 0
0
0,00005
0,0001
0,00015
0,0002
0,00025
2012 2013 2014 2015
Expressed Breast Milk Error Rate per administration
PEDS Go
Live
* Prior to PEDS, all reporting of errors were based on self reporting. After
PEDS, alert reports reviewed. Error rate describes errors that reached the
patient.
Dispensing Errors Types - Prior to
PYXIS Implementation 2015
0 5 10 15 20 25 30 35
Wrong drug dispensed
Wrong dose/strength dispensed
Wrong quantity dispensed
Omission
Wrong drug prepared
Wrong dose/strength prepared
Wrong dosage form prepared
Wrong quantity prepared
Extra drug/s prepared
Wrongdrug
dispensed
Wrongdose/stren
gthdispensed
Wrongquantity
dispensedOmission
Wrongdrug
prepared
Wrongdose/stren
gthprepared
Wrongdosage
formprepared
Wrongquantityprepared
Extradrug/s
prepared
Series3 13 6 7 11 33 7 4 5 7
Workflow Analysis :
Post-Implementation
• Most items will come out of the ADM instead of
having a cart fill.
• No need to physically print the Pick List.
Benefits Analysis: Number of Staff to
Fill and exchange the Cart Fill
(2) Two Pharmacists
(4) Four Pharmacy Technicians
(1) One Pharmacist
(1) One Pharmacy Technician
Before PYXIS After PYXIS
Benefits Analysis: Consumed Time to
Fill and Exchange Cart Fill
Five
Hours
One
Hour
Before PYXIS After PYXIS
Saving Time = 4 hrs
When will your organization reach …
Thank you!
John H. Daniels, CNM, FACHE, FIMSS, CPHIMS
Global Vice President, HIMSS Analytics