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EHR’s Impact On Nursing Care And The Patient

September 20, 2011 10:00am

Presenters

M. Terry Miller, BSEE

Victoria L. (Vicki) Bechet, BSN, RNC

Executive Vice President , GBA

Project Manager, GBA

Learning Objectives

• Identify the types and variations of information captured in the medical record – the types of information, where gathered, where entered.

• Assess physical, operational, privacy and safety

challenges f fWhy should you aschallenges typically faced in both newer and older facilities.

• Determine where integration with other medical technologies such as monitoring, pumps, beds, etc. may streamline EHR capture and accuracy.

• Evaluate the impact of EMR roll-out on nursing workflow, training and orientation, overtime during “go-live”, and follow-up activities

Why should you as an architect care?

EMR vs. EHR

EMR EHR

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EMR Mandate

Background:• Passed by Congress in 2006 • Signed into law the same year • No funding provided• ARRA Act (Stimulus Bill) of 2009 provided $40B• Must achieve “Meaningful use” by Jan 1, 2015, or:

• Reduced reimbursements• Possible fines

2015

Seven levels of Compliance

ARRA - Federal Mandates

20132011

Notable US Commitments:

• VA – started 1970, now piloting NHIN• Kaiser – implementation complete 2010 • CHI – committed $1.5B in 2009 • CHW – committed $1B February 2010• US Military – partial completion 7/11

Comparison to other countries

• Canada – established a national health database 1950’s

• Estonia was the first EU 100% EHRD k 2009• Denmark – 2009

• Britain – target 2010 – not there yet• France – target 2012• Germany, Australia, New Zealand…

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What does this mean to the Nurse?

Nurses

Cornerstone of hospital care delivery

Nurses

21 35 50 65

AvgAge: 48

47%

Nurse’s Time Spent Per Shift

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Current Work Environmentsnurse

burnout

decreased recruitment and

retention gaps in technology

infrastructure

inefficiencies and stress

retention

increased morbidity &

mortalityunsupportive organizational

cultures

work processes and physical design

Reduce Med Errors

Decrease Paper Mountain Decrease Travel Distances

Supply and equipment management

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Disaster Preparedness

Vital Signs

Traditional methods

Vital Signs

Electronic methods

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Physical Assessment Data Collection Devices

Impact of EMR on Nursing Patient Chart

History & PX ConsultsMedication

Nurses Notes

Progress Notes

Advanced Directives

PhysicianOrders

Admission Data

Misc.DietaryGraphic

ChartEKG/EEGX-Ray

ReportsLab

ReportsReport of Operation

It’s not just the nurse

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History & PX ConsultsMedication

Nurses Notes

Progress Notes

Advanced Directives

PhysicianOrders

Admission Data

You must design for all these clinicians to access the EMR.

Misc.DietaryGraphic

ChartEKG/EEGX-Ray

ReportsLab

ReportsReport of Operation

g

The Good News

You won’t have to design for these anymore!

EMR Rollout

So what happens when we go from the paper chart to the EMR?

Barriers to EMR

• Cost• Interoperability issues• Conversion of historical documents• Privacy and Security Concerns• End user adaptation

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Preparing for Roll-out

• Months to years of preparation

• Operational/Cultural shift

Construction project causes• Construction project causes additional stress

Training Modalities

• Team-based• Role-based• Simulation Training = Overtime• Super-Users

Training = Overtime

Data Collection Devices Three types of information

• Quantitative – vital signs, numerical values, quick observations

• Qualitative – physicians progress t i t d tnotes, nursing notes, order entry

• Collaborative – care plan assembly and updates, discharge planning

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Three locations

• In the room – at the bedside• Near the room – quieter, more

private – less distractionC t l Ch ti / R t R• Central Charting / Report Room –multi-disciplinary care team collaboration (not the “nurse station”)

In-room Challenges and Solutions

Ideal solution?• Wall mount• WOW• Tablet • Wall cabinet

Wall Cabinet Options Is a Tablet the Answer?iPad

Motorola Xoom

Samsung Galaxy

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Handheld PC? Are WOW’s the Answer?

Are Wow’s the Answer?

• Wireless device will never perform like a wired device

• Require charging • Require power/data outlets too low• Require power/data outlets - too low• Hallway clutter - require a garage• Trip hazard• One more big, clunky thing to push • Infection control

“Near” room Solutions

• Charting Alcoves

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“Near” room Challenges

• 8 foot corridor

“Near” Room Challenges

• Pods

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Central Charting/Report Workstation

• Close to patient rooms• Private – care team only• Set up for individual (solitary) or

ll b ti kcollaborative work

Combination of individual and collaborative charting stations

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Will I remember BP 142/71 in the time it takes me to get from the bedside to the charting station?

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It’s Not Just Nurses…

Devices use the EMR too

Sources of Information from inside the Patient Room

• Vital signs monitor• Physiological Monitor• Bed-Exit alarm• Bed (position, protocol reminders)• IV Pump• Patient fall detection• Diagnostic set• Scale• Nurse call System• ITV system• Fetal Monitoring• Neuro Monitor / Seizure Monitoring• Ventilators• Telemetry• EKG/EEG• BMS - Temp Monitoring – Light Control• Staff / Visitor Presence• Hand-washing detection

Why Integrate?

• Improve accuracy• Save time • Improve clinician workflow• Improve patient care , safety, and

satisfaction• Improve outcomes• Reduce readmissions

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“We want the wireless integration option”

Simple, right?

Project Impact

Types of “Technology Integration”

• Physical – independent function connecting through IT infrastructure

• Logical – independent function connecting through the IP networkconnecting through the IP network

• Software – sharing data – requires:– Format coordination – data cells & types– Custom interface software – both sides– May require middleware

Full Interoperability

• Capsule• Hill-Rom• Nuvon• Nurse Call• BMS• Others?

- Wireless / RFID / RTLS?

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Sources of Information from outside the Room

• ADT information – family & professional contacts, insurance

• Lab test results and reportsR di l i d t• Radiology images and reports

• Surgery images, video and reports• Cardiology information and reports• Pharmacy record

Technology Integration – 1980IT

HIS/Cable

Telecom

Telephone /Cable

Comm Syst

Nurse CallPublic Address

Equipment

RadiologyUltrasoundNuc MedSurgical LightsPat MonitorsSterilizersLab

Owner

DictationTime & AttenTV / MATVSecurityEduc TVIntercomA / VLab A / V

Technology Integration – 1991IT Tech

HISNetworkLISRISSISPhIS

Telecom Tech

Telephone /CableTelemedicineTeleradiologyWireless Tele

Comm Tech

Nurse CallPublic AddressIntercomStruc CablingSecurity

Equip Tech

RadiologyUltrasoundNuc MedSurgical LightsPat MonitorsSterilizersLab Analyzers

Owner Tech

DictationTime & AttenTV / MATVSatellite TVInteractive TVEduc VideoA / VLab Analyzers

PACSCRPrint MgmtPharm DistSpecial Procs

A / V

“Medical Technology”

Technology Integration – 2001IT Tech

HISNetworkLISRISSISPhISEHR

Telecom Tech

TelephoneTeleconferenceTelemedicineWireless Tele

Comm Tech

Nurse CallPublic AddressIntercomStruc CablingSecurity

Equip Tech

RadiologyUltrasoundNuc MedSurgical LightsPat MonitorsSterilizersLab

Special Tech

DictationTime & AttenTV / MATVSatellite TVInteractive TVEduc VideoA / VEHR

CPOEPayroll / HREduc Track(many more)

Lab PACSCRPrint MgmtPharm DistSupply DistSurgical VideoSpecial Procs(many more)

A / V(many more)

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Technology Integration- 2011 Contractor’s Responsibility

It’s more than just data drops• Adequate IT support spaces?• Data center redundancy?

Infrastructure

• Redundant connectivity?• Redundant network?• Electrical redundancy - UPS?• Building systems redundancy?

Integration Management

• Recent Project examples– IT mandate for Cerner compatibility– Quadrupling of wireless infrastructure

Wireless bed option– Wireless bed option– In-room display

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Why should you care?

Technology Planning:•Operational Analysis•Needs Assessment•Recommendations•List, Narrative & Estimate

Technology Project Management•Critical Path on-site dates•Final site-specific vendor drawings•Pre-installation coordination•Site-readiness review•Receiving, storage, transportation, security•Installation, completion, testing, certification•Final inspection and punch-list

TechnologyIntegration•Integration matrix•Physical, logical, software •Vendor-user interface•Vendor-vendor interface•Coordinate configurations•Schedule connection and testing•Track and manage process

100% CDs

TechnologyDesign•Drawings & Specifications•User Review and Sign-off•A/E and Utility coordination•100% CD Books, Specs, Estimates•Response to AHJ comment

Technology ProcurementManagement•Procurement schedule – Grps 1, 2, 3 and Critical Path•Group by procurement method•Assist w RFP’s / RFQ’s as needed•Proposal evaluation / analysis•Track and manage process

TechnologyCommissioning•Operational testing•O&M manuals•Coordinate training

EquipLV

Architect’s CA Responsibility

Summary

• Every new hospital must be designed to support EMR

• Many existing facilities will require renovation to support EMRrenovation to support EMR

• EMR requires a new workflow – new workflow means new charting locations

• “If nurses ain’t happy, ain’t nobody happy”