SynergE3 CPOE/EMR

SynergE3CPOE/EMR

1CPOE/EMRIn the Oct of 2009 we are planning a large expansion of the use of the Electronic Medical Record (EMR) for our inpatients at UNMH. The two major outcomes of the expansion will be that 1) except some physician documentation all other patient care documentation (nursing, RT, social work, OT, PT) will be done electronically2) CPOE all inpatient orders will be entered electronically by the providersThe expansion of the EMR will change the way we take care of patients at UNMH.

2Who is making this all happen?5 major teamsProvider teamCPOE development of order setsClinical teamClinical documentationInformation Technology teamApplication design and buildSupport teamEquipment and infrastructureWorkflow teamsWork redesign

3Provider TeamNancy Alton, NICUCarlos Argulles Emergency MedicinePaul Echols OrthopedicsRao Deepti Internal MedicineWilliam Dodson Family MedicineScott Forman, Resident, EDGary Iwamoto, MICU, LeaderAaron Jacobs, PediatricsSteven Jenkusky PsychiatryRobert Katz, Pediatrics Clinical LeadershipMatthew Luke, Pathology

Marc Malkoff Neurosurgery/NeurologyJohn Marinaro, SurgeryGary Mlady RadiologyAndrew Paterson OrthopedicsSharon Phelan ObstetricsSarah Pirio Richardson NeurologyKendall Rogers, Medicine Trevor Rohm InformaticsJess Schwartz, SurgeryRandall Stewart Psychiatry

4Clinical (aka PULSE) TeamSteve Bass-ICUBrian Carter-PedsKim Heinen-Med/SurgDeirdre Kearney-NeuroCarrie Khalsa-EDMary Laflin-PT/OT/SpeechKim McKinley-Senior DirectorMelanie Morris-HUCIda Placencio-RTJames Simpson-PharmacyAmanda Sorio-NICUSue Titsworth-Case ManagementBridget Yarrington-Pharmacy

5IT TeamNeil AlessioKaren DayGlen Jornigan-Exec. DirectorDiane KostagJan Krell-IT Project ManagerKellie MoudyLisa QuintanaShari ShafferDavid TurnerMargaret Wallhagen

6Support TeamTim Suchla, Clinical EngineeringMary Rivera, Equipment Project LeaderOn Site Cerner Support:Hillary Biskner, Executive LeaderKarmen Gilbert, RN Solution ArchitectLori Raynaud, RN Workflow RedesignDon Kane, MD Physician Liaison

7The expansion of the EMR will allow all care providers equal access to patient information, and improve the ability to access information and document care for all care providers.The present electronic medical record is based on paper records that are scanned into the computer. What we are moving to is an interactive system that will allow for real-time charting on all aspects of patient care, from vital signs to medication administration.

8CPOE (Computerized Provider Order Entry): Handwritten orders can often be difficult to read, and often result in errors. Orders will continue to be reviewed by pharmacists and nursing staff, but potential errors due to handwriting are eliminated. Also, since providers will enter orders directly, tests and medications can be processed much more quickly, enhancing our current process.

9Advantages of CPOE Systems Compared With Paper-BasedSystemFree of handwriting identification problems (time, date, person ordering all part of order)Faster to reach the pharmacyLess subject to error associated with similar drug namesMore easily integrated into medical records and decision-support systemsLess subject to errors caused by use of apothecary measuresEasily linked to drug-drug interaction warningsAble to link to ADE reporting systemsAble to avoid specification errors, such as trailing zerosAvailable for immediate data analysisClaimed to generate significant economic savingsOrder Sets may standardize care

10CPOEOrder sets~200 power plans covering admission, post op, specific diseases CHF, ACSSingle orders order sentencesChoices frequency, type (Stat, ASAP, Routine)For a medication dose, frequency, route, For diagnostic type test reason for exam other areas prefilled in by location and other data already in the systemEvaluate work flow in each process admitting transferring discharge, daily care of patient, post op, level of careDose range checkingFolders of common orders

11Orders from order folders, favorites and by searching

12Searching start first few letters

13Order sentences have details of dose, frequency, route options

14Power Plans are groups of orders

15Arranged in a standard way

16Common values are available as drop down boxes

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19Electronic Medical RecordDocumentation will be easier findmultiple users can access of data at the same timestandardization of documentationlegibilitydata analysisHIPPA complianceViewing data. Patient data can be viewed on any computerEMAR can view both what patient on but also view when meds given will have one MAR.Vital signs, I&O, nursing tasksDocumentation by all services

20Vital signs

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25Changes that have occurredDevelopment of the order sets and the expanded EMR have standardized many practices.Ordering of daily labs, repeating labs. Old way was the daily labs had to be entered each day by the HUC who kept track of this on a cardStandardized documentation by nursing, RT, etc.Urgent clinical documentsWill pull in Code status note, advanced directives, POA, medication contractDaily Rounds Summary

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28Rounding Summary

Time lineRev 17 June 21, RHO Sept 27, Go Live Oct 25Training 6 weeks before go live SuperUsers 8 weeks before go live

131302928272625242322212019181716151413121110987654321302928SSFTWTMOctober 200965432131432130292830292827262524213130292827272625242322212322212019181726252423222120201918171615141615141312111019181716151413131211109879876543121110987665432131213130292827543213029SSFTWTMSSFTWTMSSFTWTMSeptember 2009August 2009July 200954321302928272625242322212019181716151413121110987654321SSFTWTMJune 2009Rev 17Go LiveRHOSuperuser TrainingTraining Starts

30Training needs to coverNew functions such as adding orders and powerplansProcessesAdmit with med recTransfer with med recDischarge with med recFinding data in the chartDocumentation nursing, RT, H&P, etc; vital signs, I&O, medications and ordersCommunication

31Training2 hour classroom to cover basic ordering, processes admission, transfer, discharge, where to find the dataThe classes will assume that everyone has a basic understanding in using Power Chart can log in, find lab values, read and find documentation, write prescriptions.Would ideally like to teach in groups ie by division or department so that core processes are covered and then at the end processes specific to that area can also be addressedIn addition to the classroom training web based training, videos and tip sheets will be available

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Go LiveWhen we go live we will have superusers available on the floors to help with problemsA process in place to make changes needed as we find themThe tip sheets, web videos and training are all available by clicking the How to ? button in power chart at the topThe development of new order sets, changes to improve work flow, etc. will be an ongoing process.

Summary CPOE will improve legibility, date and timeThe enhanced EMR will have all the information on the patient in one place and improve standardization of many processes. The change is coming we need to prepare everyone for it .Superuser Training starts Sept 1Training starts Sept 15Go live set for Oct 25Training on the EMR for the hospital, lead superusers (45) 40 hrs training, super users (243) 20 hours training, users (~2000) 12 hours trainingProviders ~ 1500 superusers (~ 40 residents, ~15 attendings)To train everyone scheduling needs to be done as early as possibleAs much as possible we would like to train in groups to help emphasize areas specific to that group for example for surgery cover post op compared to admission what part of the process is different, The training plan has a basic core of what we are going to teach ordering, processes admit, transfer, discharge, med rec, and how to find data if we can teach in groups we can then emphasize specific areas that they will be doing. Some groups have already scheduled as a division meeting.

36Tasks to performLet everyone know it is coming (talks with faculty and residents)Schedule training times nowDevelop training material (ongoing)Super user training (starts Sept 1)Schedule training sessionsTraining sessions (starts Sept 15)Go live Oct 25Where we areAnesthesia contact Dr Arndt and Dr Chapman, talk presented 7/10/09, schedule training timeEmergency Medicine contact Dr Arguelles talk scheduled, working on scheduling training timeFamily Medicine need contact; need to schedule talks; need to schedule training timeMedicine contacts Dr Rogers, Dr Rao, Dr. Garcia CRTC; need to schedule talks to divisions; need to schedule training time Pulmonary and Heme Onc have scheduled training time Neurology need a contact; would like to schedule talk; schedule training timeNeurosurgery need contact; scheduling talk; need to schedule training timeOb/Gyn contact Dr Phalen; scheduling talks and training timeOrthopedics talk contacts Dr Paterson and Dr Echols; talk 7/15/09; need to schedule training timePathologycontact Dr Luke need to assess what trainingPediatrics contact Dr Jacobs; scheduling talks; need to schedule training times Neonatal contact Nancy Alton, has scheduled training times Psychiatry Adult need contact; need to schedule talks; need to schedule training time. Psychiatry Peds contact Dr Mancuso need to schedule talk and training timeRadiologycontact Dr Mlady need to assess what trainingSurgery contacts Dr. Howdishell and Dr. Schwartz; 3 talks scheduled first 7/15/09, will see if divisions want talks; need to schedule training timesResidents recruiting super users to help in training and when we go live would like to present to talk to let them know whats coming, also schedule trainingCPOE Expected Out ComesImproved legibility date, time, person ordering defined easy to find, reason for test required Order sets may improve uniformity of careImproved turn around timesWill not be faster for provider or nurse writing the order39

CommunicationA major concern is how communication will change.Electronic order entry and charting does not replace effective communication between clinicians.

How do we safeguard effective communication?46Hardware47CPOE- Computerized Physician Order EntryPower Plans a set of orders for admission, post op, specific diseases ie acute coronary syndrome.Single Orders sentences fill in the necessary details needed for that order including reason for test, STAT, routine, ASAP

48CPOEOrder sets~200 so far covering admission, post op, specific diseases CHF, ACSSingle orders order sentencesChoices frequency, type (Stat, Now Routine)For a medication dose, frequency, route, For diagnostic type test reason for exam other areas prefilled in by location and other data already in the systemEvaluate work flow in each process admitting transferring discharge, daily care of patient, post op, level of careMedications correct dosing eliminate fields that will cause confusionPediatrics order as they are used to, dose range checkingTraining on each process49Urgent Clinical Documents tabWill pull in Code status note, advanced directives, POA, medication contract,

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53USP MEDMARX Computer Technology-Related Harmful Errors (2006)CauseNumber% Barcode, medication mislabeled 20 5 Information management system 1,176 2 Computer screen display unclear/ confusing 137 1.5 Dispensing device involved 3,181 1.3 Barcode, failure to scan 114