Collaborating to Fund and Advance Research-The OHSU Experience

Jeffrey A. Gold, M.D.Professor of Medicine December 17th, 2014

Disclosures• Received funding from AHRQ,

AAMC/Donaghue Foundation

Statement of Clinical Problem• Electronic Health Records (EHRs) are at the center

of all data communication, clinical decision making and care implementation in the health care system

• Numerous studies document poor use of EHR can lead to increased patient errors and undermine communication

• The ICU appears to be a highly vulnerable environment to these issues• Massive amounts of data (>1800 data

points/day)

• Most physicians feel that current EHR training is inadequate

SolutionTo use simulation with high fidelity, contextually relevant cases to improve EHR utilization and help focus EHR redesign

What resources are required?• High fidelity (realistic) cases for training.

Need to be created by content experts Cases need to be designed specifically to test EHR

usability and safety (the controlled lie)

• Cases need to be built into the EHR

• Need a cloned version of EHR which looks identical to clinical system but doesn’t have actual patient data• Must maintain user customization

• Problem- I am a basic scientist/fellowship director with background in ICU administration

Step #1-Reach out to Informatics• Chair of Informatics-Bill Hersh

• Introduced me to Fran Biagioli who user EHR simulated cases for Medical Students

• Used resources from ARRA funds to help fund EHR educator (Gretchen Scholl) to help build simulated cases, create separate simulation environment and trouble shoot problems Leveraged support from hospital Human Resources

to allow for shared position Human Resources controls EHR training Engagement of hospital CMO

Barriers to Overcome• Cases need to be created

• Need to test meaningful use of EHR• Recognition of patient safety issues/errors-not

just charting

• Cases need to be imported into EHR• Manually done-no autoimport

• Cases must be temporally contextually correct• They must exist in realtime –cloned forward

• Can’t use actual production EHR environment• Impacts billing, pharmacy, meaningful use etc….• Need to maintain user customization and workflow

Methods

5 day real life ICU stay created in EPIC simulation environment Cases originally created in EXCEL

Every data point created and entered by hand in relative real time (no way to download data into system)-Patient “cloned” forward to day of testing so can be used in real time

Case contains clinical decompensation with 15 built- in patient safety issues• Vitals trends, medication misdosing, lack of best practices

Methods Cont..Trainees given written history, relevant clinical info for last 5 days, Bld Cx results and PE• No radiology in sim and residents told not to look for it

Trainees given 10 min to gather data in EPIC• Done in ICU to recapitulate effect of environment (lights

etc…)

Subjects told to present case as if giving daily plan and signout for weekend

Residents allowed to use own login for customization

Subjects could be tested again, at least 1 week later• Repeat testing with different case-random order

Types of Patient Safety IssuesIssues of Cognition• Recognizing trends in vitals• Recognize high Pplat

Familiarity Issues• Do they even know where things are located

Medical knowledge Issues• Do they even know appropriate VT

Fragmentation issues• How many screens are used

Step #2-See if it works

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• Run 40 housestaff through simulations and document that average clinicians miss >50% of safety items within a case

March et al BMJ Open 2013

Step #2-See if it works• Run 40 housestaff through simulations

and document that average clinicians miss >50% of safety items within a case

• Data used to obtain R18 from AHRQ for using simulation to improve patient safety

• Funds from this grant allow for creation of additional cases to document training effect

• Allow to increase N>150

Trainees Fail to Recognize Patient Safety Issues

Stephenson et al BMC Med Ed 2014

Can Simulation Improve Performance?

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Case 1 First, then Case 2

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Stephenson et al BMC Med Ed 2014

Next Level of Clinical Problem• In the ICU we round as an Interprofessional

team (RN, MD, Pharmacist, RT)

• Effective clinical decision making on rounds is dependent upon Everyone accurately retrieving and reporting

data Everyone effectively using the EHR

Best Practice for ICU Rounds

• Interprofessional Rounds, including RN, pharmacy, and RT

• Multiple studies document improved cost, improved morbidity and patient satisfaction with interprofessional rounds

• Multiple barriers, including information retrieval and EHR Both increase time and decrease

communication

• Little data in controlled settings to determine whether improved error recognition by the group Swiss cheese or Cheese cloth

EHRs Differentially Impact RN and MD Workflow

• RNs like EHRs more often than MDs

• EHR has more dramatic affects on efficiency for MDs (Poissant)

• Only 46% of handoff items overlap in data transmitted during handoff (Collins)

• RNs unaware of abnormal vitals in 43% of ward patients (Fuhrman 2012)

• 25% of goals stated in rounds are not present in EHR (collins 2009)

Solution-ICU Round Simulation• Obtained funding from the AAMC/Donaghue

foundation to allow for entire Interprofessional team to participate in simulation activities.

• Engaged hospital Nursing, Pharmacy and Medical leadership to facilitating testing of all groups.

• Have now tested all of ICU RNs and Pharmacists on same case as MD.

• Beginning full ICU rounds simulation this winter.

• Project is now an Incubator Project for National Center for Inteprofessional Education and Practice Allowed leveraging of resources from OHSU IPE

committee including nursing and pharmacy

Creation of High-Fidelity EHR Simulation for all members of IP Team.• Engaged RN and pharmacy leaders to help in

scenario and case design

• Initial simulation cases modified to ensure contain all relevant information for all professions (almost an extra 400 data pts/day for RNs)

• Needed to frame scenario for workflow

• Pharmacists review chart during mock presentation

• RNs get a mock signout from another RN

Proclivity for Different Professions in Identifying Safety Issues

Recurrent Sepsis

Vanc trough

Vanco Dose

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BP/HR

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Insulin

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Differential Patterns in EHR Utilization Amongst Professional Groups

Total of 135 Different Screens Used

Overlap in Screen Utilization

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What Are Differences in Workflow?

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Pharmacist

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Next Steps• Leveraging these data for redesign of

ICU rounds• Focusing on data veracity and patient safety

• OHSU created an ICU Change Management group focused on standardization of EHR utilization and redesign.• Allows dissemination across all ICUs

• RO1 submitted to AHRQ.

Our Team NowDivision of Pulmonary Critical Care• Jeffrey A. Gold, PCCM/CCM Program Director

Department of Medical Informatics• Vishnu Mohan, Bill Hersh

School of Medicine• Gretchen Scholl

School of Nursing• Judith Baggs

School of Pharmacy• Dave Bearden

OHSU Hospital• Jesse Bierman (Pharmacy), Ashley Mulanax (ICU RN), Adrienne

McDougal (ICU RN) • OHSU ICU Change Management Group