QUEENS HEALTH NETWORK HEALTHCARE INFORMATION SYSTEM

A MODEL FOR ELECTRONIC PHYSICIAN ORDER ENTRY

By Diane M. Carr SUMMARY AND OVERVIEW

The requirements of a rapidly changing, competitive marketplace have amplified the existing demand for improved clinical information within the healthcare organization, and focused increased attention on the expansion of ambulatory care services, especially primary care. Additionally, recent population-based “disease management” efforts by health systems directed at major chronic illnesses have increased the emphasis on safe, efficient and cost effective means to enhance patient care and measure outcomes. At the Queens Health Network (QHN), the consolidation of operations and regionalization of services compels the sharing of patient data throughout a multi-hospital system. Quality care for patients across a variety of settings, the locus of which is no longer the inpatient hospital, requires ever more rapid retrieval of longitudinal, integrated patient information at the point of service.

In the spring of 1996, implementation of a computerized medical record was proposed by senior administration to the medical staff as an integral component of the Queens Health Networks strategic and business plans. The decision was made to implement the New York City Health and Hospitals Corporation’s software choice, Ulticare/ Patient 1, by Per Se Technologies (formerly Health Data Sciences). Assistance with database design and development, as well as implementation support, was provided by Negley, Ott and Associates.

At QHN, the registration and visit scheduling systems (Siemens, formerly SMS) feed admission, discharge and transfer data to Ulticare/ Patient 1, which then transmits charge data to the billing systems for procedures performed in radiology, cardiology and the laboratories. Laboratory tests are ordered online, and results are imported via bidirectional interfaces to instruments or reference laboratories. Ulticare/ Patient 1 serves as the hub of the radiology system, transmitting orders to both the voice recognition system, Talk Technologies, and the AGFA PACS, and storing and transmitting reports received from the voice recognition systems to the PACS. With the exception of mammography, QHN is filmless.

Computerized physician order entry (CPOE) has been a reality in the Queens Health Network since January 1997. Currently, doctors throughout ambulatory care document about 3,000 patient encounters online every day, and inpatient physicians place orders and review results for thousands more. Physicians, nurses, social workers, nutritionists and other patient care providers enter and retrieve data (test and consult orders, assessments, progress notes, history and physical examinations, medication orders, patient/ family education) in Ulticare/ Patient 1 at nearly 3,000 personal computers located in exam rooms, ancillary departments and on inpatient units across the Queens Health Network.

The result is an integrated, interdisciplinary electronic patient record, located at the point of care, that’s used by physicians and other clinicians to enter and retrieve patient data. Because of this strong patient information infrastructure, the Queens Health Network is well-positioned to re-engineer care processes, coordinate patient care across the continuum of time and location, sustain multidisciplinary team functioning, and facilitate performance and outcomes measurement necessary to improve health care quality.

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About the Queens Health Network

A member of the New York City Health and Hospitals Corporation (HHC) and an affiliate of the Mount Sinai School of Medicine, the Queens Health Network is the major healthcare provider in the borough of Queens, New York City, employing 6,106 people. Serving a population of 2 million people, Queens Health Network comprises Elmhurst Hospital Center, Queens Hospital Center, 11 free-standing medical clinics and six school-based health centers. Elmhurst and Queens are teaching hospitals, with a combined total of 771 inpatient beds and 41,660 annual hospital admissions. Rotating residents are supervised by attending physicians with faculty appointments. Together, these 748 physicians provide more than 1 million ambulatory care visits each year. QHN also provided 45,293 home healthcare visits last year, and it has contracts with three hospice organizations whose services include palliative care at Elmhurst. (See APPENDIX I: Queens Health Network Facilities Locator Map). Western Queens in New York City is one of the most ethnically diverse regions in the world, populated by residents who represent more than 100 nationalities and speak more than 167 languages. Its residents are also some of the poorest: 13 of the area’s 18 ZIP codes have households with median incomes that are less than the county’s $34,186, and 12 ZIP codes have percentages of their population who earn less than the federal poverty level (12%-27%), higher than Queens County as a whole (11%).

No region has been more affected by the wave of immigration into the United States than that served by QHN. People of color and ethnic minorities comprise more than 87% of the patient population served by the Queens Health Network. Twelve of the 18 ZIP codes in the service catchment area also include from 15% to 31% of linguistically isolated households, higher that the rate of Queens County as a whole (11%).

These newly arrived immigrants avail themselves of the public hospital system in New York City, HHC, which is one of the largest municipal health systems in the country. They form a medically underserved population, denied care in many venues because of their inability to pay and generally unaware of preventive practices that promote improved health. Patients come to Elmhurst and Queens Hospitals with more advanced disease processes, complications and co-morbidities than the general population because they often seek care later and may not know where care is provided. The language and cultural barriers outlined above present an additional challenge to providing high-quality care in a vital, growing community in a high-volume, inner city healthcare system. MANAGEMENT Goals of the Healthcare Information System (HIS)

Project objectives are shared by the medical staff and administration. These include: 1) to support the improved quality of patient care through access to and availability of patient information; 2) to facilitate and improve the documentation of clinical data throughout the lifetime of the patient and across the continuum of care; and 3) to integrate clinical information available from various legacy systems.

Project Planning and Leadership

Initial efforts were launched at Elmhurst Hospital Center (EHC). A project implementation team was recruited from within the organization, and an ambitious timetable was

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outlined. A senior administrator, responsible for the provision of clinical services in the inpatient hospital, the operating rooms, and the emergency department, was relieved of those duties and designated as the project manager. A strategic management expert, she has the skill sets that enable her to effectively negotiate competing priorities, and direct the implementation process, while reporting directly to the QHN chief executive. The project manager was partnered with a data analyst with expertise in outpatient operations, who assumed the title and responsibilities of technical director. Other project team members included the Chief Information Officer, Information Systems (IS) analysts responsible for the existing lab and registration systems, the radiology system administrator, and IS technical and communications experts. The project team immediately assumed high visibility in the organization, as the project was given priority status and support.

From the start, the project was seen as key to the strategic position of the QHN in the competitive healthcare marketplace of New York City. The senior administrative team viewed the CPR as essential to the development of an effective infrastructure from which to support the reorganization of care, the design and refinement of quality measures and reporting processes, and the practice of evidence-based medicine to improve management of chronic disease. The chief executive has been tireless in his promotion of the system, endorsing it in public and private sessions throughout the organization, and never ceasing to encourage the recalcitrant or reluctant to implement it. He is joined by the medical director, who has insisted on system features that improve its ease of use by physicians, as well as enhanced decision support functionality to support patient safety and quality of care. Her advocacy of the system with the medical staff set the tone at the beginning of the project and has helped to sustain it throughout its life cycle.

The HIS steering committee, comprised of senior clinical and administrative leadership, was created to institutionalize the project, and establish clinical and operational priorities. This group includes: the medical directors of each primary care unit, as well as key specialty care services and the emergency department; the associate dean of the medical school; the nursing executive; the senior network vice president of the Queens Health Network; the directors of quality assurance and health information management; and administrators responsible for the clinical and ancillary services in ambulatory care.

The HIS development committee, comprised of senior administrators, was commissioned to research issues before consideration by the steering committee, and keep implementation on track. Both groups are chaired by the HIS project manager and meet regularly.

At project launch, every clinical and administrative department in the hospital received a brief demonstration of the project and heard a presentation on its goals and objectives. In August 1996, the HIS design team was established, and a hospitalwide informational session, with participation by all department heads, was presented by the project team to introduce and encourage support for the endeavor. Members of the design team are recruited based on their ability to provide clinical or systems expertise and participate in the development of applications specific to their service or department (See Appendix II: HIS QHN Organizational Structure). Implementation: From Paper to CPOE in Six Months

Because the success of the project was determined to be time critical, various application modules were implemented in phases, in a continuous cycle of design and development. This approach was in lieu of “building the perfect beast,” which would require the commitment of

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significant resources over a number of years, before providing any value for patient care activities.

The execution of an aggressive project time line necessitated the compression of numerous complex tasks into a series of parallel, concurrent phases, all of which were completed within six months. These initial phases included:

Creation of a physical infrastructure - Identify, design and renovate space - Design and build training center - Relocate project team

Creation of a data communication infrastructure - Design and build a local-area network - Design and build a wide-area network - Plan and install hardware

Clinical workflow analysis, including process redesign Software customization Project team training Development of system documentation Development of training program and documentation Implementation of provider training program Transition plan development and implementation Establishment of a Help Desk Software implementation and support

A hospitalwide data infrastructure, including Level 5 communication network, FDDI ring

technology, mainframe computers, and terminal servers were installed during the fall. More than 400 personal computers and 250 laser printers were located in exam rooms throughout the Elmhurst onsite clinics in December 1996. Additionally, 500 physicians and midlevel providers, nursing staff and support/ administrative personnel were trained during this month.

Implementation of the electronic medical record was initiated in ambulatory care in January 1997, with the development of interfaces to the existing electronic registration (ADT), laboratory and radiology systems. The immediate effect was to integrate and enable the retrieval of clinical test results by the physicians at their desktops. Physicians began placing test orders on the system and documenting problems on the patient problem list.

To continue to add immediate value to patient care activities, enhanced documentation features were added to the system as they were developed. Continuous project design and development cycles require ongoing implementation phasing as new functions were introduced. Each phase involves:

Analysis of the flow of patients and workflow, with suggestions made for improvements

Application design by an interdisciplinary team of users Customization of application software Interdisciplinary feedback sessions to refine the product Development of system and training documentation Provider / user training Testing of application; assessment; improvement

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Software implementation and support The Queens Health Network has established a model for the design and development of a

computerized patient information system that is collaborative and interdisciplinary in both function and in form. Physicians, nurses and other patient care providers assisted in establishing priorities for system development, and participated in every step of the design and implementation process. As a result, the HIS reflects the variation in the manner in which physicians take care of patients, and captures data particular to specific patient populations, while enabling the sharing and dissemination of data across all areas. Physician participation in development efforts also contributed to the high level of system utilization across the network: Recent analysis indicates that every physician logs on to the CPR, for an average of 43 hours per month. Point of Service Computing to Gain Physician Support

The HIS was conceived of as a way of providing essential patient information to physicians throughout a high-volume, geographically dispersed service delivery area. Doctors were frequently unable to obtain timely patient information, and once they did so, documentation of care might be illegible or incomplete. Tracking and providing the paper medical record to scores of primary and specialty care services, no less the emergency department and inpatient units, was a logistical ordeal. Reviewing patient test results required physicians to queue up in front of application specific computer terminals, first, for example, at the lab terminal, next, at the radiology terminal.

The goal of the initial software implementation was to gain the support of the medical staff by resolving the most glaring issues for doctors. For the first year of the project, attending physicians, as well as residents and mid-level providers directly supervised by attendings, were the only users of the system, with other staff trained solely in a support capacity to the physicians.

Clinical documentation required by payers and regulatory authorities was arduous and time-consuming. For example, a physician is required to note the patient’s diagnosis three times: once in the physician’s progress note; a second time, on the summary required by JCAHO for patients receiving continuing ambulatory care services; and again, on the billing form. Physicians under pressure to see a high volume of patients were reluctant to duplicate efforts seen as bureaucratic and of little value to patient care.

The project team customized the electronic patient problem list to automatically capture appropriate ICD-9 and CPT-4 codes as the physicians document the patient’s problem and the care provided at each clinic visit. In one automated process, the documentation of diagnoses and procedures is completed, and physician and hospital billing is enhanced. The linking of the financial to the clinical documentation not only streamlined both processes, but guarantees that the clinical information is entered at every encounter: physicians are required to complete the encounter (billing) form.

In turn, this ensures that the clinical data from each primary care or specialty visit is available and accessible to the doctor at the point of service for the lifetime of the patient. By December 1997, physicians throughout ambulatory care were documenting online significant diagnoses, conditions, procedures, drug allergies and writing online prescriptions for patients.

Today, a network comprising nearly 3,000 personal computers with printers, located in examination rooms, ancillary departments and on inpatient units throughout the Queens Health

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Network has been created. The HIS has become an integral part of the practice of providing quality patient care for 1,625 different doctors, nurses, social workers, dieticians, lab and radiology technicians each day. These caregivers spend an average of four hours daily accessing the clinical record and documenting clinical findings in the electronic chart. Analysis shows that an average of 579 physicians and 1,046 allied health professionals access the HIS on a daily basis. Development of an Electronic Primary Care Chart

Priority for system development and implementation was given to outpatient services generally, and primary care services, in particular: Medical Primary Care (adult), Women’s Health Services, and Pediatric Primary Care, including Adolescent Health Services. During the summer of 1997, the HIS project team assessed the flow of patients and workflow in the various primary care clinics, and developed a statement of work for those areas. These were approved by the clinical and administrative department heads and then presented to an interdisciplinary work group. Included in the group were several representatives of the Medical Records Committee, the Director of Health Information Management, the medical directors of the primary care services, as well as ambulatory care nurses and administrators.

A document describing the proposed components of an electronic, primary care patient record was presented to and modified by the group. The work document included descriptions of the types of information to be entered into the system; by whom the data would be entered; how the information would be presented, and where the information would be stored. This effort was an initial part of the process of supporting the medical staff and administrators to conceptualize the interactive process required to design and develop a product which would meet their clinical and informational needs. Discussions were focused on ensuring that system implementation would augment rather than disrupt patient care. Core record elements were defined as essential for providing patient care, and certain financial and clinical process elements were identified as those that could be incorporated at a later date. The proposal then was modified and finally approved by the HIS steering committee (See TABLE 1: Elements of an Electronic Primary Care Chart).

After the overall framework and its components were approved, design teams from the various services were convened to define and approve the details of their particular applications. Each module was tested and piloted on a controlled basis before being implemented service-wide. Before implementation, the appropriate documentation was written by the project team, and training was provided to the staff.

By the middle of 1998, interdisciplinary patient assessments had been implemented in various primary care and specialty care clinics; by February 2001, the primary care services were “practically paperless,” with physicians documenting patient histories and physical examinations, progress notes, assessments and plans online; nursing picking up doctor’s orders and documenting their assessments, patient/family education and screenings for interventions by ancillary services online; and social workers, dieticians and health educators reviewing online referrals and documenting all progress notes for new and established patients.

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TABLE 1 ELEMENTS OF AN ELECTRONIC PRIMARY CARE CHART

CORE RECORD ELEMENTS

Acute problems, diagnoses, symptomsChronic problems, diagnoses, symptoms

Allergies/Adverse Drug ReactionsDiagnostic tests

Health maintenance testsImmunization recordProcedures performed

Medications prescribedHistory of significant illnesses & surgeries

Physical examinationsProgress notes/assessments/plans

Assessments: nutritional, psychosocial, educationalHealth care proxy

Links between Outpatient & ED/Inpatient episodes - Discharge summaries

- Operative reports- Nosocomial infection

follow-up- Documentation that post

discharge visit occurred

Communication- Does payor want pre-

authorization?- Attending/PCP counter-

signature?- Which agencies &

vendors are acceptable?

Forms Assistance- Notification of specialty referral to insurance plan- Home care placement

- Documentation of disability status

- Documentation and communication regarding non face-to-face contact,

e.g. telephone triage

- Facilitation of follow-up for abnormal results &

documentation of repeat or treatment

- Disease management for chronic conditions

- Specialty consult request and response

User Training and Support

User training is coordinated with the clinical and ancillary departments and scheduled at the convenience of the caregivers. Training is provided by the project team whenever a new feature or function is introduced; at any time upon the request of the user or user’s supervisor; and to all new employees whose patient care functions require documentation on the HIS. In 2001, a computer based training (CBT) program was installed in a hugely successful effort to provide increased access to training for all levels of staff in the system’s chart review features.

Ongoing training of physicians and other patient care providers is required because: 1) Continuous system design and development guarantees that the HIS is constantly changing, to reflect users’ needs and priorities. New functionality is continually being requested, tested, piloted and implemented; 2) The needs of the various primary care and specialty care patient populations, inpatients and outpatients, have widely disparate requirements; 3) Each month, medical and surgical residents rotate into the network from its medical school affiliate; and 4) The transformation of physician practice patterns, and the integration of new technology, requires constant reinforcement. Emphasis is always on improving support for patient care providers, to enhance the quality of patient care.

Today, the HIS has become ubiquitous to the point that training must be provided on one or both campuses every day, sometimes in large groups, sometimes on a one-to-one basis. The

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training program has evolved into a highly structured, formalized endeavor, with class rosters used to register students in advance, and customized training documents for every application. Instruction and support materials are service-specific, as well as discipline-specific: pediatricians, for example, are trained to document age-specific milestones in their progress notes, while internists learn how to access a diabetic protocol to guide management of the disease. Nurses learn how to document patient/family education, while lab and radiology technicians learn how to process tests. Last year the HIS project team trained nearly 3,000 employees throughout the Queens Health Network.

Training and support is provided by the staff of the HIS Help Desk, which triage calls and walk users through the applications when needed. If the problem cannot be resolved over the phone, a Help Desk member is immediately dispatched to the clinic to address the software issue or replace hardware, as appropriate. This immediate response is essential in a busy patient care environment, where no system down time or delay is acceptable. It is also key in gaining the support of the medical staff and other clinicians for whom the use of paper has become anathema. Electronic call logs are maintained that help to identify application features that require reinforcement and/ or redesign. OPERATIONS System Security/Patient Confidentiality

Access to the electronic medical record is limited to those employees who require specific patient information, and level of access varies depending on an individual’s discipline or work function. For example, clerical and administrative staff, physicians/midlevel providers, RNs and various other nursing personnel, have different security levels, and see varying amounts and types of information. Access is restricted on a “need-to-know” basis.

Users are issued an electronic key at training and must choose a system password that changes every three months. At the initial training session, every employee signs a confidentiality statement. Both the physical device (key) and the electronic password are required to sign onto the HIS every time. This process generally takes about five seconds, and requires the use of a plastic key that is encrypted with the user’s employee file and security access information. Every admission to any patient’s chart review is recorded automatically. The system generates an audit trail that shows who viewed and/or added to each patient’s file, with a record of the date and time. Maintaining Operational Activities Throughout Continuous Development Cycles

An ongoing needs assessment process defines the efforts of the HIS project team. Requests from all levels of clinicians and administrative staff for new features or system enhancements are forwarded to the project manager. As appropriate, group or individual meetings are held to refine issues, which are then referred to the regularly scheduled development committee and steering committee meetings for consideration and prioritization. Competing needs are juggled, and progress is monitored. Improvements and further changes are implemented as required.

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While the timetable for meeting project objectives is strictly adhered to, priorities may be modified according to market needs. For example, development of the final module of the ambulatory care chart, the design and installation of specialty consultations, was postponed because of national emphasis on patient safety and the organization’s desire to mitigate errors through installation of order entry on the inpatient units.

It is the expectation of the steering committee that all functions performed in the targeted area by all employees will be automated to the greatest extent possible. To accomplish this, detailed workflow analyses of departmental processes are prepared by the HIS project team through direct observation, interviews with departmental leadership and staff, and interviews with representative caregivers who review and rely on the patient data provided by the department.

Preparation of a proposal to replace the current workflow often reveals work processes that are redundant or conflict with other departmental practices. At times, the needs of caregivers reviewing the data and those providing the data may conflict. These issues are analyzed thoroughly and recommendations for resolution are prepared.

A prototype of the new system is presented to the department, which includes a written document as well as a demonstration of CPR functionality. The current and proposed work processes are described in the document. The prototype presentation enables the targeted department to confirm that current processes and problems have been accurately defined, and to validate the proposed workflow for appropriateness. Implementation objectives are prioritized, and the expectations of the users are clarified and refined.

At times, it may not be possible to meet every objective identified as desirable, because of resource constraints or technology limitations. A thorough review of the prototype provides an initial glimpse of the impact of the implementation and the likelihood of achieving the department’s local objectives. The department and the HIS project team may also begin to identify and prepare to mitigate any potentially adverse effects of the implementation.

As the CPR develops, documentation and decision support features are customized to serve the needs of the different patient populations, then modified and improved after feedback from the physicians and other care providers. For example, an initial intake tool for adult primary care patients was implemented, including a nutritional screen performed by nursing staff. The system calculates a score based on the patient’s responses to a series of screening questions. When the score reaches a defined threshold, the patient is electronically referred for a full nutritional assessment. The clinical information is then routed to an electronic work queue to be reviewed and augmented online by the dietician assigned to that patient population. As the information is updated at subsequent visits, or by other care providers, the computer screens are refreshed, eliminating the need to repeat efforts by staff or patients to communicate.

The paper form that was in use in the primary and specialty care services provided the basis for the development of the electronic intake tool. Based on user feedback, changes were made to the calculations used to determine nutritional risk in the adult population. Additional work with physicians and other clinicians made it clear that the nutritional requirements for obstetrical and pediatric patients varied from the general adult population, and required additional sets of calculations to support their particular patient care needs. Pediatrics oversaw the design and inclusion in their progress note of age specific interval histories, including diet.

As the utilization of various documentation tools are expanded, providers will continue to be polled to determine their effectiveness. Changes will be made as necessary and appropriate to improve the data collection process and patient care.

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Evaluation of Management of the CPR Effort The most important rule to be followed as the CPR is planned and implemented is the

simplest: Listen! Listen to physicians to learn what they need to take care of patients. Listen to explanations of patient flow and paper flow to understand how to develop CPR tools to expedite these processes. Listen to users and creators of clinical information to understand what is essential and what wastes time.

Physician order entry is a realizable goal if a partnership is created between the medical staff and the project team. A return on the investment of learning a new system must be realized as quickly as possible in the demonstrated value of electronic patient information (timeliness, availability, legibility).

While pilots are important for gaining trust and testing functionality, successful implementation of a comprehensive, interdisciplinary patient record requires a “Big Bang” implementation strategy. The department or service will suffer the same period of upheaval regardless of whether the new application is rolled out to 20 or 200 or 2,000 users. Furthermore, integrated functionality must be simultaneously implemented across disciplines to provide its full capabilities and benefits to users.

The process of automating the clinical patient record is less about technology and more

about change management. People generally have a fear of the unknown, and often prefer “the devil they know over the devil they don’t.” Users learn at different rates: “superusers” aren’t always super, even if they’ve attended multiple classes. They also have varying degrees of tolerance for change. Some who are initially CPR enemies eventually come around.

Use of the CPR has moved the organization into the information age. Ironically, because

of the priority given to physicians in CPR development, support and implementation, the medical staff are often more expert at the language, complexities and capabilities of the system than the support staff. The organization has insisted that the clinicians work toward a paperless environment, while many of the mid-level managers continue to resist the role of “superuser” essential to provide the first line of support for clinicians.

The importance of physician leadership to the successful implementation of the CPR

cannot be overstated. Lack of enthusiasm for the project from the chief of service will guarantee limited satisfaction with and utilization of the CPR within a service. Differences are apparent across campuses and within services, where the application and the technology are exactly the same.

System integration is the key to providing clinical information in the easiest, most

expedient format possible. Foreign system interfaces require maintenance, troubleshooting and inevitably cause data integrity and reliability issues for clinicians.

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The development of clinical practice standards requires hard work and compromise, and they must be agreed to before system implementation. The CPR cannot be programmed to follow certain rules, providing decision support in the process, unless consensus is reached by the medical staff.

At this point in development, some paper remains part of the chart that the

Ulticare/Patient 1 software cannot accommodate. This includes images, e.g., consent for treatment and other signatures, the pediatric growth chart, and EKG strips. In addition there are a few applications that have not yet been converted (blood banking), or developed (specialty consult reports).

Keeping it simple and quick, especially for physician order entry functions, is another

key to success. The project team must remember that there are multiple customers for each application under development. It is important for system efficiency not to allow extraneous questions, inconsistent displays, and flashing reminders to clutter screens.

FUNCTIONALITY Targeted Processes From the beginning, development of the CPR was given priority within the organization because of its anticipated impact on key systems that support patient care. It was expected that implementation of an electronic patient record would go far toward improving the quality of healthcare provided by the Queens Health Network, especially with regard to: Patient safety, as physician order entry eliminates transcription errors made by caregivers

who serve as intermediaries between the physician and the patient; legibility of prescriptions, progress notes, care plans, assessments is improved; and medication errors may be reduced through use of computerized alerts regarding dosing, allergies, and adverse drug reactions.

Efficiency of care can be improved by reducing redundant laboratory and other testing,

improving multidisciplinary communication by integrating patient assessments, and making all patient information immediately accessible at the point of care.

Effectiveness of care may be enhanced through use of automated decision support

features, such as electronic reminders of health maintenance testing and immunizations, displays of certain test results and measurements trended over time, and automatic notification of a patient’s condition to providers at other care venues.

Timeliness of patient information is improved by providing real time availability of

clinical information, diagnostic tests and treatment results across the continuum of care. QHN CPR Data & Data Entry

In general, patient information is entered into the CPR by physicians or other clinicians, or captured by instrument or foreign system interfaces. The Queens Health Network’s CPR laboratory application includes 44 laboratory instrument interfaces, a bidirectional interface to the organization’s primary reference laboratory, and an interface to another HHC facility for

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which QHN serves a reference laboratory for cell immunology tests. The CPR also supports bidirectional interfaces to two PACS systems, one mammography system, and the voice recognition systems for the radiology departments, as well as patient registration and billing systems.

The software enables field level data control in both the order entry and result entry processes. At a macro level, the project team can define who can order a test and who may need to countersign the order; and who can cancel or result a test. The real uniqueness lies in the ability to prevent certain users from accessing, editing or viewing certain data (down to the field level) based on system security access or data documented in another field in the patient’s record. Creative combinations of existing system tools are used to minimize the number of tests, order and result profiles, menus, etc. The project team builds one assessment, for example, with built in logic, rather than replicating it numerous times, thereby minimizing the database links to be maintained or updated as the CPR expands.

Extensive system audit trails also help to promote the use of the fewest number of data elements possible. There is no need to over-engineer minor differences (in fact, it may not be necessary to suppress fields as described above) because it can always be determined retrospectively exactly who did what. If at the time of the application development, nurses’ aides are not permitted to perform hearing tests on children, but are permitted to do so after a training program the next year, the project team doesn’t have to alter a set of complicated rules to enable this functionality. This also permits users sharing a common title but performing different duties in different services the latitude authorized by or within their service.

Duplication of data entry has been eliminated because of system functionality enabling patient information to be displayed in order entry screens, in result entry screens, and in multiple display functions. The system’s event architecture also enables a single event to seamlessly display in multiple intrafacility and interfacility work queues (for example, a lab test ordered at Queens will automatically appear in the appropriate work queues in the Elmhurst lab, and the patient chart can be viewed anywhere in the network).

Controlling the input of patient information at its source is a powerful mechanism to ensure quality. Fields in order and result screens can be created from user defined or system defined data elements. Fields can be displayed based on the definition of customized field specific logic, called Data Element Dependencies (DEDs). Interactive entry of information as well as historical patient information can trigger the display or suppression of fields. In addition, user security levels can be used as criteria to determine the display of fields. Display, edit and required field functionality have been used to compel users to enter complete information, promoting to a safer environment for patient care.

Multiple views of data enable visual validation of information across venues, another vital mechanism to ensure data quality. The same patient information can be viewed in work queues, review queues, result verification queues, face sheet display screens, order and result screens and across multiple functions designed to process events.

For instance, in the laboratory module, culture reports contain organism and sensitivities results from the microbiology analyzer with required fields to ensure completion. Non-reportable sensitivities are marked for suppression so caregivers cannot view them. Results go into culture-specific queues for review by supervisors, regardless of the origin of the order (i.e., acute care hospital or off-campus clinic). All processing activity on a culture can be reviewed online by medical technologists and supervisors. Reports identifying organisms, diseases and patient conditions that must be reported to regulatory agencies can be reviewed online. The control in

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the input of patient information and the numerous review mechanisms ensure quality and consistency of the patient data.

The following table demonstrates the types of data captured in the QHN CPR, how it is entered and who places the order and/or documents the information, and the mechanisms for controlling the reliability and validity of data capture. This table demonstrates the scope and breadth of the QHN longitudinal patient record. Every effort is made to capture data in the CPR at the point of care by the person providing the care.

TABLE 2

QHN HEALTHCARE INFORMATION SYSTEM CLINICAL DATA CAPTURE MODEL

Function Order Entry/

Data Capture By

Data Entry Controls / Notes

Allergies ALL, RPH Standardized prompts; searches for exact medication names against CPR copy of commercial drug database

Problem List ALL Standardized lists; searches against CPR copy of ICD9 database

Outpatient Prescriptions

MD

CPR requires some fields in order process and provides standardized dose and route lists; searches for non-formulary medications, drug info, and ADR info against CPR copy of commercial drug database.

Inpatient Medications MD, RPH

CPR requires some fields in order and result processes and provides standardized dose and route lists; searches for non-formulary medications, drug, and ADR info against CPR copy of commercial drug database.

Vital Signs & Measurements

ALL Range limited fields; abnormal & critical value markings

Head Circumference Percentile

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Controlled by security position of user: MDs, NPs, and PAs only enter data. CPR automatically calculates the percentile for the patient’s age.

Coding Sheet (encounter billing data)

MD CPR has built in alerts indicating wrong specialty, old visit, or discharged visit. Searches for procedure code against CPR copy of CPT4.

Telephone Triage NSG CPR has standardized pick lists with built in logic that prints select encounters to appropriate locations upon completion.

Diabetes Protocol MD CPR displays results for diabetes management tests and links to order entry functionality to allow quick ordering of missing tests.

Pediatric Immunizations Results

ALL N/A CPR controls data entry with standardized pick lists for vaccine types (e.g. DTP, DT), manufacturer names, etc., and for users to explain why an immunization will not be done (e.g. contraindicated). The CPR speeds and controls the data entry process by giving users their own database of commonly used vaccines. E.g., users can pre-define the manufacturer, lot number, and expiration dates for the Hib vaccine they are using, which will automatically pull into the fields each time that they document administration.

Pediatric Immunization Reminders

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Reminders display on a report to the screen. This display grid shows the AAP immunization recommendations for that patient’s age. The CPR fills in vaccinations given, then displays documented reasons why an immunization will NOT be done, leaving blanks only where items are due.

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Function Order Entry/ Data Capture By

Data Entry Controls / Notes

Health Maintenance Tests Results

MD, ALL CPR controls data entry with standardized pick lists for why a test/procedure will not be done (e.g. contraindicated), and range limited prompts (e.g. for BP). The CPR’s lab and radiology departmental processing performs multiple controls for test results and, as these are pulled automatically, rather than transcribed, those controls positively affect the HMTs as well. The CPR speeds and controls data entry of immunizations for adults in the same way as for pediatric immunizations (see above). Users do not have to maintain this record of HMTs separately; it is built into their work process. They must indicate when they will NOT perform a test/procedure. Otherwise, they merely order the test or do the procedure, and the CPR recognizes it.

Health Maintenance Test Reminders

---

N/A Reminders display on a report to the screen. This display grid shows the recommendations for that patient’s age and sex. The CPR fills in laboratory (e.g. Pap), and radiology tests (e.g. mammogram), and documentation by caregivers (e.g. BP value or Hepatitis vaccination), leaving blanks only where items are due.

Psychosocial Screening

NSG CPR pulls in information about patient’s abuse history and substance use if it has already been entered on any visit (the screener may overwrite this). The screener accesses prompts with structured pick lists as reminders, then determines appropriateness of a referral for social work services. The CPR then prompts with the list of social work groups for the screener to select.

Social Worker Assessment

MD, SW The social worker is notified both via a paper request and an online work queue. The CPR pulls information entered during the screening forward into the social worker’s assessment. Once documentation is complete, the CPR changes the status of the assessment from ordered/pending to complete and removes it from the worklist.

Nutritional Screening NSG CPR pulls in height and weight if it has already been entered on any visit (the screener may overwrite this). It then calculates the desirable body weight (DBW). The screener enters information about the patient’s relevant history and risks using structured pick lists. The CPR then checks against predefined rules regarding DBW calculations/diet risks and automatically generates a referral for assessment if appropriate. CPR prints a copy of the referral for the patient, and routes it to an online work queue for the appropriate dietician.

Dietician Assessment MD, DIET The dietician is notified both via a paper request and an online work queue. As the dietician documents the assessment, the CPR calculates fields, e.g., number of Kcal and grams of protein needed per day based on patient’s size (previously entered by screener) and entries by the dietician to standard questions. The CPR then changes the status of the assessment from ordered/pending to complete and removes it from the worklist.

Specialist (Consultant) Referrals

MD CPR requires certain information from the orderer, and provides standardized pick lists to indicate subspecialty and number suggested of visits. As doctor places the order for a specialty referral, the CPR checks which insurance plan is paying for the visit. If it finds a defined managed care plan, it retrieves the rules for this payer and type of referral from another internal CPR database and displays it to the user. Regardless of the payer, it generates a specialty referral form used to move the patient through the system.

Managed Care Authorization & Forms

MD CPR automatically generates a managed care authorization form as a byproduct of every specialty referral order for a managed care patient. It also checks several internal databases to determine (and print on the referral) the patient’s plan ID number, an authorization number from the appropriate plan’s pool, the name of the PCP, checks whether the author is authorized to sign for the PCP (in the same practice group assigned to the patient), and the plan ID number of the PCP. If the orderer is the PCP or an authorized provider, it prints a message that the referral has been electronically signed, otherwise it prints a signature line. As another byproduct of the online order entry of specialty referrals, the network’s managed care office receives daily reports listing which patients had referrals and restricted procedures ordered. This gives them the lead time necessary to make sure the signed form is submitted to the plan in advance of the pending appointment or test.

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Function Order Entry/ Data Capture By

Data Entry Controls / Notes

Cytopathology MD, LAB

CPR requires several fields to order the test, and provides standardized pick lists for specimen type and body site. CPR flags all non-Gyn cytopathology orders as STAT. It controls lab data entry and processing by lab staff through security positions – restricting some staff to accessioning or initial slide creation documentation. CPR controls data entry with standardized pick lists of diagnoses and symptomology per Bethesda system of classification. CPR internal rules force supervisor or physician review based upon historic patient results (it scans for previous abnormal findings), type of finding on this slide, and technician dependent QC rules. CPR then drives the event to the appropriate work queue and will not change it’s status to complete until the appropriate action has been taken.

Surgical Pathology LAB

Orders are placed by the surgical pathology lab staff only. The CPR controls this access by security position. Pathologists code in SNOMED in the CPR by accessing the CPR’s SNOMED database.

Chemistry, Immunology, Hematology, Microbiology

MD, LAB, IF CPR requires certain information in the order and result process, prompting with standardized pick lists. Some processing is performed manually, but most data is passed back and forth between the CPR and the accessioning robot or instruments via interfaces.

Radiology MD, RAD, IF CPR requires certain info in the order and result process, and provides standardized pick lists for view, type, and body site. The CPR supports bi-directional interfaces linking together the Radiology departments’ PACS and voice recognition systems, checking patient and visit identifiers during these transactions. The CPR auto-schedules these procedures.

Obstetrical US & testing

MD, OBS

CPR requires certain information in the order and result process, and provides standardized pick lists for view and type. It provides standard pick lists of diagnoses and range limited fields for measurements. The CPR auto-schedules these procedures.

Non-Invasive Cardiology

MD, CAR

CPR requires certain information in the order and result process, provides standardized pick lists for type of study, and restricts the ordering of certain procedures to Cardiologists only. It provides standard pick lists of diagnoses and range limited fields for measurements. CPR auto-schedules these procedures.

Cardiac Catheterization

CAR

CPR requires certain information in the order and result process, and provides standardized pick lists for type of study. It restricts the ordering of all procedures to Cardiologists only, and provides standard pick lists of diagnoses and range limited fields for measurements.

Resource Scheduling RAD, CAR, OBS, CC

CPR automatically schedules tests based on timeframe indicated by the orderer and with definitions/rules about which procedures can be done where, test duration, etc. Department and clinic clerks can also manually perform the function but the CPR controls them by only displaying appropriate room and time slots.

Triage Note NSG Standardized prompts, required fields, range limited fields. History ALL Standardized prompts with pick lists, range limited fields. Physical Examination MD Standardized prompts with pick lists (especially for body system symptoms), range

limited fields, abnormal & critical markings. Assessment & Plan MD Standardized prompts with pick lists, required fields. Nursing Notes NSG Standardized prompts with pick lists, required fields. Pediatric Milestones & Guidance

ALL Standardized prompts with pick lists.

TABLE KEY QHN HIS CLINICAL DATA CAPTURE MODEL

--- = Not applicable CC = Clinic clerks

MD = MDs, NPs, CNMs, and Pas LAB = Laboratory clerks, technicians, supervisors, physicians/PhDs

ALL = MDs, NPs, CNMs, PAS, and nursing staff

RAD = Radiology clerks, technicians, radiologists

NSG = Nurses OBS = Obstetrical ultrasound clerks, technicians, maternal/fetal

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physicians RPH = Pharmacists CAR = Cardiology clerks, technicians, cardiologists

DIET = Dieticians IF = Data/information provided to CPR via interface

SW = Social workers

The above table does not include the approximately 250 new processes that physicians

have recently begun ordering online on the inpatient units. They include orders for nursing procedures, and requests to various departments for services like social work and discharge planning, food and nutrition, and respiratory therapy. Additionally, physicians have recently begun ordering all online department services (lab, radiology, cardiology, neurodiagnostic testing, obstetrical ultrasound, and all medications) for inpatients, which they were accustomed to doing for outpatients. As of April 2002, all patients seen in any EHC inpatient or ambulatory care delivery setting benefit from the application of consistent rules based clinical decision support for CPOE.

Availability of the Electronic Patient Record

There are CPR PCs in every location where clinical documentation is performed at all Queens Health Network care sites, including all outpatient examination rooms, outpatient nursing, social worker, dietician, and telephone triage nurse offices. PCs are also available at all workstations in the departments processing online which include all laboratory sections, radiology, non-invasive cardiology, neurology and rehabilitation neurodiagnostic testing areas, the pharmacies and obstetrical testing units. There are terminals on every inpatient unit, and scattered throughout the emergency departments, as well as in health information management (HIM), quality assurance (QA), finance and other departments for review of patient information.

The larger offsite clinics access the CPR directly on the wide area network (WAN), but the smaller school based clinics dial up to the servers located at EHC. The reference laboratory dials into its own PC on the network, which then communicates with the CPR. The other HHC hospital laboratory sends select specimens for processing and pushes transactions to the Queens Health Network CPR via the corporate network. CPR Features Facilitate Access to Clinical Information

The CPR provides immediate access to patient specific information, and enables the extraction and aggregation of data. Integrated displays present data regardless of whether they are documented by a physician as part of a clinic visit, by laboratory instruments, spun off by the CPR as an order. The integration of patient information processing and display in the CPR has provided significant benefits for patient review and processes, and for intradepartmental processing of tests, treatments and activities.

The Ulticare/Patient 1 Chart Review function provides summary level, detailed, longitudinal and encounter specific data review for each patient. User specific, customizable chart review screens display patient data grouped into categories for ease and precision of review. Categories may be created based on data provided by a specific department, or based on a clinically relevant event time, or based on the data’s relevance to medical body systems or disease paradigms. These data can be provided in summary, detail, trended or graphed formats.

Users may select by category (e.g., all hematology results), by test (e.g., all chest X rays), or for all activity for a specific date and time (e.g., yesterday morning at 6 a.m.), or they may simply display everything in reverse chronological order. The system also

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enables specific “data review groups” and reports to be linked to chart review that can further define the information display.

Most users across the network share the same chart review display screen, but some are restricted based on job function to their own department’s activity, e.g. cardiology clerks can only see cardiology testing, not physician notes.

A clinician may wish to check a previous value while in the middle of performing documentation (e.g. a BP result). The clinician can obtain previous test results and get to other data reviews with one keystroke, without losing the place in the current, unsaved documentation.

The software enables the creation of “data review groups,” screens containing various data elements in sequenced displays, as defined by individual services. For example, the CPR has specific review mechanisms for the medication administration record for data captured inpatient care assessments.

To satisfy a physician’s need to see the result of a specific test in the context of other results (i.e., trended with other values), the test can be defined at the level of the database. For instance, select the most recent fasting blood sugar result to review not just today’s value, but the patient’s most recent FBS by nursing, chronologically interspersed with the most recent laboratory glucose levels.

The software provides a user defined database (UDD) tool that can be programmed to display a snapshot of data according to various rules defined by individuals or departments. Reports may be generated by users from a specific menu point, system generated from within chart review, or for specified users, printed to paper. Some useful informational displays currently in use include the “Patient Summary Report,” “ACOG Summary Report,” and “Pediatric Visit Summary Report.”

Integration of patient data is transparent to users of the CPR. All patient data obtained from the two acute care hospitals and the 17 clinics in the Queens Health Network display in the electronic record. The user need not specify the particular facility, or often, the encounter in which the data were collected or documented. Summary, detail, trended and graphed data display in an integrated manner across the continuum of care. In addition, the source of the data is collected in the CPR and can be viewed by users when encounter specific review is required. DECISION SUPPORT, WORKFLOW AND COMMUNICATIONS

The most successful functions in the QHN CPR integrate the operational with the clinical, yet the multiple needs they serve are often transparent to the user. Many are global in nature, and users see the results employed throughout the CPR. The design objective is to examine clinical work processes and creatively combine the available software tools, using good, old-fashioned management techniques to create real, integrated solutions.

Because of the high level of system integration, most key functions defy classification into one category or another. For instance, when the physician orders a specialty consultation online, the CPR simultaneously provides decision support, communication between services, and support for administrative processes. The CPR integrates the processes of alerting caregivers that they are placing orders for a managed care patient, displays appropriate plan specific rules regarding care, issues a plan authorization number and generates the caregiver’s plan identification numbers or name of the primary care provider, then prints notification to the Managed Care office. The QHN CPR includes many examples of this integrated approach:

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Embedding Real Time Alerts and Information into the Order Entry Process. An integral component of the software is the ability to check during medication orders for drug-drug interactions, drug-allergy interactions, and correct dosing. Additionally, duplicate order alerts are built into the order entry process for departmental tests, medications and specialty referrals. These are knowledge based and defined in the database on a test-by-test basis. For instance, if a caregivers order a second urine culture test within an hour they are alerted to the fact that one is already ordered, while multiple orders for MI Panels within an hour do not trigger alerts. Embedding Real Time Alerts into the Order Result Process. Test results that fall outside normal defined ranges are highlighted as “abnormal” or “critical” values in chart review. Billing rules are based on the care setting; for example, outpatient caregivers are prevented from selecting emergency, inpatient, or ambulatory surgery visit types as they proceed through functions performed from the outpatient menus. Additionally, built into each specific coding sheet is logic defined by DEDs which link the appropriate codes in the ADT interface to alert the provider that they have chosen a visit for another clinic, or an old or discharged visit.

Changing the Way Physicians Receive and Review Results. Before the implementation of the CPR, departments (laboratories, radiology, cardiology, etc.) printed at least two paper copies of every patient result. The first was sent to HIM to be filed in the paper chart. The second was printed in batches by ordering location, and then either delivered, or left in mailboxes to be picked up. These efforts caused delays that could be measured in days, not hours. Printouts might be delivered to the wrong location and were not sorted by, or delivered to, the specific caregiver who ordered the test. Normal results were not filtered, so staff members were forced to review all test results.

The Ulticare/Patient 1 Physician Review Queue returns the results of tests ordered to each physician who ordered them. The queues populate in real time so that as soon as the first results of a lab panel are documented, the information begins to stream into the order author’s review queue. To expedite review of important results, data filters block certain items from appearing in the queues. For example, at the request of the steering committee, normal laboratory results don’t display in the queue, but abnormal, critical, or unmarked results do. The project team can define that results should display immediately at certain levels, and which results should be suppressed until verified by department supervisors or physicians (e.g., cytopathology results will not display in physician review queues or chart review until the required pathologist verification has been performed). The system also enables filtering by visit type: clinic patient and inpatient results display in the review queues, emergency patient results do not.

The review queue enables the medical staff to define the manner in which they review results, for example, STAT results first, or a summary list of abnormal and critical results. Data may be trended or graphed. The CPR logs an entry in the event audit trail that contains a permanent record of all processing and review activities. Providers spend less time looking for critical patient data and more time analyzing and acting on it. Applications are Customized by Service, Yet Standardized Across Services. The QHN electronic ambulatory care chart consists of co-located functions and review displays, menus, and securities customized for each service. They also share common characteristics and components that support standardization of care across services. The applications provide almost

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paperless record keeping for patients seeking care at any of the QHN sites, are shared across the continuum of care, and eliminate duplicative documentation. Primary care chart functionality includes: Extensive well patient notes, which are population specific. In pediatrics, for example,

the note prompts for age specific developmental milestones. If the child has not achieved certain milestones by the appropriate age, the CPR assigns a score to the overall delay and makes a referral recommendation in accordance with New York State Department of Health (DOH) policy. The CPR also calculates the population percentile for height, weight, and head circumference as it is documented online, and prompts with age-specific anticipatory guidance topics recommended by the American Academy of Pediatrics (AAP).

Obstetrical progress notes include extensive documentation of menstrual, contraceptive, and pregnancy history. These data are stored and redisplay at future visits so they may be reviewed and appended easily. The obstetrical note also includes measurements taken at every visit: e.g., fundal height, fetal lie, fetal heart rate, mother’s weight, which are displayed in a trend so patterns may be more easily identified.

All primary care progress notes contain patient history and physical examination findings by body system, as well as caregivers’ assessment and plan. Records of multiple pregnancies are kept separate, driven by patient’s first treatment date.

Patient intake screens include nutritional and social screenings. The CPR includes rules that calculate and identify threshold scoring that vary depending on the population, and refer patients for support services based on score and location.

Grid displays of health maintenance tests and immunizations. These are driven by the patient’s age and sex, and provide a snapshot of both what has been done and what needs to be done for the patient.

Triage notes for sick patients include chief complaint, history of present illness, and vital signs that subsequently display to the physician as s/he examines the patient.

Orders placed by physicians pull forward to display in nursing notes documented later in the visit. This enables nurses to quickly determine their responsibilities for the patient, and eliminates transcribing orders, improving patient care and patient safety.

Attending physicians expediently document their supervision of and concurrence with residents’ examinations and findings in notes utilizing options approved by finance and clinical leadership.

Interdisciplinary patient/family education is accessed by all medical, nursing, and many ancillary staff. The initial screens prompt for documentation of patient’s preferred language, barriers to learning, clinical teaching priorities, and more. Subsequent screens prompt for JCAHO-required encounter specific criteria, including topic, method, and patient comprehension.

Electronic Work Queues Reduce Reliance on Paper and Speed Turn Around Time. Ulticare’s unique event architecture can create multiple events from one order (e.g. tid) and then process each as separate entities. The software has been customized to move events from one user’s processing queue to the next as work proceeds. The work queues aid in work management, from order through completion, in the way that a paper tickler file might. After one

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part of the process is completed, the event will disappear from that queue and move into the next one in the process. Medications ordered for inpatients are electronically routed to pharmacy worklists.

Sophisticated algorithms route different types of orders to different work queues, as appropriate. For instance, discharge medications are needed now, not in the next scheduled cart fill; TPNs or chemotherapy require a third level of review and processing.

If a STAT CBC is ordered at Queens Hospital Center, it will appear in the STAT Hematology work queue to be processed by QHC’s Rapid Response Lab; however, a routine order for the same test will appear in the work queue for the Elmhurst Hospital Hematology lab. This effect of the consolidation of the network laboratories is transparent to the caregiver, and results appear in the correct order review queues and the patient’s chart review.

Events change “status” in the CPR, which are defined primarily at the test level in the database. For example, a laboratory event will first appear in a work queue to be collected by a lab phlebotomist or in another queue for collection by nursing. After the phlebotomist or nurse has documented that the specimen has been collected, it moves to a list to be accessioned, then to a dispatch work queue (if it is to be sent to another facility – this is also defined at the test level), then received and re-accessioned, then to a specific instrument work queue (there are 46 possible destinations, plus manual resulting work queues). If all required result fields have not been completed, it will move to a “partial” work queue, and when all required fields have been satisfied, it will finally fall out of every work queue as “completed.”

The Microbiology workcard functionality in the CPR enabled the phasing out of paper workcards. Complicated culture processing is performed online for all cultures, including wound, tuberculosis and fungus cultures. Complex processing algorithms that guide culture activity processing were implemented, automating the organism identification process. Free-text data entry is minimized, permitted only when online functionality is insufficient to accommodate highly variable result responses (such as is found with parasitology result processing).

Online documentation of critical test results has been improved through an integrated display of patient location with the actual laboratory test results. This facilitates communication of critical results from lab to caregiver with one phone call.

The EHC Radiology Faculty Practice group codes study supporting diagnoses after the Radiologists have finished reading by using a customized work queue, accessing an online ICD-9 database.

Result verification queues push billing encounter forms documented online by residents to the supervising physician for verification before billing.

CPR Minimizes Work Duplication and Maximizes Interdisciplinary Communication. Data elements with specific storage locations and characteristics are defined to facilitate the sharing of information. These include: non-historic data elements, which are never shared (each caregiver must take the same measurement and record it every time, e.g., fetal lie); visit-historic (saved for the duration of one visit, such as LMP, which will display to multiple caregivers throughout the

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visit); or patient-historic, which are saved for the patient’s lifetime (e.g., the age at menarche). This functionality is widely used in the primary care chart. For example: After the triage nurse documents the patient’s complaint in the triage nursing assessment,

it will appear in subsequent physician progress note screens to validate or edit, not retype. While writing the progress note the physician documents specific orders for the nurse to

carry out, e.g., “FBS,” or “educate on medications” in the “orders to nursing” field. Later, as the nurse writes a nursing note, the CPR displays these nurse-specific orders along with other orders the physician has placed online (for labs, radiology, prescriptions, specialty consults, and so on). The nurse is aware of the full care plan and can “pick up” his/her orders.

CPR Maximizes Communication Across Departments. Utilization of software features such as UDDs, DEDs, and reporting tools have improved communication across departments. The managed care office receives daily reports of specialty consults and specified

procedures ordered the previous day, enabling staff to proactively obtain the necessary PCP signature or plan pre-authorization.

CPR tools have been used to create real time printing of telephone triage documentation to the appropriate location (for example, the pediatric emergency room), under specific conditions. The triage nurses merely document their calls online, consequently alerting other staff of the pending arrival of urgently ill patients.

Referrals for ambulatory surgery, which generally require financial clearance, are printed directly from the ordering surgeon to the admitting department, alerting them to begin the clearance process.

The CPR communicates specific ordering information to caregivers. For instance, when a barium enema is ordered, the CPR requires certain questions to be answered, prompts the caregiver to prescribe certain medications to be taken the night before, and prints a set of patient instructions in English and Spanish.

CPR is Designed to Ensure that Regulations Are Met. Workflow analysis for each new application includes the definition of all applicable standards and required regulations by the department. The database is then constructed to meet these requirements, for example: The patient summary report was written to satisfy the JCAHO standard requiring that

patient problems, allergies, significant medical and surgical history, and medications known to be taken by or prescribed for the patient are available in one location in the chart.

The obstetrical record was designed to meet American College Of Gynecologists (ACOG) and New York State Prenatal Care Assistance Program (PCAP) requirements for documentation.

The pediatric immunization recommendations adhere to the AAP standard. The pediatric milestones and guidance follow the AAP standard, and generate referrals

for early intervention according to New York City DOH standards. Age-specific head circumference, and height and weight percentiles calculate according

to National Center for Health Statistics growth charts.

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The cytopathology laboratory processing utilizes the Bethesda coding schematic, and complies with the College of American Pathologists (CAP) cytopathology guidelines. All laboratory modules are CAP compliant.

All applications are constructed to generate the correct charge or prompt for manual coding, and require the appropriate verification signatures to support accurate billing per state and federal reimbursement regulations.

CPR Maximizes Organizational Quality Checks. Department specific quality assurance tools have been created to identify issues across care venues. For example: The laboratory commissioned detailed reports that identify specific organisms and

infection control patterns. Radiology utilizes a report that scans surgical pathology reports for occurrences of cancer

related strings, then searches for radiology reports for the patient within a three-month window before the surgical pathology finding. An outside radiologist consultant then compares both the body of surgical pathology report findings and the radiologist findings to determine clinical appropriateness.

Laboratory quality control processing and analysis is consolidated into the CPR utilizing online QC data capture and review functionality, eliminating manual or standalone QC programs, and incorporating electronic signature for QC data review. Data from quality controls and instrument/equipment preventative maintenance can be reviewed simultaneously, and functionality for online trending and graphing of QC data is available.

TECHNOLOGY

The computerized patient record deployed in the Queens Health Network supports the clinical activities of 2,800 clinical staff members, including nearly 800 physicians who access the CPR on a regular basis to retrieve patients’ diagnostic data. These clinicians treat more than 3,000 patients each day at two acute care hospitals and in more than 600 clinics, offsite satellite facilities and school based programs. The Queens Health Network supports integrated care delivery across all venues through the sharing of all clinical data relevant to caregivers. To get clinicians to use the CPR, the electronic data must have more value—for example, be more convenient, more timely and more relevant than the data that used to be recorded in the paper chart. Scope and Design of the CPR System

The primary system used at QHN for the CPR is the Ulticare/Patient1 system developed by Per Se Technologies. This system offers the ability to manage clinical data in all care delivery venues while maintaining data integrity. The focus on a patient centered record is important in a municipal health system where service offerings are constantly scrutinized to insure that quality care is delivered. Clinical data must flow seamlessly from the service provider to the CPR and back to the clinician. All textual clinical data that has been automated resides in this CPR and is accessible from any of the nearly 3,000 PCs across the QHN. Radiographic, MRI and ultrasound images are available at any clinical desktop via a PACS system developed by AGFA. Full diagnostic quality images are available on high-resolution monitors in key areas: the emergency department, intensive care units and orthopedics). Compressed images are available via a Web

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browser from any desktop in the organization. Clinicians also can access databases/medical libraries and Internet clinical content providers via the clinical desktop. (See APPENDIX III: Queens Health Network Health Information System.)

The Ulticare/Patient1 system is hosted on a multi-processor ring using a proprietary fail-soft technology developed by the vendor. There are two quad processor AViiON CPUs that act as the primary and secondary clinical data gateway processors. Each processor supports dual controller, mirrored, RAID5, hot swappable disk storage. There is currently 240 GB of clinical data that is mirrored, RAID5'd and stored on two separate disk arrays. These two processors act as mirror images of each other and offer the users connected via the application servers instant access to the entire clinical database. The architecture provides four copies of redundantly stored clinical data in the mirrored environment. The architecture enables these mirrored processors to be remotely sited without degrading performance as long as there is fiber in place to run the FDDI network. (See Appendix IV: QHN HIS Enterprise Network)

Clinicians log in from their PCs via an enterprise network using redundant local- and wide-area network technologies with auto fail-over to the CPR. Once connected through the remaining six Data General CPUs (AViiON 3700R dual processor machines), they can access clinical data from today through the beginning of the implementation in 1997 and also may access data that pre-dates the implementation because it was converted from legacy systems. All of the CPR servers in the processor ring are connected via a redundant FDDI inter-machine network. The architecture can support the loss of multiple processors, disk towers and fiber links without failing. The architecture accommodates as many as 5,000 concurrent users with response times of less than two seconds.

The file storage system used in the CPR is a vendor developed proprietary unified inverted binary tree structure that offers fast data access and storage times. This proprietary system cannot be accessed by external users for other purposes. The CPR takes textual data feeds from internal functional modules as well as external systems that conform to the HL-7 and ASTM communications protocols. The CPR accepts registration, admission, discharge and transfer data from two Siemens (SMS) Unity systems using a proprietary interface. Charge information is passed back down these SMS interfaces. In addition, patient registration can be done directly on Ulticare/Patient1 if the SMS systems are down, and will synchronize when restored.

Clinical data entry is performed in a variety of ways. The primary method is the use of the keyboard and mouse to interact with extensive menu driven screens that are module-, clinic-, provider- and activity-specific. These menus include templates, macros, hot keys, and table-driven selections. The software offers extensive tool kits to pre-load data for clinical validation through defined rules and templates and to collect data from diverse caregivers to consolidate into a final clinical note for physician review and annotation. The software interfaces with voice recognition systems used to dictate all radiology reports. The system also accepts data feeds from reference laboratories and other feeder systems that conform to the HL-7 standard. Finally, the system is interfaced to 46 laboratory instruments to transport clinical data in real time into the CPR.

Clinicians access the CPR from 3,000 PCs connected via the enterprise network. These PCs login through a locked down desktop so viruses cannot be introduced to the network and unauthorized programs and functions cannot be used on the system. QHN also has deployed wireless network technology on the inpatient units to support mobile devices in addition to the current hardwired devices.

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Linkages with outside customers are provided through user specific formats that are uploaded to external systems, and managed by real time interfaces conforming to the protocols above, while ad hoc data needs are met by extracting data using a robust data mining tool that creates data sets that can be sent via FTP to other external users.

The Ulticare/Patient 1 software was purchased by HHC in 1992, primarily because of the scalability of the product, its patient-centered architectural focus, fail-soft technology, the integrated nature of the application module set and the robustness of the toolkit. The CPR supports a multi-facility care delivery model that characterizes the HHC environment, one of the largest municipal hospital systems in the United States. Within the Queens Health Network, a patient-centered CPR has become a necessity to meet the needs of the patient community because patients may be seen in a clinic at one facility one day and be admitted via the emergency department at the other hospital the next day. The emergency department physician needs access to the clinic physician’s notes and the clinic physician, upon the patient’s return to clinic, needs access to the data generated during the emergency care episode. In addition, clinical services have been regionalized, so that patients, for example, are always sent to Queens Hospital for MRIs, and to Elmhurst for radiation therapy. The data must not only be accessible, but must be within a context and continuum that makes clinical sense and is not arbitrarily determined by system architecture.

Patient confidentiality is protected more effectively through the utilization of an electronic patient record than on paper. All clinical data is stored centrally in a server farm that is physically protected and monitored. There is no segregated data that resides in disparate servers in isolated corners of the health system. This centralized database model not only improves integration of clinician views, but also ensures that no clinical data is ever at physical risk. The architecture of the system does not use the local hard drive of any PC for any clinical data storage, permanent or temporary. This means that if a PC is ever stolen (although all of the PCs are physically locked down), the thief steals only hardware, not data.

The CPR uses a closed proprietary data structure that cannot be accessed or manipulated by any user of the system. To an external viewer, the data structure is a single large locked file that is 240GB in size. Users have no ability to manipulate data at the file level in the application. All user access to data is controlled by CPR application functions and these are set to view or view and edit. If a user has security to make an entry in a record, it is recorded via an audit trail with their user ID, a date and time stamp and the device location. Users cannot erase or manipulate this audit trail. Finally, if the user is modifying previously input clinical data, then the prior copy is stored and the new version is marked as supplemented or corrected data.

The system has security controls that enable QHN staff to limit access to certain patient populations or segments of the chart on a per-provider basis. Physicians can be limited to their own patients only, patients in their service or group, patients on which they are officially consulting, or a larger universe of patients. Other care givers can be limited to patients to whom that they are directly assigned, to patients with studies being performed in their work area, to patients on a specific unit or clinic, to patients checked into a specific location, or by visit type or other criteria. In all cases, every patient’s record accessed by any clinician or user of the system is logged in a file that is used to generate chart access reports for privacy audits. QHN management staff actively monitor these reports and use approved employee templates when setting up new users to insure that patient access and clinical data access is clinically appropriate and meets management-promulgated standards.

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The definition of the data model in the QHN CPR has been facilitated by the flexibility of the Ulticare/Patient 1 software. The system comes with all of the standard nomenclature and coding models (CPT, ICD, SNOMED, ACR, etc.) but there are aspects to all clinical implementations that create situations where clinical judgment and systems analysis must be applied to previously non-standardized clinical documentation. The system supports standards by enabling analysts to build clinical documentation tools using standard clinical objects and pull clinical data forward from one care delivery setting into another.

The CPR has a full set of functional and clinical tools that ensure that clinical data is not only presented in a meaningful fashion to each clinician, but can be acted on in real time without having to switch systems. If the functionality resides in the CPR, then its use is required for clinical documentation by all caregivers. Currently, the CPR is not only used for data review, but is also the vehicle for all major ancillary clinical documentation, all physician order entry, and is the primary clinical documentation vehicle for most ambulatory care and inpatient services.

Where the CPR does not offer comparable functionality, interfaces have been developed, based on two principles. First, if it is clinical data, then it must be available in the CPR in real time. Clinical data loses its value to the clinician if it is delayed at the source system. Second, the official record for text based electronic clinical data is the CPR. The CPR never purges data, so once it is migrated from the source system into the CPR, the CPR becomes the permanent storage location for that information. The CPR at QHN creates an integrated clinical data continuum that enables caregivers in any venue to view data appropriate to their needs from across all of each patient’s individual episodes of care. The clinicians cannot tell if the clinical data they are accessing was generated from a foreign system or generated by the CPR modules.

Ulticare/Patient 1 is scalable in the number of additional application processors that can be assigned to the system, as well as the total amount of disk storage allowed. The multi-processor design and data storage architecture of the CPR make the process of adding additional users and modules as easy as adding hardware and the infrastructure to support it. The database tools and programming capabilities organic to the application allow the project team to add new departments and services on demand.

The Ulticare/Patient 1 software includes a proprietary report-programming tool. Analysts knowledgeable about the QHN data model may extract data for any external party using this report writer. QHN currently extracts data for professional billing, quality monitoring, DOH immunization reporting, payer population quality indicators and health maintenance testing quality reporting. The project team has developed numerous statistical and quality reports for review of online departments and processes. Because the data model is a proprietary one, the system does not offer an extensive ad hoc reporting capability. Security and Data Integrity

The Queens Health Network uses a LAN design model that emphasizes backbone redundancy to ensure maximum availability. The design incorporates a collapsed backbone topology using a combination of Gigabit and 100FX uplinks to ensure maximum throughput and performance. Both Elmhurst and Queens Hospitals incorporate redundant core switches that are connected together via a gigabit connection with a combination of gigabit and 100FX uplinks to the edge device switches. Using wireless 802.11b (11MB), with future support for 802.11a (54MB), QHN is preparing the core hospital facilities to fully support wireless within the LAN environment.

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Queens Hospital Center, which has been recently upgraded, has incorporated a Cisco solution that includes dual Catalyst 6509 switches at the core and Catalyst 5500/6009 switches as edge devices. Each edge switch has a primary and redundant gigabit connection connected to each core switch. All core and edge switches have redundant supervisors, switching engines, and power supplies to further ensure maximum availability. The fiber infrastructure includes two separate 18-strand multi-mode fiber cables run in two physically diverse paths. VLAN and trunking technologies have been implemented for network segmentation purposes as to ensure adequate network utilization on the backbone. A structured horizontal wiring solution has been implemented using CAT5e.

Elmhurst Hospital Center has implemented an Enterasys solution that incorporates dual SRR-8600 core switches with three primary switch locations. All Elmhurst core, primary, and back-end edge switches have redundant supervisors, power supplies, and uplink ports. Elmhurst is currently in the process of upgrading its infrastructure. The three primary switch locations will utilize dual SSR-8600 switches each with a gigabit uplink to each core switch. The back-end edge switches utilize a combination of gigabit and 100FX uplinks to the primary switches. The plan is to establish a primary and redundant uplink connection to each primary edge switch and implement VLAN technology. A structured horizontal wiring solution has been implemented using CAT5.

The current WAN is based on a HHC standard design. The design utilizes ATM, Frame Relay and ISDN type communications and Cisco routing hardware. All packets that are routed within the HHC WAN are encrypted to ensure privacy of information moved between networks and corporate offices.

For the two hospitals, there are two redundant Cisco 7206 routers at each location connected to the LAN backbone via Fast Ethernet and to the AGFA LAN via Gigabit. The design has incorporated a mesh topology to ensure maximum network availability. The routers are running HRSP (Hot Standby Protocol) so that, if one router fails, the standby Fast Ethernet port becomes the primary. HRSP uses a floating default gateway address that enables devices to continue to function without changing default gateway settings/addresses. Between the two core hospitals are two OC3 ATM connections, scaled down to 45MB per connection. And there is a 6MB OC3 ATM and a 3MB OC3 ATM connection between each core hospital and the Corporate Data Center. The ATM circuits are configured for a primary and secondary connection. This provides for more than sufficient bandwidth for moving information between Queens, Elmhurst and other HHC locations.

The off-campus locations utilize Cisco Catalyst 24 Port Switches on the LAN side and Cisco 3600 series routers for the WAN connection. The sites are connected to the WAN via Frame Relay with ISDN backup. The frame circuits are either 56K or 384K depending upon network design and size of facility.

Data integrity is maintained using a combination of system and management tools. The system maintains four redundant RAID5 copies of the clinical data across the mirrored servers. Full backups of the system are done on a weekly basis with daily incremental backups. In between the incremental backups, transaction logging is performed to an automated log file so that if a data recovery from back up is required, data stored since the last back up is not lost, and can be applied from the log file. Backups are performed while the CPR is up and available for use. The backup process uses a multi-pass algorithm that will make as many as eight passes through the entire database to back up data blocks that have changed during the backup.

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Because of the multiple data redundancies in the architecture, system failures resulting in data loss have been non-existent during the five years that the CPR has been live at QHN. Even so, clinical data is moved in real time to a relational database that recycles every three days. This downtime system is designed to offer clinicians access to clinical data required to support continuity of care while the CPR is recovered and restored. The downtime system is enabled on the clinical desktop should the CPR fail. The CPR is brought down on a quarterly basis for approximately six to eight hours for software and database upgrades. The downtime system is accessible from every desktop in the network, and only enabled by the project team during scheduled and unscheduled downtimes to maintain record confidentiality.

The CPR operates in a multi-server ring. The data is mirrored across two quad processor data storage servers and the users access the CPR via six other dual processor application servers. All of the servers have redundant power supplies, FDDI controllers, disk controllers, and TCP/IP connections to the enterprise network. The architecture is designed so that up to one of the data storage servers and all but one of the application servers can fall out of the network without preventing users from accessing the CPR.

Servers can be lost for software, hardware, or environmental reasons. When an application server falls out of the network, users accessing the CPR via that server are logged off. To get reconnected they re-insert their data key and type in their password. This process takes less than five seconds. The system also sends a warning via the internal e-mail system to any user who initiated a job on the failed server (i.e., the project team) to alert them that it did not complete and to check their recent work.

QHN staff then contact the vendor and initiate a recovery plan. In most cases, the server can be re-booted and returned to the CPR network within an hour. The application servers do not maintain patient clinical data. They contain tables and files that support operations that are re-synchronized with the data storage server automatically when the server is restarted. Losing an application server degrades system performance only to the extent that the users that were accessing the CPR are redistributed to the remaining servers. Response time may not be significantly affected, depending on the number and type of processes in use as the server fails.

While losing an application server is generally transparent to the users, losing a data storage server would not be. Therefore the CPR has quadruple data redundancy across physically distinct hardware platforms. Should one fail, the risk has increased significantly. The CPR continues to operate, but it is imperative to get the full redundancy back as quickly as possible. Any failure of a data storage server for any reason automatically triggers the IS staff to immediately start a full back up of the remaining data storage server. The vendor also is contacted, and the cause of the failure of the server is determined and remedied. After the data storage server is brought back into the network, the entire CPR database must be synchronized from the data storage server that remained operational. This process takes approximately eight hours. During this time, the clinicians notice a slight degradation (a two- to three-second response time) in system performance. However, while one of the data storage servers is out of the network or being synchronized, clinicians can continue to access the system.

If the CPR is brought down in an orderly fashion, then the CPR can be restarted with minimal disruptions, and users can be logged back into the system within one or two minutes. If the CPR fails abnormally, or is not brought down in an orderly fashion, then data integrity of the CPR clinical data cannot be guaranteed. In that event, the vendor recommends that the CPR be restored from back up. This process takes approximately eight hours after the tapes are retrieved

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from off-site storage. The presence of an alternative system to enable access to clinical data is imperative to support continued clinical operations in the network.

QHN is in the process of obtaining a full disaster recovery solution that will provide a real-time copy of the database (using Storage Area Network (SAN) technology) available at an off-site data center. This disaster recovery solution will provide for the full resumption of system activity in less that two hours during a hardware failure or environmentally caused system failure. Standards

The QHN has adopted HHC wide security practices that include such areas as server and network equipment security hardening, desktop standards, anti-virus protection and intruder detection/secure access solution. INTRUDER DETECTION/SECURE ACCESS:

HHC has contracted with a security vendor to handle all aspects of security related to technology and LAN/WAN. The vendor is responsible for developing and managing policies related to the HHC WAN and enforcing such policies using various types of monitoring and security technologies. Through such technologies and systems, the vendor is able to proactively monitor the network for potential security threats related to unauthorized access, viruses and other abnormal network activities. There are routine network scans run to determine potential security holes and sensors that monitor the network around the clock for abnormal or inappropriate activities. Using a solution that combines Cisco Secure PIX firewall, Cisco Secure IDS Director/Sensors, Cisco 3640 Routers, Cisco 3005 VPN Concentrator, Cisco Catalyst 2924 Switches, and Cisco Secure Access Control Server, QHN has built a secure zone that restricts access, monitors abnormal network behavior and provides secure remote vendor/user access. SERVER AND NETWORK EQUIPMENT SECURITY HARDENING:

Using HHC security hardening policies, QHN is proactively performing hardening services as indicated for all server platforms, including Windows NT, Windows 2000, Unix, Netware, and others. Similar policies are in place for securing networking equipment such as switches and routers. Routine network scans are performed to determine potential security holes. ANTI-VIRUS SYSTEM:

QHN has adopted the McAfee Anti-Virus solution/products that include desktop anti-virus (Virus Scan and Vshield), server anti-virus (Netshield), and a centralized management system for updating anti-virus software on managed devices and actively monitoring for viruses (EPO Server and EPO Agent). The EPO agent is installed on all desktop computers and servers. The agent actively communicates with the EPO Server for pushing out anti-virus software updates and detecting viruses. The EPO Server also provides reporting capabilities for both virus detection events and anti-virus software coverage. DESKTOP STANDARDS:

Using Novell ZEN Works, QHN enforces desktop lockdown policies based on an individual network login and associated network permissions. This enables QHN to secure computer desktops to limit access to administrative tools and authorized applications, prevent access to changing computer settings, and prevent installation of software.

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The clinical desktop provides all clinicians with a common look and feel from any device in the health system. Once in the CPR, each clinician can have individualized tools to support the review and processing of clinical data consistent with their needs and securities. This means that a radiology technologist will have the same access whether they are in the department or on the floor doing a portable exam, but a physician accessing the CPR from the same device on the floor will have a different view that is consistent with their clinical data needs. Doctors who treat patients in ambulatory care settings as well as on the inpatient units have access to different functions depending on their location, but can always access the functions associated with the care delivery process in the other venue. In addition, the system enables the project team to configure various data views to optimize the presentation to clinician groups.

Data content and vocabulary standards are supported by the system based on the use of clinical data objects that offer consistent presentations of terms and vocabulary. These objects are not required for use by individual clinicians, but are available. One example is in the area of patient problem management. The physicians are responsible for managing and maintaining a problem list on every patient. These problems are defined using the ICD-9 table. The physician can select a defined problem from the table, or can free text a problem and correlate it to an existing ICD-9 code. The system supports a database tool kit that enables the development of modules to support clinical documentation in any care delivery venue. This means that QHN has the ability to create unique clinical data and vocabulary objects. QHN convenes a multi-disciplinary group from across each provider service, IT, and HIM when deploying new modules to insure that nomenclature and vocabulary meet the clinical standards mandated by QHN and outside review organizations.

At a system communication layer, QHN prefers to use HL7 and ASTM communications protocols when communicating with foreign system. Performance

The CPR operates 24 hours a day, seven days a week. There is no downtime required for back-ups. Scheduled downtimes occur three or four times per year when the software is updated. These downtimes are scheduled during off hours to minimize disruption for clinicians and ancillary departments. While the CPR is down for these scheduled downtimes, the clinicians can access recent clinical data using the downtime system.

Response time on the system is normally less than two seconds. When a data storage server is being synchronized after failure, this time will increase to three or four seconds. Filing times for orders and clinical documentation average five or six seconds. This makes clinical data immediately available to all caregivers in the enterprise within six seconds of it being input and approved.

The multi-server environment makes hardware upgrades relatively painless for the clinicians. QHN has taken servers out of service individually and in batches to make hardware and operating system upgrades while leaving the remaining servers up so clinicians can still access the CPR. The vendor releases software updates after an internal QA to all of their clients. QHN does not load this software to the development environment until it has successfully been installed by several other clients and by at least one other client in the HHC network. While on the development system, the software is tested against a series of scripted scenarios to ensure that existing functionality has not been damaged by the new software. All new application development performed by the QHN analysts is assessed by senior clinical staff from the areas

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being implemented and is reviewed for proper functionality, gap identification, standards compliance, and operational appropriateness.

QHN recognizes that a CPR can never be a static tool. Clinicians and departments are always adding new tests and services, modifying standards and procedures, responding to the paradigm shifts that affect the healthcare delivery marketplace. To be an effective tool for clinicians, the CPR must be flexible and responsive to these needs, and the IT team tasked with its deployment must be eager to embrace and codify these changes. QHN’s CPR and project team meet that challenge every day. VALUE

The need to keep patients well and keep patients well served has never been greater. In an era of cost constraints and performance expectations imposed by purchasers, regulators, and an increasingly informed public, the challenges are formidable. The expectations of the QHN Medical Board and senior administration regarding an electronic patient record were that:

Documentation of clinical data throughout the lifetime of the patient, and across the continuum of care, would be facilitated and improved.

Improved quality of patient care would be supported through access to and availability of patient information.

Clinical information from various legacy systems would be integrated into one CPR.

The successful evolution of an expanded and decentralized primary care network seemed predicated on the development of an electronic patient information system. The logistics of the exchange of patient records among numerous patient-care locations seemed insurmountable, especially when viewed in the light of the problems inherent in providing paper charts to existing locations. The decision was made to begin CPR implementation in the ambulatory-care setting, where the pressing need to provide solutions to encumbered processes was obvious, then proceed through conversion of diverse legacy systems, and on to the inpatient setting. Applications and functionality would continue to be added to the CPR in continuous development cycles.

Success would be measured by creation or improvement of processes that impact patient care: improved access to patient information; complete, legible clinical documentation to support quality patient care and promote a safe environment; and timely and accurate patient data provided at the point of service throughout the Queens Health Network. Design and implementation of an electronic medical record was viewed as essential to the development of an effective infrastructure from which to support the reorganization of care, the design and refinement of quality measures and reporting processes, and the practice of evidence-based medicine to improve management of chronic disease. Process Reengineering through Creation of a CPR

The CPR has become the primary source of clinical information for caregivers and ancillary departments in a complex, municipal healthcare network that serves a high volume of patients across a diverse ethnic and geographic region. In the process, it has transformed the way clinical information is recorded and shared.

Implementation of the CPR requires a series of activities to be defined, executed, and quantified in a way that had not been done before. Dimensions of certain processes of medical care generally accepted as basic prerequisites of good care have been automated and, in the process, improved upon. One way to quantify the contribution of the CPR to improving patient outcomes is through an interactive process of defining and transforming various operations.

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Process improvements can be measured by analyzing various actions and their effect on practices that affect patient care.

One example is the installation of nutritional screening tools for new patients in ambulatory care. (See Table 3) In response to JCAHO requirements to compile and share nutritional assessment information, nutritional screening was initiated on paper in medical primary care, then expanded to the medical and surgical subspecialties. An online nutritional screen, complete with decision support, became available in March 1998. Another tool, developed for the obstetrical population, was implemented in June 2000.

TABLE 3

DEVELOPMENT OF AMBULATORY CARE NUTRITIONAL SCREENS

Opportunity for Improvement

Action(s) Implemented

Indicator Measurement Impact on Processes/Patient Care

JCAHO Type I Recommendation: nutritional assessments incomplete

• Interdisciplinary work group convened.

• MPC nutritional

screening criteria refined and built as component of electronic primary care chart.

• Nurses, health

educators, physicians trained.

• Screening process implemented on HIS.

• On-line screening tool designed, demonstrated, revised.

• Curriculum written. • Training completed. • Number of screens

completed by nursing staff in MPC and Medical Specialties.

• Support for and

monitoring of tool utilization.

• Interdisciplinary group and HIS Steering Committee approved.

• Curriculum and training

completed for 100% of current staff.

• Number of screens

completed will increase until 100% of new patients is achieved.

• On demand training of new

staff; continuous training of all staff.

• Ongoing HELP DESK

support for all users.

• Patient screening information readily available to all patient care providers.

• Data serves as

foundation for nutritional assessment to be completed by dietician.

Need screens appropriate for Obstetrics population

• Interdisciplinary work group convened.

• WHS nutritional

screening criteria defined, then built on HIS.

• Nurses, physicians

trained. • Screening process

implemented on HIS.

• On-line screening tool designed, demonstrated, revised.

• Curriculum written. • Training completed. • Number of screens

completed by nursing staff in WHS.

• Support for and

monitoring of tool utilization.

• Interdisciplinary group and HIS Steering Committee approved.

• Curriculum and training

completed for 100% of current staff.

• Number of screens

completed will increase until 100% of new patients is achieved.

• On demand training of new

staff; continuous training of all staff.

• Ongoing HELP DESK

support for all users.

• Patient screening information readily available to all patient care providers.

• Data serves as

foundation for nutritional assessment to be completed by dietician.

The development of the electronic nutritional assessment is one component of an

incremental process of improving care delivery in ambulatory care. The electronic screening tool is an indicator that a series of measurable actions have been taken: the refinement of nutritional screening criteria, curriculum development and staff training, user support and monitoring

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utilization of the tool. Patient information that was fragmented and incomplete has been improved by making patient screening information readily available to all caregivers, and providing data to dieticians to serve as the foundation for the patient’s nutritional assessment.

Opportunities for improvement may prove possible in an electronic world and replace limited capabilities with ones that did not previously exist. For example, gestational age is automatically calculated in the QHN electronic prenatal record, replacing manual calculations made at each visit before the CPR was implemented. Patient information has become dynamic, e.g., every screen in the electronic patient record reflects in real time the aging of the patient, and the display of health maintenance test alerts will change across time to reflect the age of the patient. The characteristics of the medical record are being transformed from those of a static medium to an interactive one.

It has taken some time for the organization to recognize that the electronic media is intrinsically different from paper. The electronic media is, by definition, interactive. It requires interaction initially to design and develop and then, in its final stage, to interpret. Even the name for the paper media, “hard copy” illustrates the difference: paper is static and tangible, electronic information fluid and reactive. The process of transferring manual processes to computer is at its core different from replacing one paper form with another. The traditional method where the medical records committee approved each piece of paper for insertion into the chart, with minimal consideration of the associated work processes, has been transformed through an interactive process where redundant and useless activities and paper are replaced or eliminated altogether.

It has become necessary to examine the assumptions that underlie quality care and consider which elements must be maintained or which may be improved. The CPR has served as a focal point for discussion and compromise regarding operational and clinical practices. A rigorous methodology for consideration of these issues is adhered to by the HIS project team, and respected by the clinicians. Determinations are made regarding what information is needed to perform tests, satisfy clinical pertinence, auditors, or third-party payers, meet or exceed professional peer standards, as well as regulatory authorities. Efforts are made to include variations in practice from one service to another, and one campus to another. The system then is programmed to apply certain standards, even if the user is unaware of them. For example, the CPR prompts physicians ordering specialty consultations with rules appropriate to the various participating managed care plans. This standardization occurs regardless of the user’s awareness of changing regulations or protocols.

The CPR serves as a catalyst for the development of clinical practice standards across services and departments, both within the hospitals, and across the network. Although the Queens Health Network delivers more babies than any other provider in Queens (nearly 7,000 each year), individual practices may vary from site to site, and even from doctor to doctor. All adhere to the ACOG practice standards. However, within the Elmhurst group, it took an extensive discussion among several attending physicians, the chief of service and a physician’s assistant to define the algorithm to electronically calculate EDC, with each caregiver explaining their preferred method of twirling the pregnancy wheel, and citing academic textbooks before coming to agreement.

QHN’s commitment to institutional change extends beyond the CPR to entire operations, as opposed to piecemeal, incremental changes to paper forms. Re-engineering processes to foster improvements and access to patient care has been the hallmark of the design and development of the CPR. Now, all staff manage patient information; this is not an easy concept to grasp and

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realize. Every individual has an enhanced capability to collect and interpret patient information that did not formerly exist.

Physician Data Entry

In 1996, there were no personal computers in exam rooms, and patient information was often difficult to get and incomplete. Currently, there are almost 3,000 PCs, with local- and wide-area networks to support them. A walk through any clinic, department or inpatient unit finds nurses and doctors, dieticians and social workers, physician assistants and nurse midwives, lab and radiology techs all busy documenting their work in the CPR.

From the start, physicians, nurse practitioners, certified nurse midwives, and physician assistants have been required to place their own orders, write their own prescriptions, and document their own encounters in the CPR. This work is not written on paper and then transcribed by less medically qualified staff. While it may be true that support staff are often more amenable to computer work (not to mention faster typists!), the CPR contains and presents real time clinical information to which only the medical professional can interpret and respond. To that end, the system privileges of nursing and support staff do not allow access to the computer screens necessary to perform these functions.

Furthermore, for a CPR to communicate and guide practice patterns, for instance, by alerting the provider that a test already has been ordered, or that prescribing a drug will create an interaction with a previously prescribed medication, the most sophisticated users must interact with the system. This requires the direct involvement of those who are authorized and able to make medical decisions.

Utilization of the QHN CPR by all staff has been required throughout all phases of the project, beginning in ambulatory care. Monthly snapshots of usage statistics indicate there are more users logging onto the CPR and spending more hours in the CPR every year.

Table 4 indicates that in January 2002, every physician in the Queens Health Network logged on to Ulticare at least once. In the past year, the number of log-ons to the CPR more than doubled, and the number of users of the system was increased by 83 % (because of the lab conversion in April 2001). These statistics show utilization of the CPR at a consistently high level across the organization.

TABLE 4

UTILIZATION OF QUEENS HEALTH NETWORK CPR

Y ear T otal H ours on CPR # Log-ons # M D users # A ll users Avg H rs/U ser/M onthJanuary 97 10,657 16,753 334 505 21January 98 13,965 13,987 400 561 25January 99 34,978 35,871 545 1,064 33January 00 50,579 49,116 621 1,253 40January 01 71,145 60,474 628 1,441 49January 02* 114,187 132,247 757 2,635 43

*Increase in log-ons vs. decrease in average hours logged on because of lab conversion, with more users quickly reviewing results.

Online documentation by physicians and midlevel providers has paid big dividends in

quality and completeness of clinical documentation. Queens Hospital Center reports a 50% decrease in the number of pharmacist interventions in medication orders in ambulatory care because of the system alerts, and the improved legibility and completeness of the prescriptions.

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At Elmhurst, by 1999, the completion in the electronic medical record of certain performance indicators, e.g., patient problem lists, orders/referrals for mammography, Pap smears, and diabetic retinal examinations had reached 100 percent. (See Table 5.)

TABLE 5IMPACT OF ONLINE DOCUMENTATION ON PI INDICATORS

68% 89% 100% 100% 100%

78% 96% 100% 100% 100%

73% 98% 100% 100% 100%

68% 95% 100% 100% 100%

1997 1998 1999 2000 2001

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Problem List Completion

PAP

Diabetic Retinal Exam

Mammogram

Problem List Completion

PAP

Diabetic Retinal Exam

Mammogram

Further, compliance with the JCAHO-mandated summary list completion (patient diagnoses, significant invasive and operative procedures, allergies and ADRs, and medications known to be prescribed for or taken by the patient) was monitored three months before and six months after the summary list was converted from paper to the electronic medical record, to evaluate whether conversion to the CPR would improve completion. All four elements of the list were required to be complete in order for compliance to be achieved in any individual record. Charts were sampled in random fashion on an ongoing basis throughout the nine-month period of the study, in numbers proportional to the visit frequencies of the various primary care and specialty practices at Elmhurst Hospital Center. Implementation of the CPR led to a substantial and sustained improvement in compliance with summary list completion (from 3.7% in the three month pre-implementation period, to 100% in the six-month post-conversion period), providing immediate access to vital clinical information with much greater reliability, in addition to satisfying JCAHO requirements (R.A. David, D.M. Carr, et al. Departmental Research Day Poster Session, Elmhurst Hospital Center, Elmhurst, NY and Mount Sinai School of Medicine, New York, NY, 1999).

As CPR functionality is implemented, paper forms are removed from the clinical areas in an attempt to force the medical and support staff to use the CPR. Of course, there are still some resistant but resourceful staff who manage to find old forms. Ancillary departments generally accept the paper orders for a brief period, but eventually inform the staff that they no longer will perform tests not ordered online. By January 2002, the number of coding sheets (encounter billing forms) documented online each week had reached nearly 15,000 across the network.

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There has not always been a high level of enthusiasm among doctors for doing their own online documentation. At one steering committee meeting, one chief of service complained that the business of an academic medical center was to teach doctors to practice medicine, not to practice typing. This was challenged by her counterpart, who asserted that the skills required of any professional, including physicians, in the 21st century must include mastery of the personal computer. Complaints about caregivers spending more time with the computer than their patients have decreased as familiarity with the system has improved, and the investment of entering data pays dividends in real-time access to patient information.

There has been a gradual acceptance of the fact that computer proficiency is a skill to be developed. Throughout the project, there have been complaints that the system is not intuitive. This claim from medical professionals whose careers are devoted to keeping up with changes in the techniques and technology that comprise the art and science of medicine seemed contradictory. Indeed, a large part of CPR development is communicating how to use the system. This includes writing specific training documents for each application and updating the documents periodically, group instruction in the classroom, one-on-one training, and on-the-job training if necessary. It also includes listening to user feedback to determine whether the system training and functionality is effective.

Not only is the learning process continuous, it must be interactive. For instance, the chief of pediatrics turns over his monthly luncheon conference to the project team several times a year to discuss CPR concerns. The women’s health services caregivers on both campuses have held regularly scheduled meetings to reinforce training in new applications and work out system issues. These meetings have become informal educational sessions in which users answer each other’s questions, explaining the keystrokes that they use to perform the task in question. At times, one of the physicians may “drive” the PC, demonstrating options as the session progresses.

Complaints that online documentation takes longer have been carefully analyzed. If, for instance, caregivers filled out on paper only those elements that they thought pertinent to the visit and must now complete all fields in the online history and physical examination, it does take more time. The director of ambulatory care also has suggested that online documentation requires a different approach than scribbling on paper. He says that the process of completing neatly typed fields that prompt for information encourages complete clinical documentation and clear thinking. Rambling progress notes that reiterated unnecessary patient information have been replaced with succinct and pertinent notes that support better patient care.

In a survey of primary care physicians conducted in February 2002, physicians reported that the CPR saves them time. (See Table 6.) Ordering tests is quick and easy, and the multiplicity of colored requisition forms has been eliminated. Medication renewals, especially for the elderly and chronically ill, who require a multitude of medical equipment and supplies along with their medications, have been streamlined. In addition, 73% of EHC and 85% of QHC caregivers surveyed report that access to and availability of patient information has been improved with the CPR.

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TABLE 6 CPR SURVEY RESULTS FEBRUARY 2002

Percentage in Agreement Question: The CPR Saves Me Time When…

Reviewing pt's record

Seeing other's pt

Writing Rxs

Renewing Rxs

Looking up labs

Looking up Radiology

Ordering tests

Ordering consults

EHC Pediatrics 60 41 47 89 92 93 70 57 WHS 77 62 58 70 100 94 65 77 MPC 68 84 71 79 91 88 88 88

ALL 66 63 58 80 94 92 75 74 QHC Pediatrics 9 27 27 91 91 100 18 18 OBS/GYN 53 59 89 100 100 82 89 82

ALL 36 47 64 97 96 89 60 57

There is acceptance of the CPR as a continuously developing system. Transition periods

may be difficult, as users are forced to straddle the two worlds of paper and electronic data. Installation of new functionality always requires a learning curve and a related commitment of time and effort on the part of the users. Regardless, improvements in quality of care have caused the CPR to gain acceptance among the medical staff. In addition, its pervasiveness has convinced all but the staunchest opponents that it is here to stay. The CPR and Cultural Change

At all levels of the organization, resistance to computer automation is being confronted and transformed. Staff who had never approached a computer have become competent consumers of technology. Their language when calling the Help Desk has evolved. They have learned some PC and network terminology, and make the kind of diagnostic associations formerly consigned to the IS Department. For instance, they often know when rebooting will solve their problem, and can convey information about which network server they are logged onto. These new skills have transformed the way that staff, at all levels, manage patient information.

As the CPR has evolved, so, too, has the HIS training program. It has become specialized because of the variety of departments now using the system to perform departmental processing. The training for a hematology supervisor is far different from that of a pharmacist or a radiology technician. It is also broad-based: nearly 3,000 physicians, nurses, and other clinicians and administrative staff were trained in 2001. CPR training also includes a computer based training program (CBT), evolving in tandem with the system, which teaches a variety of formats and topics tailored to the needs of the clinicians.

Clinical staff throughout the organization have learned to speak a common technical language, although they may perform disparate functions in the CPR. Because staff use one integrated clinical system, clinic clerks, lab phlebotomists and attending physicians all know which function the Ulticare/Patient 1 keys perform, how to save data, and can determine whether a test was completed. Integrated data views provide consistency in test markings and other documentation, which present a single, shared view of the patient’s condition. Staff are not only

36

working towards a shared goal of providing quality patient care, but are doing it using the same tools and language across 19 sites and thousands of visits each day.

The organization’s physician leaders have grown into the role of technology partners. The HIS steering committee has been institutionalized as a strategic decision-making group within the network. In addition, the tone at these meetings has changed dramatically, from disagreement from some members regarding the basic premises of the project, to consideration and management of the changes related to its expansion. The committee increasingly has become a true partner in examining technology issues, assessing associated clinical risk, and proposing creative solutions.

The organization, as a whole, has developed higher expectations regarding the availability and transfer of information. Reflective of life in the Information Age, a seemingly insatiable demand for electronic data has developed. For example, after online documentation of pediatric immunizations began, only a short time passed before the project team was asked to FTP these data to the New York State Department of Health, replacing an arduous process involving the patient registration system. Likewise, it was not enough that the doctors were completing electronic coding sheets at the close of every clinic encounter. The faculty practice billing group next requested summary data on disk to replace the mountains of individual coding sheets that were collected from the clinic, manually collated, reviewed, discarded, and followed up for inaccurate or incomplete coding. And the bar has been raised: the five seconds that it takes for information to paint the computer screen may seem like an eternity, while it could have taken hours to produce the patient chart in the paper world. The Importance of Integration

The system was purchased at a time when the major ancillary departments (laboratory, radiology, pharmacy) utilized standalone systems. Caregivers were required to learn the log-in, password, and keystrokes for several different systems and queue up at specially designated terminals to look up results. Worse, several departments which used their own best-of-breed systems did not provide lookup terminals at all. Caregivers in women’s health services, for instance, were forced to telephone various departments to obtain the results of tests performed for every pregnant patient throughout the prenatal period of care: the cytopathology lab for Pap smear results, reference labs for HIV and genetic test results, and the obstetrical testing unit and/or radiology department for ultrasound and non-stress testing results.

Integrated views of patient data enable caregivers to process information and make clinical decisions faster and easier. The CPR so far has replaced a total of nine electronic and five paper departmental systems. Online radiology, non-invasive cardiology, cytopathology, and pediatric immunization systems, and two obstetrical ultrasound, two pharmacy, and one online laboratory system have been retired; as well as manual radiology, cardiology, and pediatric immunization systems, and two paper surgical pathology systems.

Initially, interfaces were employed to import data into the CPR until these systems were replaced with the Ulticare/Patient 1 system modules. Inevitably, interface errors affected the reliability of clinical data. In addition, caregivers’ access to data not yet migrated to the CPR remained limited to different views of patient information accessed by various system log-ons at inadequate numbers of terminals.

As legacy systems are retired, departmental processing is integrated into the CPR, replacing best-of-breed systems. In the process, there may be apprehension about whether or not CPR functionality will adequately satisfy local users as well as regulatory requirements. For

37

example, the best-of-breed cytopathology system containing five years of gynecological and non-gynecological test results, but it was not Y2K compliant and had to be retired in 1999. The project team developed a cytopathology module in collaboration with the department, configuring generic Ulticare/Patient 1 tools to perform all of the critical test processes. Specimen identification numbers are generated according to the prescribed format; supervisor and/or pathologist review and sign-off are forced for certain specimens based on complex rules and technologist documentation (including the existence of historical abnormal results uploaded from the one of the two million records from the retired legacy system); counts of normal specimens are calculated and supervisory review is forced of every tenth specimen resulted as normal by each technologist; and preliminary results are suppressed until finalized.

The CPR not only presents all of these data consistently at each clinician’s desktop, but it also provides customized views of data across time, e.g., prenatal flow sheets. The CPR enables caregivers to quickly retrieve information from a single source so they can review patient diagnoses and problems, allergies and adverse drug reactions, significant past medical and surgical history, vital signs and other measurements, and in the primary care services extensive intake information, interdisciplinary education records, patient histories and physicals, and progress notes. These data are displayed together with medication information and test results, while system decision support tools display alerts that reduce the rate of medication errors. The graphic system display of lab tests across time ensures that trends are immediately apparent to the caregivers and that certain values are not missed.

The QHN CPR includes digital radiography and a Picture Archiving and Communication System (PACS), as well as voice recognition, at both hospitals. The Elmhurst Hospital Radiology Department has been filmless, replacing film with digital images available at the clinical desktop, since November 1999. This has dramatically reduced the percentage of studies never read as well as the time required to issue radiologists’ reports. The result is 100% image availability to clinicians, faster interpretations, less repeat X-ray exposure to patients because of misplaced films and duplicate procedures, faster patient discharges, and better teaching opportunities for residents and fellows. (See Table 7.)

TABLE 7

SUMMARY OF PACS IMPACT ON AVAILABILITY AND TURNAROUND TIME

Elmhurst Hospital Center Radiology Department

Oct 1997 Traditional Radiology (film and dictation to transcription service)

Jan 1999 (Film, using voice recognition system)

Jan 2000 (Digital images, using voice recognition system)

Unread studies

24% 12% 2%

Studies read within 12 hours

8% 40% 97%

Patient Safety and Quality Care

The development of the CPR has led to increased standardization of data, resulting in more reliable data. Utilization of multiple clinical systems and paper records may result in discrepant data values. For example, the registration system and the radiology system may indicate a different location for the same patient, or the pharmacy system may show the patient is allergic to codeine, while the laboratory information system indicates “no known allergies.”

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Information is fragmented and may lead to disparate views of the patient’s condition. Because the systems are independently fed by various departments and users at different intervals, determining which is the correct information is difficult for the caregiver and may prove dangerous. Integrated CPR functionality minimizes discrepancies and ensures better data integrity, e.g., utilization of a single format for each data element, and updates across the record as appropriate by the user with the most recent clinical information, along with electronic audit trails clearly displaying edits and editors.

At about the same time as the CPR was in initial development, the QHN began to deploy a decentralized model of care, as well as the consolidation of redundant services. The integrated CPR has been implemented at every site, on campus and off, enabling providers to create records for new patients and access records for patients previously seen at the hospital. The same functionality supporting care delivery is available at all 19 locations, across the continuum of patient care. For instance, if patients followed in the community medical centers need to be referred for specialty care, the specialists at the hospital can view the entire patient record online. Information is available in real time, at all times, saving time and reducing opportunities for error.

According to the director of ambulatory care, the impact of the CPR on patient care has been enormous. Compare the ambulatory care 60% to 70% paper chart retrieval rate before system implementation, to 100% availability, 100% of the time for the CPR: immediate access to patient information. Patient care has improved as access to information has improved. A gynecologist recently said “the HIS makes me a smarter doctor.” Care need not be deferred until an appointment can be made and the record located, and the patient’s entire history is available for review. Because the physician has immediate access to the patient’s blood pressure and medications, for instance, adjustments to outpatient prescriptions can be made for patients with cardiac and other chronic conditions during a telephone call with the patient. Because the system provides checks against tests previously ordered, duplicate testing has been reduced, and the patient may no longer be required to make numerous treks to the hospital.

In an effort to evaluate the effectiveness of the care provided in the Elmhurst Medical Primary Care Walk-In clinic, in a seven-week study period, 210 of 678 patients presenting for medication refills were sampled. Patients would flock to the walk-in clinic and often waited for long periods of time to see a physician when it was not clinically necessary. The benchmark of quality care was that patients would receive only medication that was intended by the primary ordering physician to last until the next suggested evaluation by that physician.

The CPR proved essential to analyzing the medical condition of patients, to determine whether or not they truly needed a medical evaluation, or merely required to be directed to the pharmacy to refill prescriptions. On the clinicians desktop in the CPR resides the complete visit history, across all care settings, for the patient since January 1997, as well as the medication profile, patient problem list, all lab and radiology studies, and patient and family history. The ready access to patient data made it possible to refer and provide care appropriately and efficiently for this patient population, many of whom are taking large numbers of multiple prescriptions. The study determined that a large proportion did require medical evaluation, or needed only to have prescriptions refilled, and resulted in significant change in the medication renewal policy. Using the CPR, patients initially are identified as to whether they have valid prescriptions in the pharmacy. All other patients now are formally evaluated by a medical provider before they are given a prescription renewal. These focused evaluations are targeted to the particular organ system being treated by the prescribed medication. (S. Jiminez and R.A.

39

David, Quality Improvement in Prescription Renewal Service in an Underserved Urban Primary Care Practice, Ambulatory Care Departmental Research Day, Elmhurst Hospital Center, Elmhurst, NY, 1998)

The point-of-care availability of real-time patient information has reduced the number of hospital admissions at Elmhurst because of warfarin toxicity. Providers in the anti-coagulation clinic have easy and immediate access to drug dosage and interaction information, as well as diet, laboratory and bench top test results, and can trend them over time. While the number of patients seen in this specialty clinic over the past year has doubled, the number of hospital admissions because of complications from anticoagulation therapy have been cut in half.

The CPR supports primary care physicians with age- and sex-specific health maintenance reminders. Reminders include Pap smears, mammograms, sigmoidoscopy, blood pressure checks, lead levels, and vaccinations. Online tools are also available to help caregivers determine if the minimum testing and required referrals have been made for obstetrical and diabetic patients.

Communication has been improved between doctors and nurses. The primary care progress notes have been designed to pull the complete set of orders placed by the physician for the patient in order entry and care planning into the nursing note for sign off. Nursing staff pick up orders electronically, without the need to transcribe them from one paper form to another, reducing the opportunity for errors. The electronic patient record is interdisciplinary. All clinicians document patient care on the same system, with data deemed appropriate automatically shared in other screens. For instance, the nursing staff’s documentation of vital signs, immunizations, fingerstick glucose testing, PPDs, etc. are available online at all times across the continuum of care. This helps eliminate duplication of effort, and, more importantly, encourages users to read what the other caregivers have documented.

Paper prescriptions are often illegible, which can cause significant patient safety concerns. Electronic prescriptions are always legible and complete—the omission of certain required fields when ordering a medication will prevent it from printing. In addition, the CPR displays alerts to potential drug-drug interactions, drug-allergy interactions, and dosing errors during the writing of the prescription to reduce medication errors. Additionally, pharmacists required to verify the physician’s orders before dispensing medications also can review the patient’s diagnoses and lab values if they believe that an incorrect medication or dose has been ordered.

Legible, complete documentation improves patient safety and quality of care. Because availability of online patient information is assured at all times, fewer departments feel a need to hoard charts or maintain “shadow charts” locally. In the past, this practice lead to problems with HIM’s ability to certify that the chart was, in fact, complete. With paper, there was always a chance that the test value or note had been misplaced. Currently, if the application exists online, and certain elements of patient care are not recorded in the CPR, it is clear that the documentation was not done.

Documentation in the CPR has improved the completeness of patient records. Data entry screens are easily updated to include new questions required by practice or policy changes, and users are automatically migrated to the new screens. Additionally, data fields can be “required” so users cannot skip important questions. And medical records, billing and quality management experts may easily review records from any of the 3,000 PCs available in clinical and administrative areas to determine the quantity and quality of data and advise clinicians accordingly. The faculty practice group, for example, no longer reviews every coding sheet

40

individually for the primary care services; they are correct and complete, due in part to the formatted attending note, which prompts for clinical information, required to support reimbursement.

Access to care has been improved by the CPR. Before deployment of the CPR at EHC, for instance, patients were required to carry a paper request form from the referring physician to the department and wait in long lines to make an appointment for a radiology study. Worse, reception was closed on weekends and evenings, with the operation supporting neither off-hours nor offsite practices. Continuing with the best practices model that guides QHN CPR installation, the project team implemented Ulticare’s automatic scheduling feature during conversion of the best of breed radiology system to the CPR. Now, when a study is ordered, the system automatically searches the various modality schedules for available slots and schedules the patient for the next available. It then prints patient instructions pertinent to the study (in English and Spanish) along with an order request displaying the date, time, and location of the radiology appointment issued. Clerical staff in the clinics have been given the system privileges to move or reschedule a study without the intervention of the radiology department. With the exception of STAT tests and other outliers, patients no are longer are waiting for appointments in the radiology reception area.

Care availability, timeliness and appropriateness have been improved with the implementation in the CPR of an integrated telephone triage application. Nurses take calls from patients to determine acuity and level of care required, then document details of the encounter and advice to the patient in the patient’s electronic record. The system automatically routes paper notification to a printer in the location to which patients have been directed. If the triage nurse instructs a patient to go directly to the emergency department, for instance, the staff will be expecting the patient, as notification will have printed to the triage area of the ER before the patient’s arrival. The application also supports the telephone triage units with a tickler list of patients to call back a few hours later, or the next day. Documentation of the triage encounter is permanently stored in the CPR, a permanent record of the telephone encounter and the patient’s disposition.

The CPR supports the application for and continuation of a variety of federal and state grants for HIV patient care. As the major provider of care to the HIV-infected and affected residents of Queens, medical, nursing, psychiatric and social service, including AIDS/HIV testing and counseling are provided by a dedicated, interdisciplinary team of caregivers. To receive and maintain funding, the organization must demonstrate that each patient is receiving quality care, as defined by rigorous standards regarding frequency and appropriateness of testing. In addition to improving the effectiveness of care for this patient population, the CPR provides a detailed, current patient profile, which enables the rapid extraction of patient information, such as lab results and trends, diet and medications required to support PI data gathering required by the granting agencies. Myriad site visits—announced and unannounced—required the aggregation and analysis of significant patient data that formerly required the sifting and sorting of paper medical records. These resource-intensive efforts have been replaced with the electronic patient record, providing continuous, integrated real-time views of patients who have AIDS or are HIV-positive. Cost Impacts

An objective of CPR development is the integration of clinical information formerly available from various standalone systems into one CPR. In the process, the information systems

41

department has reduced the number of disparate servers, maintenance contracts, and dedicated hardware required of best-of-breed systems. The cost of maintaining myriad systems also includes a human component: the integrated CPR no longer requires the allocation of analysts who specialize in each of these tangential systems. Instead, there is one project team, cross-trained to utilize a common set of tools across multiple applications. Additionally, supporting multiple systems usually meant that IS had to create and maintain essentially the same database tables in multiple systems. Often, standalone systems cannot access the master charge table, for example, but need their own replica: the retired radiology, laboratory, and cardiology systems all had their own copies of the bed table. IS now has fewer interfaces to maintain and troubleshoot. The CPR enables analysts to use a common knowledge base, minimizes rework and database maintenance, and reduces the time spent supporting foreign interfaces.

In addition to the care quality and process improvements generated by the installation of the PACS and voice recognition systems, these advances have generated a savings of approximately $993,000 per year at Elmhurst Hospital. This includes savings for film, supplies, file-room space, personnel services for scheduling, filing, making appointments, and relaying results, length-of-stay reductions, and improved throughput in clinics. The conversion to the CPR with digital images in EHC radiology has enables a reduction of five FTEs and virtually eliminated phone calls to the department to obtain results. The department saves $164,000 per year in transcription costs at EHC and $206,200 at QHC, and no longer distributes four copies of each test result: to the ordering location, to medical records, to faculty practice, to the film room in the film jacket.

There is an improved return on billing because of standardized order prompts, more complete documentation, and timelier coding. Improved documentation to support claims and coding has resulted in additional reimbursement or avoided costs for penalties from lack of documentation. For one of QHN’s biggest managed-care contracts, MetroPlus, the claims denial rate decreased at EHC from 35% during the first quarter of 2001 to 21% during the first quarter of 2002; at QHC from 43% during the first quarter of 2001 to 26% during the first quarter of 2002. In addition, Elmhurst Hospital Radiology Faculty Practice revenue rose $306,000 in the year following installation of the CPR/PACS/Voice Dictation system combination.

The online CPR means that there is less paper written, printed, distributed, filed, and retrieved to support patient care. Savings from the reduction in the amount of paper forms printed for orders and charting have been achieved. Less paper has enabled the diversion in ambulatory care to financial counseling of 1.5 FTEs who formerly prepared charts for caregivers in clinics. IS staff no longer print and distribute paper results, for a savings of $20,550 per year in paper costs. The laboratories also have reassigned staff who used to distribute results to caregivers on inpatient units and in clinics.

In the Health Information Management Department, resources formerly assigned to filing mountains of loose paper in patient charts also have been reassigned to other duties. Purges of old records no longer are outsourced, as resources have become available to enable the department to focus on internal file management in compliance with mandated record maintenance and retention schedules. In addition, time spent in HIM searching for loose sheets of patient information required for patient care have been eliminated. Economies of scale have been created, enabling the addition of numerous off-campus locations without requiring additional HIM staff to support the filing and production of patient charts.

The CPR underlies the expansion of the Queens Health Network, supporting the regionalization of services and the evolution of two separate hospitals into an integrated

42

healthcare delivery system. Because patient records are available in real time at all locations, the CPR supports the queuing of lab specimens from each ordering location to the correct hospital’s departmental work lists. In a process that is transparent to providers, orders are placed online from anywhere in the network, and the CPR routes orders, results, and corrections appropriately to the patient’s chart. This process supports the regionalization of laboratory services: all routine chemistry, hematology, immunology, and all microbiology tests are sent to Elmhurst, while cytopathology exams for the network are performed at Queens. The CPR also supports a highly advanced level of laboratory automation, utilizing HHC’s only accessioning robot to process most of the 3,800 specimens each day. MRIs are only performed at Queens hospital, but EHC patients’ results are immediately available to caregivers at Elmhurst. All pediatric orthopedic and cardiology referrals are automatically sent to Elmhurst hospital. This enables the organization to employ specialists to provide excellent care efficiently and effectively.

The CPR also supports the Queens Health Network service as a reference lab for flow cytometry, performing specific tests for another HHC healthcare network. The strategic business plan of HHC is advanced by consolidating services, while providing an additional source of revenue for QHN. IMPROVING HEALTH CARE IN THE 21ST CENTURY

By April 2002, the QHN Healthcare Information System included an extensive array of personal computers with associated peripherals, used daily in examination rooms by physicians, nurses, mental health providers, social workers, health educators and dieticians to document integrated patient assessments. Patient-care providers throughout ambulatory care, the inpatient areas and the ancillary services departments enter and retrieve patient data at the point of service. Myriad standalone departmental systems have been retired, and clinical data converted to the integrated CPR. The electronic medical record has become an essential component of managing patient care across the network, with ever increasing demands for its enhancement and expansion.

Laboratory and radiology results are integrated, timely and accessible in exam rooms in offsite and on campus clinics, and in school-based health centers across the Queens Health Network. The widespread availability of these and other clinical data support ongoing efforts in the continued regionalization of duplicative and competing clinical services, and the decentralization and expansion of others. The HIS enables real-time access to patient information anywhere in the network. Consider an Elmhurst patient referred to Queens Hospital for a head MRI. The radiologist now can review prior visit history and diagnoses, results of general diagnostic radiography and CT scans, BUN, Creatine and other recent lab values, and ensure that the patient does not have a contrast allergy before the technologist performs the test. That the patient is followed at another facility in the network is not an impediment to accessing vital information. Availability of clinical information online surmounts one of the biggest obstacles to integrated, seamless care across the entire spectrum of healthcare services.

The QHN CPR positions the organization to provide patient care that is safe, effective, timely and efficient. Real-time data regarding individual patients and populations of patients with chronic conditions can be aggregated and analyzed to develop population-based approaches to disease management. Currently, a disease registry is being established for patients with diabetes in an effort to facilitate access to information about the performance and results of certain elements of care. Patients with congestive heart failure have also been targeted as a population whose outcomes can be improved with patient-specific data to assist clinicians and

43

patients in making diagnoses and evaluating treatment. The CPR is providing the foundation for the Queens Health Network to make the comprehensive changes associated with better patient and system outcomes.

44

APPENDIX I

45

APPENDIX II HEALTHCARE INFORMATION SYSTEM

QUEENS HEALTH NETWORK ORGANIZATIONAL STRUCTURE

Project Team

PEDIATRICS

Med. Director Assoc. Director

Physicians Nursing

Cl i l/Ad i

EMERGENCY DPT Med. Director

Assoc. Director Nursing

Clerical/Admin.

MEDICAL PRIMARY CARE

Med. Director Assoc. Director

Physicians Administra r to

Nursing

MANAGED CARE Sr. Assoc. Director

Faculty Practice OPD Finance

MPC Sub Specialties

WOMEN’S HEALTH

SERVICE

Clinic Director Physicians

Cert. Nurse Midwife Administrator

Physician Assistants

SPECIALTY CLINICS

And SERVICES

RADIOLOGYMed. Director

System Adminis.

A Ph s

Sub. S ltiesER

dministratorysicianWHS MPC PPC pecia

LABS Med. Director

Assoc. Director Network Manager

WHS MPC PPC

Sub. Spec alties iER

PHARMACY Director

Chair P&T Committee

WHS MPC PPC

Sub. Specialties

MENTAL HEALTH Med. Director

Assoc. Director Social Work Psychologists

Design Team

Development Committee

HIS Steering Committee

46

D e p a r tm e n ta l P r o c e ss in g

E H C C P R S urg ic a l P a tho lo gy & A u to p sy

Q H C C P R C yto p a tho lo g y

R a d io lo gy - M R I C T C T

M a m m o g rap hy M a m m o g ra p hy N u c le a r M e d ic ine N uc le a r M e d ic ine S p e c ia l P ro c e d ure s S p e c ia l P ro c e d ure s U ltra so und U ltra so und N o n-Inva s ive C a rd io lo gy

N o n-Inva s ive C a rd io lo g y

C a rd ia c C a the te riz a tio n

O b s te tric a l te s ting O b s te tric a l te s ting N e u ro d ia gno s tic te s ting

Fu ll p ro ce s s ing o f a ll C h e m is try , H e m a to lo gy , Im m u no lo g y , a nd M ic ro b io lo gy te s ts o rd e re d fo r E H C p a tie n ts

F u ll p ro c e ss ing o f S T A T C h e m is try , H e m a to lo gy , Im m u no lo g y sp e c im e ns o rd e re d fo r Q H C p a tie n ts

R e c e ip t & p ro c e s s in g o f a ll sp e c im en s re c e iv e d fro m Q H C p a tie n ts

A c c e ss io n in g & d isp a tc h ing o f N o n-S T A T a nd a ll m ic ro b io lo g y sp e c im e ns

A c c es s io n in g & d isp a tc h in g o f re fe re n c e la b sp e c im e ns

A c c e ss io n in g & d isp a tc h ing o f re fe re nc e la b sp e c im e ns

Fu ll p ro ce s s ing o f a ll F lo w C y to m e try sp e c im e ns se n t fro m o the r ne tw o rk

O u tp a tien t E n c o u n te r M o d u le

• A llerg ies & S ig n ifica n t

M ed ica l/S u rg ica l H is to ry • P ro b lem /D ia g n o ses L is ts • H ea lth M a in ten a n c e R em in d ers • P syc h o so c ia l & N u tritio n a l S c reen in g • P ed ia tric Im m u n iza tio n s • P o p u la tio n S p ec ific A ssessm en ts • S p ec ia lty C o n su lt /R eferra l R eq u es ts • M a n a g ed C a re A u th o riza tio n F o rm s • P a tien t M ed ic a tio n P ro file ,

P resc rip tio n W ritin g , D o se , A lle rg y , R ea c tio n C h ec k in g

• E n c o u n ter B illin g F o rm s • O rd er E n try fo r sp ec ia lty re fe rra ls ,

la b , rad io lo g y , c a rd io lo g y , o b s te tric a l, a n d n eu ro d ia g n o stic tes ts ; a n d o u tp a tien t p resc rip tio n s

• R esu lt n o tific a tio n q u eu es , resu lt c o m m en tin g & s ig n o ff, resu lt re triev a l b y p a tien t

• R ec o rd s o f te lep h o n e tria g e en c o u n ters ro u ted to rem o te p rin te rs if a p p ro p ria te

D e p a rtm e nta l P ro ce s s ing In c lu d e s • T e s ts p ro c e s se d fo r a ll p a tie n ts , i.e . ,

o u tp a tie n t, E R , inp a tie n t • O rd er e n try fro m a n y o u tp a tie n t s ite s ro u te to

the re g io na liz e d S u rg ic a l P a th o lo gy , C y to p a th o lo gy , a nd M R I d e p a rtm e nts a t the a p p ro p ria te h o sp ita l

• A uto m a te d sc h e d u ling fo r p ro ce d u re s • A c c e ss io n in g , b a r-c o d e la b e lin g /sc a n n ing ,

in te rfa c ility d isp a tc h ing , re su lting v ia ins trum e nt in te rfa c e o r m an ua lly , c o rre c tin g , c a nc e ling

• C u s to m iz e d w o rk lis ts fo r te c hn ic ian s , s e c o nd a ry re v ie w /Q A , p hys ic ia n ve rific a tio n , e tc .

• A uto m a te d c ha rg ing ru le s • P ro c e d u re c o d in g fo r b illing

O u tp a tien t E n c o u n ter M o d u le

• A llerg ies & S ig n ifica n t

M ed ica l/S u rg ic a l H isto ry • P ro b lem /D iag n o ses L is ts • H ea lth M a in ten a n c e R em in d ers • P syc h o so c ia l & N u tritio n a l

S c reen in g • P ed ia tric Im m u n iza tio n s • P o p u la tio n S p ec ific

A ssessm en ts • S p ec ia lty C o n su lt/R eferra l

R eq u es ts • M a n a g ed C a re A u th o riza tio n

F o rm s • P a tien t M ed ic a tio n P ro file ,

P resc rip tio n W ritin g , D o se , A lle rg y , R ea c tio n C h eck in g

• E n c o u n ter B illin g F o rm s • O rd er E n try fo r sp ec ia lty

re fe rra ls , la b , rad io lo g y , c a rd io lo g y , a n d o b s te trica l tes ts ; a n d o u tp a tien t p resc rip tio n s

• R esu lt n o tific a tio n q u eu es , resu lt c o m m en tin g & s ig n o ff, resu lt re triev a l b y p a tien t

• R ec o rd s o f te lep h o n e tria g e en c o u n ters ro u ted to rem o te p rin te rs if a p p ro p ria te

* Registration Information* Scheduling Notification

* Encounter Generation/ADT* Creates one merged

patient record fromtwo different MRN if

patient identifiers match

NYS DOHPatient-SpecificImmunization

Registry

MedispanDTMS

RadiologyVoice Recognition

System

RadiologyPACS

NYS DOHPatient SpecificImmunization

Registry

MedispanDTMS

RadiologyVoice Recognition

System

EHC DAR T SYSTEMBackup system containing a subset of the data in the full

CPR. Data is refreshed every hour and accessible via everydesktop

QHC DART SYSTEMBackup system containing a subset of the data in the full

CPR. Data is refreshed every hour and accessible via every desktop

EHC SMS QHC SMS

EHC Faculty PracticeBilling System

APPENDIX IIIQUEENS HEALTH NETWORK

HEALTHCARE INFORMATION SYSTEM

36 Instruments& 1 CLA

Quest Diagnostics

North Bronx HealthNetwork

12 Instruments Quest Diagnostics

Radiology PACS

RadiologyPenrad

47

Enterprise Network

IBM Compatible IBM Compatible

Qua

d Pr

oces

sor

Qua

d Pr

oces

sor

Qua

d Pr

oces

sor

Qua

d Pr

oces

sor

RAID5 RAID5 RAID5 RAID5

Dua

lPr

oces

sor

Dua

lPr

oces

sor

Dua

lPr

oces

sor

Dua

lPr

oces

sor

Dua

lPr

oces

sor

Dua

lPr

oces

sor

Dua

lPr

oces

sor

Dua

lPr

oces

sor

Qua

d Pr

oces

sor

Qua

d Pr

oces

sor

Qua

d Pr

oces

sor

Qua

d Pr

oces

sor

Primary Server SecondaryServer

ApplicationServers

ApplicationServers

APPENDIX IVQUEENS HEALTH NETWORK

HEALTHCARE INFORMATION SYSTEM

48