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Slide 2 SynergE3 CPOE/EMR Slide 3 CPOE/EMR In the Oct of 2009 we are planning a large expansion of the use of the Electronic Medical Record (EMR) for our inpatients at UNMH. The two major outcomes of the expansion will be that 1) except some physician documentation all other patient care documentation (nursing, RT, social work, OT, PT) will be done electronically 2) CPOE all inpatient orders will be entered electronically by the providers The expansion of the EMR will change the way we take care of patients at UNMH. Slide 4 Who is making this all happen? 5 major teams Provider team CPOE development of order sets Clinical team Clinical documentation Information Technology team Application design and build Support team Equipment and infrastructure Workflow teams Work redesign Slide 5 Provider Team Nancy Alton, NICU Carlos Argulles Emergency Medicine Paul Echols Orthopedics Rao Deepti Internal Medicine William Dodson Family Medicine Scott Forman, Resident, ED Gary Iwamoto, MICU, Leader Aaron Jacobs, Pediatrics Steven Jenkusky Psychiatry Robert Katz, Pediatrics Clinical Leadership Matthew Luke, Pathology Marc Malkoff Neurosurgery/Neurology John Marinaro, Surgery Gary Mlady Radiology Andrew Paterson Orthopedics Sharon Phelan Obstetrics Sarah Pirio Richardson Neurology Kendall Rogers, Medicine Trevor Rohm Informatics Jess Schwartz, Surgery Randall Stewart Psychiatry Slide 6 Clinical (aka PULSE) Team Steve Bass- ICU Brian Carter- Peds Kim Heinen- Med/Surg Deirdre Kearney- Neuro Carrie Khalsa- ED Mary Laflin- PT/OT/Speech Kim McKinley-Senior Director Melanie Morris- HUC Ida Placencio- RT James Simpson- Pharmacy Amanda Sorio- NICU Sue Titsworth -Case Management Bridget Yarrington- Pharmacy Slide 7 IT Team Neil Alessio Karen Day Glen Jornigan-Exec. Director Diane Kostag Jan Krell-IT Project Manager Kellie Moudy Lisa Quintana Shari Shaffer David Turner Margaret Wallhagen Slide 8 Support Team Tim Suchla, Clinical Engineering Mary Rivera, Equipment Project Leader On Site Cerner Support: Hillary Biskner, Executive Leader Karmen Gilbert, RN Solution Architect Lori Raynaud, RN Workflow Redesign Don Kane, MD Physician Liaison Slide 9 The expansion of the EMR will allow all care providers equal access to patient information, and improve the ability to access information and document care for all care providers. The present electronic medical record is based on paper records that are scanned into the computer. What we are moving to is an interactive system that will allow for real- time charting on all aspects of patient care, from vital signs to medication administration. Slide 10 CPOE (Computerized Provider Order Entry): Handwritten orders can often be difficult to read, and often result in errors. Orders will continue to be reviewed by pharmacists and nursing staff, but potential errors due to handwriting are eliminated. Also, since providers will enter orders directly, tests and medications can be processed much more quickly, enhancing our current process. Slide 11 Advantages of CPOE Systems Compared With Paper-Based System Free of handwriting identification problems (time, date, person ordering all part of order) Faster to reach the pharmacy Less subject to error associated with similar drug names More easily integrated into medical records and decision-support systems Less subject to errors caused by use of apothecary measures Easily linked to drug-drug interaction warnings Able to link to ADE reporting systems Able to avoid specification errors, such as trailing zeros Available for immediate data analysis Claimed to generate significant economic savings Order Sets may standardize care Slide 12 CPOE Order sets ~200 power plans covering admission, post op, specific diseases CHF, ACS Single orders order sentences Choices frequency, type (Stat, ASAP, Routine) For a medication dose, frequency, route, For diagnostic type test reason for exam other areas prefilled in by location and other data already in the system Evaluate work flow in each process admitting transferring discharge, daily care of patient, post op, level of care Dose range checking Folders of common orders Slide 13 Orders from order folders, favorites and by searching Slide 14 Searching start first few letters Slide 15 Order sentences have details of dose, frequency, route options Slide 16 Power Plans are groups of orders Slide 17 Arranged in a standard way Slide 18 Common values are available as drop down boxes Slide 19 Slide 20 Slide 21 Electronic Medical Record Documentation will be easier find multiple users can access of data at the same time standardization of documentation legibility data analysis HIPPA compliance Viewing data. Patient data can be viewed on any computer EMAR can view both what patient on but also view when meds given will have one MAR. Vital signs, I&O, nursing tasks Documentation by all services Slide 22 Vital signs Slide 23 Slide 24 Slide 25 Slide 26 Slide 27 Changes that have occurred Development of the order sets and the expanded EMR have standardized many practices. Ordering of daily labs, repeating labs. Old way was the daily labs had to be entered each day by the HUC who kept track of this on a card Standardized documentation by nursing, RT, etc. Urgent clinical documents Will pull in Code status note, advanced directives, POA, medication contract Daily Rounds Summary Slide 28 Slide 29 Slide 30 Rounding Summary Slide 31 Time line Rev 17 June 21, RHO Sept 27, Go Live Oct 25 Training 6 weeks before go live SuperUsers 8 weeks before go live 1313029282726 25242322212019 18171615141312 111098765 4321302928 SSFTWTM October 2009 65432131 4321302928 30292827262524 213130292827 262524232221 23222120191817 26252423222120 191817161514 16151413121110 19181716151413 121110987 9876543 1211109876 65432131 21 30292827 543213029 SSFTWTM SSFTWTM SSFTWTM September 2009 August 2009 July 2009 543213029 28272625242322 21201918171615 141312111098 7654321 SSFTWTM June 2009 Rev 17 Go Live RHO Superuser Training Training Starts Slide 32 Training needs to cover New functions such as adding orders and powerplans Processes Admit with med rec Transfer with med rec Discharge with med rec Finding data in the chart Documentation nursing, RT, H&P, etc; vital signs, I&O, medications and orders Communication Slide 33 Training 2 hour classroom to cover basic ordering, processes admission, transfer, discharge, where to find the data The classes will assume that everyone has a basic understanding in using Power Chart can log in, find lab values, read and find documentation, write prescriptions. Would ideally like to teach in groups ie by division or department so that core processes are covered and then at the end processes specific to that area can also be addressed In addition to the classroom training web based training, videos and tip sheets will be available Slide 34 Slide 35 Slide 36 Go Live When we go live we will have superusers available on the floors to help with problems A process in place to make changes needed as we find them The tip sheets, web videos and training are all available by clicking the How to ? button in power chart at the top The development of new order sets, changes to improve work flow, etc. will be an ongoing process. Slide 37 Summary CPOE will improve legibility, date and time The enhanced EMR will have all the information on the patient in one place and improve standardization of many processes. The change is coming we need to prepare everyone for it. Superuser Training starts Sept 1 Training starts Sept 15 Go live set for Oct 25 Training on the EMR for the hospital, lead superusers (45) 40 hrs training, super users (243) 20 hours training, users (~2000) 12 hours training Providers ~ 1500 superusers (~ 40 residents, ~15 attendings) To train everyone scheduling needs to be done as early as possible As much as possible we would like to train in groups to help emphasize areas specific to that group for example for surgery cover post op compared to admission what part of the process is different, The training plan has a basic core of what we are going to teach ordering, processes admit, transfer, discharge, med rec, and how to find data if we can teach in groups we can then emphasize specific areas that they will be doing. Some groups have already scheduled as a division meeting. Slide 38 Tasks to perform Let everyone know it is coming (talks with faculty and residents) Schedule training times now Develop training material (ongoing) Super user training (starts Sept 1) Schedule training sessions Training sessions (starts Sept 15) Go live Oct 25 Slide 39 Where we are Anesthesia contact Dr Arndt and Dr Chapman, talk presented 7/10/09, schedule training time Emergency Medicine contact Dr Arguelles talk scheduled, working on scheduling training time Family Medicine need contact; need to schedule talks; need to schedule training time Medicine contacts Dr Rogers, Dr Rao, Dr. Garcia CRTC; need to schedule talks to divisions; need to schedule training time Pulmonary and Heme Onc have scheduled training time Neurology need a contact; would like to schedule talk; schedule training time Neurosurgery need contact; scheduling talk; need to schedule training time Ob/Gyn contact Dr Phalen; scheduling talks and training time Orthopedics talk contacts Dr Paterson and Dr Echols; talk 7/15/09; need to schedule training time Pathology contact Dr Luke need to assess what training Pediatrics contact Dr Jacobs; scheduling talks; need to schedule training times Neonatal contact Nancy Alton, has scheduled training times Psychiatry Adult need contact; need to schedule talks; need to schedule training time. Psychiatry Peds contact Dr Mancuso need to schedule talk and training time Radiology contact Dr Mlady need to assess what training Surgery contacts Dr. Howdishell and Dr. Schwartz; 3 talks scheduled first 7/15/09, will see if divisions want talks; need to schedule training times Residents recruiting super users to help in training and when we go live would like to present to talk to let them know whats coming, also schedule training Slide 40 CPOE Expected Out Comes Improved legibility date, time, person ordering defined easy to find, reason for test required Order sets may improve uniformity of care Improved turn around times Will not be faster for provider or nurse writing the order Slide 41 Slide 42 Slide 43 Slide 44 Slide 45 Slide 46 Slide 47 Communication A major concern is how communication will change. Electronic order entry and charting does not replace effective communication between clinicians. How do we safeguard effective communication? Slide 48 Hardware Slide 49 CPOE- Computerized Physician Order Entry Power Plans a set of orders for admission, post op, specific diseases ie acute coronary syndrome. Single Orders sentences fill in the necessary details needed for that order including reason for test, STAT, routine, ASAP Slide 50 CPOE Order sets ~200 so far covering admission, post op, specific diseases CHF, ACS Single orders order sentences Choices frequency, type (Stat, Now Routine) For a medication dose, frequency, route, For diagnostic type test reason for exam other areas prefilled in by location and other data already in the system Evaluate work flow in each process admitting transferring discharge, daily care of patient, post op, level of care Medications correct dosing eliminate fields that will cause confusion Pediatrics order as they are used to, dose range checking Training on each process Slide 51 Urgent Clinical Documents tab Will pull in Code status note, advanced directives, POA, medication contract, Slide 52 Slide 53 Slide 54 Slide 55 USP MEDMARX Computer Technology-Related Harmful Errors (2006) Cause Number % Barcode, medication mislabeled 20 5 Information management system 1,176 2 Computer screen display unclear/ confusing 137 1.5 Dispensing device involved 3,181 1.3 Barcode, failure to scan 114