Generations+/Northern Manhattan Health Network
Leadership
The Challenge: Improving Patient Safety The Solution: The Electronic Health Record
Vision
Gregory Almond, MD Maricar Barrameda, NP, MSN Victor Bekker James Carr Suzanne Carter, RN, EdD Lebby Delgado, RHIA Jeannette Gorbea Glendon Henry, MD Vera Joseph, RN, MA, CNAA Hector Lewis
Resources
Carmen Lopez Louis Martir Walid Michelen, MD John Palmer, PhD Ana Rosa CarolAnn Rosado, MBA Tamal Roy Jose R. Sanchez, LMSW, LCSW Melissa Schori, MD Sara Shahim, RN, EdD
MANAGEMENT Have you ever driven through a stop sign? Called your sister when you meant to dial your daughter? Gone to bed with your keys in the front door? Over or undermedicated yourself? We are all painfully aware that being human means acknowledging that we can make a mistake. However, when our job involves caring for others we do not have that luxury. Other industries are working to minimize human error. The automobile industry is testing technology that alerts you to an inadvertent change of lane or when you car needs servicing. Health care leaders are also establishing processes to minimize human error and improve patient safety. The introduction of computerized physician order entry (CPOE) has been recognized by the Institute of Medicine, Leapfrog and others as critical to reducing medical errors. The expansion of automation to a full Electronic Health Record (EHR) provides greater functionality to improve patient safety. The following paper describes the experience of the Generations+/ Northern Manhattan Health Network (Generations+) in implementing the Electronic Health Record and its impact on the safety and quality of care provided to our patients.
South Bronx
The poorest neighborhoods in New York City are the South Bronx, and East and Central Harlem where more than one in three residents live in poverty. Life expectancy in our catchment areas are eight years shorter than in its wealthiest neighborhoods and consistently have the highest mortality rates from almost all diseases.
East Harlem
Highest mortality rate in Manhattan for influenza and pneumonia, chronic liver disease, and diabetes mellitus. Second highest mortality rates in Manhattan for all causes, heart disease, malignant neoplasm, HIV disease, mental disorders due to substance and accidental poisoning, and accidents except drug poisoning and homicide.
Central Harlem Highest mortality rate in New York City for mental disorders due to Substance and Accidental Poisoning. Second highest mortality rate in New York City for HIV disease and malignant neoplasm.
Morrisania
Highest mortality rates in New York City for HIV disease and diabetes mellitus.
1. EHR System Planning The importance of the medical record to the quality and safety of patient care has long been recognized by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) and other regulatory agencies. The emerging trend to automate the capture and transmission of patient health information was championed by the 1991 landmark report of the Institute of Medicine on improving patient records called Computerbased Patient Records: An Essential Technology for Health Care. The Leapfrog Group’s concern for patient safety noted the importance of computerized physician order entry (CPOE) in reducing medical errors. More recently, Senator Hillary Clinton and President George W. Bush expressed their commitment to programs aiding the implementation of electronic health records and encouraging the widespread use of modern information technology to improve the nation’s health care system. In 1997, the Generations+/ Northern Manhattan Health Network recognized the importance of the electronic health record (EHR) to improve the quality of patient care, reduce medical errors, reduce health care costs, and provide greater access among clinicians and health professionals. As part of the initiative launched by the New York City Health and Hospitals Corporation (NYCHHC) in 1991, the Network committed resources, time and talent to the implementation of the EHR. The Network used the Health Data Sciences (HDS) Ulticare system, now Misys CPR. The Generations+/ Northern Manhattan Health Network, located in East Harlem, Central Harlem, and the South Bronx, is the largest healthcare network of the NYCHHC. The CEO overcame the challenges in allocating resources from an already stressed budget, providing connectivity to over 40 sites, and securing involvement from an already overcommitted staff. This paper presents a description of our process.
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Organizational Overview Generations+/Northern Manhattan Health Network The Generations+/Northern Manhattan Health Network (Generations+) is comprised of three acutecare hospitals in New York City representing some of the most medically needy and underserved communities in the nation; Harlem Hospital Center in Northern Manhattan; Lincoln Medical and Mental Health Center in the South Bronx; and Metropolitan Hospital Center in East Harlem. There are three Neighborhood Family Health Centers: Morrisania, in the South Bronx; Segundo Ruiz Belvis, in the South Bronx; and Renaissance Health Care Network, in Central Harlem and Northern Manhattan. Each center offers comprehensive communitybased medical care. Additionally, thirtyeight family health centers, child health centers and schoolbased clinics are strategically located to serve our diverse populations throughout Northern Manhattan, Central Harlem, East Harlem, and the South Bronx. Though these medically and financially distressed communities present daunting challenges to healthcare delivery, New York State Department of Health ranked the Generations+ Network among the highest in New York City for quality of care to patients based on data tracked by the DOH since 2003 ( http://hospitals.nyhealth.gov)
Network Statistics 2005 Annual revenue of the healthcare Network Annual Information Technology budget Total employees of the healthcare Network Total employees in the Information Technology (IT) Department Patient volume of the healthcare Network Patient Discharges Annual Ambulatory Care – visits Annual ED – visits
$820 Million $20 Million 7,261 87 51,623 1,582,216 253,398
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Metropolitan Hospital and its associated Ambulatory Care Centers Metropolitan Hospital Center (MHC), in the East Harlem section of Manhattan, is a 333bed acutecare facility with 770 providers. The Hospital is a certified Level II Trauma Center and a 911 receiving facility. Estimated population statistics indicate that 1,153,690 residents reside in the Hospital’s combined service area, 200,210 in the primary service area and 953,348 in the secondary service area. Residents in the Hospital’s primary and secondary areas are Hispanic (55%), African American (26.2%), and White (13.2%). Average per capita income in the primary service area of East Harlem, zip code 10029, is $13,177.
Lincoln Medical and Mental Health Center and its associated Ambulatory Care Centers Lincoln Medical and Mental Health Center (LMMHC), in the South Bronx, serves the poorest borough in the city of New York. It has 342 operating beds, 737 providers and is the only public hospital located in the Downtown Bronx. Based on the 2004 census data, there was a 3.3% increase in the service population since 2000. Approximately 529,103 individuals reside in the total area served by the Hospital. Neighborhood residents are primarily of AfricanAmerican (28.6%) or Hispanic (65.7%) decent. It is estimated that 233,213 individuals of Puerto Rican ancestry, and 226,550 from the Dominican Republic reside in the surrounding community. The area has a higher proportion of residents between the ages 1 and 14 (28.8%) than in New York City as a whole (19.1%). One out of four residents (26.2%) are women of childbearing age (15 to 44). More than 30% of the population residing within LMMHC’s service area lives below the federal poverty level. This pervasive poverty has made many residents poor in health through a vicious cycle of lack of resources and education. Forty percent (40%) of the neighborhood population age 65 and above are below the federal poverty level.
Harlem Hospital Center and its associated Ambulatory Care Centers Harlem Hospital Center (HHC), in the Harlem section of Upper Manhattan, is a 272bed Hospital with 876 providers. The most recent data indicate there are 893,498 residents in the Hospital’s total service area. Seventyone percent of the residents in the Hospital’s catchment areas are under 45 years of age. The ethnic composition of these areas is AfricanAmerican (55%), Hispanic (33%), White (6.9%), and Asian (2.3%). Data from the New York City Department of Planning Community District Needs indicate that 34.3% of the Central Harlem residents and 33.3% of the Washington Heights and Inwood residents receive some type of income support. G enerations + / Northern M anhattan Health Network
M MTC Clinic
Sydenham D &TCs
St. N icholas
D rew Ham ilton
Alexander Ham ilton Clinic
H arlem Hospital
Dykeman House
Morrisania D&TC
CES 73 Belvis D&TC
Substance Abuse
East Harlem
JHS 22
E. 120 th St Clinic
Metropolitan H ospital
Lincoln Hospital
JHS 117 Lenox Avenue
PS 30/31
PS 161
PS 36
CS 46
PS 200
JH S 286
PS 123
W ashington Heights
Highbridg e
PS 197 Bronx River
Melrose Houses
IS 125
Park Avenue
PS 194
G rant Houses M orris H S
IS 10
Riverside
Daniel W ebster
Drawing Legend 45m b ATM Link
FR ASI
In the implementation of the EHR, all sites and venues of care including Inpatient units, Ambulatory Care and the Emergency Department were included as each phase of the EHR was installed. All locations described in the diagram above are using the EHR. Clinician’s utilization of the EHR is described below. 4
Title Physicians Nurses Lab Tech Dieticians Pharmacists Respiratory Therapists Physical Therapists Social Work Radiology Techs Total
Lincoln
Belvis
Harlem
Renaissance
Metropolitan
Morrisania
Total
Use of EHR
509 813.5 14 17 34
60.5 28.5 1 4 2
501 624.5 31 19 37
75.5 25 4 1 5
555.5 707.5 8 18 25
86.5 48 2 8 4
1788 2247 60 67 107
100% 100% 100% 100% 100%
28
0
13
0
15
0
56
100%
20 23
0 3
18 27
0 0
22 40
0 2
60 95
100% 100%
33 1491.5
2 101
3 1273.5
1 111.5
2 1393
4 154.5
45 4525
100%
Strategic Objectives for the Network and the EHR The Generations+/ Northern Manhattan Health Network’s strategic planning process is a participatory initiative that includes collaboration among the Network’s leadership, medical staff, employees and community representatives. The Network has established the following goals: · Establish a strong patient safety environment · Proactively manage chronic diseases: asthma, diabetes, and heart disease. · Improve patient efficiency through ambulatory care redesign · Fiscal viability · Strengthen compliance program · Strengthen security in patient medications and information through IT, administration and clinical leadership · Increase medication and IT security · Expand clinical services and new clinical initiatives, i.e. HIV testing · Develop marketing strategy · Diversity awareness, LEP · Continue to adopt cuttingedge technology in all areas of patient care
The EHR Project Goals The goals for the EHR were integrated into the Information Management Plan of the Network. The Plan was developed from an annual needs assessment and published in the Information Management manual and is accessible via the Network’s Intranet.
Goals · · · · · · · · ·
Improve the quality and safety of patient care Improve access to patient information at all points of entry Enhance the continuity of care Improve the timeliness of care Reduce medical errors Enhance productivity Provide data for decision making Reduce costs Improve revenue
These goals would be achieved through the following objectives:
Infrastructure Improvements ·
Upgrade of the LAN and enterprise cabling (1998 and 2001) 5
· · · ·
Wireless infrastructure and carts (20022004) PC deployment (1998,1999) and upgrades (2004) Server installations (1997) and upgrades (2004) Computer Room Consolidation and Redundancy (20062007)
Clinical Systems/EHR · · · · · · · · · · · · · · · · · · · ·
Computerized Physician Order Entry (CPOE) (19992001) Laboratory consolidation (19992000) Results reporting (19992004) Assessments, screening, care planning (2001) Ambulatory care notes (20012004) Integrated medication management (20022004) Operating Room /Emergency Department modules (20032006) Implement a multi media patient record including scanned documents, photos, images etc. (20032004) Picture Archiving Communication System (PACS) (2000) Capture clinical notes through voice recognition (20032004) EKGs online (2004) Graphic User Interface (GUI) front end (20032004) Managed Care, HIV, Diabetes Registry – Decision Support (2004) CHF, DVT and Depression Registries (2006) Immunization Interface (2006) Physician consults and progress notes (20042006) Abnormal test follow up (2006) Medication reconciliation (2006) Capture of Patient Photo (2006) Miscellaneous Document Imaging (20042006)
KnowledgeBased Resources · · · ·
Micromedex Healthcare Series Database (Ongoing) Upgrade intranet (2004, 2006) Executive View Analytical Tool (EVAT) (2003) Misys Data Warehouse for Decision Support (2005)
Training/Professional Development (Ongoing) · · · · ·
EHR ongoing training PC classes Expert user training Webbased training Development of online manuals
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The Relationship Between the Strategic and Information Management (IM) Plan Info rm a tio n M anage m ent Pla n G en+/N M H N Strategic Plan
Registries M edication Abn ormal Pt eH ealth D ata center Data Fin Com plete Reconciliation Test FU Photo Consolidation warehouse System Progress Upgrad e notes on line
Ch ronic disease M anagem ent Expan d Clinical services
X X
Patient Safety Program H IV Rapid Testing Clinic redesign
X
X X X
X
X X X
X
Fin ancial Viability Strengthen Compliance Prgm M edication & IS Security
X X X
X
Aggressive M arketin g
X
Accomm odate LEP Adopt cu tting edge Techn ology
X X
X
X
X
Vision for the Generations +/ Northern Manhattan Health Network and the EHR The vision for the Network is to be a patientcentered, communityoriented and safetyfocused organization in support of primary care initiatives. The role of the EHR is to enhance delivery of patientcentered care by providing information in the most effective and efficient manner possible. Our focus is to provide fully integrated information systems to support both Hospital and Networkwide operations. This vision was developed by the Information Technology (IT) Steering Committee and disseminated through Networkwide distribution of the Information Management manual, newsletters, and via the Intranet.
Leadership For almost two decades, the NYCHHC Board of Directors and the Presidents of the Corporation have planned, approved, championed and directed the implementation of the EHR. The Board approves all RFPs (Request for Proposal) and major system acquisitions. At the local level, the Senior Vice President/CEO of the Generations+/ Northern Manhattan Health Network directs the implementation of the EHR. The IT Steering Committee, chaired by the Senior Vice President, directs the needs assessment and planning activities, establishes priorities, allocates resources, approves policies, and monitors the quality of the EHR implementation process. Members include the Network’s senior staff, Medical Directors, chairs of the Medical Informatics and the Health Information Management (HIM) Committees, and the Information System (IS) division’s leadership. The Medical Informatics Committee memberships includes a widely varied interdisciplinary group from across hospital functions and is cochaired by the Clinical Systems Director. The committee not only attends IT meetings, but adds an IT perspective through their participation in other committees across the Network. The CIO and the IT directors participate in clinical leadership meetings including Medical Board and Nursing committees The proactive role of the CEO as a technology champion was critical to the success of the EHR implementation. Our CEO’s presence at the IT Steering Committee guaranteed the participation and collaboration of the Network’s senior staff. The CEO held the final word for setting project priorities, and identifying and securing funding opportunities. Programmatic issues and/or disagreements among departments that were not resolved through normal channels of communication were clarified and resolved at this meeting. A participatory decisionmaking process was encouraged in the pursuit of the EHR. The committee met monthly and rotated sites among the Network facilities. The agenda was structured to include new EHRrelated initiatives, policy issues, updates to the implementation plan, and quality management reporting.
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The CEO is a tireless champion of the IT both in the Network and in the communities we serve; he views the transition to the EHR, enhancement of billing and business systems, electronic communication enhancements and consolidation of services through automation as mission critical initiatives owned by the members of the executive team—not IT alone. An annual strategic planning retreat, which includes members of the board, community, physician groups and administration addresses the role of technology in the overall strategic plan. He has introduced legislative breakfasts and other events where local, state and federal leadership convene to discuss the network’s strategic direction and needs for legislative advocacy. His fundraising activities support technology initiatives such as wireless clinical workstations. The CEO regularly accepts several speaking engagements per week; technology initiatives are kept at the forefront of the agenda to ensure community understanding of IT’s importance in increasing market share and remaining competitive with the voluntary hospitals in our catchment area. As a Board Member of the Northern Manhattan Empowerment Zone, he has played a key role in persuading legislators to fund community based technical and educational programs to bring technology to underserved schools and neighborhoods. One such program, the Computer Zone, makes computers available to classrooms throughout the Harlem Community. He regularly meets with patient groups to promote our disease registries, and has been a leader in planning and securing State grant funding for a Bronx boroughwide RHIO. For 2006, he has committed to sending daily electronic messages to the entire Network that keep patient safety in the forefront of our daily routine. In 2003, he won the National Association of Public Hospitals Award for Patient Safety for the Network.
Governance Under the direction of the IT Steering Committee, existing committees dealing with health information and new working groups of stakeholders were organized. The existing HIM Committee changed its charter to include the EHR implementation process. As components of the patient record were brought online, the physician chairs of the HIM and Medical Informatics Committees evaluated the online screens to insure all components previously present on the paper forms were included. The chart print report, needed for external correspondence purposes, was reviewed. The committee monitored the introduction of new forms, challenging each clinician presenting a new need to “do it online”. Through clinical pertinence activities, the transition from paper to an EHR, and the transitional hybrid records, were monitored for quality. Clinicians, including physicians, nurses, social workers, pharmacists, radiology and laboratory technicians, dieticians, respiratory, physical and occupational therapists participated in the planning and oversight of the EHR through the Medical Informatics Committee. This Committee originated at one Generations+ hospital and expanded to a Network committee rotating to the three hospital sites monthly. It is chaired by a Physician Informaticist, who drives the vision and participates in setting priorities. The major focus of the medical informatics committee is championing, validating, testing, coordination and design of new modules for the EHR. Committees of the IT department managed the implementation process. These committees addressed issues of workflow assessment, database preparation, change management, project management, resource oversight, security, and quality management. They prepared agendas and served as staff to the IT Executive Steering Committee. Gen+ Northern Manhattan Ntwrk
MIS Sr. Staff Project Mgmt
QI Committee
HIM Committee
Informatics Committee
Database Committee
Forms Committee
Departtmental Ad Hoc Groups
Employee Access Control
Clinical Pertinence Working Groups
Needs Assessment All our physicians use the EHR and initial physician involvement is key to any implementation. At Generations+, the top down approach of our medical staff coupled with the involvement of expert users was our initial approach to physician involvement—in addition to all the usual tools like special physician training and a medical informatics committee. From the initial planning phase, clinicians were involved in the selection of equipment and workflow design. Of special note is the fact that 90% of our clinical IT design staff are actually clinicians— pharmacists, podiatrists, lab techs and nurses. The clinical IT staff was recruited from many levels within the organization, attends all 8
meetings and is seamlessly integrated into hospital operations. They blend in easily with the clinical users because they speak the same language. They designed every element of the system to be user friendly and were ready to make changes when they were not. Doctors love to use the system because it works for them. Although patient safety was the initial reason behind our implementation, physician workflow drove our process. Appropriate clinical and administrative staff participates in assessing the Generations+ Network’s information needs, and in selecting, integrating, and using information management (IM) technology. Methods used in conducting the needs assessment are: · Surveys All departments were surveyed regarding information needs annually. · Workflows Department operations/workflows were observed prior to new application implementation, or to address current operational issues. · Task Force/User Group Sessions are held with designated department/IT liaisons and system analysts. · Problem Reporting Customer Support Service Center calls are analyzed and trended monthly. · Strategic Planning Annual strategic planning is conducted. Needs assessment prioritization grids were completed. · Involvement The CIO was involved in Executive Leadership Committees and other IT senior staff in Network operations.
System Acquisition1 In 1986, the NYCHHC issued a RFP for a fully integrated EHR. At that time, the Selection Committee determined that no vendor system existed to meet the intent of the RFP. Acquisition was deferred and efforts refocused on the implementation of smaller departmental systems. In 1989, the RFP was reissued with an emphasis on acquiring a system to promote primary care by providing a single longitudinal record across all venues of care. Criteria for selection included the ability of the new system to support computerized physician order entry (CPOE), interface to existing departmental systems, and provide for registration and appointment functionality, and offer of high availability, redundancy, fault tolerance, and records retention. An Evaluation Committee reviewed vendor responses. In 1991, a decision to implement the HDS Ulticare system (now Misys CPR) was made. The decision was based on the system’s ability to support inpatient and outpatient longitudinal records, work lists, schedules, problem lists, care planning, alerts and warnings, multifacility access, and the ability of the hospital staff to perform necessary customization. In early 1992, the implementation at the pilot hospital began. The first inpatient and outpatient golives occurred in June 1993. While work at the pilot hospital continued, HDS laboratory and radiology modules were installed in two other NYCHHC facilities. Planning for the expansion to the Generations+ Network began in 1996 at Harlem Hospital, and in 1997, at Lincoln and Metropolitan Hospitals. The first go lives occurred at these facilities in 1998 and 1999 respectively.
Business Case While the decision to acquire the EHR was primarily driven by the need to improve the quality and efficiency of patient care, NYCHHC and its individual Networks sought methods to recoup returns on this significant investment. In 1995, KPMG working with NYCHHC and the pilot hospital, sought methods to demonstrate cost benefits, cost reduction, and cost avoidance. 2 Over a tenyear period, significant returns on investment were identified. A tenyear expected return on investment of over 360 million dollars was projected for implementation of the EHR throughout NYCHHC. The expected savings were: · Reduction in ancillary tests by 21% · Reduction in the cost of drugs by 4.9% · Reduction of medical records staff (pilot hospital reduced 11 FTEs) · Reduction in malpractice costs by 6% · Reduction in data entry costs (8 FTEs at pilot site) · Elimination of departmental systems and reduction in maintenance costs (50% of departmental systems converted) · Reduction in costs of meals by eliminating tray wastage by 2.3% · Reduction in cost of forms by 30% · Facilitation of laboratory consolidation not quantified initially The Network’s performance, as compared to these benchmarks, will be discussed in the Values section.
1
Carter,S., Sullivan,A., Broderick, M. The Computerbased Patient Record: The Jacobi Medical Center Experience. Davies CPR Recognition Proceedings, 1996 2 KPMG, NYCHHC. Cost Benefit Analysis of the HDS Clinical Information System, 1995 9
Cost The cost of implementing the EHR in the Generations+/Northern Manhattan Health Network was $38 million for software, hardware, and infrastructure. Funding was available through capital financing. An additional $1.3 million annual cost was incurred to hire 23 people to implement the EHR Networkwide. An annual maintenance cost of $573,000 is paid through operating funds. In 2004, an additional $4 million in capital funds was spent to upgrade the user interface, replace the servers and replace 2100 personal computers (PC’s). Upgrades to the servers and peripherals have continued to present day. How was it possible for us to do so much with so few resources? Our original plan was to create expertise within the network with less reliance on external resources. The skills our analysts developed conformed to the Network’s vision of the paperless record. We used more clinical staff to help facilitate and expedite the process due to their familiarity with the actual workflows. We had also standardized documentation processes by collecting all paper records across the system and rewrote them to ensure standardization. Continuity in our rollouts was important, but equally important was continuity in our resources. There was a strong commitment on the part of the key IT players, and aside from retirement, everyone involved in the implementation remains a key team member today. Expense (in Millions) Software Hardware Maintenance Personnel Total
Metropolitan/ Morrisania 5.2 9.2 .19 .44 15.03
Lincoln/ Belvis 5.2 5.8 .19 .32 11.51
Harlem/ Renaissance 5.2 8.4 .19 .45 14.24
Project Risk Management While the importance of transitioning from the paper medical record to an EHR was widely recognized, ensuring effective management of the risk of this endeavor is usually underestimated. The leadership of the EHR implementation, with its significant involvement of clinicians as team members, was well aware of the risk. To reduce the risks of failure, hospitalsavvy clinicians were commandeered to be active members of the team, and also kept their finger on the Network’s pulse. Each step in the process, including thorough assessment of each facility’s workflows, database design and training, comprehensive testing, transition planning, and user support was structured to insure patient safety. The EHR team and Quality Management jointly monitored the new processes. For all processes changed through the introduction of the EHR, a Failure Mode and Effects Analysis (FMEA) was conducted. A FMEA begins with analyzing the new workflow and identifying every point of failure. Each failure point was scored for its likelihood and impact. A Root Cause Analysis was conducted for all failure points receiving high scores. Procedures were then developed to prevent or mitigate these failures. Three recent processes subjected to a FMEA were the EHR contingency plan, patient identification, and integrated medication management. All change management requests must include back out plans.
2. Implementation Implementation Planning The planning for the EHR was a major component of the organization’s information management planning process. Every year, user evaluations and surveys of new needs were conducted. Additionally, departmental task forces and the Medical Informatics Committee identified new areas of opportunity. The CIO and clinical systems’ leadership were integrated in the Network’s operations that lead to the resolution of operational challenges with system solutions. Cost and impact and strategy fit was evaluated for the list of requested initiatives and presented to the IT Steering Committee for approval and prioritization. This process resulted in the goals identified in the annual Information Management Strategic Plan. There was never a shortage of new initiatives in the EHR implementation process. Rather, new opportunities surfaced on a daily basis. Project plans and timelines were reviewed weekly. The feasibility of new requests was examined. The EHR team recommended changes in priorities to the IT Strategic Planning Committee. The annual plan was a dynamic document and was often modified and reprioritized.
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Implementation Process The implementation of the EHR occurred in phases that were driven by pressing organizational need. In late 1998 and in 1999, driven by the need to replace an aging noncompliant Y2K laboratory system and to reduce operational costs by consolidating laboratories, the Network installed the first phase of the EHR. This initiative included the replacement of the existing laboratory system and the introduction of physician CPOE for laboratory orders to physicians. Nurses were introduced to review queues and work lists for specimen collection. Chart review was also implemented to facilitate the review of results. The implementation strategy was to go live on all units simultaneously. Unit by unit implementation was deemed to be problematic to the closing of certain laboratories, the transfer of staff, and the transporting of specimens. January 1, 2000 was rapidly approaching. In 2000, the same implementation process was used for the second phase of the EHR with respect to radiology. The pending installation Networkwide of the Phillips PACS system necessitated the replacement of the radiology information system. With deadlines looming, radiology CPOE and six discrete radiology databases, one for each Hospital and the three Neighborhood Family Health Centers (and their offsite centers) were introduced. In the Fall of 2000, the IT Steering Committee and the EHR team determined that the next phase of the implementation process was the completion of CPOE and the replacement of the pharmacy system with Misys CPR. This time, the implementation strategy was changed to a unitbyunit approach. Pharmacy managed, with some difficulty, to toggle between two systems until the implementation for each facility was completed. Nursing assessments and screening was introduced at the same time, capitalizing on the roundtheclock support. The Executive Steering Committee determined the site selected for the rollout. In general, the pilots and initial rollout were rotated among the hospitals based on the timing of their JCAHO inspection. Every year, one of the Network hospitals is scheduled for a Survey and the team focused on implementing needed functionality at that site. The EHR team was made up of Network staff and moved to the facility where the golive was occurring. The major lesson learned during the implementation process was to rollout new functionality unitbyunit providing roundtheclock support. Order entry and other functionality were more acceptable to clinicians when they did not have to toggle back and forth between systems. As long as paper order sheets remained, they were used. EHR Functionality Lab system and order entry Radiology system and order entry CPOE & Pharmacy system replacement Nursing assessments and Screens Interdisciplinary care planning Problem list and Prescriptions Op Reports Discharge Summary Patient Acuity OR system ED system Integrated Medication Management Media Manager NotesAmb Care Physician inpatient notes Patient Photos Medication Reconciliation Abnormal test follow up Registries
Approach All units simultaneously All units simultaneously
Metropolitan July 1999 Spring 2000
Lincoln December 1999 Spring 2000
Harlem October 1999 Spring 2000
Pilot, then unit by unit
Spring 2001
Spring 2001
Summer 2001
Pilot, then unit by unit
Spring 2001
Spring 2001
Summer 2001
Pilot, then unit by unit Pilot, then unit by unit Pilot, then unit by unit Pilot, then unit by unit Pilot, then unit by unit Function introduced housewide Pilot, then unit by unit Pilot, then unit by unit
Summer 2001 Fall 2000 2002 2002 Summer 2001 January 2004
Fall 2002 Fall 2000 2002 2003 Summer 2001
Spring2002 Fall 2000 Summer 2004 2003 Summer 2001 April 2004
Sept 2003 Present March 2004
Sept 2003, Jan 2006 Summer 2003
Sept 2005 Summer 2002
Pilot, then unit by unit Pilot, then unit by unit Pilot, Service by Service Selected services Pilot, service by service Pilot, hosp by hosp All
April 2004 March 2004 Fall 2005 Present
June 2004 Fall 2005 Present
Jan 2006 Fall 2005 Present
March 2006 April 2006 Dec 2005
April 2006 March 2006 Fall 2005 Dec 2005
March 2006 April 2006 Dec 2005
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Project Governance and Staffing The EHR implementation process receives its direction from the IT Steering Committee and the Network CIO. Recruiting team members with a clinical background was emphasized. The CIO is a Registered Nurse with previous experience as a Nursing Administrator. The Director of Clinical Systems is a Nurse Practitioner who directed a team of nine staff whose backgrounds included a physician, a podiatrist, a pharmacist and registered nurses. The oversight of the database, interfaces and change management was the role of the Database Manager. The Database Manager reported directly to the CIO to insure that appropriate oversight and monitoring functions occur. Technical support was provided by Site Directors at each facility and the Manager of the Customer Support Service Center. The CEO helped prioritize requested changes. Network Chief Information Officer Director Standards & Quality Management
Database Manager
Analysts 2 FTEs
Director Operations& T echnology
Director Clinical Systems
Harlem Site Administrator Client Server Applications
Director Financial Systems Decision Support Resource Scheduling
RN T rainers 4 FTEs
Customer Support 2 additional FTEs
Lincoln Site Administrator Operations
Nurse Analyst
Desktop Support 8 FT Es
Metropolitan Site Administrator
Physician Analyst
Network/Security Administrator
Director HIM
Directors Medical Libraries
Pharmacy analyst
Laboratory Analyst
Radiology, OR & Misc Ancillary Analyst
Transition to New Processes The transition between the electronic and paper record was and remains one of the greatest challenges in implementing the EHR. The phases of implementation were established with attention to logical breaks in workflow and to minimize confusion among members of the health care team. The impact of the phases described above was coordinated with Network operations. For example, the decision to implement laboratory order entry housewide was simultaneously based on the need to implement laboratory consolidation. The elimination of some laboratory functions as well as the process of dispatching specimens and returning results necessitated that all units move to the new process at the same time. On the other hand, the integrated medication management process was effectively implemented unit by unit. In this case, the integration among team members on the unit was essential for a safe transition. The ability to reengineer complex processes through the use of the EHR is recognized by all key stakeholders. Recently, the use of the system to facilitate the booking of OR (Operating Room) cases and tracking of patients through the preadmission clearance process was implemented. New initiatives are underway to assist providers in overseeing their managed care panels. Providing ‘report cards’ of their clinical performance to the Medical Director has reengineered the managed care member management process. Patient satisfaction management and denials tracking were also new initiatives. There was a positive correlation between the enthusiasm of the implementation champion for the requested initiative and the successful use of the application. As implementation proceeded through the units, we instituted a series of tighter controls and audit reports that are constantly monitored. As new functionality was introduced, documentation of “What’s Online and What’s on Paper” was distributed to all units. Staff competency in navigating the hybrid record was ensured by expert users. Quality Management and the HIM departments monitored the quality of documentation to ensure integrity of the patient record.
Training, Education and Support One key to the successful transition to the EHR was the preparation and support of the system users. The Network employed a multi faceted approach to EHR training. Initially, an assessment of computer literacy was performed. Computer literacy and basic Microsoft Window courses were conducted for those individuals requiring it. All training was interactive and conducted in facilitybased training centers. In 2005, webbased user guides and online requests for classroom training were introduced. The EHR training was organized based on clinical role and function, i.e., classes for Registered Nurses (RNs) on the online MAR (Medication Administration Record). At the conclusion of each class, the participant completed a selfassessment of their proficiency with the application. They left the class with an easy to use ‘cheat sheet’. 12
For major functions, competencies were assessed in the work area and performed by expert users. These experts were RNs, usually NYCHHC employees, working through a temporary agency. They were referred to as ‘Yellow Jackets’ because of the mustard colored vest they wore. The ‘Yellow Jacket’ concept was an affordable flexible solution to 24 hour/day, sevenday/week support (when compared to vendor support costs). Ongoing support is provided by the Customer Support Service Center, a function that is centralized at one facility and available around the clock.
3. Operations Data Management The policy of the Generations+/Northern Manhattan Network is to standardize minimum data sets, data definitions, codes, classifications, and terminology for all facilities whenever possible. For example, the naming convention for clinical procedures is identical for all of our sites. These standard data definitions and terminology are used in the recording, filing, analyzing, and reporting of information. The HIM Committee establishes the standard set of abbreviations for use in recording medical information. The HIM department applies the ICD9 CM and CPT Classification System, NYCHHC standards, local, state, and federal regulatory nomenclature, and hospital standards in the coding of medical records. The CIO required that information conform to: · Standards established by HIM Committee · Facilitywide and NYCHHCdefined common data elements including: Room and Bed Master file Charge Master file for procedural charge codes Common patient visit codes Common Medical Record numbers Common Physician/Provider Identification Codes Common employee identification numbers Common title codes, civil service codes and employee status codes (from the PSMS manual) Cost center codes for billing and reimbursement Common pay station codes Resource scheduling codes (for scheduling, tracking and reporting use of hospital resources)
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COMMON DATA ELEMENTS, AVAILABILITY AND CONTROLS SYSTEM
INFORMATION
Misys CPR
Order Entry Documentation Laboratory, Radiology, Nuclear Medicine, Blood Blood Bank Microbiology Food and Nutrition Pharmacy Ancillary Services Vital Signs Physician Order Entry
SMS/UNITY Terminals are located in all clinics, admitting, medical records and inpatient areas. UNITY /Misys INTERFACE
INTELLUS Patient tracking and chart retrieval system. Interfaces to SMSlocated in medical records 3M HDM/Codefinder
AVAIL ABILITY
COMMON DATA ELEMENTS
CHECKING MECHANISMS
24 Hours/7 Days
Medical Record #, Visit #, Patient Name, some demographics, Physician Name and SMS code, test and diagnostic codes, result reporting codes, bed, room and clinic locations, hospital formulary for drugs, interactions and dosages, standard orders, common diet, approved alias names (which expand to full names), common user security by job class, job code and job title
Admission, discharge, Transfer, Demographic, scheduling & Payor Info
24 Hours/7 Days
Medical Record #, Visit # (SMS identification number), Patient Name, demographics, Physician Name and SMS code, test and diagnostic codes, result reporting codes, bed, room and clinic locations, user security by job class, job code and job title
Chart Review on line/Work Queues/ Computerized Time stamps/Audit Trails and Error Messages/ Continuous realtime update. Preset menus of options as well as freetext to ensure consistency and readability Online entry and lookup of information. Real time updates. Audit Trail. Verification initials. Daily review and correction of transmission errors
ADT and some demographic information from Unity
24 Hours/7 Days
Medical Record #, Visit # (SMS identification number), Patient Name, demographics, Physician Name and SMS code, test and diagnostic codes, result reporting codes, bed, room and clinic locations
Scheduled patient visits to pull patient charts for timely delivery to clinics, track charts throughout the facility
24 Hours/7 Days
Medical Records Coding System
24 Hours/7 Day During pharmacy hours
Medical Record #, Visit # (SMS identification number), Patient Name, demographics, Physician Name and SMS code, test and diagnostic codes, result reporting codes, bed, room and clinic locations Test and diagnostic codes, result reporting codes
Visits identified and chart pulls completed 1 day prior to visits. Manual comparison to Unity and Lifeline systems. Feedback from clinics External chart review processes, UR review
Medical Record #, Visit # (SMS identification number), Patient Name, demographics, hospital formulary for drugs, interactions and dosages
Prescriptions and labels are checked for accuracy and patient identification
Medical Record #, Visit # (SMS account #), Patient Name, demographics (DOB, sex, race), hospital location and class of service. Interfaces with CHC system. Medical Record number, visit identification (SMS) number, SMS Physician ID, Standard billing codes and diagnostic and utilization review information
Daily (several times/day) manual and automated checking against multiple information sources Review of error reports and system reports. Operations review of job run procedures
INTERACTIVE Located in outpatient pharmacy
Outpatient Pharmacy Data
Hemocare
Blood Bank System
24 hours/7 days
SMS Financial Management Systems (includes Patient Accounting)
Processes that support patient accounting, patient billing and accounts receivables and utilization review
Available 24 hours/day
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Realtime updates. Audit trail. Reports and Patient Charts. Transmission log and Error log. QI monitoring
Security and Confidentiality Security and Integrity Protecting information security, confidentiality and integrity is a key design and support consideration for the EHR. The procedures described below are currently in effect:
Establishing security levels Security levels or access privileges for all systems containing patient information are established based on job title and assignment. Management approval is required for all system identification codes. In the annual departmental database review, each department reviews security levels. Routinely, the Human Resources department notifies the Security Administrator when a person leaves the hospital or completes a residency program, at which time the person is inactivated on the system. Inactivity for 30 days prompts the database manager to terminate the account.
Confidentiality agreements All employees sign confidentiality agreements for system access. Limiting employees’ access to patient information Unique encrypted passwords, userids and audit trails identify those who have accessed patient information. Monthly, the Database Manager reviews a sample of the patient records that have been accessed to ensure appropriateness. The Customer Support Service Center and Database Manager monitors print queues to see who requested a report (e.g., medication label and patient chart) from which location. Users who violate the Network confidentiality agreements are subject to disciplinary action.
Ensuring data integrity Through standardized menus, common terms, absence of abbreviations, and work queue procedures, the integrity of data is maintained. A formal change control process is implemented across the systems. The Database Manager monitors changes to all tables on the development (test) and production systems. Changes made directly to the production system are tightly controlled and made only when needed for patient care, with full agreement by the Database Committee.
Ensuring system security and integrity The Mirror/Archive Database facility provides realtime redundancy to the system in the event of losing a processor or a disk drive. If an interface fails or goes down, the data are queued on both sides until the connection is re established. Sequence numbers and CHKSUM digits are used to identify missing, incomplete or duplicate data. The error log, monitored daily by the Database Manager, flags all program errors and provides sufficient information to contact the user in the event of a problem. Offsite storage and system contingency plans are maintained and exercised. In the case of an interruption in service in a segment of the hospital for an extended period, caregivers may request tests or medications on paper order forms. Once the system returns, the clinical services backload that information into the system. If there is a need to return to paper orders, reports of vital signs and current active orders are distributed to the affected units.
Network security Secure vendor gateway, firewalls, encryption and intrusion detection are in place. Meeting legal requirements The strategy for this system is to maintain the longitudinal record online indefinitely. Audit trails of all accesses to patient data are maintained. All orders, clinical documentation and changes to the patient record are logged and can be reviewed. The user password and userid are the electronic signature with the legal equivalent of signing or documenting an order or clinical documentation entries. The system was designed to comply with the recommendations made by legal counsel.
Business continuity planning The network has installed a PC backup system which contains a read only database of orders, results, medications, vital signs and other critical parameters which copies data from the EHR at fifteen minute intervals.
Impact on Operations As presented in the planning phase, the phases of implementation were designed to minimize the impact of transition to the EHR on department and facility operations. The initial step of implementation was the request and approval by the authorizing department head, insuring project support at the local level. Based on the thorough assessment of the workflow, the database was designed. The database was carefully reviewed and tested by department representatives. Prior to implementation, Failure Mode and Effects Analyses were conducted to identify new points of failure in the process. Strategies for mitigating these risks were developed. Staff training and competency assessments were conducted prior to a golive. The transition process was carefully reviewed, i.e., reviewing back entry of orders when a unit went live with order entry. Expert users provided round theclock support and focused not only on user support but also on monitoring operational issues. For example, monitoring indicators such as timeliness of medications, and clinical pertinence were followed during the transition.
Ongoing Planning The ongoing planning follows the needs assessment process discussed in the Planning Section. In addition to annual assessments, needs are identified through a review of the effectiveness of hospital operations, committees and task forces, and quality reviews. Emergency needs are fast tracked through the process. Routine requests are reviewed by the department and submitted to the Medical Informatics and IT Steering Committees for prioritization and approval. 15
User and Business Unit Support After the implementation of a function or area, changes were handled through the formal change management process. A written request for change, signed by the appropriate authorizing individual, was forwarded to the Director of Clinical Systems. The request was accompanied by a completed FMEA if the change constituted a change in process. It was reviewed during the change management portion of the project management committee. Changes were made in the development system and tested by the clinical systems staff and requesting department. Changes were presented to the HIM Committee prior to the introduction into the production environment. Rollovers to move changes and new releases into production were scheduled approximately six times annually. Announcements of the rollover and any changes or new functionality were distributed via bulletins and emails to system users. In addition to expert user support, expert users were utilized on an ad hoc basis. Where extensive support or retraining was necessary, nurse trainers were assigned to each hospital. They conducted ongoing formal, informal, and on the spot training. The Customer Support Service Center provided aroundtheclock support. Clinical systems staff was on call evenings, nights, and weekends to assist customer service personnel with complex issues.
Monitoring and Evaluation The implementation of the EHR was monitored through the following processes: Monitoring of EHR system operations As a routine part of daily data center operations, the user jobs were monitored. These observations identified system performance issues and led to the replacement of the servers in February 2004. Network performance was continuously evaluated to insure optimal performance. Calls to the Customer Service Support Center were aggregated and trended. Printer issues remained the number one problem call. Workflows that minimize the use of printing, preventative maintenance, and user training in basic troubleshooting techniques reduced the number of service calls. Monitoring security of the EHR Each month, data was gathered with respect to the sharing of passwords. The data was reported to the HospitalWide Performance Improvement Committee. The Database Coordinator selected a random sample of patient cases and audits user access for appropriateness. Monitoring of sustained implementation Monitors were put in place with each stage of implementation to monitor compliance with system use. These included: reports of handwritten prescriptions and orders, monitoring of handwritten encounter forms, and the creation of work lists and queues to evaluate the timeliness and completion of system generated events. Quality monitoring The electronic patient record was subjected to clinical pertinence and other documentation reviews to evaluate the quality of the data capture. It was also used as a source of clinical data for other performance improvement projects. User satisfaction Annual user satisfaction surveys were conducted as well as surveys for direct system enhancements and new initiatives. Ad hoc user surveys were conducted with major new implementations.
4. Evaluation of Management of the EHR Effort Our approach to the implementation of the EHR was constantly reevaluated through the departmental project management meeting, the Network’s Medical Informatics Committee and the IT Steering Committee. These groups looked at user feedback, organizational needs, and quality of care issues. Successful strategies in implementing the EHR included project leadership, organization and selection of the clinical system team, infrastructure and access to workstations, and user support. The commitment of the senior leadership of the Network to the implementation of the EHR underscored to the clinicians that the use of the system was not optional. An emphasis on overcoming obstacles preventing clinician use of the EHR was evident. The clinical system team was created at the Network level to ensure standardization and efficiency. The selection of clinicians as team members ensured that functionality was developed with an understanding of workflow, clinical practice, and policy. Adequate deployment of workstations and the implementation of wireless workstations and medication carts facilitated user access. The use of the ‘Yellow Jackets’ in supporting EHR users was effective for both the quality of the training and in the reduction of the cost of support. Since these expert users were nurses and often NYCHHC employees, we expanded the base of the experts available to support the EHR. The cost of an agency nurse is onethird of the cost of vendor and consultant support, and the nurses were more amenable to working nights and on weekends. Their understanding of workflow and policy made them invaluable in providing support. Some of the successes identified above grew out of early failures. The leadership of the implementation process struggled with the need to decentralize and centralize. We found that the centralization of the leadership process expedited the phases of installation. The critical infrastructures, installed five years ago, focused on network connectivity in the clinical areas only. Physician offices, administrative suites and conference rooms were not included. The demand for access in these areas became clear, and enterprise cabling was completed two years ago. The number of workstations and printers was underconfigured in many areas. As a result, the number of devices more than doubled to the present count of 6,400 hardwired PCs. The expansion to a wireless infrastructure and the addition of more than 362 wireless workstations and medication carts was not without its challenges. It took four configurations of medication carts before we found one suitable to Nursing. As previously mentioned, the majority of customer support service calls were hardware related. With our existing staff, only 60% of these calls were closed within 24 hours. With the addition of nine outsourced positions, we were able to resolve 95% of the open tickets within 24 hours. Efforts continue to prevent problems and ratchet down the response time to hours instead of days. The following pages will describe our present level of implementation, and the values and benefits that have resulted. 16
FUNCTIONALITY 1. Targeted Processes Approach to Ongoing Management of Paper The decision to enhance the EHR was driven by the need to improve patient safety. Legibility, timeliness, security and cost reduction were key components to a computerized patient record. The Generations+/Northern Manhattan Health Network recognized that the complete transition to a paperless environment was a long way ahead, but the implementation process steadily stayed the course. Paper records were continually streamlined, forms were revised with uptodate standards, and preparations were made for the imminent automation of form acquisitions. Documents requiring patient signatures, historical records, outside documents and drawings continued in their paper format. Scanning technology provided the capability for each document to be electronically accessible. Our aim in developing the EHR was to assist all healthcare providers in managing their patients in a timely and effective manner. The transition process from paper to electronic medical records included training, meeting regulatory mandates and requirements, revising policies and procedures, and providing staff with the confidence and assurance required to handle a dual system of medical records. The existing committees were reviewed for their effectiveness and new committees were formed, as appropriate, in order to achieve a multidisciplinary approach that would involve all respective disciplines before rolling out the electronic medical record. In creating the database, security, confidentiality and integrity of the data were considered. Despite almost full automation in the Network, there still remain gaps in our electronic record: any forms requiring patient signature, e.g. consent forms, remain on paper; however, they are scanned in and can be accessed throughout the network. In addition, Harlem Hospital is still not live with physician H&Ps, consults and referrals in inpatient and clinics, though implementation is planned for next year.
Anticipated Role of Physicians and Other Caregivers in Contributing to the EHR Physicians, nurses and other caregivers played active roles in contributing to the advancement of the EHR and were aware of its value to them and to the Network. Committees met regularly and included the departmental User Task Force, the Medical Informatics Committee, the IS Strategic Committee, and the HIM Committee, expanded to include Information Systems (IS). The Medical Informatics Committee, chaired by the Chief of Emergency Medicine, is comprised of members from all clinical disciplines. At meetings, members discussed issues pertaining to policies, appropriate technology, ease of use of the EHR, and the launching of new enhancements. At User Task Force meetings, a detailed approach to the EHR was presented and discussed. Workflows, testing, user training and FMEA’s were thoroughly covered as well as the tabled implementation plan. Physicians chaired the HIM/IS Committees that were attended by the Directors of HIM and Clinical Systems and staff from nursing, quality management, ancillary and support services. At these meetings, standards were reviewed, compliance was monitored, and quality and clinical pertinence were examined. The Medical Chiefs of Service and Nursing leadership selected the potential users of the EHR. The users, in turn, participated and assisted with the development of each planned project and the implementation process. They would feedback the information to their leadership. New developments, updates, and all other issues were discussed.
Specific Processes Targeted for Improvement The Network’s senior leadership met monthly with members of the IS Strategic and Planning Committee, chaired by the Chief Information Officer (CIO), to discuss future projects, set priorities, and review budget and resource allocation. Proposed projects, with detailed projections, were presented and evaluated with regard to their impact on patient care, the expenditures they may incur, and the anticipated return on investment. Information from the annual Needs Assessment Surveys provided the basis from which projects were proposed and reviewed for their feasibility. Projects were given a priority status (high/low impact) and a cost status (high/low). The targeted processes included: · Laboratory consolidation · Paperless/ filmless radiology · Improved patient safety through CPOE · Enhanced quality and continuity of care by automating the summary/problem list, nursing assessments, screenings, interdisciplinary care plan, operative reports, discharge summaries, etc · Improved medication safety through integrated medication management and medication reconciliation · Improved work processes for emergency department, operating room, managed care, guest relations, quality management, etc. · Enhanced data capture methods, scanning, voice recognition, handwriting recognition · Improved efficiency
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2. Information Access Comprehensive Data
All Ambulatory Care Centers are installed on the Misys CPR at Harlem Hospital, Lincoln Medical and Mental Health Center, and Metropolitan Hospital Center. The EHR is a patientcentered longitudinal system and provides a lifetime record across all venues of care. The system includes comprehensive admissiontransferdischarge (ADT), orderentry, resultsreview and clinical documentation capabilities with extensive clinical decision support (CDS). A Javabased graphical user interface provides improved caregiver navigation, enhanced CDS, and the ability to integrate the intranet and Internet networks, radiology images, and other clinical information management tools into a standard clinical desktop. Clinicians access the Misys CPR through all, but not limited to, inpatient, emergency and outpatient units and departments: nursing, respiratory therapy, pharmacy, social services, laboratory, radiology, business services, speech therapy, occupational therapy, physical therapy, outpatient rehabilitation, pastoral care services, information desk/admissions, pharmacy, rehabilitation, emergency, diagnostic imaging, and health records. Currently, these venues of care utilize online problem lists, visit histories, medication lists, allergies, orders, results, immunizations, inpatient nursing assessments, physician progress notes, functional, pain, nutritional, social work, spiritual and pain screens and the interdisciplinary care plan. A program of integrated medication management, including the online administration of medications, has been implemented at all hospitals. The system has dose and allergy checking and warns of drug interactions. Reminders and review queues are in place. Patient tracking tools such as bed boards and ED white boards are used. It is recognized that clinicians cannot stay chained to a computer waiting for things to happen. Computers are great at alerting users to many different care issues, but those alerts only happen if the clinician is signed on. At Generations+, we believe that the best way to alert clinicians to changes in patient condition and workload activity is to use a large number of electronic bulletin boards in the various departments. These boards display department wide indicators and alert staff through changing colors and objects to conditions that require their attention. Now, clinicians do not have to be signed on in the ED to see lab results, or the Radiology tech does not need to be logged on to know that a STAT CXR was just ordered in CCU. These constantly updating monitors bring realtime alerts to clinicians all the time. Electronic information resources are available through separate query. Information resources that practicing clinicians can use at the point of care offering clinical decision support include access to the Micromedex Healthcare Series database, multilingual patient care instruction, access to the National Library of Medicine (NLM) biomedical and health information databases that include Medline/PubMed and evidencebased medicine, access to webbased radiology images and EKG system, and links to knowledge sources with quick access to the intranet sites of the Network. Additional functionality has been implemented, such as the integration into the patient record of historic scanned documents and patient photos. The use of voice recognition is used in inpatient and outpatient settings to facilitate the capture of clinical notes. An integrated operating room module permitting the booking/ ordering of cases online and the tracking of patients through the preoperative period is available at all hospitals. A comprehensive ED module, EDIS, was installed at Metropolitan Hospital Center.
Data Capture Network healthcare professionals use various ways to enter data into the EHR. Data are captured by the use of the conventional point and click entry using a mouse, stylus or touch screen as well as the more modern voice on wireless tablet or desktop. Structured notes with selection screens, free text or calculated responses are ways that data can be directly entered into the EHR. All entries are time stamped with its distinctive user Identification as evident in the system audit trail authentication. An indirect method of data recording is via system interfaces. Patient demographic is sent to the EHR via an inbound, unidirectional interface between the registration system (Siemens) and clinical system (Misys CPR). Patient insurance data, primary care attending, age and sex are examples of types of data transmitted via an interface. Data are used for medication calculation, sex or agespecific laboratory referenceranges, growth charts and pain management using age specific pain assessment tools. Directly entered data through order entry function is more structured and wellorganized using a combination of mandatory and optional fields. Relevant diagnoses and referring attending are “must” fields. Medication orders follow more stringent guidelines that prohibit free text entries. Tailormade dosages, routes and frequencies typical to selected medications simplify the process for the physicians. The Network’s computerized record has accrued a significant amount of historical data that remains in the EHR for future reference. The information within each patient record could be used for correlation, research, and review in efforts to improve patient care. Although data could be accessed historically across visits, order and result events are distinct to each visit. Patient historic data, such as allergies and language, abridge and improve data collection for healthcare providers. Visit historical data, such as vital signs, height and weight and chief complaints, are commonly used in outpatient settings. Historical entries by nursing staff are incorporated into the physicians’ visit notes to improve efficiency and quicker turnaround time in the clinic. 18
Paper documents are being scanned using an external tool, the Media Manager, as a means to integrate information. Teleradiology and filmless radiology technology is widely used by the Network as it allows access of images on client workstations within the Network as well as in the homes of neurosurgeons.
Methods of Entries
Data Captured
Commonly Used By
Point and click Free text Voice recognition
Order entry and documentation Documentation Reports
Handwriting recognition Barcode scanning
Documentation Patient and specimen identification Consents, paper records, outside documents Dictated reports Radiology reports Film images Results
All users All users Radiology, Pathology, OB, OR, Ancillary departments Physicians Laboratory, Radiology, ED and inpatient admissions Medical Records, Emergency Department
Image scanning File transfer protocol Teleradiology PACS Inbound interfaces
Transcription vendors Neurosurgeons Radiology Laboratory, radiology, cardiology
Computerized Physician Order Entry The Network is on full CPOE. Physicians and midlevel staff enter orders directly in real time. Order entry includes, but is not limited to, medication orders, ancillary tests, nursing orders, prescriptions and registration related activities. Except for Networkwide restraint orders, receiving departments review orders in a timely fashion utilizing designated department order review queues.
Ancillary tests require data on relevant diagnoses, referring attending, and other pertinent lab related data necessary for processing. Medication order entry is solely the responsibility of physicians and midlevel staff. Although registered pharmacists can transcribe written orders, this task is limited only in the event of a system interruption.
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Rules and standards guide physicians at the time of order entry. “Undocumented allergies check” is one feature that is critical to reducing adverse medication events. Adverse reactions, drug interaction, and duplicate orders are standard alerts that continuously serve as a reminder to physicians to ensure patient safety. Lab results, last doses, age, weight, and BSA/BMI are used to improve best practice guidelines. Physiological status, relating to pregnancy and last menstrual period, are required when placing orders for radiological examinations.
To reduce unnecessary blood loss, duplicate alerts and the specimen labels at the time of order entry offer physicians and phlebotomists the required tubes and blood volume needed to process laboratory orders.
Information Availability and Access 9/11 heightened our awareness to create more redundant hot sites, both long and short distance in different boroughs. It was the precursor to our data center consolidation. We also learned a valuable lesson about power sources during a recent New York City major sustained power outage: in spite of our robust data center, the network was incapacitated by something much more simple: the computer room was on emergency power supply that maintained the application, but the user desktops were NOT on emergency power supply. Our system was up, but we had no working hardware to access it. In our emergency procedure design preEHR, PC’s were not considered direct patient care devices. Today our PC’s are portals to patient information, so we make sure that a good percentage of our workstations are connected to the emergency supply and identified with a red outlet. Personal computers (PC), wireless or desktop are ubiquitous throughout the Network. Nursing units are equipped with one desktop PC for every five admitted noncritical patients. At least two wireless mobile carts and four medication wireless carts are assigned to inpatient units. Critical units are provided with even larger inventories of one PC for every 2 patients. In outpatient areas, each exam room is equipped with one PC and one laser printer. The Emergency Department is provided with a combination of PC desktops and wireless devices. Ancillary departments are similarly provided with workstations of the same capability, speed, and accessibility. Most times, ancillary staff has access to a workstation on a 1:1 ratio. Higher resolution PCs were made available to radiologists and to areas requiring radiology imaging interpretation. Laser printers and specimen label printers are equally important in the management of patient care. To avoid confusion in the printing of prescriptions, exam rooms were equipped with laser printers, and the number of specimen label printers depended on the volume of requests. Next month we are rolling out an initial inventory of printers with locking mechanisms in preparation for 2007 NYSDOH mandated electronic prescription requisitions. In addition, new printer capability includes barcode printing. PCs in administrative offices were equipped with Network applications relevant to their level of access. The Network provides its more than 6,000 users with access to the NYC Health and Hospitals Corporation’s GroupWise Email and its Intranet sites. Connectivity to the EHR is provided through network connected PCs at all clinical settings as well as through mobile wireless tablets and carts. There are over 6,000 PCs, printers and related equipment connected to a secure highspeed Wide Area Network (WAN). The WAN shares information between our three hospitals at speeds ranging between 155 Mbps →2.5 Gbps. Applications from Misys, Siemens, and the Picture Archive Computer System (PACS) are shared with all users.
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User Access A userid and password secure patient privacy and data integrity of the EHR. Encrypted passwords expire every ninety days or, if necessary, could be changed on demand. Access to certain data elements and functionalities is defined by various legal regulations and hospital policies as it relates to the user’s job function. When a department head submits a formal request, access is issued and user training is provided in tandem. Only credentialed physicians, approved by the Medical Staff department, will be allowed full access to the clinical system. Continuum of care is maintained throughout the Network and clinicians are allowed “read only” access to other Network facilities. We are improving the communication between Human Resources, Hospital Police and Payroll to ensure the prompt removal of users no longer affiliated with the Network.
Described are different user class and functionalities Employee Types MD/NP/CNM
Order Entry Full access
Documentation Full access
Chart Review Full access
Residents
Full access
Full access
PA
Full access
Same as physicians
Full access
LPNs
Full access requiring coauthor Nursing orders and limited protocol orders None
Full access with preceptor sign off Full access with preceptor sign off Full access
Reports Patient lists and work lists Same as physicians
Full access
RPh
Written med orders
Full access except assessments and care planning Full access
Census list, Diet list, incomplete work lists Same as RN
PCA Clerk Social Workers Dieticians
None None None None
Vital monitoring Check in/out Full access Full access
Full access Full access Full access Full access
RRT
ABG
Full access
Full access
Medical Students Ancillary staff
None Written orders
None Collection, accession and specimen processing
Full access Full access
RN
Full access
Medication profile, departmental statistics Incomplete work lists Census list, diet list Limited Diet list, incomplete worklist, labels Incomplete work list, departmental statistics Same as physicians Work lists and departmental statistics
3. Decision Support The availability of data captured in the EHR remains the central goal in automating patient records. Information integration provides the patient, healthcare professional, and administration a base from which to improve and follow the standard guidelines for best practice and the delivery of patient care. All of our CDS tools are available at point of care for every cliniciana key factor in enabling us to improve patient management. Our intent was to put as much information as possible into a chart, and from there we could formulate CDS tools. This has been a big encouragement for doctors and nurses who are able to document in the record. For clinicians, it’s almost like a perk: “You give me data, and I’ll (the system) give you CDS tools.”
Tailored Information Integration:
Interdisciplinary Care Plan Care planning is the constant reminder of patientcare team collaboration. The interdisciplinary care plan is a collaborative process between various disciplines. The care plan improves communication between clinicians in their patient care management. Diagnoses, goals, interventions and target date of completion are documented and reviewed regularly for outcomes and reevaluated by the medical staff, staff from nursing, social work, dietary, the respiratory therapist, and the physical/occupational therapist.
Integrated Medication Administration
The fulcrum is complete and fully integrated. Physician order entry, pharmacy review and the administration of medications by nurses, in real time, eliminated legibility issues, reduced omission errors and improved staff effectiveness that resulted in reduced medication errors by commission. The addition of monitors to the medication carts became another lesson learned to benefit future golives. Our intention was to make the carts small and light for ease of use. However, we found out that a larger monitor size was more important to our nurses than the cart’s 21
weight because larger screens had better resolution. We increased the screen size of the medication cart monitors, and through observing and talking to nurses, found a more efficient way to reduce cart weight: Since nurses don’t share carts, we reduced the weight of the cart by reducing its size based on the number of patients a nurse could maximally be assigned. Supplies for 30 patients were not necessary if a nurse could only see a maximum of ten to twelve patients.
Physician •Enters Orders •Dose, Allergy and Interaction Testing
EHR Pharmacist Orders sent for review;•On line patient profile •Access to drug nteraction and information
Nurse •Orders to MAR •Nurse alerted of pharmacy review •Documents Medication Administration
Medication Reconciliation Once the processes associated with medication administration has been automated, we were not only able to improve patient safety and timeliness of medication administration, we were also prepared to comply with future regulatory requirements. Our integrated medication ordering, management, and documentation use the same formulary as our integrated prescription writer. When taken in conjunction with our established clinical documentation that lists home medications on patient admission, our infrastructure provided us with all of the tools needed to meet the 2006 JCAHO standards for medication reconciliation. The system pulls medication information from these multiple treatment venues and presents an integrated view of past and current medication profile for the patient. The clinician can quickly and easily assess the appropriateness of the patient’s current medications as well as plan for the patient’s discharge needs. Our online medication reconciliation has improved patient safety so dramatically that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) commented favorably on our most recent survey: The surveyors told us they had not seen an electronic medication reconciliation summary (eMRS) across the continuum of care from point to point like the one at Generations+. “You have covered every point of failure,” they said, and asked for a copy of our reconciliation design to share with others.
Telephone Triage Our patient centered approach to data management also includes a capability to generate an integrated chart across facility boundaries. This year, in response to the overwhelming volume of nonurgent cases arriving in our EDs, we deployed a Triage Nurse Calling Service that uses a clinical decision support logic tree to support the collection of pertinent patient data and to offer remote treatment 22
recommendations as well as to make referrals to onsite ambulatory or emergent services. Patients calling Telephone Triage are immediately connected to a dedicated group of nurses, on duty 24/7 and working at computer stations. The nurses question the patient by following an algorithm developed through protocols with chiefs of each service and built into in the EHR. All nursing decisions are entered directly into the electronic record and can be followed up at the next visit. During the call, the nurse accesses relevant clinical data from the patient’s electronic chart while progressing through the clinical decision support logic tree. Clinic visits are scheduled for nonemergent cases and ongoing monitoring of critical panic values ensures appropriate follow up. If it is determined that the patient should present to the facility, the triage nurse can make the referral immediately and provide an electronic alert to the clinicians who will be able to review the entire Triage Call Log to understand what actions have occurred to date once the patient presents. Patient satisfaction surveys and managed care compliance for the program were both at 100% in 2005. In 2005, the unit answered 42,360 calls. Information about the service is disseminated through flyers and informational cards at community health fairs and repeat usage is at 53% after one year. In 2005, the program won the “Best Practices in Region” Award from NYOne News.
Quality Assurance Record Review (QARR) Reporting
Recognizing the need to improve delivery of care, physicians are provided with a selfassessment tool that can be printed on demand. This “report card” lists the physician’s panel of patients and patients’ compliance to preventative care as recommended by third party payers. The report shows the number of enrolled patients and compliance to certain managed care indicators. Examples are annual breast cancer and cervical cancer screenings and lead poisoning screening. The electronic health record affects outcomes of future orders in a positive way. For example, we reach out to patients who have broken appointments to ensure future visits. The system also tracks quality indicators, e.g. hypertensive and diabetic patients, to make sure they stay on track for future follow up care.
Patient Summary List In guiding decisionmaking, many clinicians use the “patient summary list.” It is a list that compiles a patient’s current problems, active prescriptions, allergies, and other clinical alerts. Prenatal HIV status was not always available at point of care prior to online documentation. Today, HIV screenings are available online anywhere within our system, due to our “Know Your HIV Status” campaign that prompts caregivers to screen patients. The availability of this data in the EHR became a lifesaving tool for our obstetricians. Since labor can occur anytime and anywhere, when an HIV+ patient who received prenatal care at Generations+ presents for a delivery, her HIV status is instantly available online to the care team. When she delivers, the newborn can immediately begin antiretroviral treatment (ART), which reduces the CDC conversion rate of mothertochild transmission (MTCT) by half if therapy begins 24 hours after birth. With some of the highest HIV+ rates in the nation, this enhancement has become a real lifesaving tool for our communities.
A collaborative approach to patient care is carefully guided by the assortment of data entered by staff from the various disciplines. The problem list provides the direction for an adequate treatment plan. Diagnosis is an integral piece of information linked to notes documentation, medication, or ancillary test orders.
Health Maintenance Record To optimize quality of care and to improve compliance to the recommended preventative health guidelines, a reminder tool was developed called the Health Maintenance Record (HMR). Physicians and nurses use the HMR as a “huddle sheet” in Ambulatory Care areas. The 23
report is agespecific and sexspecific and displays the patient’s adherence to his/her health needs. The clinician can quickly and easily order appropriate diagnostic services and make referrals directly in the system to bring the patient into compliance. This tool also allows clinicians to mark HMR guidelines as having been met when patients receive services outside of the health system.
Growth Chart
Decision Support Applied During CPOE Presentation of appropriate alerts and reminders applied during order entry is set at the highest criteria of sensitivity to achieve the utmost standard of care. Override reports and advisory override alerts are accessible for monitoring purposes.
TYPES OF CLINICAL DECISION SUPPORT Undocumented allergy check Drug adverse reaction alert Drugdrug interaction checking Dose checking Override comments Problem list
Automatic stop orders Height/Weight/BMI/Vital signs Duplicate entries Significant lab results Patient Specific Prompts
USAGE FOR PATIENT CARE Displays if allergy is not documented and precludes physicians from ordering medication. Supports patient safety that complies with regulatory agencies. Displays at all points of care and interacts with ordering of medications and prescription. Supports patient safety that complies with regulatory agencies. Ex Warfarin and aspirin. Displays at all points of care. Supports patient safety that complies with regulatory agencies. Displays based on age specific criteria. Supports patient safety that complies with regulatory agencies. Required always when advisory alerts are overridden. A dynamic integrated presentation of the patient’s significant present and past diagnoses, procedures, and medications. Available at all point of care, organizes chart review. Outpatient, ER and Discharge prescriptions seamlessly integrated into one list. Supports hospital policies on medication renewal. Supports patient safety that complies with regulatory agencies. Accessible to view by healthcare providers, supports alerting health care providers, calculates BMI. Prevents duplication of orders that could potentially create overdosing or unnecessary exposure to radiological exam or blood drawing. Allows correlation of data. The CPOE process not only access rules based ordering to support patient safety and order efficacy, but age, sex and patient clinical specific information prompts are generated to the clinician as appropriate to insure that the correct services are being requested. For example, on MRI procedures, the system will prompt when orders are being placed for children under a certain age to allow the doctor to request pediatric conscious sedation. This prompt will not appear for adult patients. Generating patient data based rules and alerts insures that clinicians are always asked only pertinent questions.
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Order/Clinical Practice Standardization Emergency Department · Completion of the Triage assessment generates the initial and disposition notes for physicians and nurses. · Completion of disposition note for admitted patient triggers an alert to the admission office for bed assignment. · Complaints of chest pain trigger an EKG protocol order. · A wet reading discrepancy alerts physicians the need for patient recall. Inpatient · Bed assignment predefines appropriate servicespecific admission assessment notes and care plan. · Identification of high or moderate psychosocial risk criteria, nutritional risk and functional risk triggers referrals to the Social Services department, Food and Services, and Physical Therapy. · Presence of pain triggers appropriate tool for agespecific pain assessment. · Tobacco use alerts Hospital Police and Smoking Cessation Program clinic. · Patient Relations is alerted of the need for Advance Directives/Organ Donor. · Automatic reminder for reassessment of patients with fall risks and decubitus/ulcer risks. · Food Services alerted for food preferences and fooddrug interactions. · Pastoral Services alerted for spiritual needs. · Admissions Office alerted for pending discharges. · Positive screening for Influenza/Pneumonia automates orders for flu and pneumonia shots. · Preset servicespecific admission order sets for OB, pediatrics and surgery. · Alert for medication with physiologic parameters during administration. · Isolation precautions alert clinicians of proper execution of practice. Outpatient · Financial approval and preadmission testing for every request for surgery. · Tobacco use as above. · Pain alerts as above. · Referrals to Social Services and Dietician as above. · Influenza/Pneumonia screening as above. · Diabetes screening · Developmental guidelines for pediatrics · Growth chart · Prenatal record
KnowledgeBased Prompting ·
Drug adverse reaction alert
·
Duplicate orders
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·
Automatic stop orders
· · ·
Drugdrug and drugfood interaction alert Dose checking alerts Allergy documentation Critical results
·
Language Alert, DNR and Isolation Status Alerts The language alert is as important as other clinical alerts. At the Generations+/Northern Manhattan Network, serving a diverse multi lingual patient population, effective communication begins with the clinician’s skill in history taking and recording of data. A patient’s language is recorded as historic data and is ubiquitously accessible, making it easier to identify appropriate interpreters. Interpreters are equally accessible through our telephoneaccessible language bank, the Cyracom system. Do Not Resuscitate (DNR) and isolation status are also identified as clinical alerts.
Knowledge Access The Generations+/Northern Manhattan Health Network’s intranet site provides authorized users with reliable, authoritative, and easy access to all the important medical and health information sites and databases on the internet as well as information resources available from NYCHHC. KNOWLEDGEBASED INFORMATION Micromedex Healthcare Series Database
ACCESS Provides information for clinical decision support on drugs, toxicology, acute care, patient education CareNotes, evidencebased complementary & alternative medicine, material safety data sheet (MSDS) management, and regulatory compliance.
Medical Libraries at Harlem, Lincoln and Metropolitan Hospitals / Digital libraries
Biomedical and health information databases of the National Library of Medicine (NLM), includes fulltext articles and textbooks, MEDLINE/PubMed, MEDLINEplus, ClinicalTrials, Toxnet on the Web. Links to Affiliate libraries that include UpToDate, Clinical References, MD Consult, EvidenceBased Medicine and Reviews (Cochrane Database), PsychINFO, and CINAHL (Nursing and Allied Health).
Material Safety Data
Facilitates JCAHO & OSHA compliance by providing data on chemical products. HIPAA policies, procedures and forms are available. Access to all Network administrative policies and procedures; the Telephone Directory provides information on Network employee locations and telephone numbers. Facilitates JCAHO compliance, healthcare providers and all non clinical staff have access to a list of Do Not Use Abbreviations and Approved Abbreviations. Updated.
Health Insurance Portability and Accountability Act (HIPAA) Network Administrative Policies and Procedures; Telephone Directory Do Not Use Abbreviations and Approved Abbreviations
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Emergency Management Network Newsletters and the Information Management Booklet
Polices and Procedures on Emergency Preparedness and Response are available. IM Standards, current events, Network news, technology updates, and project implementations.
Sentinel Event Alerts
JCAHO Sentinel Events are posted to insure patient safety and provide staff with current information.
Unrestricted Web Sites
Web sites that have received Corporate approval are unrestricted and can be accessed by the Network. A Corporate resource for translated materials, multilingual patient education, interpreter services, signage, and resource links. HIPAA compliance training is available for all staff. Inservice training is available on the use of a suite of computer software, and on using the Misys system. Provides clinical data continuity during disasters Link to medicare.gov drug formularies
HHC Limited English Proficiency (LEP)
Computerbased Training and Computer Lab Training
A Clinical Backup System Medicare Part D Formulary
Patient Decision Support Engaging our communities in their personal heath maintenance has always been a focus of Generations+. It is even more relevant in light of the demographic makeup of the South Bronx and Harlem and the abnormally high incidence of diseases such as asthma, diabetes and HIV. One initiative in providing Patient Decision Support is the Pediatric Asthma Buddy Program. This program permits children with chronic asthma to communicate with their physicians via the Internet, providing vital parameters regarding their peak flow, other symptoms and medication usage. Electronic Tacking System for abnormal patient notification Timely patient notification of highrisk test results is facilitated using the electronic review queue portion of the EHR. Physicians have a menu choice for abnormal test patient notification that defines the type of test (lab,radiology, pap, etc.) and documents the follow up plan. The plan designates nurse queue or clerical follow up. Nursing and clerical staff review the referral queue daily, follow the designated plan and document action taken. If, for example a follow up was designated within two weeks, the nurse will be electronically prompted after two weeks to check if follow up occurred. If not, the process is repeated. If phone contact is unsuccessful, telegrams are sent to patient. In 2005, working with the vendor, we provided web access to determine telegram delivery status. Electronic telegram tracking reduced the “unknown’ status of telegram delivery from 12% to 0%. When the clinic is unable to make contact with the patient, physicians request outreach teams to make home visits for patients with highrisk abnormal results. Our abnormal notification is not just “a new implementation”—we have many examples of how it saves lives and affects future outcomes. Last year, for example, a pregnant woman seen in the clinic for a prenatal checkup also had a CT scan. The scan showed positive for cancer. The patient missed her next appointment and the system prompted a call to her home, only to find she had left the country. Because of our electronic recall notification system, her name was retained, she was not dropped from the system, and the recall went on for months. She finally returned home and a care team went to her house and brought her in to the hospital for treatment of her cancer. We saved her life. Aggregated Data Analysis and Reporting Patient Registries The Gen+ online patient registry system supports the network’s strategic initiative to proactively manage chronic diseases. A summary of key patient information, it displays clinical measures for diabetes, asthma, CHF, depression and anticoagulation. The registry provides “at aglance” view of careteam outcomes, including a graphical breakdown of the patient population and ability to view historical trends. In addition to providing caregivers with the ability to quickly identify patients requiring intervention, it also can generate form letters for patients requiring followup, review patients’ clinical measures grouped by disease and monitor a care team’s overall outcomes.
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A broad range of information is captured and aggregated to support managerial decisionmaking, performance improvement and patient care. The uniformity of data and method of communication are essential to insure that data can be retrieved and utilized for patient care.
Valuable data is extracted to aggregate data for reporting purposes Emergency Surveillance Reporting Sate Planning and Research Corporation Systems (SPARCS) JCAHO Core Measures DOH Immunization Program Quality Assurance Record Review (QARR) Board Reporting Cancer Registry Trauma Registry Adverse Drug Reaction
Adverse Transfusion Reaction Patient Acuity Communicable Disease Patient Demographics Patient Diagnoses and Length of Stay Pharmacy Interventions Birth and Death Certificates DRG Data ORYX Indicators Quality Management Indicators
Other systems interfacing with EHR that are utilized to aggregate and analyze data SYSTEM Siemens
AGGREGATE DATA Financial System, Patient Registration, Master Patient Index, Appointment System, Patient Demographic Information
3M Health Date Management System
Encoding System, DRG Reporting, Coding/DRG Analyzer and Core Measures, Utilization Management, LOS
INTELUS
Chart Tracking System
Phillips PACS (Picture Archiving and Communication System)
An integrated computer system that acquires, stores, retrieves, and displays digital radiology images
Interactive Pharmacy System Data Warehouse/Registries
Maintains profiles on patients Patient population management for chronic diseases
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Patient Specific Tools
Figure 1 Trend Display
Figure 2 Graph Display
4. WORKFLOW AND COMMUNICATION Progressively, as the EHR replaces paper documentation, clinicians become more connected and dependent on data captured in the EHR. Collaboration amongst healthcare providers is manifested by shorter turnaround time, less errors and improved patient care. Issues related to legibility, privacy, slow response time and ineffective staffing could be attributed to outdated form of communication. Managing patient care in the electronic environment replaced verbal or written orders with CPOE; accessibility to EHR ensures security and confidentiality of patient records, work management and departmental queues improved staffing effectiveness. Overall, communication between clinicians, patients and administration improved since the implementation of the EHR within the Network. Nurses at Generations+ love the electronic health record and take great pride in our medication administration time and accuracy—after implementation, their administration time was cut in half. Nursenurse and nursedoctor handoffs are simplified and accurate. True multidisciplinary engagement with the patient has become easy not only for the doctors and nurses, but for social work, dietary, etc. When an online order placed for a late tray results in a quick response, the patient and the nurse are both happy. Streamlining their workflow, reducing redundancy and providing tools to monitor patients have increased nursing satisfaction.
WORKFLOW Integrated Medication Administration CPOE enforces complete and legible orders. Completed orders transmitted to the pharmacy review queue reduce delays in treatment and comparably decrease the length of hospital stay. While orders start with the physicians, the administration of drugs by nurses completes the cycle. Orders requiring pharmacy intervention stop the nurse from administering medications. There are several other safeguards built into the system contributing to the safe administration of drugs. Safeguards include patients’ documented allergies, last doses given, medication conditional parameters, and the drug products dispensed by pharmacists. Additionally, visual reminders for medication renewal and possible administration omission are made obvious. Medication reconciliation is fully implemented.
Functional, PsychoSocial, Spiritual Care and Nutritional Needs Work Queues Screening performed by nursing at the time of admission or whenever necessary, trigger systematic referral to various departments simply by selecting at least one risk factor inherent to patients. Responses to the referral requests, which include recommended interventions, are communicated back to the assigned physicians and nurses via a queue.
Advance Directives The lack of advance directives and the need for information is communicated to the Patient Relations department. This process starts with the Emergency Department’s completion of the triage assessment, and is later reinforced upon admission to the unit.
Whiteboard ED Patient Tracking The whiteboard displays the name of the patient, chief complaints and time of encounter at the completion of triage assessment. During the course of ED workup, clinicians are able to track patients according to their location, urgency of visit, time spent in ED, and availability
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of results. This colorcoded whiteboard displays patient admission disposition status. As a monitoring tool, the whiteboard suggests compliance to note completion by physicians and nurses.
ED Record, Admission Assessment, Comprehensive Discharge Summary and Operative Report From the point of entry to the point of discharge and revisits to the clinic or emergency department, healthcare providers at the Network follow the course of hospitalization of a patient through completed ED records, online or scanned, inpatient assessments, comprehensive discharge notes, discharge medication and instruction as well as operative reports. Probably one of our most important lessons learned is the in the ED, where ED assessment is still on paper at Lincoln and Harlem Hospitals. ED implementation has traditionally followed a “best of breed” approach and one of our biggest challenges was the advent of “best of breed” applications and our crusade “to do better than” what we already did at Metropolitan Hospital Center. It delayed our implementation of the ED notes. Committed to a paperless environment, scanning technology was employed as a workaround. The accessibility and availability of ED notes at the point of care outweigh the inconveniences of this setback. We also learned to adjust staffing for the ED golive. Situated in some of New York’s most impoverished neighborhoods, our ED’s always operate at or beyond peak capacity. Lincoln, a Level I Trauma Center, is the second busiest emergency department in the entire U.S. Our assumption was that doubling the number of staff in ED triage during golive to prevent ambulance diversion would be sufficient, but after a failed implementation we conducted time and motion studies to see where we went wrong. Our lesson learned was that that we needed to triple the staff during a golive instead.
Diet and Food/Drug Allergy Three times a day, the Food Service department receives diet orders for patients by unit. To allow for preparation and tray distribution, the EHR sends breakfast, lunch and dinner orders 23 hours prior to the unit designated meal times. The department continuously receives changes as they occur. EHR send alerts to dieticians for possible diet intervention if medications known for their interactions with food are ordered.
OR Surgery Request The Network’s surgeons initiate the surgery request in the EHR for booking by the operating room clerks. Simultaneously, requests go to the financial counselor receives for approval, preadmission nurses for preop testing, and the ombudsman for expediting the process for surgery. Work management queues organize the list for processing and monitoring. Surgeons are provided with report of patients and status of their preoperative requirements.
Visit Encounters and Visit Closing The Ambulatory Care note has a plethora of data captured for one encounter. ICD9 codes, primary and secondary, are required and are essential for billing. ICD9 codes and the CPT4 codes, needed for revenue and QARR reporting, are extensively recorded within the note. Level of service for evaluation and management and the complexity of decisionmaking information are available within the note. Resident and midlevel provider notes are forwarded to the attending for review and approval.
COMMUNICATION Integrated Problem List and Care Planning A collaborative approach to patient care is carefully guided by the assortment of data entered by staff from the various disciplines. The problem list provides the direction for an adequate treatment plan. The summary list is a compilation of data that includes the patient’s active diagnoses, allergies and active prescription. Diagnosis is an integral piece of information linked to notes documentation, medication or ancillary test orders. Care planning is the constant reminder of patientcare team collaboration.
EMail Email is extensively deployed and utilized among providers. We have recently completed a needs assessment for the ehealth initiative to implement a resource center for patients to access health information via the internet. Our CEO sends daily email messages to the organization on the topic of patient safety.
5. Data Sharing With Other Organizations We share data with the following organizations: · · · ·
NYCHHC Board Reports Maryland Joint Commission Core Measure NYS Department of Health Immunization NYS Quality Assurance Record Review 30
· · ·
NYC Emergency/Syndromic Surveillance ECLRS New York State Department of Health Infection Control NYSPORT
6. Other Operational and Strategic Activities Administrative Patient Registration The facility’s Siemens System allows patient registration to be interfaced to the clinical system. CPT4 codes and payer plans are sent to Misys and all patient information, whether from the areas of Emergency, Clinic, Inpatient, and Ambulatory Surgery is interfaced and a visit number is attached to the registration. This assists the physician in managing patient care, especially for managed care preauthorizations for treatment. Admitting Bed Board This report is designed to display the names of the current occupants for each unit. The number of pending discharges is conveniently listed in the last column. The data originates from discharge orders entered online by physicians. Two of our three Emergency Departments are Level I trauma centers, some of the busiest in the nation. The electronic bed board is designed to display the availability of beds to help alleviate congestion in the ED. Vacant beds are categorized by either availability of licensed or overflow beds, and female versus male beds.
ED Whiteboard Patient Tracking Length of stay of patients during the entire visit to the Emergency Department is monitored closely. The patient is tracked from the time of triage to the time of disposition. Essential data is available as reminders to the clinicians in the management of care.
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Patient Safety At the Gen+ Network, concern for patient safety drove the development of the EHR. Drug alerts, adverse drug reactions, dose checking, drug interaction, prohibiting doserange orders, and removal of abbreviations were among the first features that were introduced to physicians and midlevel staff with regard to the patient care management in an electronic environment. Predictably, as the legibility problems became a nonissue, nurses and pharmacists accrued more quality time spent with the care of patients and patient education, respectively. Efficient ways of recording and integrating data improved communication between clinicians. With full EHR implementation, physicians read the visit history without the need to access a paper medical record. In particular, in the ED, when time is often of the essence, the physician has immediate access to the patient’s medical record and can begin appropriate care without waiting for the paper file. Online chart retrieval has improved physician and patient satisfaction, decision making and continuity of care. Capture of Patient Photo and barcoded patient bracelets were introduced to further enhance patient safety. The component of CPOE that most improves patient safety is medication ordering. Reduction of medication errors and errors due to incomplete orders were substantial. Physicians, Pharmacy and Nursing use the EHR for the integrated management of medications to improve medication safety and reduce the likelihood of human error. After implementation of the online nursing medication administration, all the nurses agreed that patient safety was improved. A remarkable result of the system was its impact on nursing productivity – it reduced the time it takes to administer medications by almost 50%. Online Medication Reconciliation has also dramatically improved patient safety through the reduction of medication errors due to drug interactions. It provides a snapshot of all a patient’s medications (home, current, last transfer point and discharge.) Medication reconciliation has proved so successful that it is performed at each patient visit and necessary adjustments made. Pharmacy also checks each diagnosis and compares it to meds ordered. Inappropriate orders result in interventions, which range from “medication not on formulary” to a “medication inappropriate for diagnosis.” This has led to improved communication with the physician, and improved patient safety through the doctor’s immediate notification.
Research To support approved research programs, the EHR is utilized as a tool to manage and monitor the patient’s care, aggregate laboratory results, radiology results, and other ancillary reports that are available online. The EHR has the feature of displaying the data in a trend format, which is useful when aggregating data. Our link to ECLRS (Electronic Communicable Lab Reporting System) with the DOH allows epidemiological surveillance. We are currently initiating our partnership in the Bronx RHIO, where shared data will be used for multi institutional research. We have an active GME program, where the EHR is utilized in residents’ training. Through the EHR, we also track type of patient and complexity of illness that each resident is assigned. This year, we continue full accreditation for our GME programs.
Regulatory Facilities’ requirements with Federal, State, New York Department of Health, and other regulatory agencies are met by using the EHR as a valuable tool to monitor and insure compliance. The EHR was a solution to timeliness, easy access, legibility, patient safety, security, and continuity of patient care. Departments were also able to monitor compliances on indicators that are required to be screened by regulatory agencies. The NYCHHC Board Report, CIR, HANYS and QARR measures all utilize reports made possible by the electronic record. Regulatory affairs monitors chart completion using the system and clinical pertinence on a weekly basis to ensure compliance with regulatory standards, e.g. access to interdisciplinary care plans by care team (physician, respiratory therapist, physical therapist, social work, etc.) Utilization rates are monitored weekly by regulatory affairs to ensure compliance. Some examples of monitoring are first dose effect above 90% for the year. Timeliness and/or omission of medications is monitored by nurses and pharmacy. The lab monitors turnaround time. Previously, we had a history of constant struggle for the department of HIM to be in compliance with CMS regarding ADR (Additional Documentation Request.) With documentation on line, HIM no longer faces the difficulty of obtaining loose documents or staff in the clinic omitting to file the physician’s note into the paper medical record. Legibility In addition to patient safety benefits through reduction of illegible notes and orders, regulatory compliance increased. Our incidence of JCAHO, NYSDOH and other regulatory agency citations was greatly reduced. This also results in a cost benefit—we experienced far few CMS takebacks due to illegible documentation. Correspondence Unit Based on HIPAA and NYSDOH regulations, correspondence must be handled in 10 working days. Prior to the EHR, HIM had to retrieve the paper medical record, or wait until it was returned to the HIM department in order to make copies of requested documents. We now have timely handling of correspondence and enhanced productivity. This resulted in HIPAA compliance and patient satisfaction. In particular, Harlem Hospital and Lincoln Medical Center are Level I trauma centers. It is imperative those trauma patients are expedited so immediate medical decision can be made. In addition, offsite physicians can review results, including radiology images from their homes and make medical decisions for the patient.
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As procedures or forms are rolled out into the electronic medical record, the Quality Management and Health Information Management departments review them to insure that they have met all regulatory requirements.
Operation Reports and Discharge Summaries Online Operation Reports and Discharge Summaries have been useful and valuable tools for patient care, decisionmaking, and the continuity of care. When patients arrive for their followup clinic appointments, come to the ED, or are readmitted, the data is available for review. Physicians save time by having online access to medical records. It is no longer necessary to request an old medical record. Prior to the EHR, physicians were frustrated with the quality of the transcription service and had to correct numerous reports; after implementation, quality, timeliness and cost improved.
7. User Satisfaction, Productivity and Effectiveness System Use
We have demonstrated the breadth of EHR usage and system integration in the table on page 5. System use is pervasive through the organization at all levels.
User Satisfaction A clinical user satisfaction survey was conducted in 2006 and showed very high levels of satisfaction among users. 92% of users, for example, agreed or strongly agreed that patient information is available to them anywhere at any time within the system. Ninety percent (90%) of users agreed or strongly agreed that the system has become easier to use, and 93.7% agreed or strongly agreed that the clinical support tools available in the electronic record aided them in providing patient safety.
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TECHNOLOGY The technology employed in the Generations +/ Northern Manhattan Health Network EHR system supports our ability to meet user functional needs, the flexibility to evolve, and the ability to provide reliable and responsive support to patient care. This section identifies the major components of the technical platform and how these components are integrated with each other and with external systems.
1. Scope and Design of EHR system System Description The EHR system in operation at Generations +/ Northern Manhattan Health Network is anchored by the Misys CPR™ system and technologies. Misys CPR was designed from its inception with integration as a key concept. The system provides patient centered integration of clinical and personal information in a single common database. A second key point of integration comes from a common healthcare process model that provides software services and applications that caregivers and support staff use to create and view the patient centered EHR record. Figure 1 shows the relationship of a full suite of applications to the core, configurable Patient and Process Models.
Physical Therapy
Order Entry
Med Records
Misys CPR Business Model Engine
Care Planning & Assessment
Configuration Data Laboratory
Radiology
Patient Model
Process Model
Chart Review
Dietary
Medication Management
Etc. …
Figure 1: The major functional modules in Misys CPR: a patient centered data model, a general healthcare process model, a configuration module, and an extensible suite of applications. Misys CPR is designed with distinct tiers or layers and is anchored by a configurable, healthcare oriented, business model engine. This engine operates on a scalable, faulttolerant system framework of Unix database servers, Unix application servers, and Windows based user workstations. The functional characteristics of the system are based on the concept of reusable components and tools of general design which are configurable by experienced, professional healthcare oriented IT staff. With no requirements to resort to software programming, Generations +/ Northern Manhattan Health Network IT staff configure the system and applications to support the unique and ever changing healthcare operations and special requirements of the broadly based healthcare delivery network. The primary layers of the system are: · System Services · Application and Database Services · Healthcare Business Model Services · Applications · User Interfaces
System Services
System Services provide the foundation for client/server computing and Web oriented applications and are implemented with generally available, industry and de facto standard, hardware and software components. Basic components and standards include: · IBM AIX and Sun Solaris Unix Servers for the core, central services 34
· · · · · · ·
Wired and wireless MS Windows workstations Web browsers Dragon Naturally Speaking for voice to text TCP/IP network protocol Gigabit and 100 Megabit Ethernet wired enterprise network infrastructure 802.11b & g wireless network services RAID disk technology
Application and Database Services
The Application and Database Services layer is responsible for the management of the physical computing resources required by the Business Model and Application layers. It implements a scaleable, faulttolerant, distributed computing framework that supports a common shared CPR database consisting of both text oriented and multimedia data and the online transaction processing services necessary to support the higher layers in the System. It manages and synchronizes multiple copies of the database to eliminate single points of failure, and it supports distributed replication of subsets of the database to optimize system performance. Scalability and faulttolerance are supported in this layer through the use and management of a configurable cluster of Unix servers providing redundancy of services and load sharing. Unix servers can be added to or removed from the production environment without shutting down end user services.
Business Model Engine
Misys CPR Business Model Engine is based on an integrated healthcare business model consisting of both an information model and a process model. These models are general purpose and configurable to create specialized actual healthcare information management and operations supporting systems. The information model is fundamentally patientcentered while the process model is fundamentally provideroriented. Some of the basic elements of the Business Model are: patients, patient encounters (visits), patient clinical events, providers, and rules. Workflow and clinical decision support is implemented with clinical and personal information from a patient’s lifetime EHR along with configurable rules activated at various welldefined points in patient and clinical event management. When workflow rules evaluate true, various things may happen such as: · Create an order · Enqueue an event to be reviewed by one or more providers · Generate an interface message for a foreign system · Send an email message · Generate an interactive alert for the user. The power of the system comes in part through the ability to represent all clinical activity and information as specializations of an abstract event class. The model defines many specializations of events such as order events and procedure events. These model specializations are then further configured through nonprogrammer, sitespecific configuration activities to create the many types of events that represent the specific information managed within a healthcare facility or domain.
Applications
Misys CPR provides a large collection of configurable applications implemented with the features of the Business Model and running on either or both middletier application servers and user workstations. The domain for Misys CPR applications operating across the Generations +/ Northern Manhattan Health Network include in part: registration/ADT, order entry, chart review, medication administration (order management, pharmacy processing, and administration documentation), radiology and lab processing, and generic department processing. All applications utilize and contribute to the common data model implemented by the Business Model. They are fully integrated, patient centric, and provider oriented by design.
User Interface
The user interface is implemented as Windows PC based clients. Highly structured character mode user interfaces were originally provided and implemented across the Generations +/ Northern Manhattan Health Network. More recently a Java based graphical Clinical Desktop Application user interface has been deployed to give flatter and more intuitive system navigation and interaction for end users. The Clinical Desktop Application is itself configurable for each user in terms of application and data content, flow, and preferences. It includes support not only for native CPR functionality but also provides embedded Web browsers and configurable links to Web based resources such as reference resources, PACS systems, etc.
System Architecture The Misys CPR Business Model Engine and applications run on a scalable and reliable cluster of Unix servers. The Business Model Engine, applications, and database are deployed on a single server (a cluster of one) for systems of limited size where needs for fault tolerance are minimal, e.g., test and training systems. Generations +/ Northern Manhattan Health Network has implemented a production system for each of its two subnetworks: Harlem/Renaissance and associated ambulatory facilities and Lincoln/Metropolitan/ Morrisania/Belvis and associated facilities. Each production system is implemented on multiple servers providing scalability and fault tolerance with replicated databases, distributed transaction processing, and 24x7 full functional operation. 35
Figure 2 provides a high level overview identifying the core system servers, enterprise network, and end user devices and instruments. The system is anchored by two identical IBM AIX servers. each of which maintains a complete copy of the entire CPR database and participates in load sharing for direct execution of the CPR Business Model Engine code. Each of these database/application servers supports all information and application services necessary for all CPR applications in the cluster. Their databases are fully synchronized at all times allowing either one to assume sole database and application services responsibility should the other fail. The system has been designed for scalability. Additional application servers can be dynamically introduced into the system should end user loads increase beyond the capabilities of the current servers. Regardless of the number of servers in the cluster, application load is automatically distributed across all available servers.
Enterprise Network
Network Switches
Multimedia Database Server
Redundant Load Sharing Database/ Application Servers
Optional Future Growth Application Servers
Gigabit Server Network
Figure 2: End User PC workstations supported by a cluster of Misys CPR application and database servers A failure of a server in the cluster does not affect system functionality or compromise the integrity of the database. Failed components can be diagnosed, repaired, and introduced back into the cluster without shutting down the cluster. Database storage is implemented with RAID1 (mirrored pair) technology so that individual disk system component failures are totally invisible to any of the servers in the cluster. The cluster provides full system functionality while making transactionally consistent backups of the database for disaster recovery purposes.
Data Model Misys CPR defines a healthcare Business Model with both data and process features. The data model portion includes a master patient index, patient centric clinical information, and the logical and physical organization of the healthcare enterprise. The major elements in the data model, each of which is extensible during configuration, are identified below. Some data elements in this model are statically defined in CPR code, but most are defined or refined with nonprogrammatic tools during the configuration and implementation of CPR. The Generations +/ Northern Manhattan Health Network has tailored the basic model to capture and manage information specific to the healthcare operations in each of the Network facilities. Figure 3 shows the key objects of the patient portion of the model. The model is shown and described at a high level of granularity to emphasize the principal objects and relationships.
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Patient 1 1 0..1 Problem
0..* 0..*
0..*
Visit 1
0..*
1 0..*
0..* 0..* Event
0..*
Order 0..1 0..*
1
0..* Procedure Event
Order Block Event
0..*
1
1
1..* Block Order
1
Procedure 0..*
1
1..*
Figure 3: Key objects in the Misys CPR Information Model. ·
·
·
·
· ·
·
Patient A Patient record includes staterelated information such as personal demographics, identifier(s), usual healthcare providers/practitioners, allergies, medication profiles, immunizations, and Generations +/ Northern Manhattan Health Network defined data elements. Visit A Visit record is created for every patient visit at a Generations +/ Northern Manhattan Health Network facility and contains information identifying the nature and status of the visit. Examples of Visit types include acute inpatient, emergent, ambulatory, long term care, and home health. Problem A Problem record contains information identifying a clinical problem which may be current or past and may have discrete begin and end dates or may be openended. Visits and Events can be associated with a Problem to create a problemoriented clinical record. Event An Event is a discrete entry in the clinical patient record and the collection of Events for a patient constitutes the entire historical, current, and prospective clinical information for a patient. There are many subclasses of Events. Two of the most important are: Procedure Events, also known as clinical service events or workflow events, are the primary kind of event manipulated by the CPR workflow engine. These events represent a discrete step or task in the healthcare delivery process as defined in a Procedure which contains the metadata used by the workflow engine. An Order Block Event is an event containing a collection of orders authored by a healthcare provider in a single order session or orders triggered and created together from a clinical pathway or rules engine. Block Order A Block Order is a discrete request for a clinical service or a change to a previous request. The clinical services are represented in the data model as Procedures. Examples of Block Order types include new, change, discontinue (DC) and renew. Order An Order is the object that controls the scheduling of clinical services through the creation of Procedure Events. An Order is created when a healthcare provider writes a “new” Block Order. An Order is changed by the writing of a “change” Block Order. An Order can be extended or stopped by the writing of a “renew” or “DC” Block Order. Procedure A Procedure is the definition of a discrete clinical service and is one of the major user configurable elements in the model. It describes a diagnostic service or a therapeutic service or a service that has both aspects. Each Procedure contains all of the definitions for the ordering, scheduling, workflow, documentation, summarization, reviewing, and viewing of information for orders and procedure events for a specific clinical service.
Not shown in the patient object model diagram but a significant supporting part of the CPR Business Model are tables that define key business, clinical and operational characteristics of the healthcare enterprise. The Generations +/ Northern Manhattan Health Network enterprise is described in the enterprise tables in terms of its business and clinical practice rules, its business and accountability units and facilities, its physical locations (sites of care, sites of record access), its information disclosure policy and assurance mechanisms, its security policy domains, its security and access control administration, its accountability and data integrity mechanisms, its healthcare practitioners and authorized system users, its resources (persons, locations, equipment, supplies, time), its allocation and deployment methods, and its communication directory (telephones, beepers).
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System Deployment System IT Platform
Figure 4 provides a detailed view of the servers, SAN storage, and network services comprising the production system for the Lincoln/Metropolitan/ Morrisania/Belvis and associated facilities. In order to keep the diagram relatively simple, the system media manager server and database are not shown but are identified in the following list of primary components in the system: · · · · · ·
IBM p670 servers with eight CPU’s and 16 GB of main memory each for core CPR services IBM FAStT 700 SAN’s for the CPR database each with 584 GB of usable mirrored storage Sun Solaris multimedia server Redundant Fibre Channel adapters and paths Fibre Gigabit IP adapters Redundant Cisco network switches
Figure 4: Generations +/ Northern Manhattan Health Network EHR IT Platform Components The system enterprise network supports communication between the system servers managed in secure IT facilities and workstations, printers, instruments, and other devices in essentially all operating environments throughout the Generations +/ Northern Manhattan Health Network. Dual Cisco Catalyst 6509 network switches anchor the enterprise network and provide the connection between system servers and the enterprise network. The enterprise network backbone is implemented with fibre media and provides over 32 Gbits/sec bandwidth while the horizontal fan out LAN segments are implemented with full duplex switched 100 mbits/sec Ethernet operating over copper media. Wireless network access has been broadly implemented throughout essentially all patient care areas with Cisco wireless access points providing 802.11b and 802.11g service. This wireless network provides service for hand held and medication cart mounted wireless PC’s. The following two tables identify by count and general types the size and distribution of network services and workstation devices.
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Network Deployment by Type and Count Facility
Wireless Access Points
Wired Switches
Harlem
68
63
Lincoln
76
47
Metropolitan
59
50
Workstation Deployment by Type and Count Facility
Wireless PCs
Med Carts Based Wireless PCs
Wired Workstations
Harlem
33
42
1800
Lincoln
133
76
2000
Metropolitan
45
33
2600
Voice Recognition Voice recognition technology has been deployed and fully integrated into the Generations +/ Northern Manhattan Health Network EHR on workstations throughout the Department of Surgery. This service provides automated transcription service for over 110 multispecialty attending and resident surgeons in the department. The voice recognition system has been implemented with technologies and services from Voicebrook and fully integrates their VoiceOver 2.2 with the Misys CPR system to allow doctors to dictate operative notes and reports directly into EHR database without the need for an external interface or third party transcriptionist. Surgeons finishing a surgical procedure access one of thirteen PC workstations in the Department of Surgery where they log into the Misys CPR and the user can then dictate the case notes within the electronic medical record using a combination of speech recognition templates and hot keys on a Philips SpeechMike. Surgeons use either predefined or their own structured templates and can additionally dictate in an unstructured, free text style. When the dictation is complete, the user issues a voice command that triggers Misys CPR to save the report as a partial or completed case within the patient’s record. Completed case notes are immediately available within the system for all authorized caregivers. Templates are designed by each specialty group and are available for each member of the department. Templates reduce the amount of repetitive text that users must dictate and help standardize the reporting format for each department. Templates can be navigated like a form using the Philips SpeechMike buttons in order to quickly enter the details of a case. Users can dictate free text and overwrite any words in a template at their discretion. The Voicebrook solution supports roaming profiles that allow users to dictate, automatically transcribe in real time, and edit results using natural language commands from any workstation that is enabled with VoiceOver using their unique voice and template profile. Any changes made to a profile are uploaded to the server and are then immediately available at any of the designated workstations the next time the user uses the voice recognition services.
Integration EHR Integration of patient oriented clinical information in a single database is a natural result of implementing the Misys CPR system data and process models. Generations +/ Northern Manhattan Health Network care givers use and produce information in a single database with native CPR applications. Other supporting and participating systems in the Generations +/ Northern Manhattan Health Network are interfaced with CPR and are identified in the following diagram and table.
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M e d i c a l R e c o r d M a n a g e m e n t
C O P A T H P a t h o l o g y
H E M O C A R E B l o o d B a n k
Q U E S T L A B
D e p a r t m e n t o f H e a l t h
I n t e l l u s
E C L A I R S
ECLRS
M i s y s C P R S c h e d u l i n g
B E L L E V U E L A B
C P O E / N u r s in g M o d u l e / P h a r m a c y / E m e r g e n c y / C a r e P la n n i n g / P a t i e n t E d u c a t i o n / F o o d a n d N u t r i t i o n / S o c ia l S e r v i c e s / R e s p i r a t o r y / M D D o c u m e n t a t i o n / M e d i c a t i o n A d m i n is t r a t io n
I m m u n i z a t i o n R e g i s t r y D O H
D i c t a t e d O p e r a t i v e R e p o rt s S i e m e n s R e g i s t r a t i o n
S i e m e n s B i l l i n g
P E N R A D
P A C S
T A L K T E C H
M e d i a M a n a g e r
M i c r o M e d e x
INTERFACE
CPR PURPOSE
BHC Reference Lab Quest Lab Talk Tech Siemens Charge Outbound Interface
Send orders to and receives results from the Bellevue reference lab. Sends orders to and receives report results from the Quest Diagnostics Laboratory Sends orders to and receives report results from the Talk Tech dictation system. Sends charges to the Siemens (SMS) financial system for all healthcare services managed by CPR. Receives patient demographic, registration, and discharge information from the Siemens financial system. Receives results from the CoPath pathology system. Sends orders to and receives report results from the PenRad mammography system. Sends patient demographics from Siemens to the Pyxis medication dispensing system. Sends patient demographics, orders, and reports to PACS Sends orders to and receives results from Hemocare blood bank system Receives word processing report results from transcription processing services. Receive image study results from PACS systems. Send and receive images and image key information with the multimedia Media Manager service in CPR. Send immunization record information to the DOH immunization registry service. The Department of Health submits lead screening results back to the facility via paper reports where information is transcribed into CPR. When electronic reports are available, they will be received automatically by CPR. Reports infectious diseases to the New York State Department of Health through the Electronic Clinical Laboratory Reporting System.
Siemens Registration CoPath Inbound PenRad Pyxis PACS Outbound Hemocare Dictated Operating Reports PACS Media Manager Immunization Registry DOH Department of Health
ECLRS
Transferability The underlying design and architecture of the EHR System at Generations +/ Northern Manhattan Health Network is more than simply a collection of predefined applications and fixed data models; it is a framework of technologies and healthcare information management tools configured by Generations +/ Northern Manhattan Health Network to create end user applications, work flows, and computer based patient records tailored for the Network’s unique patient care services. Generations +/ Northern Manhattan Health Network configuration standards are first developed in a corporate development environment and then transferred to and tailored for each of the acute care facilities and the Network’s many ambulatory service facilities.
Scalability The CPR System architecture of Application and Database servers is by design scalable. The number of servers configured for a system is determined by the number and type of applications and expected number of concurrent users of the system. The design and implementation of the system is such that additional servers can be acquired, tested, and installed into the production system without incurring System downtime. This allows for the incremental addition of processing capability as system utilization grows. This approach significantly reduces the need to purchase “excess” processing power at the beginning of system deployment simply to be prepared to handle work loads that might legitimately not occur for several years into system deployment and operation. 40
Emerging Technologies The Application and Database Services layer and the User Interface layer of the System isolate the Business Model Engine and Application layers from specific instances of technology. This design allows the technical implementation of the System to evolve while protecting the investments made by Generations +/ Northern Manhattan Health Network in configuring the CPR and the data collected over years of operation. Evolution of the CPR user interface technology from character mode to graphical user interfaces in Java is an example. The Lincoln/Metropolitan/ Morrisania/Belvis and Harlem/Renaissance systems were originally installed on separate Data General Unix servers and disk storage. Recently the Lincoln/Metropolitan/ Morrisania/Belvis system was upgraded to IBM AIX servers and storage without loss of information or system functionality. The Harlem/Renaissance system will soon be upgraded to operate on the same IBM cluster. The ability to link external reference knowledge sources into patient records and user workflow has enabled Generations +/ Northern Manhattan Health Network to quickly and easily incorporate the rich and growing resources on the Web and with the Generations +/ Northern Manhattan Health Network Intranet. Rapid technology evolution in media services has enabled Generations +/ Northern Manhattan Health Network to create nontextual data to complete a patient’s electronic medical record. Generations +/ Northern Manhattan Health Network is incorporating scanned documents, photos, clinical images, etc. into CPR with multimedia management services available in the system.
2. Security and Data Integrity Security/Confidentiality and HIPAA Compliance The Generations +/ Northern Manhattan Health Network EHR system implements a comprehensive security system based on authenticated users, user roles, workstation location, and system resources consisting of system function points and data elements. System security begins with a secure, common user authentication for all applications where users identify themselves by username and password. Passwords are encrypted for transport over the system network and in the database with 3DES encryption protocols to protect the integrity and security of the authentication system and processes. Idle user sessions on a workstation are automatically logged out after a workstation specific timeout occurs. System function points range in granularity from complete applications such as order entry to specific uses of an application such as controlled access to a specific procedure within order entry. Access controls can be placed on both system functions and data elements. One or more customer defined security keys are associated with each system resource to be controlled. Similarly, one or more role based sets of security keys are associated with each user registered in a user profile database. The system supports dynamic role definitions for employees who may have varying jobs based on things like time of day or work location. Upon login, the proper user role is automatically assigned based on configurable role selection rules. In order for a user to have access to a system resource, the user’s current set of role based security keys must contain at least one key that matches at least one key associated with the resource. Access to a specific patient record is further qualified by dynamic patient caregiver assignments. The access control mechanism has been designed to be effective and practical to support easy patient record access and realistic, critical, unplanned care scenarios. A user’s access into a patient care record is always logged. No user visible controls are displayed to a care giver when accessing a record for a patient assigned to the care giver. A care giver is allowed to access a patient record for nonassigned patients, but only after a visible warning that the patient is not assigned to the care giver and the care giver acknowledges the warning. Generations +/ Northern Manhattan Health Network has configured CPR so that each user is given access to only the applications and information authorized for the user’s assigned role.
Data Quality and Integrity The single database and process model foundation for the Generations +/ Northern Manhattan Health Network CPR eliminates most of the data quality and integrity problems evident in EHR systems consisting of multiple data models and databases. All information whether created by native CPR applications or coming via an interface into CPR is normalized into the CPR data model. All updates to the database are implemented with transaction controls to ensure the proper atomic nature of multiple database changes within a transaction.
System Integrity and Disaster Recovery System integrity features are incorporated into the basic system design. The goal for the system is that no single failure in system components will result in a complete failure of the system. Key to accomplishing this is redundancy. The operational system is configured with multiple application servers, each of which is capable of running any application, i.e., the application servers have access to all 41
applications and data such that any server is able to run any application. Each database server is fully functional by itself to support any and all application servers. Consequently, the failure of a database server will not result in the failure of the system. With the redundant database and application servers in the CPR system, continued availability of the CPR is ensured for nearly all potential failures. Each of the two databases is essentially a real time concurrent backup of the other database and provides the information needed to restore the other database should a failure of the other database or database server occur. Disaster protection is achieved with two complementary services. First, full (complete) backups of the database to tape are made once a week and incremental backups are created every day between full backups. The backup tapes are stored in secure, protected areas off site from the data center. Users continue to have full access to and use of system features and applications while transactionally consistent backups are created. A transaction journal and database backup and restore services provide additional layers of protection for the integrity of the system. The transaction journal provides the information and services needed to restart a system that has gone down ungracefully, e.g., following some type of failure affecting both database servers. Restoration of data from backup tapes is required should catastrophic corruption or physical failure of both the primary and secondary databases occur. There has been no requirement to perform such a restoration on the Generations+ system for over six years, so time to restore based on experience is not available. To provide additional protection against even unlikely outages of the CPR system, Generations +/ Northern Manhattan Health Network has implemented a second complementary service consisting of a relatively simple system designed to be used when the CPR is not available. This Clinical Data Access System CDAS can be accessed via a clinician’s workstation desktop or via the facility’s intranet. Users are authenticated to CDAS with an ID and password before access is allowed. The system is updated every fifteen minutes with new patients, orders and results information from the CPR system. The system provides clinician’s with the ability to look at near current patient information by starting with patient lookup by nursing unit, clinic, patient name, or medical record number.
Data Archiving and Storage The Generations +/ Northern Manhattan Health Network EHR system instantiates a permanent longitudinal health record for each Network patient. As new information is added to a patient’s record, existing information is preserved thus creating a complete, fully integrated, historical, and current healthcare record. Each of the redundant database servers is configured with 438 GB for database storage implemented on highly reliable RAID1 mirrored disk systems. The system supports physical storage into the multiple terabytes range, thus providing relatively unlimited growth in storage for historical information. Each database server is also configured with 146 GB of RAID1 storage allocated for the system’s transaction journal.
3. Standards Effective, optimal implementation and management for any EHR system requires a focus on standardization within the system while providing the services end users need. The single database approach with the CPR system implemented at Generations +/ Northern Manhattan Health Network provides the focus needed to support standardization. All applications deployed in the Misys CPR system utilize common user interface standards. Network IS staff do not have to acquire variant UI development skills across the application suite, nor is it necessary to teach new User Interface paradigms to end users as new applications are introduced. Generations +/ Northern Manhattan Health Network has implemented standard data information models shared across disciplines within a facility and across facilities. These models incorporate standard definitions and terms including: · Mininium Data Sets include: Pt.ID (Med Rec #), DOB, sex, race, residence, Hosp ID, adm & discharge dates or date of service, Physician ID, disposition, financial class, diagnosis, procedure. · Use facilitywide and NYCHHCdefined common data elements including: Room and Bed Master file Charge Master file for procedural charge codes Common patient visit codes Common Medical Record numbers Common Physician/Provider Identification Codes Common employee identification numbers Common title codes, civil service codes and employee status codes (from the PSMS manual) Cost center codes for billing and reimbursement Common pay station codes Resource scheduling codes (for scheduling, tracking and reporting use of hospital resources) The CPR system exchanges information with other supporting systems with messages and protocols available and supported by the other systems. In most cases, HL7 version 3.2 messaging is used. The technical platform consists of Unix server operating systems, Windows 42
workstations, and TCP/IP networking. Consistent use of these mainstream technologies has allowed Generations +/ Northern Manhattan Health Network to evolve the CPR system platform to meet the evolving needs of a changing healthcare business and additional users. An example of this was a major upgrade to IBM AIX servers in 2004 to provide strong hardware vendor support and the performance required for system growth. All applications and data operating on older Unix servers were preserved with no loss of functionality and no end user training. Additionally, TCP/IP communication standards fit naturally with our rapidly growing WAN and LAN environments supporting many diverse communication needs.
4. Performance System availability and system response time are crucial to the success of an electronic health record. As the reliance on automation increases, this is a critical consideration that contributes directly to user attitude towards the system. The Generations +/ Northern Manhattan Health Network staff monitors the system on a consistent, ongoing basis. The target goal of not less than 99.9 percent for system availability is accomplished in part by the high availability features of CPR and by carefully planning the implementation of occasional vendor updates and database changes. The target service level for end user screen to screen changes is for eighty percent of such changes to be completed in one second or less and ninety percent to be completed in two seconds or less. End user performance is entirely consistent with this service level agreement. Support Services. The IS department operates a Customer Support Service Center at all times twentyfour hours a day. User calls are logged in an incident tracking system. Issues that cannot be resolved over the phone are dispatched to either IS technical staff located in the various facilities for hardware/infrastructure related issues or to clinical analysts for investigation and resolution. Senior, experienced support staff are available at all times either directly or by pager. Upgrades and Enhancements. System upgrades and enhancements occur at all levels within the system. Generations +/ Northern Manhattan Health Network encourages feedback from end users to plan for ongoing changes and additions to meet end user needs. Clinical analysts use this information along with evolving corporate needs to identify changes and additions to the system configuration to implement applications that support those needs. This is an ongoing process resulting in applications, reports, workflows, etc. that are configured and tested in a development environment and then rolled into the production environment. Misys also provides new releases of Misys CPR to provide new and enhanced system capabilities. These releases are installed and tested in a development and test environment, completely isolated from the production environment, where new features and workflows are configured and evaluated by Generations +/ Northern Manhattan Health Network clinical analysts. These changes ultimately are rolled over to the production environment for end users. Infrequent but significant upgrades occur at the hardware platform level. This includes networks, workstations, disk storage, and servers. The upgrade in 2004 to IBM AIX servers is an example of how we have been able to incorporate new technologies to achieve the required performance levels while system usage increases.
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VALUE Every day at Generations + Northern Manhattan Network, new opportunities are identified for EHR system solutions. It is patient safety that drives our process. As we continue to enhance and finetune our existing EHR, our strategic objectives for quality patient care have helped us meet the public health needs of our communities. The EHR has been instrumental in helping us implement patient registries, expand HIV testing and lower turnaround times for services. The electronic health record is fully integrated into every aspect of the operations of the Generations+/Northern Manhattan Health Network. The Chief Information Officer (CIO) and members of the clinical systems team are an integral part of all decision making. We are represented on committees addressing patient care, medication management, safety, quality management, health information management, managed care, denials tracking and revenue management. Every day new opportunities are identified for an EHR system solution. The system has exceeded the expectations stated in the original business case. The evolution of the EHR in use today was never envisioned in the original RFP process. The value of the EHR in achieving our clinical, business, and financial expectations is presented.
1. Success in Meeting Expectations of Project Goals and Business Case Projected Goals The goals for the EHR that follow have been achieved and the quantifiable results will be presented in this section. Improve the quality and safety of patient care Data will be presented to demonstrate the improvements made in patient safety and quality. These include reductions in medication errors, improved turnaround times for results, and enhanced communication among caregivers. Reduce Medical Errors. There are three major areas where the EHR initiative has reduced actual or potential medical errors. The first area is patient identity. The addition of patient photos in behavioral health has reduced potential errors in identifying patients who have removed their ID band. The use of “do not use abbreviations” in the order entry process has been totally eliminated. Most importantly, actual medication errors have been reduced by 6070%. Improve availability of patient information at all points of access With about 6,800 devices connected to the clinical system and more than 6,000 users, the system has been widely deployed at every venue of care in the Generations+/Northern Manhattan Health Network. A summary of data including problems, medications, allergies, alerts, and status of health screenings provides quick access to the patient’s medical history. Enhance productivity Reductions in staff required for data entry and filing of paper are presented in the cost benefit analysis. Improved turnaround times for radiology studies will be presented in the targeted processes section. A byproduct of the integrated medication management initiative was a 50% reduction in the time spent by nurses administering medications. Provide data for decision making Data for decision support is provided both at the individual clinician level and as aggregated reports. At the individual clinician level, worklists, queues, alerts and reminders, and HTML summary reports are provided. These reports alert the physicians to their patients’ need for health maintenance tests and their compliance against guidelines for Diabetes and HIV. Aggregate data from the system provides administrative information including turnaround time, incomplete work lists, chart completion data, chart access monitoring, department productivity, etc. Clinical reporting includes data for specific populations, procedures and provider specific report cards. A clinical data repository has been implemented this year to provide increased access to data at the department level. Regulatory Compliance We had a history of constant struggle for the department of HIM to be in compliance with CMS regarding ADR (Additional Documentation Request) With documentation on line, HIM no longer faces the difficulty of obtaining loose documents or staff in the clinic omitting to file the physician’s note into the paper medical record. This resulted in 100% compliance with CMS requests. In addition to patient safety benefits through reduction of illegible notes and orders, regulatory compliance increased and also resulted in a cost benefit through far few CMS takebacks due illegible documentation. Based on HIPAA and NYSDOH regulations, correspondence must be handled in 10 working days. Prior to the EHR, HIM had to retrieve the paper medical record, or wait until it was returned to the HIM department in order to make copies of requested documents. We now have timely handling of correspondence and enhanced productivity. This resulted in HIPAA compliance and patient satisfaction. In particular, Harlem Hospital and Lincoln Medical Center are Level I trauma centers. It is imperative those trauma patients are expedited so immediate medical decision can be made. In addition, offsite neurology physicians can review the radiology results from their homes and make medical decisions for the patient. Disease Management Prompts for expanded HIV testing ( a core measure and a NYS DOH requirement) is now built into the EHR as part of our “Know Your HIV Status” campaign. At every point of entry, the provider has a screen prompt to ask patients in the appropriate age category if they would like to be tested for HIV. Prior to the implementation of this prompt, a single HIV outreach provider approached patients in the clinics and ED. Since early detection is so important in HIV, this has a real impact on community health—today more than 150 people a day answer ”Yes, I want to be tested.” 44
Also new this year is online ordering of PAP smears. All abnormal results, including low grade and ASCUS, showed patient notification at 100%, with appropriate follow up, evaluation and treatment documented online. Laboratory consolidation All laboratory functionality, including order entry, results reporting, lab processing and a peertopeer interface is automated and integrates seamlessly with the Generations+ EHR. This year, we tied diagnosis to lab ordering: the EHR allows physicians to correlate lab tests with a patient’s diagnosis by a screen showing every lab test ordered for that diagnosis. Although patient safety was the primary motivation for tying diagnosis to lab orders, an ancillary benefit is reduction in claims denials since each test is specifically tied to a diagnosis. Reduce costs and improve revenue The impact of the implementation of the EHR on the Network costs and revenue are discussed in the following costbenefit analysis. Paperless/ filmless radiology The role of the EHR in providing a PACSready Radiology information system, as well as a vehicle to communicate orders and results, were pivotal. Radiology images are now available at all desktops throughout the Network, improving access to information not previously available. Clinicians throughout the Network have reported on the impact of the availability of images on improving the quality of patient care. However, this has not as yet been quantified. Turnaround time for film interpretation has improved dramatically due to the replacement of transcribed reports by voice recognition software and the return of these interpretations electronically. The results are presented in the table.
Radiology Report Turn Around Time Pre & Post Talk Tech Installation Average Time From Radiologist Dictation To Report Availability For Clinicians PreImplementation PostImplementation HHC 2.5 days 5 seconds to 1 minute LHC 3.5 days 5 seconds to 1 minute MHC 3.5 days 5 seconds to 1 minute Belvis 7 days 5 seconds to 1 minute Morrisania 7 days 5 seconds to 1 minute
Enhanced data capture methods, scanning, voice recognition, handwriting recognition The use of voice recognition software in Radiology and special procedures and, recently, the Operating Room has provided immediate access to reports. The cost of transcription was reduced by $600,000 annually.
Business Case: The Results A costbenefit analysis modeled after the original analysis conducted by KPMG at the pilot site was conducted. Since significant expenditures were made in the sixth project year, the model was extended to ten years. 3
Costs The costs for acquiring the system include an initial outlay of $38 million for software and hardware and an additional $4 million in FY 2004 for upgrades to the servers and desktops. The personnel costs include the addition of 23 FTEs (fulltime employees) Networkwide. These positions included Directors of Clinical Systems and Database Management, 4 Trainers, 7 Analysts, 8 Level 1Technicians for desktop repairs, and 2 additional staff members for the Customer Support Service Center.
Savings/ Benefits · · · ·
· · · · 3
Maintenance on the Radiology (SD&G), Laboratory (CHC) and Pharmacy (Pharmakon) system was eliminated due to their replacement by integrated modules in the EHR. Radiology and Operative transcription costs were eliminated by the use of voice recognition software. Decreased printing requirements and server consolidation decreased 1 FTE needed for computer operations. Consistent with the business case, there was a reduction in laboratory testing by 30%. There was no reduction in radiology procedures. This savings amounted to $95/discharge. It was multiplied by a variable cost component of 35% and multiplied by the total number of discharges. There was no demonstrated reduction in costs due to laboratory consolidation or in pharmacy costs. Dietary costs were reduced, to compensate for ordering delays, by the number of trays sent to each unit. This decreased the number of trays by two per meal per unit multiplied by the average cost for food of $2.00 per tray. Medical records had a decrease in 45 FTEs Networkwide due to a decrease in chart preparation, loose sheet filing, and chart completion functions. Data entry personnel involved in keying ancillary charge tickets were reduced by 3 FTEs.
KPMG, NYCHHC. Cost benefit Analysis of the HDS Clinical Information System, 1995 45
· · · ·
Approximately 40 forms were removed from the inpatient record at $0.03 per form or a total of $1.20 per discharge. In Ambulatory Care, 10 forms at $0.03 were eliminated for a total of $0.30/ visit. There was an overall decrease, through attrition, of 20 Information Systems (IS) staff. The addition of new staff identified above has resulted in increased salary costs but not an increase in head count. The LOS (length of stay) for the Network has been reduced by an average of .7 days, ultimately resulting in a savings of $6 million. The casemix index has increased by an average of 15% resulting in increased revenue of $12 million in year 2003.
2. Success in Achieving Desired Change in Targeted Processes EDIS (Emergency Department Information Systems) Immediate accessibility of the medical record in the ED is often key to a patient’s survival. EDIS eliminated the need to wait for paper chart retrieval so physicians can immediately access chart review, progress notes, labs and medications, thus allowing immediate treatment. Tyr Wilbanks, M.D., associate chief of surgery, said, “I was in the ED at 2:00 a.m. with a patient who had been seen in our clinics. Because I could access the patient’s information online, I immediately knew her entire health history with us, and could act quickly to help her.” Patient satisfaction rates in the ED increased due to shorter wait times. Preimplementation of EDIS, in the first quarter of 2005, 46.7% of patients were registered in 030 minutes. Postimplementation of electronic triage, the 030 minute registration rate rose to 71.7%. Electronic Tacking System for abnormal patient notification Timely patient notification of highrisk test results resulted in improved follow up plans and documentation. In 2005, working with the vendor, we provided web access to determine telegram delivery status, thereby reducing the “unknown’ status of telegram delivery from 12% to 0%. When the clinic is unable to make contact with the patient, physicians request outreach teams to make home visits for patients with high risk abnormal results. Since this initiative began in 2005, improvements in patient notification were dramatic: · HGSIL pap followups increased from 17% to 75% · 69% of patients receiving home visits returned for follow up · Telegram delivery status went from 57% “unknown in May 2005 to 0% in December Operative Notes · Implementation of Voicebrook and reports directly into the Misys CPR, without the need for an external interface or third party transcriptionist. Completed cases are immediately available within the system to be referenced by all authorized participating caregivers. 46
· ROI from transcription service replacement · Instant turnaround timereports are immediately available · Reduced errors due to immediate dictation of reports after surgery or procedure · Increased compliance of physicians dictating their reports in a timely manner · Increased internal staff productivity · Removed noncaregivers (transcriptionists) from seeing private patient data Health Information Management Improved Chart Retrieval: With full EHR implementation, physicians read the visit history without the need to access a paper medical record. Online chart retrieval has reduced clinic visit time from three hours to one hour, improved physician and patient satisfaction, decisionmaking and continuity of care. Savings on duplication of forms: In the past two years, Generations+ has eliminated 40 paper forms—and we continue the quest for a paperless system. At Metropolitan Hospital, for example, we no longer use the paper ED Record. Within the network we are eliminating progress and nurse’s notes, consultations, History & Physical, Education Form, DVT, and Advance Directives.
Elimination of Redundant Processes There has been complete elimination of redundant patient queries, i.e. allergies and histories. The referral process has also eliminated redundancy through the nursing admission assessment notes: patients meeting criteria for referral to social work, dietician, physical therapy, etc trigger an immediate referral. Regulatory requirements are stringent and strictly monitored—highrisk patients must been seen within 24 hours and our compliance is above 95%. Duplicate phone calls, paper forms and scheduling no longer exist.
Enhanced Quality and Continuity of Care By automating the summary/problem list, nursing assessments, screenings, interdisciplinary care plan, operative reports, discharge summaries, etc., quality and continuity of care have improved. The summary list, which integrates care across visits, and the impatient care plan have improved dramatically since being incorporated in the EHR. Improvements in Interdisciplinary Documentation 100% 80% 60%
Pre Go Live
40%
Post Go Live
20% 0% Summary List
Care Plan
Screenings
3. Success in Meeting Other Corporate Objectives Patient Access to Care and Information
Improved work processes for ED, Operating Room, Managed Care, Guest Relations, Quality Management, etc. The EHR system has served as a vehicle to automate the ED, OR, Managed Care, Guest Relations and Quality Management and facilitate interdepartmental communications and processes. In the OR, booking requests are generated electronically. These requests route to the preadmission area for health and financial clearances and to the booking area for scheduling. Managed Care information, including the patient’s health maintenance status, is available. Guest Relations document Patient Satisfaction Surveys in a secured procedure in the EHR. The ED workflow including triage, patient tracking, order entry, rounding and documentation has been automated, shaving valuable time off ED triage. This has slightly decreased the mean LOS but has significantly reduced the standard deviation. In the clinic cycle, availability of the online chart has reduced waiting time in the clinics. The system has enabled us to improve our communication with patients. For abnormal test notification, letters to patients are generated automatically and immediately. Discharge instructions are also generated automatically. Because we can trend results, patients can actually see these results—doctors can point right to the screen to show trends, graphs and progress. Seeing their results in a visual way helps patients begin to engage in their own health maintenance. They can also go home with growth charts, trended results for the lab, immunization records, etc—all printed out instantly. We anticipate a further expansion of patient communication through an ehealth initiative that was recently approved. Part of the patient demographic will be email and cell phone numbers as point of contact.
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Mea n T im e U n til Adm itted T o ur 3
M ea n T im e U n til A d m i tted T o u r 2 21 : 36
1 9:12
19 : 12 1 6:48 16 : 48 1 4:24 14 : 24 1 2:00 12 : 00 9:36 9 : 36
S eries 1
S eries1 7:12
7 : 12
4:48
2 : 24
2:24
0 : 00
0:00
20
20 0
0/0 20 7 00 20 /09 00 /1 20 1 01 /0 20 1 01 20 /03 01 /0 20 5 01 20 /07 01 /0 20 9 01 20 /11 02 /0 20 1 02 /0 20 3 02 20 /05 02 /0 20 7 02 20 /09 02 /1 20 1 03 /0 20 1 03 20 /0 3 03 /0 20 5 03 20 /07 03 /0 9
00 2 0 /0 7 00 / 2 0 09 00 2 0 / 11 01 /0 20 1 01 / 20 03 01 2 0 /0 5 01 / 20 0 7 01 2 0 /0 9 01 2 0 /1 1 02 2 0 /0 1 02 2 0 /0 3 02 2 0 /0 5 02 2 0 / 07 02 / 20 0 9 02 / 20 1 1 03 2 0 /0 1 03 / 20 03 03 2 0 /0 5 03 / 2 0 0 7 03 /0 9
4 : 48
Patient Safety/Quality Assurance Improved Patient Safety through CPOE The component of CPOE that most improves patient safety is medication ordering. In an early study, conducted at Metropolitan Hospital, there was a 40% reduction in medication errors in the first 12 months after CPOE implementation was reported. 4 Errors due to illegible orders were virtually eliminated. Errors due to incomplete orders were reduced by 70%. The charts describe the number of illegible and incomplete orders annually for the year prior to the implementation of CPOE as compared to the postimplementation year. We learned a valuable lesson from our implementation of allergy alerts. CPOE, when introduced separately from allergy documentation, did not eliminate adverse allergy reactions. This was due to the fact that providers did not HAVE to document an allergy. Physicians were alerted if and only if the allergy had been documented. The solution to this was integrating two functions; allergy alert to medication order. We wrote in a prompt for this in 2001 and since then physicians cannot place a medication order unless allergies are first documented. Now that we have more documentation online allergy information is a mandatory field. Physicians, the Pharmacy and Nursing have closely monitored the effectiveness of an electronic system for the integrated management of medications. All have reported that the system improves medication safety and reduces the likelihood of human error. As mentioned above, after implementation of the CPOE and the Integrated Pharmacy, dispensing errors in Pharmacy were reduced. During the second phase of the project incorporating online medication administration, the results from Harlem and Lincoln indicated a 66% reduction in administration errors by Nursing. After implementation of the online nursing medication administration, 94% of the nurses gave the system favorable ratings in ease of use. All the nurses agreed that patient safety was improved. A remarkable result of the system was its impact on nursing productivity – it reduced the time it takes to administer medications by almost 50%. Medication Reconciliation has dramatically improved patient safety through the reduction of medication errors due to adverse drug effects. It provides a snapshot of all a patient’s medications (home, current, last transfer point and discharge.) Medication reconciliation has proved so successful that it is performed at each patient visit and necessary adjustments made. Pharmacy also checks each diagnosis and compares it to medications ordered. Inappropriate orders result in interventions, which range from “medication not on formulary” to a “medication inappropriate for diagnosis.” This has led to improved communication with the physician, and improved patient safety through the doctor’s immediate notification. Hospital3
Medication Errors 160
25 Number of Errors
140 120 100
20 15 10
Pre IMM
80
Post IMM Y ear 1
60
Post IMM Year 2
40
Hospital3
20
5
0
0 Hospital1
Pre IMM
Hospital2
Year 1
Year 2
Post IMM
Post IMM
In the diagram above, Hospitals 1 and 2 reported a marked decrease in their medication errors, whereas Hospital 3 reported a significant increase in its medication errors. On further review of data reported, in addition to errors by commission, Hospital 3 also began reporting errors by omission and timeliness of administration.
4 Igbochi,C., Ng,C., Yang, C, & Buckner A. Impact of Computerized Prescriber Order Entry on Medication Errors at an Acute Tertiary Care
Hospital. Hospital Pharmacy. Vol 38, Number 3, pp227231.2003 48
Unreconciled Meds/100 Adm issions OctApr 2006 4 0 0
400 400
3 5 0
325
3 0 0
288 275
2 5 0
15 0
Metropolitan
213
2 0 0
168
183 138
10 0
108 103 92
5 0
88
Lincoln
65
0 J
Oct
In the last quarter of 2005 the Network began monitoring medication reconciliation across the continuum of care as presented in the diagram above.
Colonoscopies Online prompting for colonoscopies has greatly increased the numbers of procedures performed from 778 in 2002 to 2,937 in 2005. Online ordering allows orders to be tracked to ensure the patient completes the procedure. The Network follows up with all noshows. Since June 2003, when procedure notes became available online, the provider communication rate is 100% and GI clinic visits and GI consultation notes are available 24/7 and reduced GI clinic wait time. Patient Navigators utilizing patient education and close follow up impacted the broken appointment rates
Tobacco Screening The NYCHHC has taken an aggressive approach to reducing tobacco use in the population it serves. Tobacco screenings and referrals are documented through the EHR. Patients are screened at all points of entry. While there is no preimplementation data available, 100% of in and out patients are screened for smoking through the EHR.
Registries Data from the EHR populates online patientspecific data against clinical guidelines. The Network uses this data to create diseasebased registries to evaluate the overall health of certain populations. Our ECLRS system is seamless. The DOH gets all communicable disease information from the laboratory on a daily basis, eliminating the lag time for notification and communication that can make the difference in disease containment. ECLRS is also operative in the ED for all infectious diseases, and is especially relevant to bioterrorism and syndromic surveillance, where the DOH immediately forwards information to the CDC.
Core Measures We consistently track our core measures: acute MI, pneumonia, and pregnancy and related conditions. Core Measure Action National Rate Pneumonia Pneumococcal vaccination 54% Pneumonia Antismoking counseling 67% Acute MI Aspirin at arrival 91%
Gen+ Network Rate 93%100% 95%100% 100%
Community and Public Health Board Reports are presented monthly to the NYC HHC Board of Directors, including the Commissioner of Health, which share our data with regulatory and other agencies. Compliance is monitored and improvement plans and corrective actions are determined directly from these reports. Core measures and performance indicators are reported hospitalwide, and root cause analysis occurs where needed.
Data Sharing with Other Organizations This month our CEO received approval to go ahead with a RHIO project for the borough of the Bronx. Our CEO is on the planning board of the project.
Research Although our Misys system does not link directly with regulatory agencies such as JCAHO, there is interconnection between their systems and our HIM coding and financial systems. Our data is utilized in their research projects.
Conclusion As the Generations+ Network continues to work steadily to minimize the human error in patient care, we have found that the use of the electronic health record has removed or lessened many of the common pitfalls that can occur. Both our caregivers and patients feel more satisfied and safer because of it. The positive effect of the EHR on patient safety has motivated our caregivers to be creative and engaged in developing new and better uses for IT—and for raising the bar for patient safety. 49
REFERENCES
Bell DS, Cretin S, Marken RS, Landman AB. A conceptual framework for evaluating outpatient electronic prescribing systems based on their functional capabilities. J Am Med Inform Assoc 2004 JanFeb; 11(1): 6070. Epub 2003 Oct 05. Carter S, Sullivan A, Broderick M. The computerbased patient record: the Jacobi Medical Center Experience. Davies CPR Recognition Proceedings, 1996 Dick, RS, Steen, EB, editors. Institute of Medicine (US). Committee on Improving the Patient Record, Division of Health Care Services. Computerbased patient records: an essential technology for health care. Washington, D.C.: Institute of Medicine, 1991. Generations+/Northern Manhattan Health Network. Community needs assessment 2004. New York: New York City Health and Hospitals Corporation, January 2004 Greenes RA. Decision support at the point of care: challenges in knowledge representation, management, and patient specific access. Adv Dent Res. 2003 Dec; 17:6973. Kohn LT, Corrigan, JM, Donaldson, MS, editors. Institute of Medicine (US). Committee on Quality Health Care in America. To err is human: building a safer health system. Washington, D.C. National Academy Press, 2000. KPMG, New York City Health and Hospitals Corporation. Cost benefit analysis of the HDS clinical information system, 1995 Stoop AP, Berg M. Integrating quantitative and qualitative methods in patient care information system evaluation: guidance for the organizational decision maker. Methods Inf Med. 2003; 42(4):45862. Walsh, SH. The clinician’s perspective on electronic health records and how they can affect patient care. BMJ 2004; 328:11841187 (15 May). Zeng Q, Cimino JJ, Zou KH. Providing conceptoriented views for clinical data using a knowledgebased system: an evaluation. J Am Med Inform Assoc. 2002 MayJune: 9(3):294305 Carter, Suzanne, Barrameda, Maricar. Improving Medication Safety. Advance News Magazine for Health Information Executives, 2004
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