Electronic health record- Nursing Informatics

ELECTRONIC HEALTH RECORD FROM A HISTORICAL PERSPECTIVE

OBJECTIVES1.Describe the Nicholas E. Davies

Program2.Name the four key criteria sections of

the Davies application3.Name and describe one feature of an

electronic health record (EHR) implementation that has not changed over time.

4.Describe an external factor that has impacted HER implementation

5.Describe several of the commonalities found in all Davies winners

INTRODUCTION TO DAVIES

The Computer-based Patient

Record Institute (CPRI)

Nonprofit membership organization

founded in 1992

Represents all stakeholders in

healthcare, focusing on clinical

applications of information technology

First nationally based organizations

which initiate, coordinate activities

to facilitate and promote the routine

use of (CPRs) throughout healthcare.

WHAT’S THE SAME?

How they define the Effort?

• Prior to the onset of effort, the winning clearly made the EHR a key component of the strategic vision.

• Recognized organizations know and understand the healthcare is an information business.

The 19 Organizational Davies winners

• Mission is to provide high-quality healthcare for America’s veterans

• made the development of an HER a major long term goal.

Health Administration (VHA)1st year winner, 1995

• Decided in 1989 to redevelop their information systems.

• Moving the computer from its role as a reporter of requested facts to an integral tool in the healthcare process.

• Vision encompassed the establishment of a new technical platform that would serve as the base to provide the processing power and scalability envisioned fort the future.

Brigham & Women’s Hospital (BWH), 1996 winner

• Turned to the EHR to managed competition• deregulated reimbursement system, which

goal to expand rapidly into an integrated delivery system placed the EHR at the core of its new business model.

Maimonides Medical center ,1996 in New York

• vision encompassed a multisite, multispecialty group practice whose EHRs linked to its practice management system

Harvard Vanguard, 1997

• clear part of the strategic vision• and defined remarkably similar

organizational goals and objectives.

HER implementation in all organization winner was a:

• Delineated several key objectives:• Improving the accessibility and availability of

clinical information• Support of integrated care delivery across two

different sites• Maximizing improvements in quality care through

the use of order entry and order checks and reminders.

Veterans Affairs (VA) Puget Sound Health Care System (VA Puget Sound), 2000 winner

• All medical staff and administration• Those included improved quality of patient care

through timely access to patient information• Improved documentation of clinical data

throughout the continuum of care• Integration of clinical information from a variety of

legacy systems

Queens Health Network (QHN), 2002 winner

• 2 strategic objectives which took precedence in planning, design and implementation of EHR.• Made optimizing patient safety,• followed by optimizing consistency in care

Cincinnati Children’s Hospital Medical Center (CCHMC), 2003 winner

How is the Effort Organized?

• is a daunting effort. Implementation of EHR

• the shared belief that information management is a key tool to the clinical and business processes of the hospital.

Common element to all Davies winners is

• absolutely necessary to ensure continued funding and appropriate resources needed for the project to realize success.

The champion is

• requires the skills of financial and operational administrators as well as clinician for all departments working with IT professionals

Planning process

• must be directly involved and engaged throughout the planning and implementation cycles

Owner of the business, the clinicians,

• need to participate in design review• serve as champions• and provide local resources to ensure the planned

implementation will enhance their ability to care for the patient.

Nurses

• the selection process or design phase required input from not only clinician but also information specialist.

Due to technologies involved

• was guide by hospital administration and information system personnel with close oversight of the financial, technical, and legal implications.

The contract negotiation phase

• usually consisting of hardware and software installs was led by IT personnel.

The early portion of system implementation

• Formed a steering committee (chief of med. Nursing, mental health, and ambulatory care)

• Nominated member for 2 special group, Clinical User, and Super User

• Clinical champions (20 physicians, nurses and other allied health professionals)• advocates of the project and willing to lead the discussions

and provide presentations and education sessions for other member of the their professions

• The Super Users, train more and work closely with the developers in planning system changes and improvements• Serve as local resources for the colleagues, answering

questions , and providing on the spot training

VA Puget Sound

• is the customer service• and constant consideration of the impact of the system on the

end user.

Consistent character of winning organizations

• has been the active pursuit of feedback from all users• Have employed user-inclusive design for feedback or have

develop help” buttons allow the clinician to instantly communicate frustrations or suggestions for design improvement.

Another characteristic Davies winners

Impact to Value

• Avoidance of a medication error• Directly through non-duplication of an ordered test.

Documenting the impact of EHR

• applicants were asked to provide examples of impact derived for the organization from the EHR.

• As applications were evaluated, great emphasis were placed in the organizations ability to demonstrate positive impact

• They were encouraged to provide quantitative examples of benefits that had been obtained against the costs that had been incurred to help and guide and direct expectations in other settings

1995 -2001

• Demonstrated proof of value through research and publications

• Have contributed significantly to the body of research on the power and importance of clinical decision support to improve the process of healthcare and patient safety.

Intermountain Health Care (IHC)

• through avoidance of medical error• increased appropriateness of care interventions• and compliance with managed care and disease

management protocols were obtained by all organizations.

Quality of care enhancement

• Improved continuity of care as medical records• Plans of care were available in detail for residents on

call or weekend triage nurses

Additional quality impact was noted in:

• to measure the business value of its’ project.• Provides balance decision-making criteria including

tangible and intangible benefits and risks• The resulting analysis provides net present value,

internal rate of return, payback periods and ROI for each system

Maimonides used Eclipsys’ strategic investment model

• Improvement of the processes that impact patient care,• Improved access to patient information• Complete legible clinical documentation• Timely accurate patient data at point of service• Process improvements were measured by analyzing different tools, their

actions, and effects on patient care.• Example: Nutritional screening tools

QHN and medical board cognizant that the value of EHR technology must be demonstrated and determined that for their organization to success and business case would be measured by the:

• Mandated summary list completion which included patient diagnoses, , procedures, allergies and adverse drug reaction, and patient medications.

• All elements of the summary list were required to be complete in order for compliance to be achieved for any individual record

Joint Commission of Health Care Organization (JJACHO)

• Believed patient safety was cornerstone of quality.• Medication Safety• Patient Safety• Risk Management deficiencies in the area of patient safety• These deficiencies at times were related to inconsistency of care between

providers• As a result of EHR implementation, clinician generate, complete,

unambiguous , legible orders that include clinician contact name and pager number on all orders

CCHMC. 2003 winner

Still Expensive

• cost of their HER implementation; expensive. • The trait continues even today.

A commonalty shared by all Davies Organizational winners is the :

• organization after organization has set aside multiple millions from their capital budgets to finance the cost of the infrastructure, hardware.

• And software all needed for an HER implementation.

Over the years of the Davies program

• Employee hours lost from patient care for planning process, design phase, testing

• and educational needs all required for success implementation

Difficult to calculate but consistently present

What’s Different?

Where Winners Obtained Systems?

• winning organizations had spent years in the development of their award winning systems.

In the first years of the Davies

• honored in the first year of the program all developed their own systems.

The three organizations

• was the practice site for a visionary group of clinicians and scientists.

IHC in Utah

• they began experimenting with the process of applying computer technology to the provision of care

Around 1965

• rule base patient centered information system entitled• Expanded in 1985 and when became apparent that an

enterprise-wide Clinical Information System (CIS) was needed.

HELP (health evaluation through logical processing)

• Received the first year award for CIS• which was built a central hub that enable

clinical systems on disparate platforms to share patient data.

• The hub consisted of a series of concentric layers that can handle requests various clients applications to store or retrieve data.

Columbia Presbyterian medical Center

• Comprehensive system covering medical management, fiscal and clinical functions

• Served as the fundamental information system for the VHA’s medical care network supporting 171 medical centers, 450 OPD clinics, and 131 nursing homes

• Major goal of this system was to share and exchange data, first throughout the VHA, then with other federally based health care facilities, and finally with the private sector organization

Decentralized Hospital Computer Program (DHCP)

• One of the project goals was to change the computer’s role of results reporting in the healthcare process.

• Instead of assuming the traditional role of the computer, it become an active partner in promoting optimal quality of care, reducing adverse events, and reducing costs.

BWH developed Brigham integrated computing system (BICS) with the help of large number of clinicians

• Utilized an automated medical record system (AMRS)• Tried to self development, and then

codevelopment, before implementing their current system which purchased from a vendor.

Harvard Vanguard Medical Associates

• Implemented commercially sold multicomponent system procured from a variety of vendors• This modified best-of-breed approach met

the physician and department head need while conforming to the medical center’s interfacing, hardware, software and operating standard.

• This technology employed affects the ability to meet user expectations including a wide variety of functional and organizational needs, reliability, response time and scalability.

All winners since 2000

• Several cases of completely home-grown systems based on different technology platforms, a mainframe-base vendor solution and document imaging

Over the years

Time to Get There

• available EMRs the timeline form initial planning, through purchase, training, and successful implementation shortens.

As more healthcare organizations purchase commercially

• the EMR was part of a strategic plan

For early Davies winners like the VHA, Brigham & Women’s,

• belief that industrial engineering principles could be applied to healthcare.

The Regenstrief Institute, founded in 1969 in Indianapolis, Indiana,

• Has the vision of a longitudinal, integrated, acute and ambulatory care record that provided the information for clinical decision support and other applications developed over three decades

• By the end of 1997 the clinical information stored in their EMR was available at approximately 120 different locations within their healthcare delivery system

Mc Donald 1997

• Placed the development of a robust information technology infrastructure to in organizational strategic plan.

• 2003, development of the Information Services Department and accompanying increase in network infrastructure to support the vigorous development and implementation of clinical systems

• March 2000, completed the implementation of an enterprise-wide PACS system

• December 2002, the EMR was implemented on 13 inpatient care units.

CCHMC

External Agenda

Factors external to healthcare organizations helped to accelerate the timeline for adoption of EMRs.

• the driving force for developing an advanced CIS at Queen’s Medical Center in Honolulu, Hawaii, was the onset of healthcare reform and managed care.

In 1993

• Planning committee from which emerged the vision held by all physicians, nurses and allied health professionals that CPR was essential to improve care

1999,

• EMR at UIMC was initially develop to mitigate the concerns that the organization’s legacy patient care information system was not Y2K compliant.

2001,

• Heritage Behavioral Center of Decatur, Illinois found themselves poorly prepared with an outdated back office system

• An agency-wide, point of service information system would give the organization a competitive edge in quality-base, effective clinical services

• The focal point of this information system was to be an EMR supported the delivery of care

Mid 1990’s

• EMR was viewed as essential to the development of an effective infrastructure from which to support• the reorganization of care• design of quality measures• streamlined reporting processes• and the cornerstone of evidence-based

medicine to improve management of chronic disease..

2002, EMR at QHN in Queens

Technology

• ability to meet user demands for rapid response• system reliability• future growth• and customization.

The technology behind each EMR affects the

• have emerged and are being incorporated into the systems being deployed today.

New technologies

• is difficult to precisely replicate due to data capture

The technology at any Davies winner

• such as interfaces, users agreement, cultural changes, workflow revisions and window, and menu customizations.

EMR uniqueness

• which is a key component of a transition strategy as an organization moves from a paper-based to an electronic system

EMR have been incorporated in Document imaging system

• this technology makes a diagnostic quality images, available wherever high resolution monitoring are found in ER, ICU’s, and ambulatory surgeries

PACS have been develop

• issued an electronic key at training and must choose a password are required to sign onto the system every time.

• This process taking about 5 seconds, requires the use of plastic key which containing encrypted user file and security access information (2002).

Queens in New York,

• Mobile wireless work stations in ICU were key improving tem function that could be wheeled about and used in the patient rooms improved clinicians efficiency and the quality of patient care.

Wireless technology in 1999, Queens of Hawaii

• was imitated their system on serial terminals of hardware for the EMR

Intel-286-based personal computers

• help manage work flow and clinical communications.

Today high speed work stations with flat monitors

• facilitate communications within and to remote locations of the organizations.

Fiber-optic cables

Davies Pool of Applicants

Nicholas E. Davies Program

Founded by CPRI in 1993 awards in excellence in HER implementation

• the award program has recognized 20 healthcare organizations

• 7 primary care practices, • and 3 public health initiatives

Organized in 3 different categories,

• These questions are focused on the four board areas of:• Management• Functionality• Technology• And value

Applicants for the award answer questions outlined by the project evaluation criteria.

• awarded to a community hospital

To date Davies has not yet been

• to include primary care practices and public health agencies

Davies program has widened in the past 2 years

Davies Primary Care award was initiated in 2003

Award for Public Health in 2004

3 Primary Care Practices were awarded in 2003,

and additional 4 practices in 2004.

Thank you for listening