The Challenge of Adoption

Webinar: http://www.medsphere.com/infinite/Voice: (888) 346-3950Participant code: 1302465

The Challenge of Adoption: A Nurse's View of EMR and the Road Ahead

December 2008 Community Call

Presenters

• Kathy English

• Kris Hanke

• Larry Washington

• Carol Bair

• Jon Tai

• Ben Mehling

Agenda

• The Challenge of Adoption

• Closed Loop Medication

• Guest Speaker: BCMA from the frontlines

• Community Discussion

• Medsphere.org: Tip of the Month

The Challenge of Adoption: A Nurse’s View of EMR & the Road Ahead

December, 2008

Introduction

• Kathy English

– Vice President Product Management, Medsphere

• Kris Hanke

– Director Clinical Operations, Medsphere

Objectives

• Review of “what makes it difficult to deliver great nursing care”

• Show how Open Source technology and principles can address challenges in nursing care delivery and result in adoption of information technology

Poll

Nursing Executives are challenged to:

• Drive delivery of safe patient care

• Meet the demands of regulation

• Keep up with the demands of new technology

• Adhere to staffing requirements & prevention of attrition

• Increase staff satisfaction

• Support improvements in patient satisfaction

• …and, do it all with a constrained budget

Let’s talk about disruption…

"In 1834 The Times said, regarding a significant piece of medical technology, that, 'it will never come into general use notwithstanding its value. It is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble to both the patient and the practitioner; and because its hue and character are foreign and opposed to all our habits and associations. It is just not going to get used.”

There is an ever increasing focus on patient safety and the prevention of medical errors

The human error rate is 11%

Greater than 60% of error events1

It is estimated that on average every ICU patient suffers 1.7 medical errors per day2

2 Donchin et al. Crit Care Med 1995; 23:294-300

Patient safety

1 Romney B Duffey, John W. Saull; The Probability and management of Human Error.2004

More than medication errors

Nursing Errors

Medication, 58%

Charting, 11.9%

Procedural, 18.4%

•5000 errors per year

•On a Sample of 393 RN’s

•58% Medication Errors

•18.4% Procedural

•11.9 % Charting

(1.) Balas MC, Scott LD, Rogers AE. The prevalence and nature of errors reported by hospital staff nurses. Appl Nurs Res 2004;

Errors

40% of Nursing errors that impact patients are not caused from medications or administering medications.

Other errors identified from a recent study

– Procedural

– Charting

Related causes

Fatigue

Overtime

Burnout

Human nature

(1.) Balas MC, Scott LD, Rogers AE. The prevalence and nature of errors reported by hospital staff nurses. Appl Nurs Res 2004;

Information technology the Answer!

“When people become patients, they place their trust in their health care providers. As providers assume responsibility for their diagnosis and treatment, patients have a right to expect that this will include responsibility for their safety during all aspects of care. However, increasing epidemiological data make it clear that patient safety is a global problem. Improved nursing care may prevent many adverse events, and nursing must take a stronger leadership role in this area. Although errors are almost inevitable, safety can be improved, and health care institutions are increasingly making safety a top priority. Information technology provides safety benefits by enhancing communication and delivering decision-support; its use will likely be a cornerstone for improving safety. “

Source : PMID: 15246041 [PubMed - indexed for MEDLINE]

The use of systems that prompt bedside

providers to institute and maintain best practicesfor routine care, have

been shown to improve clinical outcomes and decrease the cost of

care*

* Holcomb et al. Curr Opin Crit Care 2001; 7:304-11

Placeholder

Pharmacy Screenshot

Manual records are subject to interpretation

9

A Typical Critical Care Flowsheet……..

“A significant number of dangerous human errors occur when transcribing information. Many of these errors could be attributed to problems of communicationbetween the physicians and nurses.” *

* Donchin et al. Crit Care Med 1995; 23:294-300

Real time accurate communication is critical

Patient Summary

Interdisciplinary clinical notes

Poll

Nursing climate

• There is a shortage of experienced nurses

• Nurses are right out of school or from agencies needing further education

• Staffing ratios are dictated & difficult to achieve

• Other countries are providing Nurses– Communication barriers

– Care responsibilities are different

– Advanced technology options are different

• Installation and use of information technology takes nurses away from primary responsibilities

*Health Management Academy CNE Forum; Scottsdale, Arizona, Fall 2006

Open Source initiatives to help

• Academic Universities are collaborating– Oklahoma University

– University of Arizona

– University of Washington

– University of Hawaii

– Georgetown

• Collaboration efforts– Best practice protocols

– Training programs

– Lutheran Medical Center – ED Charting Templates & Tracking board

– Midland Memorial Hospital – Documentation Templates

Care delivery protocols embedded in notes

Factory build & advanced training programs

CIS MODULE FOR CPOE

I. ObjectivesA. Place Orders in the Electronic Medical Record (EMR)

B. Sign and update order by changing, renewing, and discontinuing orders in the EMRC. Place Delayed Orders in the EMRD. Creating personal quick order templates.

II. Review of Patient Selection ScreenA. Patient Selection

1. Ward/Unit2. Clinic Name3. Provider4. Last,First name5. Saving default patient selection

B. Notifications (Two types – information only and action)1. Unsigned notes and orders2. Critical lab/imagining results3. Consult updates4. Flagged orders5. Completing action notifications6. Viewing notice only notifications

CIS MODULE FOR CPOE

I. ObjectivesA. Place Orders in the Electronic Medical Record (EMR)

B. Sign and update order by changing, renewing, and discontinuing orders in the EMRC. Place Delayed Orders in the EMRD. Creating personal quick order templates.

II. Review of Patient Selection ScreenA. Patient Selection

1. Ward/Unit2. Clinic Name3. Provider4. Last,First name5. Saving default patient selection

B. Notifications (Two types – information only and action)1. Unsigned notes and orders2. Critical lab/imagining results3. Consult updates4. Flagged orders5. Completing action notifications6. Viewing notice only notifications

CIS MODULE FOR CPOE

I. ObjectivesA. Place Orders in the Electronic Medical Record (EMR)

B. Sign and update order by changing, renewing, and discontinuing orders in the EMRC. Place Delayed Orders in the EMRD. Creating personal quick order templates.

II. Review of Patient Selection ScreenA. Patient Selection

1. Ward/Unit2. Clinic Name3. Provider4. Last,First name5. Saving default patient selection

B. Notifications (Two types – information only and action)1. Unsigned notes and orders2. Critical lab/imagining results3. Consult updates4. Flagged orders5. Completing action notifications6. Viewing notice only notifications

Clinician satisfaction in a challenging climate

• Recruitment is challenging

• Nurse to patient ratios are mandated

• Overtime due to hours spent documenting

• Fatigue & burnout

Improving Nurse satisfaction

• Recruitment

– Attracting good Clinicians to your organization

• Nurse to patient ratios

– Maintaining Good Nurse/Patient ratios

– Tools to manage your Patients better

• Overtime

– Eliminating Redundant documentation

– Streamlining workflow and process

– Deploying tools to improve Process

Streamline Process

• Organizational

• Departmental

• Role

• User

Most often Clinicians will be focused on their own responsibilities and not the bigger picture of care

Regulatory Requirements

• HIPAA

• Core Measures

• Never Events

• Mandatory reporting, Registries

• Decrease variance

• Adherence to care protocols

In summary

“given the moral importance of patient safety and quality care innursing and related health care domains, the inseparable link between nursing practice and patient safety, and the central role that research has to play in driving safety improvements in these domains, it is morally imperative that the nursing profession gives sustained and focused public attention to patient safety and quality care as a national research priority. “

PMID: 16541827 [PubMed - indexed for MEDLINE]

Poll

Nurses will adopt IT that solves problems

• Promotes safe patient care delivery

• Meets the demands of regulation without extra work

• Keeps up with the demands of new technology through ease of use, easy to learn & provides information in real time at the point of care

• Does not negatively impact staffing requirements

• Prevents attrition by permitting a streamlining processes

• Increases staff satisfaction with their job

• Support improvements in patient satisfaction through safe and efficient care delivery

• …and, do it all with reduced cost and time to efficiency

The Ecosystem and Community: Together

Who is better positioned to solve the challenges to nursing in healthcare?

…a community of nursing care providers who collaborate to bring complete and best practice solutions to healthcare

Closed Loop Medication Process

Pharmacy

Medication Administration

Guest Speaker

Carol Bair, LVN, Educator/Trainer HIS

Carol presents lessons learned at Midland Memorial Hospital from the frontlines of an EMR and BCMA rollout.

BCMA from the frontlines

Carol Bair

LVN, Educator/Trainer HIS

Midland Memorial Hospital

Workflow: Pharmacy

• If starting with CPOE learn how to finish orders off as if you have BCMA.

• Insure ordered items are pre packed with barcodes.

• Maintain barcodes.

• Trouble shooting users.

• Flagging data/comments in order to show.

Workflow: Nursing

• Important: BCMA is for patient safety and not for the convenience of the nurse.

• Time management will change.

• Nursing will need to wait until pharmacy verifies orders and should verify orders in Vista before giving in BCMA.

Example

• Be aware that when a medication is ordered that the dosage they have in their hand needs to match with what is supplied by pharmacy.

• For example: Lasix 20mg IVP is ordered, the nurse has a Lasix40mg vial on hand, but pharmacy finishes the order as a Lasix20mg vial. When the nurse scans the vial she will receive an error message that says invalid medication look up.

Team Effort

• Pharmacy and nursing need to work closely together.

• During training, nursing and pharmacy need to see what they other department sees. E.g., Nursing will say to pharmacy when they call “it is the third medication order down (in CPRS/CIS)”, yet pharmacy’s view is via a different (Terminal-based) application.

The BCMA Committee

Committee should consist of BCMA analyst, Pharmacy Coordinator, BCMA educator, pharmacist, nursing

administration, cardiopulmonary, staff nurses (valuable).

BCMA Committee:

Policies and Procedures:

• What to do when BCMA goes down (Downtime Contingency Plan)

• What happens if safety using BCMA is not followed

• How often to run reports (e.g., missing med and prn effectiveness)

• Range orders (such as Lortab 7.5 1-2 tabs q 4 – 6 hrs): Order will need to be finished either q 4 hours or q 6 hours.

• Decide on reasons for held, refused, prn’s, and IV sites.

• Who will be able to access BCMA? Nurses, students, physicians?

BCMA Committee

Technical Details:

• Decide if BCMA will be loaded onto desktops or only Computers on Wheels (COWs).

• Decide what scanners and carts to use.

• Verify barcodes scan on armbands, medications, and IV bags. (e.g., Light colored barcodes are hard to scan.)

BCMA Committee

Responsibilities:

• How much training and who will be trained?

• How will implementation be conducted?

• Competencies -- who is responsible for filling out?

• General support coverage (24-7). (Also, make sure you have adequate (additional) staffing during go live.)

Going Live!

• Decide when to go live with BCMA

• Consider a “soft go live” (i.e., select only one or two patients)

• Make certain that adequate support staff are available/scheduled during go live

• During the go live, meet daily to document, discuss, and solve any issues

• Decide who will print armbands. Extra armbands available if all units can print

Questions?

Discussion, questions and comments?

Authors:Carol Bair -- [email protected]

Randy Adams -- [email protected]

Medsphere.org Tip of the Month

December 18, 2008

Searching on Medsphere.org

• Accessing the Search feature

– Persistent User Bar on Medsphere.org

– Getting Started widget on Medsphere.org home page

– Adding Medsphere.org to your browser’s built-in search box

• Default search is an AND search

– Content containing all of the words in your query will be returned

More Options

• You can limit your search by

– Content type

– Last modification date

– Community

– Author

Advanced Searching

• You can limit your search to the

– Subject, e.g., subject:FAQ

– Body, e.g., body:HIPAA

– Attachments, e.g., attachmentsText:autofax

– Tags, e.g., tags:linux

• Use quotes for phrases

– e.g., “medical record” or “OpenVista CIS”

• Use OR and AND keywords

– e.g., (laboratory OR radiology) AND autofax

• Use NOT to exclude keywords

– e.g., (laboratory OR radiology) NOT autofax

• Use ^ to boost a keyword’s importance

– e.g., “medical record”^5 VA

Additional Reading

• More search resources

– Jive blog post on improved searching in Clearspace 2.x

• http://www.jivesoftware.com/jivespace/blogs/jivespace/2008/06/16/search-improvements-in-20x-and-21

– Medsphere.org search tips page

• http://medsphere.org/search-tips.jspa

• Questions?