Adherence to Clinical Reminders at the VA New England Healthcare by yaofenjin


									         Hospitals and Health Systems:
Nurses and Physicians in the Implementation of the
  EMR at NYC Health & Hospitals Corporation

Marie Ankner, RN, MS, CNAA, HHC
Abha Agrawal, MD, Kings County Hospital/HHC
Louis Capponi, MD, HHC
Glenn Martin, MD, Queens Health Network/HHC
Nadia Sultana, MBA, RN, BC, HHC
         HHC Mission Statement
   To extend equally to all New Yorkers, regardless of
    their ability to pay, comprehensive health services of
    the highest quality in an atmosphere of human care,
    dignity and respect;
   To promote and protect, as both innovator and
    advocate, the health, welfare and safety of the people of
    the City of New York;
   To join with other health workers and with
    communities in a partnership which will enable each of
    our institutions to promote and protect health in its
    fullest sense -- the total physical, mental and social well-
    being of the people we serve.
    11 Hospitals
      5 DTC’s
      4 LTC’s
   100 Clinics

   Home Care
   MetroPlus
•Revenues totaled approximately $4.3 billion.
•Nearly one million ER visits.
•Five million outpatient visits
  including 2 million primary care visits.
•210,000 Hospital Discharges
•The single largest provider of psychiatric
 services in New York City
•23,000 births
         HHC Organization Chart
 Mayor Appoints            Board of Directors

                        Benjamin Chu, MD, MPH
 Mayor Appoints

(7) Networks      SVP    SVP     SVP      SVP   SVP

                HHC EMR Timeline
 1991    /      1997           2000            2002      2004        2005

HDS Pilot, Jacobi Medical Center
Labs, CPOE, Documentation

                Installation throughout HHC
                Lab, Lab Consolidation

                          CPOE                                              LTC

                                   OPD Documentation/Coding

                                                      Smart Cards

                                                      DC Summaries

                                                         Disease/Pt. Registries
                                                              Medication Admin.

Vision for HHC Clinical Systems

   Leaders in Clinical Outcomes
   Reliably Support the Care Team
   Complete Information Availability
   Positive Fiscal Impact
         Critical Success Factors
   Increase the Speed of Innovation
     Complete Projects
     Facilitate System Consistency

   Enhance Clinical Information Access
     Registries
     Close the Data Warehouse Loop

     EMPI

   Successful 4.1/4.2 GUI implemented
         Critical Success Factors
   Continuous Engagement
     SVP IT Steering Committee
     NISA, PISA, DW Users Group

     IT Senior Staff

     Front Line Staff

   Provide Support, Resources & Leadership
   Improve Management of our Partners
Using IT to Improve Patient

          Abha Agrawal, MD
   Chief Medical Informatics Officer
       Associate Medical Director
  Kings County Hospital, Brooklyn, NY

     HIT Summit, Oct. 2004. Washington, DC
Medication Errors

      One million serious medication
       errors every year.
      20% are life-threatening.
      7000 deaths annually.
      $2 billion nationwide in hospital
       costs alone.
IT to Reduce Med. Errors

         Information Technology is
            a critical ingredient to
          reduce medication errors.
            Medication Process

               Medication Order      CPOE

                 Dispensing        Pharmacy

 Nurse         Administration     E- Med Admin
     CPOE with Decision Support
   Electronic prescribing – eliminates illegibility
   Drug-allergy checking.
   Drug-drug interaction checking.
   Coming up - Drug-lab checking.
   Pharmacy review of meds – matched against an
    electronic profile.
CPOE: Incorrect dose warning
CPOE: Drug-drug interaction
          Electronic Medication
   Wireless network and mobile carts on wards
   Real-time data entry
   Decision support e.g. delayed med admin, too
    high dose etc.
   Error reporting
   No errors during transcription from paper to
    MAR sheet
   Next steps: Bar-coded matching of patient and
    of medication
Med Admin: Info. available to RN
Med Admin: Pharmacy Review
Med Admin: Incorrect Time
    Challenges in Implementation
   Complexity – interdisciplinary
   Clinician buy-in – MD, RN, Pharmacy
   Cost of the software, even more – the cost of
    the implementation
         Putting this in perspective
   5-10% hospitals have adequate CPOE.
   <10% hospitals have Electronic Med. Admin.
   2003 HIMSS Patient Safety Survey
       Issues that IT can address
            Top issue - Medication errors – 93% respondents.
   14th annual HIMSS leadership survey
       Projected IT priorities
            Top issue – Reduce medical errors, promote pt safety –
             59% respondents.
         It’s All About Results
12-month Evaluation of CPOE at Metropolitan
 Overall Med. Error rate down by 40%
   Incomplete orders down by 70%
   Incorrect orders down by 45%

   Illegible orders virtually eliminated

   Errors due to drug therapy problems - unchanged

                          Igboechi et al. Hospital Pharmacy 2003
Nursing at New York City Health
  and Hospitals Corporation

     Scope and Informatics
     Marie Ankner, RN,MS,CNAA
    Assistant Vice President , Nursing
     New York City Nursing Services

   Each facility led by a Chief Nurse Executive
   6600 RNs located throughout the five boroughs
   Nursing teams include ancillary personnel
   Interdisciplinary approach to patient care
   Unionized environment
       NYSNA, 1199, DC 37
Nursing Presence:

   7 Networks
   11 Acute Care
   4 Long Term
    Care Facilities
   Diagnostic and
   Ambulatory Care
   Home Care
   MetroPlus
   Child Health
            In the beginning …
   RFP was developed and reviewed by an
    interdisciplinary team representing all facilities
   Pilot developed at Jacobi Medical Center
       Initiative led by nursing and fostered
        interdisciplinary screen building
   Individualized Network /Facility expansion
           Nursing Climate
   National Nursing Shortage
   Average age of the RN in NYS is 48 yrs.
       Knowledgeable, aging workforce
   Workplace Drivers
     Increased patient complexity
     Decreased length of stay

     NYS regulatory requirements

     Focus on access, health promotion and prevention
                 HHC Environment
  HHC RNs average age 48 yrs
  - 60 % direct care providers have > 10 yrs of service
 Nursing and the Electronic Record

  - variation in templates and terminology
 Initiation of the NISA committee

 Identification of Nursing Informatics Educational Needs
       Nursing Conference incorporated Nursing Informatics
       Pre hire assessment of computer skills
               NISA Goals
   Identification and adoption of Best Nursing
   Collaboration of knowledge, expertise
   Work smarter not necessarily harder
   Safeguard patient care
   Assure professional practice
   Support Nursing and IT
   Maximize IT utilization to support patient care
     Driving Force is Patient Care
   Cost effective, quality, safe patient care
   Provide IT support for all health care providers,
    including nursing
   Computerize Nursing Process
       Literature reports that Nursing Documentation
        Utilize13-28 % RN time
   Online electronic medical records
       Pharmacy, lab and radiology
    Medication administration pilots
   Patient education
   Health Promotion
   Immunization screens
   Home Care telemedicine program
   Paperless NICU at Jacobi Medical Center
   Smart Cards
The Nursing and Technology Link
     Nadia Sultana          MBA RN,BC
Senior Director, Clinical Information Systems
    NYC Health & Hospital’s Corporation
          October 23,2004

   User Groups developed data collection screens separately to
    meet their immediate needs:
    -   Physician Documentation screens
    -   Physician Order Entry
    -   Nursing Assessments and Flow sheets

   Data collection screens lack
    standardization …impacting
    Data Warehouse initiative and
    ability to implement timely changes
    to CPR
                     Action Plan

   Formation of …

       NISA = Nursing Information System
               Advisory Group

     …to promote dialogue, share best practices and
     foster Nursing Informatic education
            NISA Framework
 Network Nursing Service Representation
 Regular Monthly meetings

 Co-chaired by Corporate Nursing and IT

 Specific Agenda

 Initiation of an Issues List with Follow-up

 Guest Speakers
Current Concepts in discussion…

    Development of standardized data collection screens
     with data element identification

    Establishment of Change Control Procedures

    Identification of Educational Needs

    Planning next modules incorporating
      “best practice”

   First attempt - Development of the VISTA Desktop
    Nursing Standard

    Outcome – some variation continued post
     implementation …emphasized the need for
     change control process…and need to
     continue to Standardize

                                                                   • Medium Issue -
                                                                   Redundant icon function

                                   CONEY                           • Recommendation –
                                                                   Remove icon
                                   • High Issue - Block
                                   functions should appear as      • Response – Rebuilding
                                   tabs. Substantial deviation     new desktop by April 18th
                                   from NISA standards.
                                                                   • Status - verify with Misys
                                   • Recommendation – Align        analyst if this issue will be
                                   desktop with NISA               fixed on new desktop
                                                                   • Next Steps - Re-audit
                                   •Response – Rebuilding          desktops when desktop
                                   new desktop for April 18th.     build is complete.

                                   •Status –verify with Misys
                                   analyst if this issue will be
                                   fixed on new desktop

                                   •Next Steps – Re-audit
                                   desktops when desktop
                                   build is complete.

Non-Compliance IP Nursing Issues

                        • Medium Issue – Duplicate review queue

                        • Recommendation – Remove desktop shortcut

                        • Status – IT rep will not sign off change control
                        form or make changes until audit has been
                        reviewed with NISA rep.

                        • Next Steps – Review audit results with NISA Rep
                        and IT.

Non-Compliance IP Nursing Issues
      Change Control Procedures

…Experience with VISTA Desktop
 Standardization and Phase I Development of
 Data Warehouse Reports highlighted need for
 Change Control Procedures to Decrease
 variation of key data elements and terminology
Change Control Process -CPR /DATA WAREHOUSE
                Education efforts

   Development of Survey to assess needs

   Standardized CPR Modules Training and
     issue CEUs

   Perform “Gap Analysis” – focus on
     Nursing Documentation and CPR usage
      to determine “best practice”
Planning next modules incorporating
“best practice”…

  Medication   Administration Expansion
  Interdisciplinary Documentation
  Clinical Pathways
     Glenn Martin, MD
Director, Medical Informatics
  Queens Health Network
Now that we have an EHR how do
we use the data it generates?

  Shift focus from process to outcomes
  Create clinical data repository and
     management registries
    Convert data into useful information
      Use data to segment patient populations according
       to condition and acuity
      Draw on clinical repository to measure indicators
       and track improvement in patient health outcomes
Report writer sits on QHN Intranet and
provides user-friendly query access:
    • Provides flexible parameters for
    key indicators
    • Output can be saved for
    retrospective review
    • Can sort data to facilitate patient
    • Includes patient telephone numbers
    and primary care provider name
Diabetes   Diabetes
And information needs to be coordinated and flow seamlessly to
community providers who serve our patients outside the hospital

                                                   providers can
                                                   requests and
                                                   receive reports
How do we plan to ensure that patients drive
our services and make decisions about where
to get their care?

 Smart cards empower patients and connect providers
 across communities and health systems

    Effectively make patients the owner of   their
    Provide patients the opportunity to carry their
     medical information at all times
    Offers patient a vehicle for communicating
     current information to their provider of choice
    Health Connection Card
   Functions as Patient ID          6,000 patients own the
   Includes 64K chip                Health Connection Card
   Patient summary updated at
    each encounter with:
       Patient information
       Emergency contact
       Problem List and Allergies
       Active Medications                    Patients Name
       Complete, relevant lab

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