AHRQ 2006 Annual Conference on Patient Safety and Health IT

AHRQ 2006 Annual Conference on Patient Safety and Health ITSocio-Technical Approach to Planning and Assessing Redesign Huron Hospital CPOE Implementation

June 5, 2006Greg Kall, CPHIMSRegional Vice President, Information Technology

Socio-Technical Approach to Planning and Assessing Redesign l June 5, 2006 l 2

Huron Hospital

• 211-bed, acute care, urban hospital• Located in East Cleveland, Ohio• 361 member voluntary medical staff

52 residents in Medicine and Surgery

• Level II Trauma Center, Obstetrics, Community Health Center• Part of 4 hospital CCHS East Region


Components Live at Huron• Electronic Medical Record (EMR)

Patient Lists Clinical Results Review

• Clinical Documentation Electronic Medication Administration Record (eMAR) On-line Discharge Process

• Computerized Physician Order Entry (CPOE) Clinical Decision Support (Rules and Alerts) Order Sets Electronic Signature Strong Authentication

• Remote Access


Implementation Facts• Go-Live in July of 2004

Phase I: Psych Unit and OB Unit Phase II: ICU Phase III: Remainder of hospital

• 1,000,000 eOrders processed to date

• CPOE utilization rates Residents: 94% Overall: 75%

TwoWeeks

Between


Organization Strategy• Inclusive

All 4 hospitals in CCHS East Region participated from the start

• Multidisciplinary Physicians, Nurses, Ancillaries, IT Together from the very beginning

• Implementation Team Clinically Focused - More Clinicians than IT! Pharmacists, Nurses, Laboratory

• Ongoing/Active Management Multi-year project Simultaneous phasing activities

• Design, Implementation, Maintenance

Executive Sponsors

Physician Advisory Committee

Regional CMO, Hospital Chiefs of Staff, Hospital Physician, Advisors, Director Medical Education

• CPOE Design• Medical Staff Bylaws and

Policies• Order Sets and Other Clinical

Content• Physician process redesign

Steering Committee

Regional and Hospital Executives

• Monthly Status Reports• Remove Barriers• Executive-level Support

Patient Care Advisory Committee

Regional and Hospital Executives and Managers of Nursing, ED, Ancillary, Clinical Services, and Quality Departments

• CPOE Design• Hospital and Department

Policies and Procedures

Project Management

Office

Four Hospital Physician Advisory Groups

Clinical Informatics Council

Regional CMO, Physician Advisors, Hospital CNOs, Project Staff

• Collaborative clinical decision-making

Implementation Team

Team Members• 4 Physician Advisors• 1 Pharmacist• 3 Nurses• 1 Medical

Technologist• 1 HR Trainer• 1 Project Manager• 1 Interface Engine

Analyst• 1 Report Writer• 1 ADT/Charge

Master AnalystFunctions• Planning• Analysis• System Design• Application Build• Interfaces• Testing• Implementation• Support

Task Forces

Communication

• Develop and Execute Plan

Security


Process Redesign

• Standard Flows• Unit Review• Custom content

Training


HIS Process

Nursing Process

Pharmacy Process

Project Organization


Design StrategyPatient Care Advisory Committee

• Learn the software

• Identify processes likely to be impacted By policies and procedures By function By department

• Form workgroups, including front-line staff Flowchart existing processes Correlate the process to the software Identify where changes may occur Flowchart new and revised processes


Nursing Workflow Redesign Examples

Order written to transfer orCPOM “transfer request”

Transfers withEMR

February 9, 2004

Unit calls floor for bed,or admitting is notifiedvia an EMR requisitionfor transfer request

Bed assignedUnit notified bed is

ready

Nurse calls or fax’sreport

Pack up patientmeds, belongings

and chartCall transport

Sending unitenters order in the

EMR “transferconfirmed”

Transfer received

ChangeAccommodation

code (H,E,S only)requisition entered in

the EMR

Reassemble chart

Transcribe orders

Does the ptneed to bephysicallytransferred

NoYes

Patient physicallytransferred to

new bed

Registration moves ptin HBOC, pt is moved

in the EMR via interface

Registration changesthe accommodation

code in HBOC

Patient scheduled forSurgery

Sending Unit prints the Active MedicationReorder sheet at the time the patient isleaving the unit and places the form on

the chart.

Does post opphysician participate in

EMR?

The physician reordersthe medications in theEMR using the session

type of Post Op

Pharmacy isnotified via theEMR that the

medication hasbeen reordered.

Nursing Staff faxesthe completed

form to thepharmacy

Nursing releasesthe hold orders

when the patient isreceived in theinpatient unit.

The physiciancompletes the

Active MedicationReorder Sheet

The medicationadministration record isupdated with the date of

renewal

Active Medication ReorderingTuesday, February 21, 2006

YesNo


Design Strategy• Validate new workflows

Design Endorsement Sessions to demo workflows Audience includes physicians, nurses, pharmacists, ancillary

departments Structured scenarios with written participant evaluations Iterative process

• Revise policies and procedures to support new workflows

• Conduct unit-specific workflow review sessions to identify exceptions

• End-user training must include workflow changes and new Policies &Procedures


Design StrategyPhysician Advisory Committee

• Establish clinical priorities

• Create and modify policies and by-laws

• Review and approve design

• Review workflows and process

• Create and manage order sets

• Create and manage rules and alerts

Clinical Informatics Council

• Where everything comes together!

• Also provides ongoing post-live management


Feedback and Improvement StrategyClinical Informatics Specialist

• New position dedicated to supporting clinicians

• One-on-one training (carries beeper)

• Grand Rounds

• Weekly resident meetings

• Monthly User Group meetings

Local Physician Advisor Group

• Workflow feedback

• Data/performance review


% Orders Cancelled or Modified by MLM Huron Hospital

05

1015202530354045

Duplicate Drug Interaction Allergy

4th Quarter 2004

1st Quarter 2005

2nd Quarter 2005

3rd Quarter 2005

Huron Order Sets/Dischg

0.00.20.40.60.81.01.21.41.61.82.0

Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05

Regional Order Set Utilization per Discharge

Performance Tracking Examples

0

20

40

60

80

100

120

Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06

Direct Order Entry Huron Hospital

% D

irect

Ord

er E

ntry

All Clinicians Residents

Survey Instrument


Survey Dimensions

EMR Adoption & Ongoing use

Technology-based perspectives Social Perspectives

Task

User

Task-Technology FitFit with technology, User

evaluation, Relative advantage

IT Acceptance ModelPerceived usefulness, Ease of use, Attitudes,

Behavioral intention

Cognitive Processes,

Information quality, Bounded rationality

Information overload

Organizational Imperative

Power and control, Information politics

AHRQ 2006 Annual Conference on Patient Safety and Health IT

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