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22ndnd Annual Regional Nursing Informatics Annual Regional Nursing Informatics ConferenceConference: : Promoting Patient Safety Promoting Patient Safety Excellence Through TechnologyExcellence Through Technology
Supporting Quality, Reducing Clinician BurdenSupporting Quality, Reducing Clinician Burden
ObjectivesObjectives
• State 3 examples of EMR activities that reduce State 3 examples of EMR activities that reduce clinical burdenclinical burden
• Describe the workflows for 2 activitiesDescribe the workflows for 2 activities
• Identify the limitations of prior efforts of quality Identify the limitations of prior efforts of quality compliance.compliance.
• List 3 considerations that must be addressed in List 3 considerations that must be addressed in order to reduce clinical burden of quality alerts order to reduce clinical burden of quality alerts
• Describe actions taken to ensure successDescribe actions taken to ensure success
• State those successesState those successes
OutlineOutline
1.1. BackgroundBackground
2.2. NomenclatureNomenclature
3.3. Clinical BurdenClinical Burden
4.4. WorkflowsWorkflows
5.5. Real Live ExamplesReal Live Examples1.1. ImplementationImplementation2.2. The learning curveThe learning curve3.3. MetricsMetrics
6.6. QuestionsQuestions
BackgroundBackground
Evanston Northwestern Healthcare Evanston Northwestern Healthcare – ENH Hospitals and ClinicsENH Hospitals and Clinics
> Evanston HospitalEvanston Hospital> Glenbrook HospitalGlenbrook Hospital> Highland Park HospitalHighland Park Hospital
– ENH Medical GroupENH Medical Group– ENH Home ServicesENH Home Services– ENH Research InstituteENH Research Institute
BackgroundBackground
• CharacteristicsCharacteristics– Integrated delivery networkIntegrated delivery network
> physician officephysician office> hospital inpatient carehospital inpatient care> hospital outpatient carehospital outpatient care> home carehome care
– More than 50 sites of ambulatory careMore than 50 sites of ambulatory care
• Major teaching hospitals for Northwestern University with Major teaching hospitals for Northwestern University with 720 beds and 40,000 annual admissions 720 beds and 40,000 annual admissions
• Ranked #1 in the State of Illinois and #10 in the United Ranked #1 in the State of Illinois and #10 in the United States among multi-specialty independent research States among multi-specialty independent research hospitals with total external grant awards exceed $115 hospitals with total external grant awards exceed $115 million.million.
• Fully integrated EMR across the NetworkFully integrated EMR across the Network
Background - EMR ProjectBackground - EMR Project
• 2001 – Decision & Contract Signing2001 – Decision & Contract Signing
• 2002 – Plan / Build / Test / Training2002 – Plan / Build / Test / Training
• 2003 – Training / Install Epic2003 – Training / Install Epic
• 2004 – Make The EMR Work for Us2004 – Make The EMR Work for Us
• 2005 – Make The EMR Work for 2005 – Make The EMR Work for YouYou
PatientPatientDataData
PatientPatientDataData
ENH’s Portfolio of EMR ProductsENH’s Portfolio of EMR Products
ONCOLOGYONCOLOGY
ICU SYNOPSISICU SYNOPSIS
HOVHOV
My ChartMy Chart
2004 Davies Award for Excellence –2004 Davies Award for Excellence –Organizational AwardOrganizational Award
NomenclatureNomenclature
• CUICUI
• BPABPA
• Programming PointsProgramming Points
• Order ValidationOrder Validation
• NavigatorsNavigators
• Activity TabsActivity Tabs
My Soapbox!My Soapbox!
• Challenges to health care providers to create Challenges to health care providers to create ever-safer patient care environments ever-safer patient care environments
• Clinical Burden is immenseClinical Burden is immense
• Technical Burden is immense Technical Burden is immense
• Regulatory Burden is immenseRegulatory Burden is immense
In Essence We Need to Make The Systems Work In Essence We Need to Make The Systems Work for Usfor Us!!
Current National Campaign To Save 5 Million Current National Campaign To Save 5 Million From Harm (IHI, 2006)From Harm (IHI, 2006)
Reducing the Clinical BurdenReducing the Clinical Burden
• Clinically meaningful alerts Clinically meaningful alerts
• Making it obviousMaking it obvious
• Data Capture as a result of normal Data Capture as a result of normal workflowworkflow
• Reduction of the memory loadReduction of the memory load
AlertsAlerts
Alerts are designed to: Alerts are designed to:
• PreventPrevent
• CommunicateCommunicate
• EnforceEnforce
They do this by They do this by interruptinginterrupting the workflow-The the workflow-The trick is to do it in the most effective and trick is to do it in the most effective and
informative way!informative way!
Considerations for Reducing the Considerations for Reducing the Burden of AlertsBurden of Alerts
Use a Selective Approach:Use a Selective Approach:
• Targeted audienceTargeted audience
• Present the user with the information and the Present the user with the information and the tools to manage the alerttools to manage the alert
• Identify patient populations using data entered Identify patient populations using data entered through normal clinical workflowsthrough normal clinical workflows
• Avoid conditional alert workflowsAvoid conditional alert workflows
• Education and CommunicationEducation and Communication
Workflow – Text and CUIsWorkflow – Text and CUIs
New note composed
Smart list item selected
Item have CUI set
Set CUI
CUI filed for later retrieval
Note composition completed
No
Yes
Note accepted
Workflow – Workflow – Order Validation Order Validation Data/Order
entered and filed/signed
Run validation programming point
ResultValidation Data
Row
File Data/order signed
Trigger BPA message
False
TrueYes
No
Yes Item set
Clock? Set clockYes
No
No
Workflow – Identifying EligibilityWorkflow – Identifying Eligibility
Patient over 65?pneumonvax
filed
Patient allergic to vaccines or
products
Patient is potentially eligible
for vaccine
Does patient have active
ICD 9 on problem list
Bone Marrow Transplant =
Yes
Fire AlertAnd add to system list
Reference Patient INI
Item = “Droplet” is filed?
Quit
Reference Pneumonia
Grouper for ICD 9 Codes to search
for
Reference Flowsheet row Category list
Reference Immunizations INI
Date given with in T-5yrs
Reference Allergies INI
Reference Pneumonia
Allergen Grouper
Reference Pneumonia
History Grouper
Reference orders INI
ERX # ordered
Reference orders released between
Admit date and now
Procedure date within T-1 yr
CUI filed
Reference CUI INI
Data File in flowsheet activity
Reference Patient INI
Reference Problem List
Status = active, completed or
D/C
Reference Flowsheet row Category list
Data filed in row
Quit Quit
YesNo
Yes
No
Yes
Yes
Yes
No
No
Yes
Yes
NoYes
No
YesNo
No
Quit
Yes
Set clock I
Set CUI
No
Yes
No
No
The Real Thing!The Real Thing!
MRSAMRSA
MRSA - FactsMRSA - Facts
• 2001 through 20032001 through 2003– Several MRSA outbreaks (USA 300) in neonatal ICU, Several MRSA outbreaks (USA 300) in neonatal ICU,
orthopedic ward raising concernorthopedic ward raising concern
• 20042004– Screening of at risk populations introducedScreening of at risk populations introduced– Point prevalence survey at ENH found:Point prevalence survey at ENH found:
> MRSA prevalence = 8.5%!MRSA prevalence = 8.5%!> 2/3 not previously known2/3 not previously known
• Baseline: ~100 hospital-acquired MRSA Baseline: ~100 hospital-acquired MRSA infections per yearinfections per year
Local Cost of MRSA HAILocal Cost of MRSA HAI
Mean Mean Total CostTotal Cost
95% CI95% CI
No MRSA HAI No MRSA HAI ((nn=23,144) =23,144)
$31,321$31,321 ($24,178, ($24,178, $38,478)$38,478)
MRSA HAIMRSA HAI
((nn=178)=178)
$71,148$71,148 ($62,727, ($62,727, $79,569)$79,569)
ExcessExcess $39,820$39,820 ($35,270, ($35,270, $44,371)$44,371)
Ari Robicsek, MD- Hospital EpidemiologistEvanston Northwestern Healthcare
• Prevention of ~50 hospital-acquired MRSA Prevention of ~50 hospital-acquired MRSA infections per year will balance the infections per year will balance the 1,000,000 excess cost of MRSA 1,000,000 excess cost of MRSA surveillancesurveillance
MRSA-Justification MRSA-Justification
Universal Surveillance gets Administrative Blessing
MRSA- ImplementationMRSA- Implementation
• Initiated August 1, 2005Initiated August 1, 2005
• Maximize compliance : One workflow with Maximize compliance : One workflow with minimal decision points minimal decision points
• Patient Safety: Reduce exposure to MRSA by Patient Safety: Reduce exposure to MRSA by early detection of colonized patientsearly detection of colonized patients
• Reduce Clinician Burden: Use available data to Reduce Clinician Burden: Use available data to identify patients and communication informationidentify patients and communication information
• Collect Data: Minimal non-workflow data Collect Data: Minimal non-workflow data collection. Reports fields, frequency and collection. Reports fields, frequency and feedback mechanisms identifiedfeedback mechanisms identified
• Improve Quality: Reduce number of MRAS HAIsImprove Quality: Reduce number of MRAS HAIs
Patient Admitted overnight
Unit called and RN informed
Patient Education>13yrs
No action
ConsentOpen order set and sign order
Lab Workflow
Colonized
Infection Control receives report
Patient into isolation and cart
ordered
Infection Control RN enters problem
on problem list
Orange alert banner fires in all
key patient summary reports
Physician orders MRSA
Decontamination kit
Central Lines or fever
Alert fires on each flowsheet filing for RN and PCT only
No action
Patient Discharged with remainder of treatment
Refused
Agreed
No
Yes
No
Yes
Flowsheet Documentation
No
Yes
User reviews Order review for
order statusOrder status
Complete Documentation
Order sent
Order entered but not sent
Obtain nasal swab
No order
Maximize Maximize compliance : compliance : One workflow One workflow with minimal with minimal
decision pointsdecision points
Patient Safety: Patient Safety: Reduce exposure to Reduce exposure to
MRSA by early MRSA by early detection of colonized detection of colonized
patientspatients
Reduce Clinician Reduce Clinician Burden: Use available Burden: Use available data to identify patients data to identify patients
and communication and communication informationinformation
The MetricsThe Metrics
• Of 31,835 admissions tested, 6.4% were Of 31,835 admissions tested, 6.4% were positive on admissionpositive on admission– Accounting for false positives, true positive Accounting for false positives, true positive
percentage was percentage was 5.0%5.0%
Surveillance Compliance
0
10
20
30
40
50
60
70
80
90
100
Augus
t
Septe
mbe
r
Octobe
r
Novem
ber
Decem
ber
Janu
ary
Febru
ary
Mar
chApr
ilM
ayJu
ne July
August 2005 through July 2006
Pe
rce
nt
sc
ree
ne
d o
n a
dm
iss
ion
ICULabor and DeliveryMed-SurgPediatricsPsychiatryTotal
MRSA prevalence by DRG
0.0
5.0
10.0
15.0
20.0
25.0
30.0
Vag D
elive
ry
GI Diso
rder
s w/C
C
Pneum
onia
Age>1
7
CHF and
Sho
ck
C-sec
tion
Joint
Rep
lacem
ent
Septic
emia
Age>1
7
Psych
oses
CVA
Renal
Failur
e
Med
ical B
ack P
robs
GI Blee
d with
CC
UTI
GI Dise
ase
Met
aboli
c Diso
rder
s
COPD
Vag D
elive
ry w
/CC
Per
cen
t p
osi
tive
on
ad
mis
sio
n
n n = 8,586= 8,586
MRSA:Bloodstream Infections
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14
Pre
va
len
ce
De
ns
ity
P , 0.001
MRSA:Bloodstream Infections
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14
Pre
va
len
ce
De
ns
ity
P , 0.001
ICU surveillance
MRSA:Bloodstream Infections
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14
Pre
va
len
ce
De
ns
ity
P , 0.001
ICU surveillance
MRSA:Bloodstream Infections
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14
Pre
va
len
ce
De
ns
ity
P , 0.001
ICU surveillance Universal surveillance
MRSA:Bloodstream Infections
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14
Pre
va
len
ce
De
ns
ity
ICU surveillance Universal surveillance
p < 0.01
MRSA:Blood, Respiratory, Urine and Surgical Site Infections
0
2
4
6
8
10
12
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14
Pre
va
len
ce
De
ns
ity
ICU surveillance Universal surveillance
p < 0.01
Prevalence DensityRatio: 0.45
MRSA Bacteremia LOS>2
0
1
2
3
4
5
6
7
8
9
10
2003/04 2004/05 2005/06
August through July
BS
I/10,
000
Ad
mis
sio
ns
10 Comparator Organizations
ENH
*P<0.05
*P=NS
(N = 831,757 patients)
SuccessSuccess
Annual Annual average average pre-USpre-US
Annual Annual average average post-USpost-US
∆∆
BloodstreamBloodstream 1616 88 -8-8
UrinaryUrinary 1212 44 -8-8
Surgical SiteSurgical Site 1717 88 -9-9
RespiratoryRespiratory 3737 1111 -26-26
TotalTotal 8282 3131 -51-51
Intra-admission MRSA infectionsIntra-admission MRSA infections
Lessons Learned MRSALessons Learned MRSA
• Specialty Departments need extra attentionSpecialty Departments need extra attention
• Preference List IssuesPreference List Issues
• Alert took user to order entry, but should Alert took user to order entry, but should have been order reviewhave been order review
• Verbal communication constraintsVerbal communication constraints
The Real Thing!The Real Thing!
PneumovaxPneumovax
VaccinationVaccination FactsFacts
• Pneumococcal Vaccination is 75% effective in preventing Pneumococcal Vaccination is 75% effective in preventing pneumococcal bacteremia and meningitis which carries a pneumococcal bacteremia and meningitis which carries a high mortality for persons 65 years of age and older. high mortality for persons 65 years of age and older.
• In the United States, only 56% of adults over the age of 65 In the United States, only 56% of adults over the age of 65 years received the pneumococcal vaccine. years received the pneumococcal vaccine.
• Only 38% of nursing home residents received the Only 38% of nursing home residents received the pneumococcal vaccine.pneumococcal vaccine.
• Only 28% of eligible patients receiving PneumovaxOnly 28% of eligible patients receiving Pneumovax
ENH - % of Patients Meeting the Pneumococcal MeasureENH - % of Patients Meeting the Pneumococcal MeasureJan. 2005 – Dec. 2005Jan. 2005 – Dec. 2005
0
20
40
60
80
100
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
2005
(%)
Mee
ting P
neu
moco
ccal
Vacc
inati
on M
easu
re
Achievable Benchmark of Care = 95.0%
Pneumovax-JustificationPneumovax-Justification
• Failing the measure despite current effortsFailing the measure despite current efforts– Order setsOrder sets– Education of Physicians and NursingEducation of Physicians and Nursing– Concurrent TrackingConcurrent Tracking– Ordered and Discharged withoutOrdered and Discharged without
Pneumovax - ImplementationPneumovax - Implementation
• Initiated July 5, 2006Initiated July 5, 2006
• Maximize compliance : One workflow with minimal Maximize compliance : One workflow with minimal decision points decision points
• Patient Safety: Protect against future pneumonia episodesPatient Safety: Protect against future pneumonia episodes
• Reduce Clinician Burden: System identifies patients and Reduce Clinician Burden: System identifies patients and presents support tools for the RN to adhere to protocol. presents support tools for the RN to adhere to protocol. Workflow documentation switches off alert.Workflow documentation switches off alert.
• Collect Data: Easy concurrent reporting tools for managers Collect Data: Easy concurrent reporting tools for managers to track patientsto track patients
• Improve Quality: All eligible patients will receive Improve Quality: All eligible patients will receive PneumovaxPneumovax
Vaccine on MAR to be administered
T+3 at 9AM
Patient had pneumonvax
previously
Sign order as verbal order with “Per protocol” as
the reason
Patient allergic to vaccines
Patient eligible for vaccine
Document in MAR
Education and Consent
Complete goal on pneumonia care
plan
Document allergy if not already
noted in Allergy Activity
Document historical vaccine in immunizations
activity if neccessary
Yes No
Refused
Accept
YesYes
Complete goal on pneumonia care plan
Document in immunizations activity
2-20-06
Alert FiredClick on Hyperlink to go to Navigator
Review each section of the navigator with
patient
Consent
Vaccine due
Adjust date by 24hr in the future
Document refusal in flowsheet
Bone Marrow Transplant in
last yearNo No
Yes
Call Physician
Afebrile
Febrile
Maximize Maximize compliance : compliance : One workflow One workflow with minimal with minimal
decision decision pointspoints
Reduce Clinician Burden: Reduce Clinician Burden: System identifies patients and System identifies patients and presents support tools for the presents support tools for the
RN to adhere to protocol. RN to adhere to protocol. Workflow documentation Workflow documentation
switches off alert.switches off alert.
Collect Data: Easy concurrent reporting Collect Data: Easy concurrent reporting tools for managers to track patientstools for managers to track patients
MetricsMetricsCMS Core Measure Outcomes
Evanston Northwestern Healthcare - 1st Quarter FY 2007
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
HF-1
HF-2
HF-3
HF-4
AMI - 1
AMI - 2
AMI - 3
AMI - 4
AMI - 5
AMI - 6
AMI - 8a
PN - 1PN - 2PN - 3a
PN - 3b
PN - 4
PN - 5b
PN - 6
PN - 7
SCIP - 1
SCIP - 2
SCIP - 3
**SCIP - 4
**SCIP - 6
**SCIP - 7
Pneumovax – Lessons LearnedPneumovax – Lessons Learned
• Ordering delayOrdering delay– Missed vaccinesMissed vaccines
• Education missed cultural issuesEducation missed cultural issues
• Political issuesPolitical issues
The Real Thing!The Real Thing!
D/C InstructionsD/C Instructions
D/C InstructionsD/C Instructions
• Workflow StreamlinedWorkflow Streamlined
• CUIsCUIs
• Visual TriggerVisual Trigger
• Automatic ComplianceAutomatic Compliance
The Real Thing!The Real Thing!
Notes Capturing DataNotes Capturing Data
Quality Behind the ScenesQuality Behind the Scenes
• CUIs behind smart CUIs behind smart ListsLists
• Reporting from Reporting from notesnotes
The Real Thing!The Real Thing!
DVT PreventionDVT Prevention
DVT-ImplementationDVT-Implementation
• Initiated August 28, 2004Initiated August 28, 2004– Risk Assessment is completed – Alert FiresRisk Assessment is completed – Alert Fires
• Revised May 4, 2005Revised May 4, 2005– Risk Assessment not completed – Alert firesRisk Assessment not completed – Alert fires
• Revised December 19, 2005Revised December 19, 2005– Programming in place to identify at risk patientsProgramming in place to identify at risk patients
Risk Assessment Completion Rates
20667 45 31 17 36 28
544
928
675 674545 525 526 567 547
477
169
2612 27552641
28362715 2747
25932171
19282046
2268
2102
23122214 2230 2267
2158
1046
0
250
500
750
1000
1250
1500
1750
2000
2250
2500
2750
3000
05/0506/0507/0508/0509/0510/0511/05 12/0501/0602/0603/0604/0605/0606/0607/0608/0609/0610/06
# P
atie
nts
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
# of I npatients with completed Risk Assessment. # of inpatients with no Risk Assessment Percentage with Risk Assessment
Anticoagulants Recieved
1194 11901142 1164 1146
1214
11461209
1369
12071268
12181284
1225 1190 12151157
484
1624 1632
1544
1703
15861569
1475
1506
1487
1514
1674
1429
1553
15151607 1599
1478
731
0
500
1000
1500
2000
2500
3000
3500
05/05 06/05 07/05 08/05 09/05 10/05 11/05 12/05 01/06 02/2006 03/2006 04/2006 05/2006 06/2006 07/2006 08/2006 09/2006 10/2006
# of I npatients received Anticoagulants # of I npatients did not received Anticoagulants
The FutureThe Future
New ProjectsNew Projects
Sepsis ProtocolSepsis ProtocolBPA Pop Up box
opens after data is filed in flowsheet
Data is filed in Flowsheet
Alert Programming runs
Alert triggeredPatient appears on Sepsis screening
system list
Message appears in BPA section of patient summary
reports
Clinician clicks on blue hyperlink in
BPA to open Sepsis Navigator
Selects new patient and opens
their chart
Goes to Sepsis Navigator
Reviews patient summary report and evaluates
patient condition
Positive screen?
Alert switched off by selecting
“Patient meets criteria” option in
flowsheet row
Alert programming does not run again for this patient for
this encounter
Documentation of review completed
Alert switched off selecting any option except “patient meets
criteria” in flowsheet row
Alert programming runs again X hours
after Alert was switched off
Yes
No
No
YesRapid Response
team Called
Initiates sepsis resuscitation order set Part I (ID# ?)
Specialty note “Sepsis” for BPA evaluation
Need to build smart phraseNeed to build flowsheet row
Questions?Questions?
Contact InformationContact Information
Katherine Reynolds, RNKatherine Reynolds, RN
Senior Director Medical Informatics - InpatientSenior Director Medical Informatics - Inpatient
Evanston Northwestern HealthcareEvanston Northwestern Healthcare
4901 Searle Parkway4901 Searle Parkway
Suite 220, PO Box 1006Suite 220, PO Box 1006
Skokie, IL 60076-8006Skokie, IL 60076-8006
Tel: (847) 982-3999Tel: (847) 982-3999
Fax: (847) 982-6986Fax: (847) 982-6986
Pager: (847) 479-0878Pager: (847) 479-0878
email: email: [email protected]@enh.org