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HITWA Perth 9th November 2018
• 2001 – Decision & Contract Signing
• 2002 – Plan / Build / Test / Training
• 2003 – Training / Install
• 2004 – Make Epic Work for Us
• 2005 – Make Epic Work for You
Steering Committee formed• CEO, COO, CFO, & CIO, • Sr. Vice President of Medical Informatics, • President of Hospitals and Clinics, • President of the Medical Group and the chairman of
two key physician groups
Meet Every 2 weeks to provide overall guidance and oversight
Physician Advisory Committee Formed
(12 physicians)
6 Project Teams created
(150 end-users)
1) One time, error free, data entry; Get it right the first time2) Streamline workflows3) Always maintain patient safety and confidentiality 4) Do not vary from the Epic standardized approach5) Do what is best for the organization, not what is best for the
individual or area6) 100% commitment from everyone to successful implementation7) Maintain common look and feel 8) Share information across the enterprise9) Provide users the appropriate tools, training and ongoing support, to
maintain maximum productivity, value, and satisfaction10) Do not customize source code 11) Comply with all regulatory and legal requirements
Comprehensive Electronic Medical Record Patient-focused Record Streamlined and Standardized Work Flows and Cost
Improvement Error Reduction Increased Patient Satisfaction/Convenience/Safety Single, Enterprise-wide Registration Physician Order Entry Improved Physician Satisfaction Access to Enterprise-wide Data Facilitate Teaching and Research Self Service
Relationship between: Information Technology Organizational Culture Quality Indicators (CQI)
The perfect opportunity to study the relationship between the culture, IT and QI
HierarchicalInformation Management,Communication, StabilityControl, Rules, Security
Leadership - conservative,cautious
RationalPlanning, Goal setting,Production, EfficiencyContract, CompetenceLeadership - directive,
goal-oriented
GroupCohesion, Morale,
Development of humanresources, Affiliation,
attachmentLeadership - concerned,
supportive
DevelopmentalAdaptability, Readiness,
Growth, ResourceAcquisition
Leadership - inventive,risk-taking
Peop
le
Organization
Control
Flexibility
Adapted from Zammuto and Krakower (1991)
To monitor the effect of improved information systems on the organizational culture.
To analyze the effect of informatics on the degree of CQI maturity within the organization
To assess the effect of informatics on quality of care
To monitor sustainability of any changes in organizational culture, CQI maturity and QI indicators
Study Design Observational Study over 4 years
Baseline, 12, 24, & 36 Months Primary and Secondary DataMeasures Culture and Quality Questionnaire1
Culture Inventory QI Implementation Scale
Quality Indicators using reported CMS measures
1Adapted by Shortell, et. al. (1992)
Redesigned over 500 work flows Inpatient - 150 Ambulatory – 70 Hospital Outpatient Visit - 150 Registration and scheduling - 80 Physician billing – 70
Grew to over 1500 workflows Weekly Meeting to review progress and
integration Workflows are required for any changes
Physician entersmedication order into
Epic
Pharmacistverifies order
Medication sentup to unit
MedicationAdministration
Workflow
Go to Pyxis andremove
medication. Ifmed not in Pyxis
then call topharmacy for stat
prep.
Yes
Pyxis Override
RN clicks“acknowledge”
button to sign offorder in order
review
Medication appears automatically on theelectronic MAR
Medicationrequired now? No
System performsduplicate therapy
checks and allergychecks
Physicianaddresses the
warningsaccordingly and
signs order
Physician writesmediation order onpaper order sheet
Pharmacistverifies orderagainst other
medications andallergies
Medication sentup to unit
MedicationAdministration
Workflow
Go to Pyxis andremove
medication.
Yes
Pyxis Override
If present tubedor faxed to the
pharmacy
Medicationrequired now?
No
RN signs off/acknowledges
order on the paperorder sheet
RN transcribes theorders onto paperMAR and writes inscheduled timesfor medication as
applicapable
Problemidentified? Yes
Pharmacy callsthe physician todiscuss order
OrderChanged?
Pharmacy entersorder into the
pharmacy system
No
Yes
OrderCancelled?
Yes
Physician callsfloor to speak
with RN recancelled order
Physician callsfloor to speak
with RN rechanged order
No
RN checkswritten order on
the old MARagainst Printed
order on the newMAR
Medicationappears on the
MAR sent up forthe next 24 hours
No
If med not inPyxis then call topharmacy for stat
prep.
Order given tounit pharmacist
Formed April 2002 12 Physicians: 3 IM, 3 Surg, 2 ER, 1 Anesth
1 Psych, 1 OB, 1 Peds Charged with: Learn Epic, build tools, support training,
support go-live, support evolution, provide MD input for clinical and political decisions
Expectation: 18 hours monthly, weekly meeting Targets: #s of tools built, hours of support, practices
using our EHR Built > 600 local text templates and accompanying lists Compensation: monthly stipend + target incentive
Adoption of rule requiring use of Epic Support of Department Chairmen to
mandate training Involvement of Medical Executive
committee to support use in key areas Use of problem list Standardization and Best Practice Workflow redesign
Huge initiative Off-site training center
13 Classrooms On-Site Training
Facilities 3 Hospitals (6 Classrooms) Medical Group Building
Created 51 Custom Training Courses
8 General Topics
Recruited and Certified over 30 Full time and Supplemental Trainers delivered 17,000+
Trained nearly 400 Super Users Scheduling and Training 10,000 Users Proficiency Testing at Completion of Training for
Physicians Proficiency testing by Super Users for all others Recogniton
– Professional Staff Dues waived in 2003– C.M.E.’s for Physicians after training– Recognition Gift
Wireless Jetson’s (650)
Wireless Nurse Server Carts (57)
PC’s & Wyse Terminals (4331)
Laser Printers (1087)
Label Printers (205)
And a Windows 2000 Upgrade
End Users did the testing (huge commitment)
Scripts were provided Groups of end users scheduled
at different times of the day to execute predefined scripts that would “exercise” the system.
FIT before Go Live at each Hospital and Office
3 full weeks of Testing for each hospital
Preference Lists
Order Sets Documentation Navigators Patient
Summary Chart review Patient Lists
Clinician Name: Validation Date:Department/Unit: Validation Start and End Times:
Task Ready Not ReadyNotes
(Please provide specific detail. If needed, attach screen prints to cla Preference Lists
Confirm all preference lists are available. -Are you able to enter all of your common orders and medications? Try both the preference list tree and order search.Order Sets
Confirm order sets are available and appropriate.
Documentation Tools
Confirm smart texts are available and appropriate. Go to both notes and d/c instructions.
Navigators
Confirm that you can access all of the navigators (admission, transfer and discharge).
Patient Summary and Chart Review
Confirm that the patient summary reports are accurate and appropriate.
Confirm that you can access Chart Review to review past visits and past results. Patient Lists
Make sure that you can access unit and your own list under system lists. If you work in an area that sees outpatients, make sure you have access to a shared list for that department.
Make sure that you can create a new MyList. Adjust the
Clinician Validation ChecklistPlease fill out all of the following information
Record is complete-no paper charts and filing that is behind
Faxing prescriptions to area Pharmacies Tracking inpatients from the office or home ED and consulting physicians have
access to the complete record-both office and hospital visits
Instant “After visit” summary Patient education Use of Patient Portal
Leadership Physician Champion Opinion Leaders
• Physicians• Staff
Clear Expectations of Behavior Training Communication Recognition Technology Ownership
Don’t even open the door! Workflow walkthroughs Superuser and physician validation Endusers do the testing Training is functionality only Keep the old workflows Cannot have too many order sets Produce the success data
Feed the 5000! Set dates and stick to them Identify the SWAT team Patience Know your downtime
procedures Make no autocratic
decisions!!!!
0102030405060708090
100
Group Developmental Hierarchical Rational
Group A Group B Group C Group D Group E
BL
n=34
BL
n=157
BL
n=32
BL
n=250BL
n=142
T2
n=34
T2
n=121
T2
n=22
T2
n=180T2
n=102
The Impact of Converting to an Electronic Health Record on Organizational Culture and Quality Improvement Cindy J. Nowinski, MD, PhD, et al International Journal of Medical Informatics 2007 Jun;76 Suppl 1:S174-83. Epub 2006 Jul 14.
