Project #4: Health Care System Assessment
Nadzeya Lazarev
NUR 4070 – Section 2738: Nursing Informatics
Dr. Patricia A. Cholewka
May 21, 2012
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Introduction
New York Methodist Hospital is a member of the New York-Presbyterian Healthcare
System. “The Hospital is a non-sectarian, voluntary institution that includes an acute care
general facility and an extensive array of ambulatory and outpatient sites and services”
(Employee Information Guide, 2009, p. 1).
New York Methodist Hospital has recognized the need for an electronic patient
record at the beginning of 21st century. The complexity of the healthcare provided by the
hospital has grown, and paper records have been no longer able to manage complex
information pertinent to patient care. In 2003, the health care information system Cerner
Millennium was implemented in the hospital to serve the organization’s needs and improve
patient care outcomes. Cerner Corporation presents their system in the following way:
Cerner is transforming health care by eliminating error, variance and waste for health
care providers and consumers around the world. Cerner® solutions optimize
processes for health care organizations ranging in size from single-doctor practices, to
health systems, to entire countries, for the pharmaceutical and medical device
industries, employer health and wellness services industry and for the health care
commerce system. These solutions are licensed by more than 9,000 facilities around
the world, including approximately 2,600 hospitals; 3,500 physician practices
covering more than 30,000 physicians; 500 ambulatory facilities, such as laboratories,
ambulatory centers, cardiac facilities, radiology clinics and surgery centers; 800
home-health facilities; and 1,600 retail pharmacies. (“Cerner to Present,” 2011)
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Health Care System Assessment
History of the system implementation
PowerChart, the Cerner Millennium electronic health record (EHR), has been
adopted into the clinical information system of New York Methodist Hospital in 2003. Since
that time PowerChart has continuously undergone many minor and major updates to fix bugs
and issues and keep it running smoothly. The latest update of the system was done on May
6th, 2012 (W. J. Christie, personal communication, May 9, 2012).
The first departments to implement PowerChart were pharmacy, radiology and
laboratory departments. The information system of these three departments has provided “a
foundation for other clinical systems” (Thede & Sewell, 2010, p. 351). In 2006, nursing
documentation and the computerized provider order entry (CPOE) were included in the
information system. Today, 98% of all the hospital documentation is done through the Cerner
system, and the hospital works continually to expand electronic documentation throughout
the entire hospital (Marks, 2012).
Goals and objectives addressed by PowerChart
The hospital implemented PowerChart as the documentation system to address the
following goals and objectives of the health care delivery:

To meet the Joint Commission requirements in improving disciplinary
charting and legibility of records/ notes;

To streamline administration and documentation processes throughout the
entire hospital;

To make information retrievable, viewable and up-to-date across a whole
process of the health care delivery and across all health care disciplines;
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
To make ordering process swift and accurate and reduce medical errors;

To arrange qualitative and quantitative reviews of medical errors;

To save the organization’s resources and reduce the costs of the health care;

To enhance patient’s safety and care;

To access and store patient’s information securely (W. J. Christie, personal
communication, May 9, 2012).
PowerChart has accomplished mainly all these goals and objectives of the hospital
(W. J. Christie, personal communication, May 9, 2012).
Quality measures
PowerChart is certified as a “Complete EHR on October 28th, 2010 by the
Certification Commission for Health Information Technology (CCHIT), an Office of the
National Coordinator for Health Information Technology – Authorized Testing Certification
Bodies (ONC-ATCB)” (“Cerner Solutions,” 2010). PowerChart has the capacity to meet the
2011/2012 eligible provider certification criteria established by the Secretary of Health and
Human Services (HHS) and required for funding of financial incentives for the hospital’s
services. PowerChart is capable of demonstrating meaningful use of EHR in order to
participate in the incentive programs initiated by the Centers for Medicare and Medicaid
Services (M. Jenkins, personal communication, April 25, 2012).
Cost benefit and return on investment
PowerChart is an expensive solution. Purchasing PowerChart, New York Methodist
Hospital spent only about one million dollars initially. Every year PowerChart requires
constant capital resources for purchasing updates, staffing the information technology (IT)
department, training, and system maintenance. PowerChart has been a necessary expense due
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to internal and external forces, including the JCAHO requirements to documentation and the
Centers for Medicare and Medicaid incentive programs (M. Jenkins, personal
communication, April 25, 2012). “Yet there are recent studies that suggest that – despite
upfront costs – the right EHR system, one that has been fully integrated and optimized, can
actually save money in the long run and increase productivity that can lead to further
revenue” (Evans, 2011, p. 5). Refusing to disclose any specific information related to cost
benefit and return on investment, W. J. Christie, MSN, RN, NE-BC, the Director of Nursing
at New York Methodist Hospital, noted that after implementing PowerChart there has been
decrease in operating costs and increase in health care professionals’ productivity (personal
communication, May 9, 2012).
Interoperability
PowerChart maintains interoperability only within the hospital, but it is not
interoperable with outpatient clinics and offices. For instance, the patient is seen in the
emergency department where health care professionals enter data not into PowerChart, but
into another information system such as First Net Prod, which is also a part of the Cerner
solutions. The data that is entered in First Net Prod goes automatically into PowerChart;
therefore, there is no need to document the information more than once. As another example,
in April 2012, the operating rooms have integrated the documentation system Surgine Prod,
which is one of the Cerner solutions. Even though the operating rooms (OR) adopted their
system behind of other departments, but the OR system works and shares data smoothly with
PowerChart and First Net Prod. However, when the patient is discharged from the hospital
and transferred for further care to an outpatient clinic, the inpatient information system is not
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able to share the patient’s data with the outpatient information system (M. Jenkins, personal
communication, April 25, 2012).
User design
The number of PowerChart users is about four thousands. PowerChart enables
physicians, nurses, social workers, and other authorized health care workers to enter, store,
capture, access, and retrieve patient health information. Mostly all health care professionals
are satisfied with the user screen design. For nursing documentation, an interactive view is
developed, so the nurse can chart everything that he/she needs pertinent to patient care on
one list. This feature helps to avoid incomplete entries. When documenting in PowerChart,
the nurse can access Ad Hoc Charting that includes various uniform assessment tools which
can be seen on Figure 1. For example, there are four different pain scales based on the age
and development of the patient (see Figure 2). Figure 3 represents how the nurse can use two
different pain scales 0-10 and Wong-Baker pain intensity scales at the same time (M.
Jenkins, personal communication, April 25, 2012).
M. Jenkins, RN, NP, the Clinical Nurse Leader of the Division of Pediatrics at New
York Methodist Hospital, stated that after PowerChart training, it was easy for many nurses
on her unit to perform basic tasks while working with the information system; once learned
many of the system capabilities, the nurses have been able quickly accomplish the needed
tasks with very few errors (personal communication, April 25, 2012). However, M. Jenkins
noted that there are some issues with the site navigation: sometimes it is difficult to find an
appropriate place where to chart (personal communication, April 25, 2012). For instance, the
nurse usually looks for any notes in the Clinical Notes section, but there is no Pediatric
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Admission Note here; Pediatric Admission Note is located in the Form Browser section and
the Document Viewing section (M. Jenkins, personal communication, April 25, 2012).
System errors and issues
M. Jenkins stated that PowerChart works accurately most of the time; occasionally,
the nurses experience slow processing of data and frozen screen (personal communication,
April 25, 2012). Moreover, there is one issue with medication prescriptions. The system has
set times (10:00 am and 10:00 pm) for every 12 hour medications. If a doctor charts a
medication order for every 12 hours, and does not select a specific time frame, the system
automatically sets 10:00 am and 10:00 pm. This, in turn, can lead to medication errors (M.
Jenkins, personal communication, April 25, 2012).
In addition, PowerChart does not have the capability to customize forms and pages
for reports. Data entry and output are standardized. For example, the nurse manager uses
standardized progress note for round reports which is depicted in Figure 4. The health care
professionals are able to perform only standardized infection control and isolation reports
(M. Jenkins, personal communication, April 25, 2012).
Confidentiality
PowerChart is protected against unauthorized access by a login process. The person
who enters the system must use a valid login name and password. The password is case
sensitive and must be changed every 45 days. When a new password is chosen, the system
does not say the strength of the password. PowerChart has the function of automatic log-out.
“Knowing emergencies often arise that involve calling a nurse away from the computer,” the
system “will time out after a given length of time with no input activity (Thede & Sewell,
2010, p. 369). The users of PowerChart “have a single sign-on for use of clinical information
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systems, which improves work flow and prevents accidental breaches of security and
confidentiality” (Thede & Sewell, 2010, p. 369).
Proposed changes to PowerChart
During the assessment of PowerChart, some system issues have been encountered.
To address these problems and improve the system, the following changes are proposed:
1. Wristbands should be embedded with the radio frequency identification (RFID)
that will allow the connection with the PowerChart EHR. This change will
enhance the accuracy of patient’s identification (Thede & Sewell, 2010).
2. PowerChart should include clinical decision support that can “be used to alert the
provider to double-check their order intent” (Thede & Sewell, 2010, p. 365). To
resolve the medication order issue with set times, the system should have various
order options (e.g., the time of the last dose of medication given; at what time to
start the medication). This change will benefit the hospital in improving
medication safety.
3. PowerChart should have a feature of the form and report customization. When
the nurse manager reports results, for example, for surveys, it will be much easier
to work with the system that allows the customization of the pages for reports.
4. The navigation of PowerChart should be improved through the help of the system
users. As the nurses experience some difficulties with the site navigation, they
should work with the collaboration of the IT department and Cerner
representatives and provide their feedback. The improvements in the navigation
will benefit the hospital in reducing the time for documentation and
documentation errors, and increasing user satisfaction (Thede & Sewell, 2010).
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5. To protect the confidentiality of patients’ records, biometrics should be utilized
when entering PowerChart. “The most secure method of authentication is
biometrics – the use of physiological characteristics such as iris or retinal scan,
fingerprint, or a voiceprint that is presumably unique to the particular person”
(Thede & Sewell, 2010, p. 370).
6. Interoperability should be enabled in PowerChart with other information systems
to allow effective exchange of patient’s medical information among unaffiliated
facilities (e.g., between the hospital and an outpatient clinic). The system
interoperability will facilitate a continuity of the patient care.
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Conclusion
Implementing PowerChart was an inevitable expense for New York Methodist
Hospital, but PowerChart has facilitated the health care delivery to be more coordinated,
streamlined, and accurate. The hospital has adopted the system slowly, “one step at a time,
and sometimes, one keystroke at a time” (Thede & Sewell, 2010, p. 373). Not all issues
related to the system functionality have been resolved. There are still some issues with user
design, customization of forms, interoperability with another hospitals’ and clinics’ systems,
confidentiality, and medication prescriptions. The healthcare professionals, including nurse
leaders, constantly collaborate with the Cerner representatives to improve the capabilities of
the system. For the future considerations, as “the nurse plays a key role in the adoption and
use of information technology, access and use of CISs [clinical information systems] should
be designed to assist the nurse in the delivery of efficient safe care” (Thede & Sewell, 2010,
p. 357).
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References
CERNER solutions PowerChart®, FirstNet®, Profile®, HealthSentry®, CERNER Health,
CERNER® health record, IQHealth® and P2Sentinel™ receive ONC-ATCB
2011/2012 certification. (2010, November). Cerner Newsroom. Retrieved from
http://www.cerner.com/newsroom.aspx?id=17179869334&blogid=2147483710&lang
Type=1033
Cerner to present at Stifel Nicolaus 2011 Healthcare Conference. (2011, August). Cerner
Newsroom. Retrieved from
http://www.cerner.com/newsroom/Cerner_to_Present_at_Stifel_Nicolaus_2011_Heal
thcare_Conference/
Employee information guide. (2009). New York Methodist Hospital.
Evans, A. (2011). Exploring the costs. Supplement to Dermatology World. Retrieved from
http://digital.ipcprintservices.com/publication/?i=90983&p=6
Marks, G. (2012, February). Electronic medical record transition. Presentation conducted at
the nursing leadership meeting of New York Methodist Hospital, Brooklyn, NY.
Thede, L.Q., & Sewell, J.P. (2010). Informatics and nursing: Competencies and applications
(3rd ed.). Wolters Kluwer Health/ Lippincott Williams & Wilkins.