Collaborating to Fund
and Advance ResearchThe OHSU Experience
Jeffrey A. Gold, M.D.
Professor of Medicine
December 17th, 2014
Disclosures
• Received funding from AHRQ,
AAMC/Donaghue Foundation
Statement of Clinical Problem
•
Electronic Health Records (EHRs) are at the center
of all data communication, clinical decision making
and care implementation in the health care system
•
Numerous studies document poor use of EHR can
lead to increased patient errors and undermine
communication
•
The ICU appears to be a highly vulnerable
environment to these issues
• Massive amounts of data (>1800 data
points/day)
•
Most physicians feel that current EHR training is
inadequate
Solution
To use simulation with high fidelity,
contextually relevant cases to improve EHR
utilization and help focus EHR redesign
What resources are required?
•
High fidelity (realistic) cases for training.


Need to be created by content experts
Cases need to be designed specifically to test EHR
usability and safety (the controlled lie)
•
Cases need to be built into the EHR
•
Need a cloned version of EHR which looks
identical to clinical system but doesn’t have
actual patient data
• Must maintain user customization
•
Problem- I am a basic scientist/fellowship
director with background in ICU administration
Step #1-Reach out to Informatics
•
Chair of Informatics-Bill Hersh
•
Introduced me to Fran Biagioli who user EHR
simulated cases for Medical Students
•
Used resources from ARRA funds to help fund
EHR educator (Gretchen Scholl) to help build
simulated cases, create separate simulation
environment and trouble shoot problems



Leveraged support from hospital Human Resources
to allow for shared position
Human Resources controls EHR training
Engagement of hospital CMO
Barriers to Overcome
•
Cases need to be created
•
•
Cases need to be imported into EHR
•
•
Manually done-no autoimport
Cases must be temporally contextually correct
•
•
Need to test meaningful use of EHR
•
Recognition of patient safety issues/errors-not
just charting
They must exist in realtime –cloned forward
Can’t use actual production EHR environment
•
•
Impacts billing, pharmacy, meaningful use etc….
Need to maintain user customization and workflow
Methods
5 day real life ICU stay created in EPIC simulation
environment Cases originally created in EXCEL
Every data point created and entered by hand in relative
real time (no way to download data into system)-Patient
“cloned” forward to day of testing so can be used in real
time
Case contains clinical decompensation with 15 built- in
patient safety issues
• Vitals trends, medication misdosing, lack of best practices
Methods Cont..
Trainees given written history, relevant clinical info for last
5 days, Bld Cx results and PE
• No radiology in sim and residents told not to look for it
Trainees given 10 min to gather data in EPIC
• Done in ICU to recapitulate effect of environment (lights
etc…)
Subjects told to present case as if giving daily plan and
signout for weekend
Residents allowed to use own login for customization
Subjects could be tested again, at least 1 week later
• Repeat testing with different case-random order
Types of Patient Safety Issues
Issues of Cognition
• Recognizing trends in vitals
• Recognize high Pplat
Familiarity Issues
• Do they even know where things are located
Medical knowledge Issues
• Do they even know appropriate VT
Fragmentation issues
• How many screens are used
Step #2-See if it works
Run 40 housestaff through simulations and document
that average clinicians miss >50% of safety items within
a case
40
# S u b je c ts
•
C o rre c t
Inc o rre c t
30
20
10
R ecurrent S epsis
B P /H R
P lat
Fever
V an c troug h
V an co D ose
Zosyn D ose
D5
G lucose > 200
N eed for In sulin
MASS
D aily A w akening
TV
Fluid B alan ce
0
March et al BMJ Open 2013
C linic al
C hang e
M e d ic atio n F ailure to
E rro r
A d he re to B e s t
p rac tic e
Step #2-See if it works
• Run 40 housestaff through simulations
and document that average clinicians
miss >50% of safety items within a case
• Data used to obtain R18 from AHRQ for
using simulation to improve patient safety
• Funds from this grant allow for creation of
additional cases to document training
effect
• Allow to increase N>150
Trainees Fail to Recognize Patient Safety
Issues
Stephenson et al BMC Med Ed 2014
Can Simulation Improve Performance?
B.
C.
Case 1 First, then Case 2
Pre
Post
p<0.0001
40
60
40
20
20
0
0
p=0.0003
st
0
60
Po
20
80
% Correct
40
80
Po
st
60
100
Pr
e
% Correct
% Correct
80
Case 2 First, then 1
100
e
All Subjects
100
Pr
A.
p=0.001
Stephenson et al BMC Med Ed 2014
Next Level of Clinical Problem
•
In the ICU we round as an Interprofessional
team (RN, MD, Pharmacist, RT)
•
Effective clinical decision making on rounds is
dependent upon
 Everyone accurately retrieving and reporting
data
 Everyone effectively using the EHR
Best Practice for ICU Rounds
•
Interprofessional Rounds, including RN, pharmacy,
and RT
•
Multiple studies document improved cost, improved
morbidity and patient satisfaction with
interprofessional rounds
•
Multiple barriers, including information retrieval and
EHR
 Both increase time and decrease communication
•
Little data in controlled settings to determine
whether improved error recognition by the group
 Swiss cheese or Cheese cloth
EHRs Differentially Impact RN and MD
Workflow
•
RNs like EHRs more often than MDs
•
EHR has more dramatic affects on efficiency
for MDs (Poissant)
•
Only 46% of handoff items overlap in data
transmitted during handoff (Collins)
•
RNs unaware of abnormal vitals in 43% of ward
patients (Fuhrman 2012)
•
25% of goals stated in rounds are not present
in EHR (collins 2009)
Solution-ICU Round Simulation
•
Obtained funding from the AAMC/Donaghue
foundation to allow for entire Interprofessional team
to participate in simulation activities.
•
Engaged hospital Nursing, Pharmacy and Medical
leadership to facilitating testing of all groups.
•
Have now tested all of ICU RNs and Pharmacists
on same case as MD.
•
Beginning full ICU rounds simulation this winter.
•
Project is now an Incubator Project for National
Center for Inteprofessional Education and Practice
 Allowed leveraging of resources from OHSU IPE
committee including nursing and pharmacy
Creation of High-Fidelity EHR Simulation
for all members of IP Team.
•
Engaged RN and pharmacy leaders to help in
scenario and case design
•
Initial simulation cases modified to ensure
contain all relevant information for all
professions (almost an extra 400 data pts/day
for RNs)
•
Needed to frame scenario for workflow
•
Pharmacists review chart during mock
presentation
•
RNs get a mock signout from another RN
Proclivity for Different Professions in
Identifying Safety Issues
Fluid Balance
TV
Recurrent Sepsis
100
90
80
70
Vanc trough
Vanco Dose
60
50
40
30
Plat
Zosyn Dose
20
10
0
Pharm
Housetsaff
RN
Daily Awakening
Fever
maas
BP/HR
D5
Glucose
Insulin
Differential Patterns in EHR Utilization
Amongst Professional Groups
Total of 135 Different Screens Used
Overlap in Screen Utilization
Housetaff
3
1
3
3
Pharmacist
4
0
RN
6
What Are Differences in Workflow?
1
135
100
2
90
128
3
80
70
113
5
60
50
40
111
6
30
20
10
110
Pharmacist
9
0
Housestaff
RN
85
10
82
14
36
17
23
19
20
Next Steps
• Leveraging these data for redesign of ICU
rounds
• Focusing on data veracity and patient safety
• OHSU created an ICU Change
Management group focused on
standardization of EHR utilization and
redesign.
• Allows dissemination across all ICUs
• RO1 submitted to AHRQ.
Our Team Now
Division of Pulmonary Critical Care
• Jeffrey A. Gold, PCCM/CCM Program Director
Department of Medical Informatics
• Vishnu Mohan, Bill Hersh
School of Medicine
• Gretchen Scholl
School of Nursing
• Judith Baggs
School of Pharmacy
• Dave Bearden
OHSU Hospital
• Jesse Bierman (Pharmacy), Ashley Mulanax (ICU RN), Adrienne
McDougal (ICU RN)
• OHSU ICU Change Management Group