Stage 6 and Beyond
St. Michael’s Hospital
Michael Freeman MD
Medical Director Heart and Vascular Program
Director of Medical Informatics
Director of Nuclear Cardiology
St. Michael’s Hospital
Associate Professor of Medicine
University of Toronto
Stage 6 and Beyond
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Where we have travelled
Structure
Case study of CPOE
What follows after Stage 6
St. Michael’s Hospital: Toronto’s Urban Angel
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A leading academic health sciences centre, fully
affiliated with the University of Toronto
Recognized as a provider of compassionate care
Provide primary and secondary care to the region’s
largest homeless and inner city health population
Major tertiary referral and regional trauma centre
Strong focus on research and education
Innovations 2011 – Clinical Solutions 3 - Session # 5 – IT Adoption Hat Trick
Phase 1 Master Plan Limitations
St. Michael’s: An Academic Health Sciences Centre
Li Ka Shing Knowledge Institute
Li Ka Shing International
Healthcare Education
Centre
Keenan Research
Centre
Education
Research
Knowledge
Translation
Bridge to
St. Michael’s
Hospital
Patient
Care
Information Management Vision
• Recognizing:
• Health care is knowledge based
• Extends beyond the boundaries of the hospital
• Information Systems:
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Patient-focused
Enabler for quality and safety
Support business processes through information access and flow
Enable process improvement through inquiry and change
Enable practice excellence
Delivering the right information, right person, right time
A History Lesson
• 2001- SMH has new IM strategic plan that sets the stage
for an integrated clinical system
• Perceived to be behind peers
• Clinical results viewing available; no other legacy
applications except in diagnostic departments (Lab, DI,
Cardiology)
• Siemens contract signed 2002
Project Gemini
• Twinning of transformation
and technology
• Clinical transformation as the
underpinning to the project
• Harness power of workflow
technology to enable practice
and process change
Project Gemini Goals
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Improve access to health services
Improve clinical outcomes for patients
Increase patient safety; reduce risk of error
Improve coordination of care
Increase patient satisfaction
Improve the quality of worklife
Reduce overall delivery costs
And the best laid plans….
• SARS
• Immature product
• Expansive scope and short timeline
• Unprepared clinicians
How will we achieve adoption?
1.Build and Demonstrate Value
2.Build Partnerships to engage clinical leadership
3.Innovation- leverage technology and tools with an
emphasis on workflow enabled process
Articulate a Shared Vision
• The vision for clinical transformation at SMH is about much
more than simply automating our existing paper systems.
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• It is about carefully designing a patient centered, bestpractice framework for implementation.
– That is based on a model of interprofessional practice
– Includes the use of evidence based care processes and
decision-support systems to achieve the best outcomes
for our patients.
1. Value
• Understand the needs of clinicians
• Clinical user group
• Push the envelope with the design teams
• Participation in validation sessions
• Engagement with the vendor
• Define benefits and share with clinicians
2. Delivery
• Provide stability
• Act, respond
• Thoughtful, detailed planning for implementations
• Understand, anticipate and redesign the workflow
• Active and visible issues management
3. Innovation
• Be creative
• NO is not in our
vocabulary ..
Enabling Infrastructure for Adoption
• People / Processes
– Interdisciplinary culture / model
– Workflow redesign expertise
• Technology
– Design of technological tools
– Access devices to bring technology to the point of care
– Software - user centric design with clinical
decision support
Results of Demonstrating Value
CPOE Project Scope
• Electronic ordering of all
diagnostics, medications,
treatments and care orders
for Inpatient units
• Electronic MAR with bar code
closed loop administration
Learning's From our Launching of CPOE
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Governance and organizational models are required to support
complex clinical system implementations
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Strategies are required for a phased-in implementation approach for
CPOE/eMAR and the successful transformation of a patient
centered care delivery model
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Enabling roles, processes and evaluation necessary to successfully
promote clinician adoption of CPOE/eMAR
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CPOE/eMAR & MAK Scope
All patient care orders,
non-medication orders
and medication orders
are placed by an MD or
resident
To dispense
medications,
Pharmacists
validate all
electronic
medication
orders
All providers
can view
medication
history
Nurses chart all
medications
administration
electronically
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CPOE/eMAR Committee & Team Structure - Planning
eHealth
Executive
Committee
Operations
Committee
CPOE/eMAR
Advisory
Committee
Content
Development
Subcommittee
eMAR
Subcommittee
Physician Leads
Design/Build
Subcommittee
Change
Management /
Education
Subcommittee
Design/Build Team
Education/Support
Team
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Moving from Planning to Implementation
• Planning structure created ‘Silos’ that challenged the teams working
relationships
• Implementation required greater co-operation and ownership between
these ‘Silos’
• Performed an analysis of project structure and identified the needs for
implementation
Conclusion:
The CPOE/eMAR Project Structure needed to CHANGE
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CPOE/eMAR Project Team Structure - Implementation
eHealth Executive
Workstreams
Project Structure & Committees
CPOE Advisory
CPOE Project Sponsor
Physician
Leads
Operations Committee
CIO & CMO
CPOE Leadership Team
Content
SubCommitee
Medical Informatics
Clinical Informatics
Project Management
Medication
Management
Professional Practice
Pharmacy
Information Technology
Key Partners
CPOE Project Team
Project Management
Change Management
Clinical Informatics
Content
Development
Soarian
Development
Order Sets
Design
Medications
Build
Non-medication
Test & UAT
ICT
Clinicians including RNs, Pharmacists and Others Team
Rx
Team
Clinical
Unit
Team
Communication
Education &
Support
Unit
Engagement
Workflow & Practice
Metrics &
Evaluation
Technical
Devices
Change Management
Interfaces
Impl. Scoping
Release Management
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Our Implementation Approach – How?
Demonstration Unit
12 bed Medical
Unit
Go-Live Day 1
& MAK
LiveSoarian
CPOE
Validation Unit 1
30 bed Medical
Unit
Go-Live Day 1
Validation Unit 2
36 bed Surgical
Unit
Go-Live Day 1
MAK
Go-Live Day 14
Soarian
CPOE
Soarian
CPOE
Go-Live Day 10
MAK
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Implications of Different Day 1 Go-Lives
Big Bang – CPOE & MAK on Day 1
• Initial chaos on the unit; complete transfer from paper to electronic
environment
• Many different users to support (i.e. MDs, RNs, HDs, etc); fewer support
team members to users
• Move directly from current state workflows into future state workflows
Phased Approach – CPOE or MAK on Day 1
• Focus the changes on one key process (order entry/management vs.
medication administration)
• Support team members can focus “at the elbow” training with key users
of the process
• Users must adapt to interim processes before fully transitioning into
future state processes
• Significant workload impact on pharmacy to bring MAK live first preCPOE.
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What was included with each implementation?
Scoping &
Engagement
Design,
Build &
Testing
Education
& Training
Post Live
Support
Key Activities:
• On unit observations and interviews with key
stakeholders
• Understanding patient/information flow and
unique workflows (i.e. self medication
program)
• 7 week engagement sessions focusing on
processes, changes, Soarian/MAK
functionality, considerations for clinical team,
etc.
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What was included with each implementation?
Scoping &
Engagement
Design,
Build &
Testing
Education
& Training
Post Live
Support
Key Activities:
• Collection of unique content (i.e. care
orders, predefined medications, etc.)
• Analysis of content and order sets
• Design and development of new
electronic orders and orders sets
• Testing of new electronic content
• Migration from DEV to TRAIN to PROD
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What was included with each implementation?
Scoping &
Engagement
Design,
Build &
Testing
Education
& Training
Post Live
Support
Key Activities:
• Documentation of unique workflows
• 7.5 hour RN training session (in
classroom)
• 2 hour MD/resident training (in
classroom)
• 2 hour HD training (in classroom)
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What was included with each implementation?
Scoping &
Engagement
Design,
Build &
Testing
Education
& Training
Post Live
Support
Key Activities:
• 24/7 on unit support for 4 to 5 weeks
• Command centre to log, triage and
resolve issues
• Daily status meeting with Project
Leadership, Team, Unit leaderships
and end users
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Driving Clinical Adoption – Physician Perspective
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Ensuring future state process fit with physician workflow
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Clear and consistent communication regarding the benefits of the
changes
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Engaging physicians to develop orders sets which incorporate
evidence-based, best practice guidelines
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Providing flexibility for training sessions
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Leveraging Physician Leads role in key clinical areas as champions
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Enabling multiple Soarian access points – remotely from home and
through various devices (iPhones, blackberries, computers on wheels,
iPads, etc.)
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Leveraging existing structures for communication, input into key
decision points and project updates (i.e. Medical Advisory Committee)
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Driving Clinical Adoption – Staff/Unit Perspective
• Understanding a clinical unit’s culture, practices and flow to define an
implementation scope that most appropriate for the unit
• Ensuring transitions function as smoothly as possible (i.e. OR transfer
workflow, ED admissions, etc.)
• Focus on creating shared ownership of the project between the project
team, stakeholders and clinical unit
• Tackling less than desirable practices and processes;
• Frequency of telephone and verbal orders
• Using physician order sheets as a communication tool
• Minimizing incomplete orders
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Driving Clinical Adoption – Challenging Processes
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Consult Orders
• Suggest orders from a consulting MD that require review and
acceptance from the MRP
Transfers of Care
• From service to service or one level of care to another
• Increased complexity when transferring from paper based area to
electronic unit
Supporting SMH’s educational mandate
• Organization trains over 300 nursing students, 150 medical students
and 400 residents
• Currently, no safe electronic solution is available to support medical
student workflows
Enhancement Requests/Content Change Requests
Clear downtime procedures
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Where we are today…..all med/surg beds are live!
• All staff physicians,nurse
practitioner’s and residents
enter orders electronically
• 215 physicians, 650 residents
have been trained
–>2,500,000 medication,
investigations, diagnostics and
care orders have been placed
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Our 360 CPOE Trained RNs received 3694 Medication Alerts
Right Drug = Drug Type + Dose + Route + Frequency
Each alert (incorrect drug, dose, or route) helps avoid a potential medication error
* Reporting period: March 9, 2010 to March 31, 2011, Source: Siemens MAK
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Ordering efficiencies are improving lab test utilization
Comparison of Biochemistry Lab Test Volumes – Pre & Post CPOE
Post-CPOE
# of Biochemistry Tests
Pre-CPOE
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• The real value has been on the integration of the process
analysis methodology with the implementation. We have
uncovered many “hidden gems” in the implementation
Unanticipated Workflow Changes
• Self administration policy on CF unit. Partnership of RN and
patient
• Eliminated “take own meds”
• Standardized transfer order sets from critical care to floor
• Nurse patient assignments changed to geographic
• MDs have changed their rounding practices
• And we have over 95% orders entered directly by MDs
Implications
• Engaging clinicians is about driving value. Workflow can be
a key asset in demonstrating early wins.
• Workflow analysis and technology, combined with advanced
clinical information systems can be a
mechanism to:
• Deliver information to the clinician desktop
• Assist organizations to transform practice
• Facilitate knowledge translation from bench to bedside
The Result – SMH is now a leader in EMR deployment
• Over 30% of Ontario hospitals are between Stage 0 and 2
• Only TWO Ontario Hospitals have reached Stage 6.
What’s Next?
• Enabling the Emergency Department and Critical Care
• Adoption Sustainability Strategy & Optimization
• Implementation of Embedded Analytics (business analytics tool)
Road to Stage 7
Challenges to Attaining HIMSS 7
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Physician Documentation
Interoperability
Changing technologies
Financial Pressures
People
Competing organizational priorities
Questions
Michael Freeman, MD
Director, Medical Informatics
St. Michael‘s Hospital
freemanm@smh.ca
Purvi Desai, MBA
Senior Clinical Project Manager
St. Michael‘s Hospital
desaip@smh.ca
Anne Trafford, BSc. RN
Vice President, Information Management,
St. Michael’s Hospital
trafforda@smh.ca
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