Hospitals and Health Systems: Nurses and Physicians in the Implementation of the EMR at NYC Health & Hospitals Corporation Marie Ankner, RN, MS, CNAA, HHC Abha Agrawal, MD, Kings County Hospital/HHC Louis Capponi, MD, HHC Glenn Martin, MD, Queens Health Network/HHC Nadia Sultana, MBA, RN, BC, HHC HHC Mission Statement To extend equally to all New Yorkers, regardless of their ability to pay, comprehensive health services of the highest quality in an atmosphere of human care, dignity and respect; To promote and protect, as both innovator and advocate, the health, welfare and safety of the people of the City of New York; To join with other health workers and with communities in a partnership which will enable each of our institutions to promote and protect health in its fullest sense -- the total physical, mental and social wellbeing of the people we serve. 11 Hospitals 5 DTC’s 4 LTC’s 100 Clinics Home Care MetroPlus www.nyc.gov/HHC HHC •Revenues totaled approximately $4.3 billion. •Nearly one million ER visits. •Five million outpatient visits including 2 million primary care visits. •210,000 Hospital Discharges •The single largest provider of psychiatric services in New York City •23,000 births HHC Organization Chart Mayor Appoints Board of Directors Mayor Appoints Benjamin Chu, MD, MPH President (7) Networks Facilities SVP SVP SVP SVP SVP HHC EMR Timeline 1991 / 1997 2000 2002 2004 2005 HDS Pilot, Jacobi Medical Center Labs, CPOE, Documentation Installation throughout HHC Lab, Lab Consolidation CPOE LTC OPD Documentation/Coding Smart Cards DC Summaries Disease/Pt. Registries Medication Admin. Portals Vision for HHC Clinical Systems Leaders in Clinical Outcomes Reliably Support the Care Team Complete Information Availability Positive Fiscal Impact Critical Success Factors Increase the Speed of Innovation Complete Projects Facilitate System Consistency Enhance Clinical Information Access Registries Close the Data Warehouse Loop EMPI Successful 4.1/4.2 GUI implemented Critical Success Factors Continuous Engagement SVP IT Steering Committee NISA, PISA, DW Users Group IT Senior Staff Front Line Staff Provide Support, Resources & Leadership Improve Management of our Partners Using IT to Improve Patient Safety Abha Agrawal, MD Chief Medical Informatics Officer Associate Medical Director Kings County Hospital, Brooklyn, NY HIT Summit, Oct. 2004. Washington, DC Medication Errors One million serious medication errors every year. 20% are life-threatening. 7000 deaths annually. $2 billion nationwide in hospital costs alone. IT to Reduce Med. Errors Information Technology is a critical ingredient to reduce medication errors. Medication Process Physician Medication Order CPOE Pharmacy Dispensing Pharmacy Nurse Administration Review E- Med Admin CPOE with Decision Support Electronic prescribing – eliminates illegibility issue. Drug-allergy checking. Drug-drug interaction checking. Coming up - Drug-lab checking. Pharmacy review of meds – matched against an electronic profile. CPOE: Incorrect dose warning CPOE: Drug-drug interaction warning Electronic Medication Administration Wireless network and mobile carts on wards Real-time data entry Decision support e.g. delayed med admin, too high dose etc. Error reporting No errors during transcription from paper to MAR sheet Next steps: Bar-coded matching of patient and of medication Med Admin: Info. available to RN Med Admin: Pharmacy Review Warning Med Admin: Incorrect Time Warning Challenges in Implementation Complexity – interdisciplinary Clinician buy-in – MD, RN, Pharmacy Cost of the software, even more – the cost of the implementation Putting this in perspective 5-10% hospitals have adequate CPOE. <10% hospitals have Electronic Med. Admin. 2003 HIMSS Patient Safety Survey Issues that IT can address Top issue - Medication errors – 93% respondents. 14th annual HIMSS leadership survey Projected IT priorities Top issue – Reduce medical errors, promote pt safety – 59% respondents. It’s All About Results 12-month Evaluation of CPOE at Metropolitan Hospital Overall Med. Error rate down by 40% Incomplete orders down by 70% Incorrect orders down by 45% Illegible orders virtually eliminated Errors due to drug therapy problems - unchanged Igboechi et al. Hospital Pharmacy 2003 Nursing at New York City Health and Hospitals Corporation Scope and Informatics Marie Ankner, RN,MS,CNAA Assistant Vice President , Nursing Services New York City Nursing Services Each facility led by a Chief Nurse Executive 6600 RNs located throughout the five boroughs Nursing teams include ancillary personnel Interdisciplinary approach to patient care Unionized environment NYSNA, 1199, DC 37 Nursing Presence: 7 Networks 11 Acute Care Facilities 4 Long Term Care Facilities Diagnostic and Treatment Centers Ambulatory Care Sites Home Care Telemedicine MetroPlus Child Health Clinics In the beginning … RFP was developed and reviewed by an interdisciplinary team representing all facilities (90’s) Pilot developed at Jacobi Medical Center Initiative led by nursing and fostered interdisciplinary screen building Individualized Network /Facility expansion Nursing Climate National Nursing Shortage Average age of the RN in NYS is 48 yrs. Knowledgeable, aging workforce Workplace Drivers Increased patient complexity Decreased length of stay NYS regulatory requirements Focus on access, health promotion and prevention HHC Environment HHC RNs average age 48 yrs - 60 % direct care providers have > 10 yrs of service Nursing and the Electronic Record - variation in templates and terminology Initiation of the NISA committee Identification of Nursing Informatics Educational Needs Nursing Conference incorporated Nursing Informatics Pre hire assessment of computer skills NISA Goals Identification and adoption of Best Nursing Practices Collaboration of knowledge, expertise Work smarter not necessarily harder Safeguard patient care Assure professional practice Support Nursing and IT Maximize IT utilization to support patient care Driving Force is Patient Care Cost effective, quality, safe patient care Provide IT support for all health care providers, including nursing Computerize Nursing Process Literature reports that Nursing Documentation Utilize13-28 % RN time Achievements Online electronic medical records Pharmacy, lab and radiology Medication administration pilots Patient education Health Promotion Immunization screens Home Care telemedicine program Paperless NICU at Jacobi Medical Center Smart Cards The Nursing and Technology Link Nadia Sultana MBA RN,BC Senior Director, Clinical Information Systems NYC Health & Hospital’s Corporation October 23,2004 Historically User Groups developed data collection screens separately to meet their immediate needs: - Physician Documentation screens Physician Order Entry Nursing Assessments and Flow sheets Data collection screens lack standardization …impacting Data Warehouse initiative and ability to implement timely changes to CPR Action Plan Formation of … NISA = Nursing Information System Advisory Group …to promote dialogue, share best practices and foster Nursing Informatic education NISA Framework Network Nursing Service Representation Regular Monthly meetings Co-chaired by Corporate Nursing and IT Specific Agenda Initiation of an Issues List with Follow-up Guest Speakers Current Concepts in discussion… Development of standardized data collection screens with data element identification Establishment of Change Control Procedures Identification of Educational Needs Planning next modules incorporating “best practice” Standardization First attempt - Development of the VISTA Desktop Nursing Standard Outcome – some variation continued post implementation …emphasized the need for change control process…and need to continue to Standardize CONEY • Medium Issue Redundant icon function CONEY • Recommendation – Remove icon • High Issue - Block functions should appear as tabs. Substantial deviation from NISA standards. • Response – Rebuilding new desktop by April 18th • Recommendation – Align desktop with NISA standards. •Response – Rebuilding new desktop for April 18th. •Status –verify with Misys analyst if this issue will be fixed on new desktop •Next Steps – Re-audit desktops when desktop build is complete. Non-Compliance IP Nursing Issues • Status - verify with Misys analyst if this issue will be fixed on new desktop • Next Steps - Re-audit desktops when desktop build is complete. WOODHULL • Medium Issue – Duplicate review queue functionality • Recommendation – Remove desktop shortcut • Status – IT rep will not sign off change control form or make changes until audit has been reviewed with NISA rep. • Next Steps – Review audit results with NISA Rep and IT. Non-Compliance IP Nursing Issues Change Control Procedures …Experience with VISTA Desktop Standardization and Phase I Development of Data Warehouse Reports highlighted need for Change Control Procedures to Decrease variation of key data elements and terminology Change Control Process -CPR /DATA WAREHOUSE Education efforts Development of Survey to assess needs Standardized CPR Modules Training and issue CEUs Perform “Gap Analysis” – focus on Nursing Documentation and CPR usage to determine “best practice” Planning next modules incorporating “best practice”… Medication Administration Expansion Interdisciplinary Documentation Clinical Pathways SMART CARDS Glenn Martin, MD Director, Medical Informatics Queens Health Network Now that we have an EHR how do we use the data it generates? Shift focus from process to outcomes Create clinical data repository and management registries Convert data into useful information Use data to segment patient populations according to condition and acuity Draw on clinical repository to measure indicators and track improvement in patient health outcomes Report writer sits on QHN Intranet and provides user-friendly query access: • Provides flexible parameters for key indicators • Output can be saved for retrospective review • Can sort data to facilitate patient segmentation • Includes patient telephone numbers and primary care provider name Diabetes Diabetes And information needs to be coordinated and flow seamlessly to community providers who serve our patients outside the hospital Community providers can forward consultation requests and receive reports on-line quickly confidentially How do we plan to ensure that patients drive our services and make decisions about where to get their care? Smart cards empower patients and connect providers across communities and health systems Effectively make patients the owner of their information Provide patients the opportunity to carry their medical information at all times Offers patient a vehicle for communicating current information to their provider of choice Health Connection Card Functions as Patient ID Includes 64K chip Patient summary updated at each encounter with: Patient information Emergency contact Problem List and Allergies Active Medications Complete, relevant lab results 6,000 patients own the Health Connection Card Patients Name