2 nd annual regional nursing informatics conference: promoting patient safety excellence through...

22ndnd Annual Regional Nursing Informatics Annual Regional Nursing Informatics ConferenceConference: : Promoting Patient Safety Promoting Patient Safety Excellence Through TechnologyExcellence Through Technology

Supporting Quality, Reducing Clinician BurdenSupporting Quality, Reducing Clinician Burden

ObjectivesObjectives

• State 3 examples of EMR activities that reduce State 3 examples of EMR activities that reduce clinical burdenclinical burden

• Describe the workflows for 2 activitiesDescribe the workflows for 2 activities

• Identify the limitations of prior efforts of quality Identify the limitations of prior efforts of quality compliance.compliance.

• List 3 considerations that must be addressed in List 3 considerations that must be addressed in order to reduce clinical burden of quality alerts order to reduce clinical burden of quality alerts

• Describe actions taken to ensure successDescribe actions taken to ensure success

• State those successesState those successes

OutlineOutline

1.1. BackgroundBackground

2.2. NomenclatureNomenclature

3.3. Clinical BurdenClinical Burden

4.4. WorkflowsWorkflows

5.5. Real Live ExamplesReal Live Examples1.1. ImplementationImplementation2.2. The learning curveThe learning curve3.3. MetricsMetrics

6.6. QuestionsQuestions

BackgroundBackground

Evanston Northwestern Healthcare Evanston Northwestern Healthcare – ENH Hospitals and ClinicsENH Hospitals and Clinics

> Evanston HospitalEvanston Hospital> Glenbrook HospitalGlenbrook Hospital> Highland Park HospitalHighland Park Hospital

– ENH Medical GroupENH Medical Group– ENH Home ServicesENH Home Services– ENH Research InstituteENH Research Institute

BackgroundBackground

• CharacteristicsCharacteristics– Integrated delivery networkIntegrated delivery network

> physician officephysician office> hospital inpatient carehospital inpatient care> hospital outpatient carehospital outpatient care> home carehome care

– More than 50 sites of ambulatory careMore than 50 sites of ambulatory care

• Major teaching hospitals for Northwestern University with Major teaching hospitals for Northwestern University with 720 beds and 40,000 annual admissions 720 beds and 40,000 annual admissions

• Ranked #1 in the State of Illinois and #10 in the United Ranked #1 in the State of Illinois and #10 in the United States among multi-specialty independent research States among multi-specialty independent research hospitals with total external grant awards exceed $115 hospitals with total external grant awards exceed $115 million.million.

• Fully integrated EMR across the NetworkFully integrated EMR across the Network

Background - EMR ProjectBackground - EMR Project

• 2001 – Decision & Contract Signing2001 – Decision & Contract Signing

• 2002 – Plan / Build / Test / Training2002 – Plan / Build / Test / Training

• 2003 – Training / Install Epic2003 – Training / Install Epic

• 2004 – Make The EMR Work for Us2004 – Make The EMR Work for Us

• 2005 – Make The EMR Work for 2005 – Make The EMR Work for YouYou

PatientPatientDataData

PatientPatientDataData

ENH’s Portfolio of EMR ProductsENH’s Portfolio of EMR Products

ONCOLOGYONCOLOGY

ICU SYNOPSISICU SYNOPSIS

HOVHOV

My ChartMy Chart

2004 Davies Award for Excellence –2004 Davies Award for Excellence –Organizational AwardOrganizational Award

NomenclatureNomenclature

• CUICUI

• BPABPA

• Programming PointsProgramming Points

• Order ValidationOrder Validation

• NavigatorsNavigators

• Activity TabsActivity Tabs

My Soapbox!My Soapbox!

• Challenges to health care providers to create Challenges to health care providers to create ever-safer patient care environments ever-safer patient care environments

• Clinical Burden is immenseClinical Burden is immense

• Technical Burden is immense Technical Burden is immense

• Regulatory Burden is immenseRegulatory Burden is immense

In Essence We Need to Make The Systems Work In Essence We Need to Make The Systems Work for Usfor Us!!

Current National Campaign To Save 5 Million Current National Campaign To Save 5 Million From Harm (IHI, 2006)From Harm (IHI, 2006)

Reducing the Clinical BurdenReducing the Clinical Burden

• Clinically meaningful alerts Clinically meaningful alerts

• Making it obviousMaking it obvious

• Data Capture as a result of normal Data Capture as a result of normal workflowworkflow

• Reduction of the memory loadReduction of the memory load

AlertsAlerts

Alerts are designed to: Alerts are designed to:

• PreventPrevent

• CommunicateCommunicate

• EnforceEnforce

They do this by They do this by interruptinginterrupting the workflow-The the workflow-The trick is to do it in the most effective and trick is to do it in the most effective and

informative way!informative way!

Considerations for Reducing the Considerations for Reducing the Burden of AlertsBurden of Alerts

Use a Selective Approach:Use a Selective Approach:

• Targeted audienceTargeted audience

• Present the user with the information and the Present the user with the information and the tools to manage the alerttools to manage the alert

• Identify patient populations using data entered Identify patient populations using data entered through normal clinical workflowsthrough normal clinical workflows

• Avoid conditional alert workflowsAvoid conditional alert workflows

• Education and CommunicationEducation and Communication

Workflow – Text and CUIsWorkflow – Text and CUIs

New note composed

Smart list item selected

Item have CUI set

Set CUI

CUI filed for later retrieval

Note composition completed

No

Yes

Note accepted

Workflow – Workflow – Order Validation Order Validation Data/Order

entered and filed/signed

Run validation programming point

ResultValidation Data

Row

File Data/order signed

Trigger BPA message

False

TrueYes

No

Yes Item set

Clock? Set clockYes

No

No

Workflow – Identifying EligibilityWorkflow – Identifying Eligibility

Patient over 65?pneumonvax

filed

Patient allergic to vaccines or

products

Patient is potentially eligible

for vaccine

Does patient have active

ICD 9 on problem list

Bone Marrow Transplant =

Yes

Fire AlertAnd add to system list

Reference Patient INI

Item = “Droplet” is filed?

Quit

Reference Pneumonia

Grouper for ICD 9 Codes to search

for

Reference Flowsheet row Category list

Reference Immunizations INI

Date given with in T-5yrs

Reference Allergies INI

Reference Pneumonia

Allergen Grouper

Reference Pneumonia

History Grouper

Reference orders INI

ERX # ordered

Reference orders released between

Admit date and now

Procedure date within T-1 yr

CUI filed

Reference CUI INI

Data File in flowsheet activity

Reference Patient INI

Reference Problem List

Status = active, completed or

D/C

Reference Flowsheet row Category list

Data filed in row

Quit Quit

YesNo

Yes

No

Yes

Yes

Yes

No

No

Yes

Yes

NoYes

No

YesNo

No

Quit

Yes

Set clock I

Set CUI

No

Yes

No

No

The Real Thing!The Real Thing!

MRSAMRSA

MRSA - FactsMRSA - Facts

• 2001 through 20032001 through 2003– Several MRSA outbreaks (USA 300) in neonatal ICU, Several MRSA outbreaks (USA 300) in neonatal ICU,

orthopedic ward raising concernorthopedic ward raising concern

• 20042004– Screening of at risk populations introducedScreening of at risk populations introduced– Point prevalence survey at ENH found:Point prevalence survey at ENH found:

> MRSA prevalence = 8.5%!MRSA prevalence = 8.5%!> 2/3 not previously known2/3 not previously known

• Baseline: ~100 hospital-acquired MRSA Baseline: ~100 hospital-acquired MRSA infections per yearinfections per year

Local Cost of MRSA HAILocal Cost of MRSA HAI

Mean Mean Total CostTotal Cost

95% CI95% CI

No MRSA HAI No MRSA HAI ((nn=23,144) =23,144)

$31,321$31,321 ($24,178, ($24,178, $38,478)$38,478)

MRSA HAIMRSA HAI

((nn=178)=178)

$71,148$71,148 ($62,727, ($62,727, $79,569)$79,569)

ExcessExcess $39,820$39,820 ($35,270, ($35,270, $44,371)$44,371)

Ari Robicsek, MD- Hospital EpidemiologistEvanston Northwestern Healthcare

• Prevention of ~50 hospital-acquired MRSA Prevention of ~50 hospital-acquired MRSA infections per year will balance the infections per year will balance the 1,000,000 excess cost of MRSA 1,000,000 excess cost of MRSA surveillancesurveillance

MRSA-Justification MRSA-Justification

Universal Surveillance gets Administrative Blessing

MRSA- ImplementationMRSA- Implementation

• Initiated August 1, 2005Initiated August 1, 2005

• Maximize compliance : One workflow with Maximize compliance : One workflow with minimal decision points minimal decision points

• Patient Safety: Reduce exposure to MRSA by Patient Safety: Reduce exposure to MRSA by early detection of colonized patientsearly detection of colonized patients

• Reduce Clinician Burden: Use available data to Reduce Clinician Burden: Use available data to identify patients and communication informationidentify patients and communication information

• Collect Data: Minimal non-workflow data Collect Data: Minimal non-workflow data collection. Reports fields, frequency and collection. Reports fields, frequency and feedback mechanisms identifiedfeedback mechanisms identified

• Improve Quality: Reduce number of MRAS HAIsImprove Quality: Reduce number of MRAS HAIs

Patient Admitted overnight

Unit called and RN informed

Patient Education>13yrs

No action

ConsentOpen order set and sign order

Lab Workflow

Colonized

Infection Control receives report

Patient into isolation and cart

ordered

Infection Control RN enters problem

on problem list

Orange alert banner fires in all

key patient summary reports

Physician orders MRSA

Decontamination kit

Central Lines or fever

Alert fires on each flowsheet filing for RN and PCT only

No action

Patient Discharged with remainder of treatment

Refused

Agreed

No

Yes

No

Yes

Flowsheet Documentation

No

Yes

User reviews Order review for

order statusOrder status

Complete Documentation

Order sent

Order entered but not sent

Obtain nasal swab

No order

Maximize Maximize compliance : compliance : One workflow One workflow with minimal with minimal

decision pointsdecision points

Patient Safety: Patient Safety: Reduce exposure to Reduce exposure to

MRSA by early MRSA by early detection of colonized detection of colonized

patientspatients

Reduce Clinician Reduce Clinician Burden: Use available Burden: Use available data to identify patients data to identify patients

and communication and communication informationinformation

The MetricsThe Metrics

• Of 31,835 admissions tested, 6.4% were Of 31,835 admissions tested, 6.4% were positive on admissionpositive on admission– Accounting for false positives, true positive Accounting for false positives, true positive

percentage was percentage was 5.0%5.0%

Surveillance Compliance

0

10

20

30

40

50

60

70

80

90

100

Augus

t

Septe

mbe

r

Octobe

r

Novem

ber

Decem

ber

Janu

ary

Febru

ary

Mar

chApr

ilM

ayJu

ne July

August 2005 through July 2006

Pe

rce

nt

sc

ree

ne

d o

n a

dm

iss

ion

ICULabor and DeliveryMed-SurgPediatricsPsychiatryTotal

MRSA prevalence by DRG

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Vag D

elive

ry

GI Diso

rder

s w/C

C

Pneum

onia

Age>1

7

CHF and

Sho

ck

C-sec

tion

Joint

Rep

lacem

ent

Septic

emia

Age>1

7

Psych

oses

CVA

Renal

Failur

e

Med

ical B

ack P

robs

GI Blee

d with

CC

UTI

GI Dise

ase

Met

aboli

c Diso

rder

s

COPD

Vag D

elive

ry w

/CC

Per

cen

t p

osi

tive

on

ad

mis

sio

n

n n = 8,586= 8,586

MRSA:Bloodstream Infections

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14

Pre

va

len

ce

De

ns

ity

P , 0.001


0.0

0.5

1.0

1.5

2.0

2.5

3.0

Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14

Pre

va

len

ce

De

ns

ity

P , 0.001

ICU surveillance


0.0

0.5

1.0

1.5

2.0

2.5

3.0

Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14

Pre

va

len

ce

De

ns

ity

P , 0.001

ICU surveillance Universal surveillance


0.0

0.5

1.0

1.5

2.0

2.5

3.0

Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14

Pre

va

len

ce

De

ns

ity


p < 0.01

MRSA:Blood, Respiratory, Urine and Surgical Site Infections

0

2

4

6

8

10

12

Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14

Pre

va

len

ce

De

ns

ity


p < 0.01

Prevalence DensityRatio: 0.45

MRSA Bacteremia LOS>2

0

1

2

3

4

5

6

7

8

9

10

2003/04 2004/05 2005/06

August through July

BS

I/10,

000

Ad

mis

sio

ns

10 Comparator Organizations

ENH

*P<0.05

*P=NS

(N = 831,757 patients)

SuccessSuccess

Annual Annual average average pre-USpre-US

Annual Annual average average post-USpost-US

∆∆

BloodstreamBloodstream 1616 88 -8-8

UrinaryUrinary 1212 44 -8-8

Surgical SiteSurgical Site 1717 88 -9-9

RespiratoryRespiratory 3737 1111 -26-26

TotalTotal 8282 3131 -51-51

Intra-admission MRSA infectionsIntra-admission MRSA infections

Lessons Learned MRSALessons Learned MRSA

• Specialty Departments need extra attentionSpecialty Departments need extra attention

• Preference List IssuesPreference List Issues

• Alert took user to order entry, but should Alert took user to order entry, but should have been order reviewhave been order review

• Verbal communication constraintsVerbal communication constraints


PneumovaxPneumovax

VaccinationVaccination FactsFacts

• Pneumococcal Vaccination is 75% effective in preventing Pneumococcal Vaccination is 75% effective in preventing pneumococcal bacteremia and meningitis which carries a pneumococcal bacteremia and meningitis which carries a high mortality for persons 65 years of age and older. high mortality for persons 65 years of age and older.

• In the United States, only 56% of adults over the age of 65 In the United States, only 56% of adults over the age of 65 years received the pneumococcal vaccine. years received the pneumococcal vaccine.

• Only 38% of nursing home residents received the Only 38% of nursing home residents received the pneumococcal vaccine.pneumococcal vaccine.

• Only 28% of eligible patients receiving PneumovaxOnly 28% of eligible patients receiving Pneumovax

ENH - % of Patients Meeting the Pneumococcal MeasureENH - % of Patients Meeting the Pneumococcal MeasureJan. 2005 – Dec. 2005Jan. 2005 – Dec. 2005

0

20

40

60

80

100

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

2005

(%)

Mee

ting P

neu

moco

ccal

Vacc

inati

on M

easu

re

Achievable Benchmark of Care = 95.0%

Pneumovax-JustificationPneumovax-Justification

• Failing the measure despite current effortsFailing the measure despite current efforts– Order setsOrder sets– Education of Physicians and NursingEducation of Physicians and Nursing– Concurrent TrackingConcurrent Tracking– Ordered and Discharged withoutOrdered and Discharged without

Pneumovax - ImplementationPneumovax - Implementation

• Initiated July 5, 2006Initiated July 5, 2006

• Maximize compliance : One workflow with minimal Maximize compliance : One workflow with minimal decision points decision points

• Patient Safety: Protect against future pneumonia episodesPatient Safety: Protect against future pneumonia episodes

• Reduce Clinician Burden: System identifies patients and Reduce Clinician Burden: System identifies patients and presents support tools for the RN to adhere to protocol. presents support tools for the RN to adhere to protocol. Workflow documentation switches off alert.Workflow documentation switches off alert.

• Collect Data: Easy concurrent reporting tools for managers Collect Data: Easy concurrent reporting tools for managers to track patientsto track patients

• Improve Quality: All eligible patients will receive Improve Quality: All eligible patients will receive PneumovaxPneumovax

Vaccine on MAR to be administered

T+3 at 9AM

Patient had pneumonvax

previously

Sign order as verbal order with “Per protocol” as

the reason

Patient allergic to vaccines

Patient eligible for vaccine

Document in MAR

Education and Consent

Complete goal on pneumonia care

plan

Document allergy if not already

noted in Allergy Activity

Document historical vaccine in immunizations

activity if neccessary

Yes No

Refused

Accept

YesYes

Complete goal on pneumonia care plan

Document in immunizations activity

2-20-06

Alert FiredClick on Hyperlink to go to Navigator

Review each section of the navigator with

patient

Consent

Vaccine due

Adjust date by 24hr in the future

Document refusal in flowsheet

Bone Marrow Transplant in

last yearNo No

Yes

Call Physician

Afebrile

Febrile

Maximize Maximize compliance : compliance : One workflow One workflow with minimal with minimal

decision decision pointspoints

Reduce Clinician Burden: Reduce Clinician Burden: System identifies patients and System identifies patients and presents support tools for the presents support tools for the

RN to adhere to protocol. RN to adhere to protocol. Workflow documentation Workflow documentation

switches off alert.switches off alert.

Collect Data: Easy concurrent reporting Collect Data: Easy concurrent reporting tools for managers to track patientstools for managers to track patients

MetricsMetricsCMS Core Measure Outcomes

Evanston Northwestern Healthcare - 1st Quarter FY 2007

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

HF-1

HF-2

HF-3

HF-4

AMI - 1

AMI - 2

AMI - 3

AMI - 4

AMI - 5

AMI - 6

AMI - 8a

PN - 1PN - 2PN - 3a

PN - 3b

PN - 4

PN - 5b

PN - 6

PN - 7

SCIP - 1

SCIP - 2

SCIP - 3

**SCIP - 4

**SCIP - 6

**SCIP - 7

Pneumovax – Lessons LearnedPneumovax – Lessons Learned

• Ordering delayOrdering delay– Missed vaccinesMissed vaccines

• Education missed cultural issuesEducation missed cultural issues

• Political issuesPolitical issues


D/C InstructionsD/C Instructions

D/C InstructionsD/C Instructions

• Workflow StreamlinedWorkflow Streamlined

• CUIsCUIs

• Visual TriggerVisual Trigger

• Automatic ComplianceAutomatic Compliance


Notes Capturing DataNotes Capturing Data

Quality Behind the ScenesQuality Behind the Scenes

• CUIs behind smart CUIs behind smart ListsLists

• Reporting from Reporting from notesnotes


DVT PreventionDVT Prevention

DVT-ImplementationDVT-Implementation

• Initiated August 28, 2004Initiated August 28, 2004– Risk Assessment is completed – Alert FiresRisk Assessment is completed – Alert Fires

• Revised May 4, 2005Revised May 4, 2005– Risk Assessment not completed – Alert firesRisk Assessment not completed – Alert fires

• Revised December 19, 2005Revised December 19, 2005– Programming in place to identify at risk patientsProgramming in place to identify at risk patients

Risk Assessment Completion Rates

20667 45 31 17 36 28

544

928

675 674545 525 526 567 547

477

169

2612 27552641

28362715 2747

25932171

19282046

2268

2102

23122214 2230 2267

2158

1046

0

250

500

750

1000

1250

1500

1750

2000

2250

2500

2750

3000

05/0506/0507/0508/0509/0510/0511/05 12/0501/0602/0603/0604/0605/0606/0607/0608/0609/0610/06

# P

atie

nts

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

# of I npatients with completed Risk Assessment. # of inpatients with no Risk Assessment Percentage with Risk Assessment

Anticoagulants Recieved

1194 11901142 1164 1146

1214

11461209

1369

12071268

12181284

1225 1190 12151157

484

1624 1632

1544

1703

15861569

1475

1506

1487

1514

1674

1429

1553

15151607 1599

1478

731

0

500

1000

1500

2000

2500

3000

3500

05/05 06/05 07/05 08/05 09/05 10/05 11/05 12/05 01/06 02/2006 03/2006 04/2006 05/2006 06/2006 07/2006 08/2006 09/2006 10/2006

# of I npatients received Anticoagulants # of I npatients did not received Anticoagulants

The FutureThe Future

New ProjectsNew Projects

Sepsis ProtocolSepsis ProtocolBPA Pop Up box

opens after data is filed in flowsheet

Data is filed in Flowsheet

Alert Programming runs

Alert triggeredPatient appears on Sepsis screening

system list

Message appears in BPA section of patient summary

reports

Clinician clicks on blue hyperlink in

BPA to open Sepsis Navigator

Selects new patient and opens

their chart

Goes to Sepsis Navigator

Reviews patient summary report and evaluates

patient condition

Positive screen?

Alert switched off by selecting

“Patient meets criteria” option in

flowsheet row

Alert programming does not run again for this patient for

this encounter

Documentation of review completed

Alert switched off selecting any option except “patient meets

criteria” in flowsheet row

Alert programming runs again X hours

after Alert was switched off

Yes

No

No

YesRapid Response

team Called

Initiates sepsis resuscitation order set Part I (ID# ?)

Specialty note “Sepsis” for BPA evaluation

Need to build smart phraseNeed to build flowsheet row

Questions?Questions?

Contact InformationContact Information

Katherine Reynolds, RNKatherine Reynolds, RN

Senior Director Medical Informatics - InpatientSenior Director Medical Informatics - Inpatient

Evanston Northwestern HealthcareEvanston Northwestern Healthcare

4901 Searle Parkway4901 Searle Parkway

Suite 220, PO Box 1006Suite 220, PO Box 1006

Skokie, IL 60076-8006Skokie, IL 60076-8006

Tel: (847) 982-3999Tel: (847) 982-3999

Fax: (847) 982-6986Fax: (847) 982-6986

Pager: (847) 479-0878Pager: (847) 479-0878

email: email: [email protected]@enh.org

mailto:[email protected]

2 nd annual regional nursing informatics conference: promoting patient safety excellence through...

Documents

emr work

integrated emr

immensetechnical burden

burden of alertsuse

clinical burdendescribe

vaccinedoes patient

patient safety excellence

examples of emr activities