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Maimonides Medical CenterMakes a Quantum Leap with Advanced

Computerized Patient Record Technology

Health Information Management Systems Society

San Diego Convention CenterFebruary 12, 2003

2

Maimonides Medical Center Makes a Quantum Leap with Advanced Computerized Patient Record Technology

Fredrick Cassera, RPh, MBADirector Pharmacy

Steven J. Davidson, MD, MBAChairman Emergency Medicine

Shoshana Haberman, MD, PhDDirector Perinatal Unit

Allan Strongwater, MDChairman Orthopaedic Surgery &

Musculoskeletal ServicesAnn C. Sullivan, MBA

Sr. VP/Chief Information Officer

3

CPR System PlanningThe Medical Center

Brooklyn

Staten Island

Ambulatory sites

Voluntary physician practices with office MACS

Hospitals:Coney Island Medical CenterLutheran Medical Center

Manhattan

Mt. Sinai School of Medicine

Note: Community physician offices toonumerous to indicate on map

36,861 Inpatients5.05 Length of Stay1.87 CMI253,316 Outpatients77,118 Emergency Visits

$564.5 Million Revenue4,612 Employees277 Employed Physicians401 Residents978 Community Physicians

Top 100 Cardiovascular Hospitals (Solucient)Top 100 Most Wired Hospitals (H&HN) 2000, 2001, 20021998 Computerworld Smithsonian Award - Medicine

4

CPR System Planning

Vision…

To improve the quality and effectiveness of patient care by providing real time access to comprehensive clinical information wherever and whenever needed.

5

CPR System PlanningStrategic Priorities

Clinical excellence & patient safetyHumane, patient focused, patient centered careStrengthen physician collaboration & effective communicationSupportive environment for physiciansFiscal viability. . .

6

CPR System Planning Leadership and Governance

CEO firmly committed to project & necessary organizational change

Leadership, financial, medical staffCommunicate process & project statusFinancial commitment includes all ongoing support

7

CPR System PlanningNeeds Assessment

“Stuck in key punch era”New York State’s deregulationStrategic priorities necessitatestate-of-the-art ITDepartmental-specific CPRs

8

CPR System PlanningSystem Acquisition

Inpatient CPR was purchased in 1992 deployed in 1996Patient safety and outcome initiatives required CPRs with knowledge-based decision supportTargeted an integrated single vendor CPR solution

9

CPR System PlanningSystem Acquisition (continued)

No supplier could deliverClinical Department’s diverse requirements were best addressed by CPRs from different vendorsModified “Best of Breed” approach with vendors who conformed with our technology standards

10

CPR System PlanningBusiness Case for CPR

Complexity and expense of implementationUser, workflow committees, task forces, HIS executive committee identify capital initiatives that meet hospital-wide, departmental and individual needsGained buy-in throughout organization

11

CPR System PlanningBusiness Case for CPR (continued)

Strategic priorities yielded investment of $43.909 millionContinuing annual request for $30 millionMetrics tie to business returnRequired technology supports strategic priorities

12

Capital Allocation and Prioritization

Systems (example)Ambulatory, Eclipsys enhancements, ED, document imaging, medication administration, etc.

User wantsClinical success factorsSystem prioritiesEconomic priorities

13

Project Risk ManagementTimeliness, Budget, Completion

Risk reduction strategiesImplementation credibilityResistance to workflow changesManaging vendor relationshipsLack of technology infrastructureUncertainty of success with CPOE with community physicians

14

ImplementationPlanning and Process

InfrastructureATM enterprise networkLeonia, NJ, data centerOS 390/2.5 mainframeOC48 Sonet ring2300+ desktops and wireless devices113 serversNew MIS site

15

ImplementationPlanning and Process (continued)

Simultaneous applications and upgrades 1996–1998

Radiology Information SystemPACSVoice RecognitionDocument Imaging

TranscriptionBlood Bank LaboratoryAnatomical PathologyPatient RegistrationMaster Person IndexPatient AccountingFinancial/HR/PayrollDecision Support

16


Physicians sought knowledge-based decision support (1999)Eclipsys SCM to replace E7000Purchased A4HealthSystemsHMED CPR; NextGen CPR –Ambulatory and FacultyPractices; E&C IntelligentPatient Record for Obstetrics

17


Data collection, workflow modifications, application screen designIntegrated testing of applications and interfacesDowntime procedures, workflow and useraccess policiesRoll forward approaches“Just-in-Time” Training System “Go Live” support

18

Implementation—Project Governance“Right” Planning Environment

HIS Executive CommitteePhysician Task ForceNursing CouncilProject sponsors break down barriersProject Teams -> user committeesTechnology Infrastructure—command center, training, etc.

19

ImplementationProject Staffing

Maimonides physicians, nurses, pharmacists, lab and radiology technicians

Knowledge of hospital culture, formal and informal organization, institutional memory and medical staff relationshipsIT skill mix broadened by adding cliniciansIT technologists broadened skill mix

20

Impact on OperationsSuccessful System Implementation

Minimize adverse impact on hospital operationsThree to six weeks of go-live supportClosely managed phased approach based on user tolerance

“Big Bang” not possiblePatients come first!

21

Evaluation of Management of CPR Effort Lessons Learned—the Don’ts

Two or more CPRs at the same time“Go Lives” in peak census periods“Go Live” without full volume loadintegrated testing

22

Evaluation of Management of CPR EffortLessons Learned (continued)

Backload data from paper chartsCustomized order sets require physician consensusTrain around the clock with clinicians who understand the specialty and workflow

23

Evaluation of Management of CPR EffortLessons Learned (continued)

Standardize alert levels among CPRsMonitor interfaces 24x7Evaluate and adjust downtime procedures post implementation—Do they really work?Double testing timeQuadruple support for full CPR’s

24

FunctionalityManaging Paper—Ongoing for Years

Scanning forms & documents; signature padsBalance computerized and paper-based dataChart Content Committee:

CPR contentPrinting for internal chart reviewStandardized paper chart for external review

25

FunctionalityKnowledge-Based Prompting

Drug-Drug Interaction CheckingPerinatal- FDB Version “S”Ambulatory- FDB Version “T”ED – FDB Version “U”Inpatient – FDB Version “V”Eclipsys SCM - Multum

26

FunctionalityKnowledge-Based Prompting (continued)

Treatment/Monitoring RecommendationsPerinatal – YesAmbulatory – YesED – NoInpatient – NoEclipsys SCM – Yes

27

MACS guides caregivers, speeding order entry and clinical documentationMACS Perinatal includes:

Order sets and note templatesClinical pathwaysCare plans based on risk or population groupClinicians common choices and preferences (individual and departmental)

FunctionalityOrder / Clinical Practice Standardization

28

Patient Decision SupportRecognizing when patient education is needed

RefusalDate

29

Workflow and Communication

The users se lect from radio buttons at the bottom to update the status in the forth column. This also resets the timer.

To access the patient record, the user se lects the des ired patient –highlighting the row.

The user se lects from the tabs at the top.

Placing the pointer over an icon produces a pop up window giving the user more information at a glance .

In this example the tracking board is sorted by acuity. Color coding denotes acuity level.

Those whose acuity is unassigned are at the top in Teal.

Black is the most acute, followed by red, blue, olive and green. Patient location is

displayed in the 1st column.

The 2nd column displays patient name, total time in the ED, and chief complaint.

Age, sex, and vis it type are in the 3rd column.

The users se lect from radio buttons at the bottom to update s tatus and reset the timer in the 4th

column.

30

Communication Tools

31

Pregnant patient arrives at triage and is registered.H&P reveals a 32y patient, GA 41w+6d, G5 P2022, whose chief complaint included contractions and lower abdominal pain. Streamed-in data from previous visits included OB US with BPP data suggesting Polyhydramnios.

Decision SupportJ. C. - Case Study

32

Data streamed from Data streamed from previous visitsprevious visits

33

The following ESSENTIAL The following ESSENTIAL items were presented items were presented (indicating the essential (indicating the essential documentation items missing documentation items missing in this specific casein this specific case

34

‘Exists’ button was ‘Exists’ button was pressed to the two pressed to the two Suggested ProblemsSuggested Problems

35

Prompted after Done Prompted after Done Sequence in completedSequence in completed

36

EFM was entered = Reactive, ReassuringBlood Type and Screen was orderedPelvic Exam was entered = Dilatation: 4 cm; SROM; Light Meconeum

The following was then presented:

J. C. - Case Study

38

Flexibility (Modified “Best of Breed”)

Applications chosen by users, with MIS guidanceIntegration, Communication, and Security are back-end standard deliverables

AccountabilityTechnical Personnel assigned to applications, not technologiesTechnical Managers responsible for insuring application support coverage

Technology

Philosophy:

39

ScalabilityRolling 3 year capacity planning for all systemsExperience shows almost impossible to over spec storage, memory, or CPU

Transferability“No Fault” Post implementation analysisNo single success, all projects part of evolutionary process improvementInvolvement from all disciplines at all phases

Technology

Philosophy:

40

Technology

Interface EngineSAN (Storage Area Network)Enterprise Network

LANWANWireless

Intrusion Detection Systems

ClusteringInter-System Communication Large storageCommunicationsSecurityRedundancy

De-Mystifying: The driver is healthcare solutions, not technology

41

How to deliver orders, results, & clinical information to all departments quickly and securelyHow to provide 99.999% information availabilityData SecuritySystem Integrity

Interface EngineEnterprise Network

LANWANWireless

SAN (Storage Area Network)Intrusion Detection SystemsClustering

Technology

42

Constantly evaluating flexibility vs. supportabilityIt cannot be achieved 100%

The process of asking the question does yield improvement in efficiency of technology support

It’s touch can be seen in all MMC systemsStandardization creates an inverse relationship between complexity and Total Cost of Ownership

Technology

Standardization: a means to an end

43

Technology

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Maimonides Medical CenterEnterprise Network

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Cisco AS5300A

Cisco AS5300B

PSN

56K Modem

56K Modem

56K Modem

Catalyst 2820

10BT

Cisco 2610

18 Remote Sites (Typical)

PSNISDN

Dial Backup

Data Center

HMED

Server

Command Center

100BT

To Alicomp -Eclipsys E7000

64th StreetDS-3

OC-3

OC-3

OC-12

OC-3

Switched 10/100

To Alicomp(Backup)

64th Street(Backup)

DS-3

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100BT

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Maimonides Medical Center

Network Dwg by : Server Farm

OC3100BT 100BT

DataCenter A DataCenter B

ADMIN A ADMIN BA B

A B

CompOps A CompOps B

Aron BldgCMHC BldgGellman BldgKronish BldgOPD BldgProfessional BldgResearch Bldg

LECSBackup#3

LECS-PrimaryLES/BUS-VLAN1

LECS-Backup#1LES/BUS VLAN2

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Unisys NCCNetwork

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100BT

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NextGenServer Farm

Server

100BT

Server Farm

Internet

T1

Cisco 7200CheckPoint

FirewallEmailServer

WEBServer

DMZ

OC3

OC12 OC12

7513

100BT10BT

LS1010

Displ

I n p a t i e n t C P R

8 0 . 0 0 %

8 5 . 0 0 %

9 0 . 0 0 %9 5 . 0 0 %

1 0 0 . 0 0 %

Ja n

Mar

May Ju

l

S ep

No v

U p t i m e % 2 0 0 0U p t i m e % 2 0 0 1U p t i m e % 2 0 0 2

A m b u l a t o r y C a r e C P R

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P e r i n a t a l C P R

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Jan

Ma r

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99% SLA 99% SLA

99% SLA 99% SLA

MACS CPR Availabilty vs. Internal SLA

E7000Electronic Medical

Record

SMSADT & Billing

TSI

PeopleSoftFS

FlexilabSunquest

IDXRAD

Fuji 1

StorCommPACS

Talk StationADT

E*GateInterfaceEngine

ADT

Non-PatientCash; Daily

GL Monthly

DRGSystem

Softmed

Admin.Membership

Software

Omnipro

CSC

IDX BAREPS

SurgiServer

EagleAccess

NEICEnvoy

SPARKSDOH

Synersource

MRCMedrite

Fleet Bank

Blue Cross

EMEVSMedicaid

ClaimSubmissio

n

BronchoscopyHolterMonitorPeds Echo

Pulmonary LabTrace MasterVascular Lab

Clicks Ultrasound

FaxedResults

OrdersStatusResults

ADT

IPCOMM

OPCOMM

DowntimePC

MPI

DailyDischarges

OPMDCR

OP BLCR

IP MDCR

IP BLCR

IP MDCDOP

MDCD

Proc IPDisch

IPBed

Census

DiagIP Disch

IPChrgs

OP 90Visits

IPPaymnts

OPVisits

OPChrgs

IP 90Adm

OPPaymnts

IPAdm

CDMChrges

CDMChrgs

CDMChrgs

DailyED

Chrgs

Daily EDVisitsDaily ED

VisitUpdt

DailyVisits

MEDEAmerica

DailyAdmits

MDCRBC

Remit

APReconcil

PeopleSoftHR

PayrollReconcil

PayrollGL

DirectDeposit

Visits

CDMChrgs

VisitUpdate

ADT

ADT

RADOrders

RADOrdersResults

RADOrdersResults

RadOrdersResults

MACSADT

Fuji 2

Monthly

GL(batch)

OrdersStatus

Results

Fuji 3

CancleOrder

ADT

LabOrders

LabOrders

ADT

ADT

ADT

Maimonides Medical CenterInterface Diagram

October 25 2002

Fuji 4

ADT, Rad Ords, Sched,Cancel

FaxedResults

HemoCare

ADT&

Orders Orders& Results

Charges

OPProc

OPDx

MonthlyBatches

Monthly

Payroll(batch)

DailyDRG

Pt Info

Medicare

EligibilityQuery

PhysicianBilling

HMEDEDIS

EWEB-AIE

NextGenAmbulatory

RecordRosetta-AIE

E&CPMIS

ADT

ADT

ADT

OrdersStatusResults

OrdersStatusResults

OrdersStatusResults

OrdersStatus

OrdersStatus

OrdersStatus

Med/IVOrdersChartin

g

RADOrdersResultsRAD

OrdersResults

CancleOrder

CancleOrder

All E7InitiatedOrders

QuestLabs

QuestLabs

BatchADT/

Orders

BatchResultss

BatchResultss

BatchADT/Orders

RADOrdersResults

ClicksUS

AgilentFetal

Monitoring

ADT

ADTResultrs

Orders

PhysicianBilling

PhysicianBilling

PhysicianBilling

DailyChrgs

DailyChrgs

DailyVisitUpdt

DailyVisitUpdt

DailyVisits

DailyVisits

Fuji 5

44

CPR Value

Organizational objectives:Patient safety – clinical excellenceHumane, patient-focused, patient-centered careStrengthen physician collaboration through effective communicationSupportive environment for physiciansStrengthen teaching and researchFiscal viability

Prove return on investment:Demonstrate value of the applicationProvide qualitative and quantitative benefit statementsPromote awareness of process redesign, cultural and organizational issuesIntegrate people, process and technologyInitiate a smarter implementation

45

CPR Return on Investment

9.4%ROI3.84Payback (years)75,876Savings and Efficiencies58,086Ongoing Expenses$31.697Net Cost(4.962)Grants(7.250)Capital Reimbursement

$43.909CPR’s Ancillary; Enterprise Network Interface Engine

(000’s)

46

Warns clinicians of safety checksrequired for High Alert medicationsEnsures safe selection of confusinglook-a-like, sound-a-like drugnamesVerifies the selection of the correct patientReduces the number of adverse drug reactionsImprove medication turnaround timeReduces pharmacy’s drug expenditure; drug spending for 1999-2002 has remained below National Average


Patient Safety

47

The prescriber is required to check the patient’s serum creatinine and age

After review of the serum creatinine and age, the prescriber may safely proceed to order Metformin


Patient Safety – High alert medication

48


Patient Safety – High alert medication, cont.

Pharmacists similarly review patient’s serum creatinine and age, intervening with prescriber if necessary

49


When viewing the medication index, look-a-like, sound-a-like medications are highlighted in different colors

After selecting the desired medication, its indication for use is displayed to further alert clinicians of the intended use

Patient Safety – Look-a-like – Sound-a-like Drugs

50

The prescriber selects a patient from the inpatient screen

After selecting the patient, additional specific information appears. “Is This The Correct Patient?” must be answered

Patient Safety – Verifying the Correct Patient


51

435

1046

619

1450

436

1603

325

1873

0

200

400

600

800

1000

1200

1400

1600

1800

2000

1998 1999 2000 2001

# Adverse Drug Reactions (ADR's)

# Pharmacy's Clinical Interventions

As the number of pharmacist’s clinical interventions increases, the number of adverse drug reactions decreases (optimizing medication use reduces the number of adverse drug reaction reports)


Patient Safety – Reduced Adverse Drug Reactions

52


Efficiency / Patient Focused Care

3.32.8 3 3

3.4

0.47 0.50.8 0.7 0.6 0.6 0.6

0.3

1 10.6

5.14.5 4.3 4.3

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0.530.36 0.35

0.60.60.640.70.7

0

1

2

3

4

5

6

1992 1993 1994 1995 1996 1997 1998 1999

Time from when order is initiated until Pharmacy acknowledges order Time for Pharmacist to process order

Time for prescription to be filled and delivered to patient area. TOTAL TIME REQUIRED

Medication Turnaround Time

53

$10,516,953

$9,692,496

$10,802,384$11,158,487

$11,562,929*

$12,296,652**

$14,202,633*

$8,000,000

$9,000,000

$10,000,000

$11,000,000

$12,000,000

$13,000,000

$14,000,000

$15,000,000

1999 2000 2001 2002

MMC actual dollar expenditures

Adjusted expenditures that reflect annual budget increase on drug purchases experienced by Non-FederalHospital

* Projected expenditures for 2002** Projected expenditures based on data from first 6 months of 2001

CPOE Cost Avoidance InitiativesMedication Ordering Pathways

IV to PO

Dosage Modifications

Therapeutic Interchange


Fiscal Viability

IV Push

54


Efficiency / Patient Focused Care

Serology

11640

10460

11433

10884

11900

11515

9500

10000

10500

11000

11500

12000

12500

19 96 19 97 19 98 19 99 20 00 200 1

Tot

al N

umbe

r of T

est

Chemistry

780000

443662 475458 490265 505174

990000

0

20000 0

40000 0

60000 0

80000 0

100000 0

120000 0

1996 1997 1998 1999 2000 2001

Year

Tota

l Num

ber o

f Te

st

Microbiology

60000

4889 9 4 8623

8 0000

474 9149422

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

1996 1997 1998 1999 2000 2001

Tota

l Num

ber

of T

est

Urinalysis

20000

15551 16018

27 000

1576616288

0

50 00

100 00

150 00

200 00

250 00

300 00

19 96 19 97 19 98 19 99 20 00 20 01

Tota

l Num

ber

of T

es

Hematology/Coagulation

231807258466280000

246000262999262936

0

5000 0

10000 0

15000 0

20000 0

25000 0

30000 0

1996 1997 1998 19 99 2000 2001

Year

Tota

l Num

ber

of T

es

Laboratory Tests 1996 - 2001

55


Patient Focused Care

0

20

40

60

80

100

120

140

160

180

200

Jan-9

9Feb

-99Mar-

99Apr-

99May

-99Ju

n-99

Jul-9

9Aug

-99Sep

-99Oct-

99Nov-9

9Dec-9

9Ja

n-00

Feb-00

Mar-00

Apr-00

May-00

Jun-0

0Ju

l-00

Aug-00

Sep-00

Oct-00

Nov-00

Dec-00

Jan-0

1Feb

-01Mar-

01Apr-

01May

-01Ju

n-01

Jul-0

1Aug

-01Sep

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01Nov-0

1Dec-0

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Feb-02

Mar-02A

vera

ge T

ime

Com

plet

ed E

xam

to F

inal

Rep

ort

(hou

rs)

Radiology Turnaround Time to Final Report

56


Fiscal Viability

Radiology Department Monthly Comparison of Procedures 1999; 2000; 2001; 2002

15249

14489 14493

13702

10500

11500

12500

13500

14500

15500

Jan Feb Mar Apr May Jun Jly Aug Sept OctNov Dec

1999

2000

2001

2002

57

70%

85%

69%

84%

63%

80%

67%72% 73%

84%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1997 2001 1997 2001 1997 2001 1997 2001 1997 2001


Patient SatisfactionIn

form

atio

n/Co

mm

unic

atio

n/

Educ

atio

n

Tran

sitio

n an

d

Cont

inui

ty

Satis

fact

ion

with

Adm

issi

ons

/ Reg

istr

atio

n

Ove

rall

Med

ical

/ S

urgi

cal

Patie

nt S

atis

fact

ion

Like

lihoo

d to

Rec

omm

end

58

The Ambulatory CPR:Improved compliance withproblem lists from 67% to 97%Improved allergydocumentation from 88% to 100%Improved pain assessment documentation to 95%Improved medication list documentation from 67% to 100%


Patient Safety / Regulatory Compliance

59


Patient Access

804332,168230,6602.21Total

1818727035,626.172001

1833733135,687.232000

1784713735,493.261999

1198479233,148.051998

949379432,150.911997

461184430,200.561996

0028,3561995

Discharges Attributed to MACS

Incremental Discharges vs. Base

YearDischargesLength of Stay

ReductionYear

60

Cash 1996 – 2001 (in millions)

203

134

71

43

2636

020406080

100120140160180200

Dec-96 Dec-97 Dec-98 Dec-99 Dec-00 Dec-01

POE

PACS&

RAD

TSI,Reinstallation

of PatientAccounting

MedAdmin Ambulatory EMR

Emergency EMRObstetrical EMR


Fiscal Viability

61

Vision For Future

Expand patient safety initiativesExpand decision support and knowledge documentation CPRsBreak Ground New Hospital – planning to become a Digital Hospital

OR/Anesthesia RecordsVirtual Imaging RadiologyClinical Equipment Integration CPR, physiological, images, audioPhysical plant computers

maimonides medical center makes a quantum leap with ... · 2 maimonides medical center makes a...

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