Transcript CPOE and Evidence at the Point of Care: A Canadian Experience

Journey to Stage 6
on the HIMSS EMR
Adoption Model
Jeremy Theal MD FRCPC
Chief Medical Information Officer
Sonia Pagliaroli RN CPHIMS-CA Manager, Clinical Informatics
HIMSS Ontario Chapter Webinar • June 13, 2013
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Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
Community teaching hospital
affiliated with the University of Toronto
Catchment area: > 400,000
Three Sites:
General, Branson, Seniors’ Health
Beds: 418 acute care
192 long-term care
Volume per year:
2
113,000 ED visits
29,500 inpatient cases
5,800 births
Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
Challenges in Inpatient Care
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EMR Adoption – Canada and U.S.
• Progression to HIMSS EMRAM Stage 4 and above
associated with improved quality and safety outcomes
- Amarasingham R et al. Arch Intern Med 2009 169(2):108-14
- 2006 HIMSS EMR Sophistication Correlates to Hospital Quality Data
- 2012 HIMSS Analytics Report: Quality and Safety Linked to Advanced IT-Enabled Processes
• US has 11x the proportion of sites at HIMSS Stage 4 and
above compared with Canada
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What is eCare?
Advanced Electronic
Medical Record (EMR)
+
Standardization on
Evidence-Based Care
+
Safe Prescribing and
Medication Administration
+
Clinical Decision Support
(Rules, Alerts)
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Multi-year hospital-wide clinical
transformation project utilizing health
information technology
=
A new era in patient care
using EMR technology
Phase 1:
Phase 2:
Phase 3:
Phase 4:
Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
June 2008
October 2010
May 2012
October 2013
Goals of the eCare Project
• Implement advanced electronic medical record technology
to improve patient outcomes:
 Quality and safety of patient care
• Embrace culture of evidence-based care, best practices
 Make it “easy to do the right thing”
 Build evidence into clinical workflow
• SHARED VISION = “by clinicians, for clinicians”
 100% clinician adoption
 Team-based interprofessional approach/workflows
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Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
Phase 2 System Components:
• Computerized Provider Order Entry (CPOE)
• Evidence-Based Order Sets & Clinical Workflows
• Closed-Loop Medication Administration
• eMAR, Medication Reconciliation, Depart Process
• Advanced Clinical Decision Support
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Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Cerner Core, PM,PowerChart, RadNet,
Profile, OE/RR
OE/RR Transfusions, GenLab, Haem
PharmNet, Procure
RadNet Scheduling
PharmNet printed MAR
Dietary
Transcribed Notes in PowerChart
Microbiology OE/RR PowerChart
Cerner Solutions
Harmonization Branson Site
Pathology OE/RR
Upgrade 2005.02.42
Upgrade 2007.08
eCare Phase I
eCare Phase II
eCare Phase III
eCare Phase IV
GE PACS
EDIS Wellsoft
Disparate
Solutions
EMPI / WTIS
OPIS
PowerScribe Voice Recognition
OnBase
Scanning
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Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
Teletracking
The NYGH eCare Project is unique in Canada:
– First Canadian deployment of CPOE with
regularly-updated evidence integrated into
the physician decision-making workflow
– First Canadian hospital to roll out closed-loop barcode
medication administration in all Medical, Surgical and
Critical Care units
– First HIMSS Stage 6
community teaching hospital in Canada
(only 4 hospitals in Canada overall)
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Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
eCare: Key Success Factors
1. Organizational Vision, Cultural Readiness, Commitment
2. Engagement of front-line clinicians:
– Respected local clinician champions for peer-driven change
– Clinicians have direct input into design of system  ownership
3. Effective communication plan:
– Understand reasons and impetus for change
– Recognize unique adoption characteristics of each clinician group
4. Clinical Integration: Clinicians, Evidence, Workflows
5. Robust and reliable Technical Infrastructure
6. Continuous Measurement, Learning and Improvement
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Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
• Insert eCare picture here
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HIMSS Stage 4
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Computerized Provider
Order Entry (CPOE)
Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
Integrating Evidence:
Pneumonia Evidence-Based Order Set
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Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
Interprofessional Order Set Review
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Evidence Links
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HIMSS Stage 5
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Closed Loop Medication
Administration
Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
“Closed Loop”
Medication Process
HIMSS Stage 5
LISA, MONA
Barcoded
Medication
Positive Patient
Identification
Barcoded
Staff ID
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HIMSS Stage 6
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Clinical Decision Support and
Structured MD Documentation
Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
Clinical Decision Support based on
Structured Data – HIMSS Stage 6
Intervention
No intervention – no VTE protocol
Compliance
10-40%
Simple-to-follow VTE protocol, paper
(3-level risk stratification, not score-based)
50%
Standardized, evidence-based VTE order
module, embedded into CPOE order sets
65-85%
Real-time electronic
clinical decision support
95%+
Dr. Greg Maynard, Director, Center for Improvement Science, UCSD
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VTE Prophylaxis Study – NYGH Medicine
% Appropriate VTE Prophylaxis
100
96
90
84
80
65
70
60
50
50
40
30
17
20
10
0
2007
(GEERTS ET AL)
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2007
(PAPER VTE
ORDER SET)
2010
(PRE-CPOE)
Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
2010
(POST-CPOE NO
ALERT)
2012
(POST-CPOE
WITH ALERT)
Medication Reconciliation – Decision Support
80.4%
>22% absolute increase
in Admission Meds Rec
amongst
Medical eCare Units
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80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
41.4% 70.9%
48.2%
37.0%
Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
40.8%
Surgery
Medicine
Cancer Care
MEDREC: NYGH MEDICINE PROGRAM
Best Possible Med History
Admission Med Rec
Discharge Med Rec
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
Post-CPOE:
45% admit,
70% discharge
NOW: MedRec
85% admit, 77%
discharge
40.00%
Admit MedRec Alert:
Increased to 70% avg
30.00%
20.00%
10.00%
Pre-CPOE:
7 to 9% avg
0.00%
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Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
Prevention of C. Difficile Relapse
Warning: High risk for C. difficile Relapse
You are about to order an antibiotic for a patient who has been positive for
C. difficile toxin within the last 180 days. Please re-assess the need for
antibiotics and consider infectious disease consultation as indicated.
Medications that trigger this alert are as follows…
Ceftriaxone
Clindamycin
Azithromycin
Clarithromycin
Ciprofloxacin
Levofloxacin
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Moxifloxacin
Piperacillin-Tazobactam
Amoxicillin-clavulanic acid
Imipenem
Meropenem
Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
The View from Stage 6
Outcomes and Lessons Learned
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Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
System Maintenance and Support
• What does “Maintenance and Support” mean
to a Stage 3 hospital vs a Stage 6 hospital?
– Support is “Mission-critical”  demands on team and vendor!
– Maintenance:
– number of systems / volume of resources to maintain
– number/complexity of support requests = “customer service”
– Training, change management – ongoing, not just at go-live
– Significant impact on pharmacy and CPOE teams:
– Formulary/medication build and barcoding, drug shortages
– Order catalog – changes to policy, procedure,
available lab/rad tests, utilization management
– Order sets – evidence updates, workflow change, new requests
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Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
System Improvements
System becomes a new
“common pathway”
for practice change
•
demand on informatics team:
– Reports (outcome measurement)
– Order catalog, order set changes
– Clinical decision support changes
– Liaison for monitoring, improving,
integrating workflows
– Communication and training
• Increased demand on EPR
capabilities – vendor partnership
and resources are crucial
(uCern user community)
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New
evidence,
Best
practices
Quality
Improvement
Initiatives:
(Strategic,
Mandated)
Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
Measured
Outcomes
Savvy Users
Informatics Team
System Improvements
Stage 6: Ongoing Quality Improvement
Operating
$
QIP
MAINTENANCE
MAINTENANCE
MAINTENANCE
MAINTENANCE
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Outcomes
Measurement
Real-Time Clinical
Decision Support
Closed-Loop
Medication Admin.
CPOE + Evidence-based
Order Sets, CMV
Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
Requirements for Success
in a Stage 6 World
• Adequate resources – budget, skilled staff (don’t underestimate!)
• Customer service – responsive team,
defined processes for user feedback
• Clearly defined change control process
• Outcomes: dashboards, reporting, business intelligence
• Feedback to clinical and administrative teams:
– What requests can we support? Where can we improve?
• Organizational change:
– Administration, quality improvement, clinical teams need to
understand capabilities/limitations of an advanced EPR
– Consolidate capabilities in Informatics, Quality,
Decision Support, Health Records
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Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
Metro Edition
\
Thursday Dec 13, 2012
In-Hospital Death Rates Down
Across Greater Toronto Area
• Annual CIHI Report demonstrated that
preventable in-hospital deaths were reduced
• NYGH – top performer in Greater Toronto
and second best in all of Canada
• CEO Tim Rutledge: “health information
technology has hard-wired quality and safety
into the hospital”
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Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
CPOE + Evidence + CDS = Improved Outcomes
Study population of all Medicine patients at NYGH with
primary discharge diagnosis of COPD or Pneumonia:
• Pre-CPOE (Jan-Sep 2010) n=520
• Post-CPOE (Jan-Sep 2011) n=511
Outcome
Death adjusted
for Probability of
Death and CrCU
Admission
.
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Comparison
Odds
Ratio
95% Confidence
Interval
p-value
CPOE vs Paper
0.547
0.36-0.83
0.005
Diagnosis-appropriate order
set
0.437
0.21-0.90
0.024
Order set close to, but not
matching diagnosis
1.821
0.78-4.23
0.163
Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
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HIMSS Stage 7
Journey to the Summit:
A Paperless, Connected Hospital
Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
HIMSS Stage 6 to HIMSS Stage 7
• Stage 6 requires functionality
to be demonstrated on a single clinical unit
• THE SUMMIT:
Stage 7 requires hospital-wide paperless functionality
– All requirements for stage 1 to 6
applicable in all areas of the hospital
– Longitudinal “single source of truth” eMAR for entire
patient record (including ED, OR, Critical Care)
– Data continuity with ED, hospital ambulatory and outpatient
– Warehousing of discrete data, with clinical/financial
outcome reports, system improvements based on results
– CCD (Continuity of Care Document, or similar standard)
transactions to bidirectionally share data with the
community via HIE (Health Information Exchange)
– On-site audit by HIMSS Analytics Team
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Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
Advancing on the EMRAM:
Key Strategic/Tactical Considerations
• Organizational eHealth Strategy:
– Specific patient-centered and organizational benefits (ROI)
– Allocate significant resources required (budget, skilled staff)
• Tactical plan:
– Steps required to achieve goal (series vs. parallel)
– Consider existing legacy systems, committed user groups
– Account for competing/complimentary local and provincial
projects and priorities, interoperability requirements
• Vendor:
– Does your core vendor provide the necessary functionality?
– Integrated system strategy vs. best-of-breed:
– Integration is key for functionality such as HIMSS Stage 5
(closed loop medication administration)
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Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
HIMSS EMRAM Fever!
• Careful - it’s contagious!
• Beware the symptoms:
– Goal-setting based on “checking the boxes”
– Pressure to “go live”
• Remember:
– HIMSS EMRAM focusses primarily on functionality achieved,
rather than directly on specific patient outcomes
– Design, build and implement in a cautious, methodical way:
–
–
–
–
–
–
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Involve front-line clinicians in patient-centered design
Study current and future state workflows
Conduct usability testing
Ensure robust technical infrastructure
Ensure privacy, security, data integrity
Measure and improve based on specific clinical outcomes
Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
cpoe-toolkit.ca
• Share CPOE implementation tools, templates, tips, tricks
• Share CPOE order sets
– 520 evidence-based order sets
(Medicine, Surgery, Critical Care, Paediatrics)
– CPOE library is growing!
– 2013: Mental Health, Maternal/Newborn
– All hospitals can contribute
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Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013
Thank You
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Journey to Stage 6 on the HIMSS EMR Adoption Model | June 13, 2013 | Copyright NYGH 2013