Hospitals and Health Systems: Nurses and Physicians in the Implementation of the EMR at NYC Health

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Hospitals and Health SystemsNurses 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

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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 well-being of the
  people we serve.

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• 11 Hospitals
• 5 DTCs
• 4 LTCs
• 100 Clinics
• Home Care
• MetroPlus

www.nyc.gov/HHC
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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

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HHC Organization Chart
Board of Directors
Mayor Appoints
Benjamin Chu, MD, MPH President
Mayor Appoints
SVP
SVP
SVP
SVP
SVP
(7) Networks
Facilities
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HHC EMR Timeline
1991 / 1997 2000
2002 2004 2005

HDS Pilot, Jacobi Medical CenterLabs, CPOE,
Documentation
Installation throughout HHC Lab, Lab Consolidation
CPOE
LTC
OPD Documentation/Coding
Smart Cards
DC Summaries
Disease/Pt. Registries
Medication Admin.
Portals
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Vision for HHC Clinical Systems

• Leaders in Clinical Outcomes
• Reliably Support the Care Team
• Complete Information Availability
• Positive Fiscal Impact

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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

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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

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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
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Medication Errors

• One million serious medication errors every year.
• 20 are life-threatening.
• 7000 deaths annually.
• 2 billion nationwide in hospital costs alone.

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IT to Reduce Med. Errors

• Information Technology is a critical ingredient
  to reduce medication errors.

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Medication Process
Medication Order
CPOE
Physician
Pharmacy Review
Pharmacy
Nurse
E- Med Admin
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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.

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CPOE Incorrect dose warning
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CPOE Drug-drug interaction warning
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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

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Med Admin Info. available to RN
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Med Admin Pharmacy Review Warning
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Med Admin Incorrect Time Warning
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Challenges in Implementation

• Complexity interdisciplinary
• Clinician buy-in MD, RN, Pharmacy
• Cost of the software, even more the cost of the
  implementation

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Putting this in perspective

• 5-10 hospitals have adequate CPOE.
• lt10 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.

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Its 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
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Nursing at New York City Health and Hospitals
Corporation

• Scope and InformaticsMarie Ankner,
  RN,MS,CNAAAssistant Vice President , Nursing
  Services

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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

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• 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

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In the beginning

• RFP was developed and reviewed by an
  interdisciplinary team representing all
  facilities (90s)
• Pilot developed at Jacobi Medical Center
• Initiative led by nursing and fostered
  interdisciplinary screen building
• Individualized Network /Facility expansion

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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

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HHC Environment

• HHC RNs average age 48 yrs
• - 60 direct care providers have gt 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

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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

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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

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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

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• The Nursing and Technology Link
• Nadia Sultana MBA RN,BC
• Senior Director, Clinical Information Systems
• NYC Health Hospitals Corporation
• October 23,2004

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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

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Action Plan

• Formation of
• NISA Nursing Information System
• Advisory Group
• to promote dialogue, share best practices and
• foster Nursing Informatic education

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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

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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

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Standardization

• First attempt - Development of the VISTA Desktop
  Nursing Standard
• Outcome some variation continued post
  implementation emphasized the need for change
  control processand need to
• continue to Standardize

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• CONEY
• Medium Issue - Redundant icon function
• Recommendation Remove icon
• Response Rebuilding new desktop by 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.

• CONEY
• High Issue - Block functions should appear as
  tabs. Substantial deviation from NISA standards.
• 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
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• 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
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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

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Change Control Process -CPR /DATA WAREHOUSE

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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

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Planning next modules incorporating best
practice

• Medication Administration Expansion
• Interdisciplinary Documentation
• Clinical Pathways
• SMART CARDS

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Glenn Martin, MDDirector, Medical
InformaticsQueens Health Network
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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

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• 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

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Diabetes
Diabetes
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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
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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

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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
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