AHRQ 2006 Annual Conference on Patient Safety and

AHRQ 2006 Annual Conference on Patient Safety and

AHRQ 2006 Annual Conference on Patient Safety and Health IT Socio-Technical Approach to Planning and Assessing Redesign Huron Hospital CPOE Implementation June 5, 2006 Greg Kall, CPHIMS Regional Vice President, Information Technology Huron Hospital 211-bed, acute care, urban hospital Located in East Cleveland, Ohio 361 member voluntary medical staff 52 residents in Medicine and Surgery Level II Trauma Center, Obstetrics, Community Health Center Part of 4 hospital CCHS East Region Socio-Technical Approach to Planning and Assessing Redesign l June 5, 2006 l 2 Components Live at Huron Electronic Medical Record (EMR) Patient Lists Clinical Results Review Clinical Documentation Electronic Medication Administration Record (eMAR)

On-line Discharge Process Computerized Physician Order Entry (CPOE) Clinical Decision Support (Rules and Alerts) Order Sets Electronic Signature Strong Authentication Remote Access Socio-Technical Approach to Planning and Assessing Redesign l June 5, 2006 l 3 Implementation Facts Go-Live in July of 2004 Phase I: Psych Unit and OB Unit Phase II: ICU Phase III: Remainder of hospital Two Weeks Between 1,000,000 eOrders processed to date CPOE utilization rates Residents: 94% Overall: 75% Socio-Technical Approach to Planning and Assessing Redesign l June 5, 2006 l 4 Organization Strategy Inclusive

All 4 hospitals in CCHS East Region participated from the start Multidisciplinary Physicians, Nurses, Ancillaries, IT Together from the very beginning Implementation Team Clinically Focused - More Clinicians than IT! Pharmacists, Nurses, Laboratory Ongoing/Active Management Multi-year project Simultaneous phasing activities Design, Implementation, Maintenance Socio-Technical Approach to Planning and Assessing Redesign l June 5, 2006 l 5 Executive Sponsors Steering Committee Regional and Hospital Executives Project Organization Project Management Office Implementation Team Team Members 4 Physician Advisors 1 Pharmacist 3 Nurses 1 Medical Technologist 1 HR Trainer

1 Project Manager 1 Interface Engine Analyst 1 Report Writer 1 ADT/Charge Master Analyst Functions Planning Analysis System Design Application Build Interfaces Testing Implementation Support Monthly Status Reports Remove Barriers Executive-level Support Physician Advisory Committee Clinical Informatics Council Patient Care Advisory Committee Regional CMO, Hospital Chiefs of Staff, Hospital Physician, Advisors, Director Medical Education CPOE Design Medical Staff Bylaws and Policies

Order Sets and Other Clinical Content Physician process redesign Regional CMO, Physician Advisors, Hospital CNOs, Project Staff Collaborative clinical decision-making Regional and Hospital Executives and Managers of Nursing, ED, Ancillary, Clinical Services, and Quality Departments CPOE Design Hospital and Department Policies and Procedures Four Hospital Physician Advisory Groups Task Forces Communication Develop and Execute Plan Nursing Process Process

Redesign Standard Flows Unit Review Custom content HIS Process Training Security Develop and Execute Plan Develop and Execute Plan Pharmacy Process Design Strategy Patient Care Advisory Committee Learn the software Identify processes likely to be impacted By policies and procedures By function By department Form workgroups, including front-line staff

Flowchart existing processes Correlate the process to the software Identify where changes may occur Flowchart new and revised processes Socio-Technical Approach to Planning and Assessing Redesign l June 5, 2006 l 7 Nursing Workflow Redesign Examples Transfers with EMR February9,2004 Active Medication Reordering Tuesday, February 21, 2006 Order written to transfer or CPOM transfer request Patient scheduled for Surgery Unit calls floor for bed, or admitting is notified via an EMR requisition for transfer request Bed assigned Yes Does the pt need to be physically transferred No

Change Accommodation code (H,E,S only) requisition entered in the EMR Registration changes the accommodation code in HBOC Sending Unit prints the Active Medication Reorder sheet at the time the patient is leaving the unit and places the form on the chart. Unit notified bed is ready Nurse calls or faxs report Pack up patient meds, belongings and chart Call transport Yes Sending unit enters order in the EMR transfer confirmed Registration moves pt

in HBOC, pt is moved in the EMR via interface Patient physically transferred to new bed Transfer received The physician reorders the medications in the EMR using the session type of Post Op Pharmacy is notified via the EMR that the medication has been reordered. Does post op physician participate in EMR? No The physician completes the Active Medication Reorder Sheet Nursing Staff faxes the completed form to the pharmacy

Reassemble chart Transcribe orders Nursing releases the hold orders when the patient is received in the inpatient unit. The medication administration record is updated with the date of renewal Socio-Technical Approach to Planning and Assessing Redesign l June 5, 2006 l 8 Design Strategy Validate new workflows Design Endorsement Sessions to demo workflows Audience includes physicians, nurses, pharmacists, ancillary departments Structured scenarios with written participant evaluations Iterative process Revise policies and procedures to support new workflows Conduct unit-specific workflow review sessions to identify exceptions End-user training must include workflow changes and new Policies &Procedures Socio-Technical Approach to Planning and Assessing Redesign l June 5, 2006 l 9 Design Strategy Physician Advisory Committee

Establish clinical priorities Create and modify policies and by-laws Review and approve design Review workflows and process Create and manage order sets Create and manage rules and alerts Clinical Informatics Council Where everything comes together! Also provides ongoing post-live management Socio-Technical Approach to Planning and Assessing Redesign l June 5, 2006 l 10 Feedback and Improvement Strategy Clinical Informatics Specialist New position dedicated to supporting clinicians One-on-one training (carries beeper) Grand Rounds Weekly resident meetings Monthly User Group meetings Local Physician Advisor Group Workflow feedback Data/performance review Socio-Technical Approach to Planning and Assessing Redesign l June 5, 2006 l 11 Performance Tracking Examples %Direct Order Entry 120 % Orders Cancelled or Modified by MLM Huron Hospital 100 80 60 40

20 0 Jul-05 45 40 35 30 25 20 15 10 5 0 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Direct Order Entry Huron Hospital 4th Quarter 2004 Huron Order Sets/Dischg 1st Quarter 2005

Duplicate 2.0 1.8 1.6 1.4 1.2 Drug Interaction 1.0 0.8 0.6 0.4 0.2 0.0 2nd Quarter 2005 All Clinicians Residents 3rd Quarter 2005 Allergy Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Regional Order Set Utilization per Discharge Socio-Technical Approach to Planning and Assessing Redesign l June 5, 2006 l 12 Survey Instrument Survey Dimensions Technology-based perspectives Task

Social Perspectives Cognitive Processes, Task-Technology Fit Fit with technology, User evaluation, Relative advantage Information quality, Bounded rationality Information overload EMR Adoption & Ongoing use User IT Acceptance Model Perceived usefulness, Ease of use, Attitudes, Behavioral intention Organizational Imperative Power and control, Information politics Socio-Technical Approach to Planning and Assessing Redesign l June 5, 2006 l 14

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