The Challenge of Adoption

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The Challenge of Adoption: A Nurse's View of EMR and the Road Ahead

- A Nurse's View of the EMR -- Kathy English, Kris Hanke
- Closed Loop Pharmacy Safety Demo -- Kris Hanke
- Clinical Coordinator -- Carol Blair, Midland Memorial
- Questions and Discussion
- Medsphere.org: Tip of the Month

The December call will center on a Nurse's perspective of the EMR and will feature a demonstration of the closed loop medication capabilities of OpenVista. This would be an excellent call for any clinical application coordinators, specialists and nurses to join. Please feel free invite any colleagues that might find this topic relevant.

When: December 18, 12:30 - 2pm Pacific
Where: Dial-in: (888) 346-3950 // Participant Code: 1302465
Web conference: http://www.medsphere.com/infinite/

Details and Recording available here: http://medsphere.org/blogs/events/2008/12/18/community-call-december-2008

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The Challenge of Adoption

  1. 1. Webinar: http://www.medsphere.com/infinite/ Voice: (888) 346-3950 Participant code: 1302465
  2. 2. The Challenge of Adoption: A Nurse's View of EMR and the Road Ahead December 2008 Community Call
  3. 3. Presenters • Kathy English • Kris Hanke • Larry Washington • Carol Bair • Jon Tai • Ben Mehling
  4. 4. Agenda • The Challenge of Adoption • Closed Loop Medication • Guest Speaker: BCMA from the frontlines • Community Discussion • Medsphere.org: Tip of the Month
  5. 5. The Challenge of Adoption: A Nurse’s View of EMR & the Road Ahead December, 2008
  6. 6. Introduction • Kathy English – Vice President Product Management, Medsphere • Kris Hanke – Director Clinical Operations, Medsphere
  7. 7. Objectives • Review of “what makes it difficult to deliver great nursing care” • Show how Open Source technology and principles can address challenges in nursing care delivery and result in adoption of information technology
  8. 8. Poll
  9. 9. Nursing Executives are challenged to: • Drive delivery of safe patient care • Meet the demands of regulation • Keep up with the demands of new technology • Adhere to staffing requirements & prevention of attrition • Increase staff satisfaction • Support improvements in patient satisfaction • …and, do it all with a constrained budget
  10. 10. Let’s talk about disruption… quot;In 1834 The Times said, regarding a significant piece of medical technology, that, 'it will never come into general use notwithstanding its value. It is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble to both the patient and the practitioner; and because its hue and character are foreign and opposed to all our habits and associations. It is just not going to get used.”
  11. 11. Patient safety There is an ever increasing focus on patient safety and the prevention of medical errors The human error rate is 11% Greater than 60% of error events1 It is estimated that on average every ICU patient suffers 1.7 medical errors per day2 1 Romney B Duffey, John W. Saull; The Probability and management of Human Error.2004 Donchin et al. Crit Care Med 1995; 23:294-300 2
  12. 12. More than medication errors •5000 errors per year Nursing Errors •On a Sample of 393 RN’s Procedural, •58% Medication Errors 18.4% •18.4% Procedural •11.9 % Charting Charting, 11.9% Medication, 58% (1.) Balas MC, Scott LD, Rogers AE. The prevalence and nature of errors reported by hospital staff nurses. Appl Nurs Res 2004;
  13. 13. Errors 40% of Nursing errors that impact patients are not caused from medications or administering medications. Other errors identified from a recent study – Procedural – Charting Related causes Fatigue Overtime Burnout Human nature (1.) Balas MC, Scott LD, Rogers AE. The prevalence and nature of errors reported by hospital staff nurses. Appl Nurs Res 2004;
  14. 14. Information technology the Answer! “When people become patients, they place their trust in their health care providers. As providers assume responsibility for their diagnosis and treatment, patients have a right to expect that this will include responsibility for their safety during all aspects of care. However, increasing epidemiological data make it clear that patient safety is a global problem. Improved nursing care may prevent many adverse events, and nursing must take a stronger leadership role in this area. Although errors are almost inevitable, safety can be improved, and health care institutions are increasingly making safety a top priority. Information technology provides safety benefits by enhancing communication and delivering decision-support; its use will likely be a cornerstone for improving safety. “ Source : PMID: 15246041 [PubMed - indexed for MEDLINE]
  15. 15. The use of systems that prompt bedside providers to institute and maintain best practices for routine care, have been shown to improve clinical outcomes and decrease the cost of care* * Holcomb et al. Curr Opin Crit Care 2001; 7:304-11
  16. 16. Placeholder Pharmacy Screenshot
  17. 17. Manual records are subject to interpretation A Typical Critical Care Flowsheet…….. 9
  18. 18. Real time accurate communication is critical “A significant number of dangerous human errors occur when transcribing information. Many of these errors could be attributed to problems of communication between the physicians and nurses.” * * Donchin et al. Crit Care Med 1995; 23:294-300
  19. 19. Patient Summary
  20. 20. Interdisciplinary clinical notes
  21. 21. Poll
  22. 22. Nursing climate • There is a shortage of experienced nurses • Nurses are right out of school or from agencies needing further education • Staffing ratios are dictated & difficult to achieve • Other countries are providing Nurses – Communication barriers – Care responsibilities are different – Advanced technology options are different • Installation and use of information technology takes nurses away from primary responsibilities *Health Management Academy CNE Forum; Scottsdale, Arizona, Fall 2006
  23. 23. Open Source initiatives to help • Academic Universities are collaborating – Oklahoma University – University of Arizona – University of Washington – University of Hawaii – Georgetown • Collaboration efforts – Best practice protocols – Training programs – Lutheran Medical Center – ED Charting Templates & Tracking board – Midland Memorial Hospital – Documentation Templates
  24. 24. Care delivery protocols embedded in notes
  25. 25. Factory build & advanced training programs CIS MODULE FOR CPOE I. Objectives A. Place Orders in the Electronic Medical Record (EMR) B. Sign and update order by changing, renewing, and discontinuing orders in the EMR C. Place Delayed Orders in the EMR D. Creating personal quick order templates. II. Review of Patient Selection Screen A. Patient Selection 1. Ward/Unit 2. Clinic Name 3. Provider 4. Last,First name 5. Saving default patient selection B. Notifications (Two types – information only and action) 1. Unsigned notes and orders 2. Critical lab/imagining results 3. Consult updates 4. Flagged orders 5. Completing action notifications 6. Viewing notice only notifications
  26. 26. CIS MODULE FOR CPOE I. Objectives A. Place Orders in the Electronic Medical Record (EMR) B. Sign and update order by changing, renewing, and discontinuing orders in the EMR C. Place Delayed Orders in the EMR D. Creating personal quick order templates. II. Review of Patient Selection Screen A. Patient Selection 1. Ward/Unit 2. Clinic Name 3. Provider 4. Last,First name 5. Saving default patient selection B. Notifications (Two types – information only and action) 1. Unsigned notes and orders 2. Critical lab/imagining results 3. Consult updates 4. Flagged orders 5. Completing action notifications 6. Viewing notice only notifications
  27. 27. CIS MODULE FOR CPOE I. Objectives A. Place Orders in the Electronic Medical Record (EMR) B. Sign and update order by changing, renewing, and discontinuing orders in the EMR C. Place Delayed Orders in the EMR D. Creating personal quick order templates. II. Review of Patient Selection Screen A. Patient Selection 1. Ward/Unit 2. Clinic Name 3. Provider 4. Last,First name 5. Saving default patient selection B. Notifications (Two types – information only and action) 1. Unsigned notes and orders 2. Critical lab/imagining results 3. Consult updates 4. Flagged orders 5. Completing action notifications 6. Viewing notice only notifications
  28. 28. Clinician satisfaction in a challenging climate • Recruitment is challenging • Nurse to patient ratios are mandated • Overtime due to hours spent documenting • Fatigue & burnout
  29. 29. Improving Nurse satisfaction • Recruitment – Attracting good Clinicians to your organization • Nurse to patient ratios – Maintaining Good Nurse/Patient ratios – Tools to manage your Patients better • Overtime – Eliminating Redundant documentation – Streamlining workflow and process – Deploying tools to improve Process
  30. 30. Streamline Process • Organizational • Departmental • Role • User Most often Clinicians will be focused on their own responsibilities and not the bigger picture of care
  31. 31. Regulatory Requirements • HIPAA • Core Measures • Never Events • Mandatory reporting, Registries • Decrease variance • Adherence to care protocols
  32. 32. In summary “given the moral importance of patient safety and quality care in nursing and related health care domains, the inseparable link between nursing practice and patient safety, and the central role that research has to play in driving safety improvements in these domains, it is morally imperative that the nursing profession gives sustained and focused public attention to patient safety and quality care as a national research priority. “ PMID: 16541827 [PubMed - indexed for MEDLINE]
  33. 33. Poll
  34. 34. Nurses will adopt IT that solves problems • Promotes safe patient care delivery • Meets the demands of regulation without extra work • Keeps up with the demands of new technology through ease of use, easy to learn & provides information in real time at the point of care • Does not negatively impact staffing requirements • Prevents attrition by permitting a streamlining processes • Increases staff satisfaction with their job • Support improvements in patient satisfaction through safe and efficient care delivery • …and, do it all with reduced cost and time to efficiency
  35. 35. The Ecosystem and Community: Together Who is better positioned to solve the challenges to nursing in healthcare? …a community of nursing care providers who collaborate to bring complete and best practice solutions to healthcare
  36. 36. Closed Loop Medication Process
  37. 37. Pharmacy
  38. 38. Medication Administration
  39. 39. Guest Speaker Carol Bair, LVN, Educator/Trainer HIS Carol presents lessons learned at Midland Memorial Hospital from the frontlines of an EMR and BCMA rollout.
  40. 40. BCMA from the frontlines Carol Bair LVN, Educator/Trainer HIS Midland Memorial Hospital
  41. 41. Workflow: Pharmacy • If starting with CPOE learn how to finish orders off as if you have BCMA. • Insure ordered items are pre packed with barcodes. • Maintain barcodes. • Trouble shooting users. • Flagging data/comments in order to show.
  42. 42. Workflow: Nursing • Important: BCMA is for patient safety and not for the convenience of the nurse. • Time management will change. • Nursing will need to wait until pharmacy verifies orders and should verify orders in Vista before giving in BCMA.
  43. 43. Example • Be aware that when a medication is ordered that the dosage they have in their hand needs to match with what is supplied by pharmacy. • For example: Lasix 20mg IVP is ordered, the nurse has a Lasix 40mg vial on hand, but pharmacy finishes the order as a Lasix 20mg vial. When the nurse scans the vial she will receive an error message that says invalid medication look up.
  44. 44. Team Effort • Pharmacy and nursing need to work closely together. • During training, nursing and pharmacy need to see what they other department sees. E.g., Nursing will say to pharmacy when they call “it is the third medication order down (in CPRS/CIS)”, yet pharmacy’s view is via a different (Terminal-based) application.
  45. 45. The BCMA Committee Committee should consist of BCMA analyst, Pharmacy Coordinator, BCMA educator, pharmacist, nursing administration, cardiopulmonary, staff nurses (valuable).
  46. 46. BCMA Committee: Policies and Procedures: • What to do when BCMA goes down (Downtime Contingency Plan) • What happens if safety using BCMA is not followed • How often to run reports (e.g., missing med and prn effectiveness) • Range orders (such as Lortab 7.5 1-2 tabs q 4 – 6 hrs): Order will need to be finished either q 4 hours or q 6 hours. • Decide on reasons for held, refused, prn’s, and IV sites. • Who will be able to access BCMA? Nurses, students, physicians?
  47. 47. BCMA Committee Technical Details: • Decide if BCMA will be loaded onto desktops or only Computers on Wheels (COWs). • Decide what scanners and carts to use. • Verify barcodes scan on armbands, medications, and IV bags. (e.g., Light colored barcodes are hard to scan.)
  48. 48. BCMA Committee Responsibilities: • How much training and who will be trained? • How will implementation be conducted? • Competencies -- who is responsible for filling out? • General support coverage (24-7). (Also, make sure you have adequate (additional) staffing during go live.)
  49. 49. Going Live! • Decide when to go live with BCMA • Consider a “soft go live” (i.e., select only one or two patients) • Make certain that adequate support staff are available/scheduled during go live • During the go live, meet daily to document, discuss, and solve any issues • Decide who will print armbands. Extra armbands available if all units can print
  50. 50. Questions? Discussion, questions and comments? Authors: Carol Bair -- carol.bair@midland-memorial.com Randy Adams -- randy.adams@midland-memorial.com
  51. 51. Medsphere.org Tip of the Month December 18, 2008
  52. 52. Searching on Medsphere.org • Accessing the Search feature – Persistent User Bar on Medsphere.org – Getting Started widget on Medsphere.org home page – Adding Medsphere.org to your browser’s built-in search box • Default search is an AND search – Content containing all of the words in your query will be returned
  53. 53. More Options • You can limit your search by – Content type – Last modification date – Community – Author
  54. 54. Advanced Searching • You can limit your search to the – Subject, e.g., subject:FAQ – Body, e.g., body:HIPAA – Attachments, e.g., attachmentsText:autofax – Tags, e.g., tags:linux • Use quotes for phrases – e.g., “medical record” or “OpenVista CIS” • Use OR and AND keywords – e.g., (laboratory OR radiology) AND autofax • Use NOT to exclude keywords – e.g., (laboratory OR radiology) NOT autofax • Use ^ to boost a keyword’s importance – e.g., “medical record”^5 VA
  55. 55. Additional Reading • More search resources – Jive blog post on improved searching in Clearspace 2.x • http://www.jivesoftware.com/jivespace/blogs/jivespace/2008/06/16/search- improvements-in-20x-and-21 – Medsphere.org search tips page • http://medsphere.org/search-tips.jspa
  56. 56. • Questions?

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