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

1. Webinar: http://www.medsphere.com/infinite/
Voice: (888) 346-3950
Participant code: 1302465

2. The Challenge of Adoption:
A Nurse's View of EMR and the Road Ahead
December 2008 Community Call

3. Presenters
• Kathy English
• Kris Hanke
• Larry Washington
• Carol Bair
• Jon Tai
• Ben Mehling

4. Agenda
• The Challenge of Adoption
• Closed Loop Medication
• Guest Speaker: BCMA from the frontlines
• Community Discussion
• Medsphere.org: Tip of the Month

5. The Challenge of Adoption: A Nurse’s
View of EMR & the Road Ahead
December, 2008

6. Introduction
• Kathy English
– Vice President Product Management, Medsphere
• Kris Hanke
– Director Clinical Operations, Medsphere

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. Poll

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. 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. 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. 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. 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. 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. 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

17. Placeholder
Pharmacy Screenshot

19. Manual records are subject to interpretation
A Typical Critical Care Flowsheet……..
9

22. 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

24. Patient Summary

25. Interdisciplinary clinical notes

26. Poll

27. 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

28. 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

29. Care delivery protocols embedded in notes

30. 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

31. 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

32. 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

33. Clinician satisfaction in a challenging climate
• Recruitment is challenging
• Nurse to patient ratios are mandated
• Overtime due to hours spent documenting
• Fatigue & burnout

34. 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

35. Streamline Process
• Organizational
• Departmental
• Role
• User
Most often Clinicians will be focused on their own
responsibilities and not the bigger picture of care

38. Regulatory Requirements
• HIPAA
• Core Measures
• Never Events
• Mandatory reporting, Registries
• Decrease variance
• Adherence to care protocols

43. 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]

44. Poll

45. 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

46. 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

47. Closed Loop Medication Process

54. Pharmacy

64. Medication Administration

68. 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.

69. BCMA from the frontlines
Carol Bair
LVN, Educator/Trainer HIS
Midland Memorial Hospital

70. 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.

71. 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.

72. 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.

73. 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.

74. The BCMA Committee
Committee should consist of BCMA analyst, Pharmacy
Coordinator, BCMA educator, pharmacist, nursing
administration, cardiopulmonary, staff nurses (valuable).

75. 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?

76. 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.)

77. 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.)

78. 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

79. Questions?
Discussion, questions and comments?
Authors:
Carol Bair -- carol.bair@midland-memorial.com
Randy Adams -- randy.adams@midland-memorial.com

80. Medsphere.org Tip of the Month
December 18, 2008

81. 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

82. More Options
• You can limit your search by
– Content type
– Last modification date
– Community
– Author

83. 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

84. 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

85. • Questions?