Essentials of Nursing Informatics international edition 4th edition written by Virginia K. Saba

1. ELECTRONIC HEALTH RECORD
FROM A HISTORICAL PERSPECTIVE

2. OBJECTIVES
1.Describe the Nicholas E. Davies Program
2.Name the four key criteria sections of the
Davies application
3.Name and describe one feature of an
electronic health record (EHR)
implementation that has not changed over
time.
4.Describe an external factor that has
impacted HER implementation
5.Describe several of the commonalities
found in all Davies winners

3. INTRODUCTION TO DAVIES

4. The Computer-
based Patient
Record Institute
(CPRI)
Nonprofit membership
organization founded
in 1992
Represents all
stakeholders in
healthcare, focusing
on clinical applications
of information
technology
First nationally based
organizations which
initiate, coordinate
activities to facilitate
and promote the
routine use of (CPRs)
throughout healthcare.

5. WHAT’S THE SAME?
How they define the Effort?

6. • Prior to the onset of effort, the winning clearly made the EHR a
key component of the strategic vision.
• Recognized organizations know and understand the healthcare is
an information business.
The 19 Organizational Davies winners
• Mission is to provide high-quality healthcare for America’s
veterans
• made the development of an HER a major long term goal.
Health Administration (VHA)1st year winner, 1995
• Decided in 1989 to redevelop their information systems.
• Moving the computer from its role as a reporter of requested facts
to an integral tool in the healthcare process.
• Vision encompassed the establishment of a new technical
platform that would serve as the base to provide the processing
power and scalability envisioned fort the future.
Brigham & Women’s Hospital (BWH), 1996 winner

7. • Turned to the EHR to managed competition
• deregulated reimbursement system, which goal to
expand rapidly into an integrated delivery system placed
the EHR at the core of its new business model.
Maimonides Medical center ,1996 in New
York
• vision encompassed a multisite, multispecialty group
practice whose EHRs linked to its practice management
system
Harvard Vanguard, 1997
• clear part of the strategic vision
• and defined remarkably similar organizational goals and
objectives.
HER implementation in all organization
winner was a:

8. • Delineated several key objectives:
• Improving the accessibility and availability of clinical
information
• Support of integrated care delivery across two different
sites
• Maximizing improvements in quality care through the use
of order entry and order checks and reminders.
Veterans Affairs (VA) Puget Sound Health Care
System (VA Puget Sound), 2000 winner
• All medical staff and administration
• Those included improved quality of patient care through
timely access to patient information
• Improved documentation of clinical data throughout the
continuum of care
• Integration of clinical information from a variety of legacy
systems
Queens Health Network (QHN), 2002 winner
• 2 strategic objectives which took precedence in
planning, design and implementation of EHR.
• Made optimizing patient safety,
• followed by optimizing consistency in care
Cincinnati Children’s Hospital Medical Center
(CCHMC), 2003 winner

9. How is the Effort Organized?

10. • is a daunting effort.
Implementation of EHR
• the shared belief that information management is
a key tool to the clinical and business processes of
the hospital.
Common element to all Davies winners
is
• absolutely necessary to ensure continued funding
and appropriate resources needed for the project to
realize success.
The champion is
• requires the skills of financial and operational
administrators as well as clinician for all
departments working with IT professionals
Planning process
• must be directly involved and engaged throughout
the planning and implementation cycles
Owner of the business, the clinicians,

11. • need to participate in design review
• serve as champions
• and provide local resources to ensure the planned implementation
will enhance their ability to care for the patient.
Nurses
• the selection process or design phase required input from not only
clinician but also information specialist.
Due to technologies involved
• was guide by hospital administration and information system
personnel with close oversight of the financial, technical, and legal
implications.
The contract negotiation phase
• usually consisting of hardware and software installs was led by IT
personnel.
The early portion of system implementation

12. • Formed a steering committee (chief of med. Nursing, mental health, and
ambulatory care)
• Nominated member for 2 special group, Clinical User, and Super User
• Clinical champions (20 physicians, nurses and other allied health
professionals)
• advocates of the project and willing to lead the discussions and provide
presentations and education sessions for other member of the their
professions
• The Super Users, train more and work closely with the developers in
planning system changes and improvements
• Serve as local resources for the colleagues, answering questions , and
providing on the spot training
VA Puget Sound
• is the customer service
• and constant consideration of the impact of the system on the end user.
Consistent character of winning organizations
• has been the active pursuit of feedback from all users
• Have employed user-inclusive design for feedback or have develop help”
buttons allow the clinician to instantly communicate frustrations or suggestions
for design improvement.
Another characteristic Davies winners

13. Impact to Value

14. • Avoidance of a medication error
• Directly through non-duplication of an ordered test.
Documenting the impact of EHR
• applicants were asked to provide examples of impact derived for the
organization from the EHR.
• As applications were evaluated, great emphasis were placed in the
organizations ability to demonstrate positive impact
• They were encouraged to provide quantitative examples of benefits
that had been obtained against the costs that had been incurred to
help and guide and direct expectations in other settings
1995 -2001
• Demonstrated proof of value through research and publications
• Have contributed significantly to the body of research on the power
and importance of clinical decision support to improve the process of
healthcare and patient safety.
Intermountain Health Care (IHC)

15. • through avoidance of medical error
• increased appropriateness of care interventions
• and compliance with managed care and disease
management protocols were obtained by all organizations.
Quality of care enhancement
• Improved continuity of care as medical records
• Plans of care were available in detail for residents on call or
weekend triage nurses
Additional quality impact was noted in:
• to measure the business value of its’ project.
• Provides balance decision-making criteria including tangible
and intangible benefits and risks
• The resulting analysis provides net present value, internal
rate of return, payback periods and ROI for each system
Maimonides used Eclipsys’ strategic investment
model

16. • Improvement of the processes that impact patient care,
• Improved access to patient information
• Complete legible clinical documentation
• Timely accurate patient data at point of service
• Process improvements were measured by analyzing different tools, their actions, and
effects on patient care.
• Example: Nutritional screening tools
QHN and medical board cognizant that the value of EHR technology
must be demonstrated and determined that for their organization to
success and business case would be measured by the:
• Mandated summary list completion which included patient
diagnoses, , procedures, allergies and adverse drug reaction, and patient medications.
• All elements of the summary list were required to be complete in order for compliance to
be achieved for any individual record
Joint Commission of Health Care Organization (JJACHO)
• Believed patient safety was cornerstone of quality.
• Medication Safety
• Patient Safety
• Risk Management deficiencies in the area of patient safety
• These deficiencies at times were related to inconsistency of care between providers
• As a result of EHR implementation, clinician generate, complete, unambiguous , legible
orders that include clinician contact name and pager number on all orders
CCHMC. 2003 winner

17. Still Expensive

18. • cost of their HER implementation; expensive.
• The trait continues even today.
A commonalty shared by all Davies
Organizational winners is the :
• organization after organization has set aside multiple
millions from their capital budgets to finance the cost of
the infrastructure, hardware.
• And software all needed for an HER implementation.
Over the years of the Davies program
• Employee hours lost from patient care for planning
process, design phase, testing
• and educational needs all required for success
implementation
Difficult to calculate but consistently present

19. What’s Different?
Where Winners Obtained Systems?

20. • winning organizations had spent years in the development of their award
winning systems.
In the first years of the Davies
• honored in the first year of the program all developed their own systems.
The three organizations
• was the practice site for a visionary group of clinicians and scientists.
IHC in Utah
• they began experimenting with the process of applying computer
technology to the provision of care
Around 1965
• rule base patient centered information system entitled
• Expanded in 1985 and when became apparent that an enterprise-wide
Clinical Information System (CIS) was needed.
HELP (health evaluation through logical processing)

21. • Received the first year award for CIS
• which was built a central hub that enable clinical systems
on disparate platforms to share patient data.
• The hub consisted of a series of concentric layers that can
handle requests various clients applications to store or
retrieve data.
Columbia Presbyterian medical Center
• Comprehensive system covering medical
management, fiscal and clinical functions
• Served as the fundamental information system for the
VHA’s medical care network supporting 171 medical
centers, 450 OPD clinics, and 131 nursing homes
• Major goal of this system was to share and exchange
data, first throughout the VHA, then with other federally
based health care facilities, and finally with the private
sector organization
Decentralized Hospital Computer Program
(DHCP)

22. • One of the project goals was to change the
computer’s role of results reporting in the
healthcare process.
• Instead of assuming the traditional role of the
computer, it become an active partner in promoting
optimal quality of care, reducing adverse
events, and reducing costs.
BWH developed Brigham integrated
computing system (BICS) with the help
of large number of clinicians
• Utilized an automated medical record system
(AMRS)
• Tried to self development, and then
codevelopment, before implementing their current
system which purchased from a vendor.
Harvard Vanguard Medical Associates

23. • Implemented commercially sold multicomponent system
procured from a variety of vendors
• This modified best-of-breed approach met the
physician and department head need while
conforming to the medical center’s
interfacing, hardware, software and operating
standard.
• This technology employed affects the ability to meet
user expectations including a wide variety of functional
and organizational needs, reliability, response time
and scalability.
All winners since 2000
• Several cases of completely home-grown systems
based on different technology platforms, a mainframe-
base vendor solution and document imaging
Over the years

24. Time to Get There

25. • available EMRs the timeline form initial planning, through
purchase, training, and successful implementation shortens.
As more healthcare organizations purchase commercially
• the EMR was part of a strategic plan
For early Davies winners like the VHA, Brigham & Women’s,
• belief that industrial engineering principles could be applied to healthcare.
The Regenstrief Institute, founded in 1969 in
Indianapolis, Indiana,
• Has the vision of a longitudinal, integrated, acute and ambulatory care record
that provided the information for clinical decision support and other
applications developed over three decades
• By the end of 1997 the clinical information stored in their EMR was available
at approximately 120 different locations within their healthcare delivery
system
Mc Donald 1997
• Placed the development of a robust information technology infrastructure to in
organizational strategic plan.
• 2003, development of the Information Services Department and
accompanying increase in network infrastructure to support the vigorous
development and implementation of clinical systems
• March 2000, completed the implementation of an enterprise-wide PACS
system
• December 2002, the EMR was implemented on 13 inpatient care units.
CCHMC

26. External Agenda

27. Factors external to healthcare organizations helped to
accelerate the timeline for adoption of EMRs.
• the driving force for developing an advanced CIS at Queen’s Medical
Center in Honolulu, Hawaii, was the onset of healthcare reform and
managed care.
In 1993
• Planning committee from which emerged the vision held by all
physicians, nurses and allied health professionals that CPR was
essential to improve care
1999,
• EMR at UIMC was initially develop to mitigate the concerns that the
organization’s legacy patient care information system was not Y2K
compliant.
2001,

28. • Heritage Behavioral Center of Decatur, Illinois
found themselves poorly prepared with an outdated
back office system
• An agency-wide, point of service information
system would give the organization a competitive
edge in quality-base, effective clinical services
• The focal point of this information system was to be
an EMR supported the delivery of care
Mid 1990’s
• EMR was viewed as essential to the development
of an effective infrastructure from which to support
• the reorganization of care
• design of quality measures
• streamlined reporting processes
• and the cornerstone of evidence-based medicine
to improve management of chronic disease..
2002, EMR at QHN in Queens

29. Technology

30. • ability to meet user demands for rapid response
• system reliability
• future growth
• and customization.
The technology behind each EMR affects
the
• have emerged and are being incorporated into the
systems being deployed today.
New technologies
• is difficult to precisely replicate due to data capture
The technology at any Davies winner
• such as interfaces, users agreement, cultural
changes, workflow revisions and window, and menu
customizations.
EMR uniqueness

31. • which is a key component of a transition strategy as an organization
moves from a paper-based to an electronic system
EMR have been incorporated in Document imaging
system
• this technology makes a diagnostic quality images, available wherever
high resolution monitoring are found in ER, ICU’s, and ambulatory
surgeries
PACS have been develop
• issued an electronic key at training and must choose a password are
required to sign onto the system every time.
• This process taking about 5 seconds, requires the use of plastic key
which containing encrypted user file and security access information
(2002).
Queens in New York,
• Mobile wireless work stations in ICU were key improving tem function
that could be wheeled about and used in the patient rooms improved
clinicians efficiency and the quality of patient care.
Wireless technology in 1999, Queens of Hawaii

32. • was imitated their system on serial
terminals of hardware for the EMR
Intel-286-based personal
computers
• help manage work flow and clinical
communications.
Today high speed work stations
with flat monitors
• facilitate communications within and to
remote locations of the organizations.
Fiber-optic cables

33. Davies Pool of Applicants

34. Nicholas E. Davies Program
Founded by CPRI in 1993 awards in
excellence in HER implementation
• the award program has recognized 20 healthcare
organizations
• 7 primary care practices,
• and 3 public health initiatives
Organized in 3 different categories,
• These questions are focused on the four board
areas of:
• Management
• Functionality
• Technology
• And value
Applicants for the award answer
questions outlined by the project
evaluation criteria.

35. • awarded to a community hospital
To date Davies has not yet been
• to include primary care practices and public health agencies
Davies program has widened in the past 2 years
Davies Primary Care award was initiated in
2003
Award for Public Health in 2004
3 Primary Care Practices were awarded in
2003,
and additional 4 practices in 2004.

36. Thank you for listening