This document discusses achieving physician buy-in for effective IT adoption and engagement. It begins with biographical information about the speaker, Dr. Michael Wagner, who has experience leading IT projects in both academic and community physician practices. The presentation outlines key factors to consider for a successful IT implementation, including engaging physician leadership, understanding how invasive the new technology will be, ensuring appropriate organizational support, and addressing provider concerns. Effective project management and establishing a core implementation team are also emphasized.
This document discusses issues related to care transitions and medication safety. It notes that care is often uncoordinated, leading to poor patient outcomes like medical errors and increased costs. Effective care transitions require coordination between providers, patient education, and medication reconciliation. Ineffective transitions are linked to wrong treatment, delays in diagnosis, adverse events and increased costs. The document examines medication discrepancies that commonly occur during transitions between care settings like hospitals, nursing homes, and patients' homes. It also identifies system-level and patient-level barriers that contribute to poor coordination during care transitions.
The document discusses guidelines for patients leaving the hospital against medical advice (AMA). It defines key terms like leave against medical advice (LAMA) and against medical advice (AMA). It outlines steps providers should take to determine a patient's capacity to leave AMA and ensure they understand the risks. Providers are advised to document the discussion of treatment options, risks of leaving AMA, and patient's informed refusal. Special circumstances like suspicious situations or those lacking capacity require additional measures.
A patient undergoing blood transfusion experienced an allergic reaction after the nurse failed to properly monitor his vital signs as required every 30 minutes. Transfusion reactions can be life-threatening if not properly monitored and treated. Nurses have a duty of care to patients under their care. By neglecting to monitor the patient's vital signs as ordered, the nurse breached their duty of care, which likely contributed to the patient's adverse reaction going unnoticed and untreated. Strengthening nursing home staff training and increasing minimum staffing requirements could help avoid such medical errors and improve patient safety and outcomes.
This document discusses medical errors and increasing patient safety. It summarizes several studies that found medical errors are common, with rates of adverse events from around 3-17% of hospital admissions. Errors result in tens of thousands of unnecessary deaths annually. Most errors are due to cognitive mistakes and "system" failures rather than individual negligence. To improve safety, the document argues we must think of errors as systems failures and implement strategies like checklists, standardized procedures, training, and a culture where safety is a top priority and errors are reported to fix underlying issues rather than blame individuals.
An emergency department quality improvement projectyasmeenzulfiqar
The document discusses improving vital sign documentation during triage in emergency departments. It aims to investigate factors affecting vital sign data quality during measurement and documentation, and provide recommendations for improvement. A literature review found that timely and accurate vital sign documentation is important for identifying deteriorating patients. However, studies on nursing workflows and documentation of vital signs are limited. The objective is to study nurses' vital sign documentation process through a questionnaire of nurses and analysis of the data. Results showed teamwork and quality improvement efforts like education and training can enhance compliance with vital sign documentation standards during triage. Recommendations include departments addressing challenges in measurement time and reviewing results to improve performance.
This document provides instructions for a case study on fall risk assessment and prevention for an elderly patient. It includes background information on the patient, subjective data collected, nursing diagnoses identified, and next steps outlined. The CNS's next steps are to review additional interdisciplinary assessment data focusing on cardiovascular health, functional status, environment, and medication usage to fully understand fall risk factors and develop an evidence-based fall prevention plan.
1. The document discusses various methods that have been used to track and reduce medical errors, including chart reviews, self-reporting, and direct observation. Errors are often caused by systemic issues rather than individual mistakes.
2. A systems approach aims to identify error sources within healthcare systems and implement solutions like checklists, improved teamwork, and computerized physician order entry.
3. An individual approach provides education to improve cognitive skills and decision-making and reduce biases. Integrating systems solutions and cognitive training shows promise but requires more research.
This document discusses issues related to care transitions and medication safety. It notes that care is often uncoordinated, leading to poor patient outcomes like medical errors and increased costs. Effective care transitions require coordination between providers, patient education, and medication reconciliation. Ineffective transitions are linked to wrong treatment, delays in diagnosis, adverse events and increased costs. The document examines medication discrepancies that commonly occur during transitions between care settings like hospitals, nursing homes, and patients' homes. It also identifies system-level and patient-level barriers that contribute to poor coordination during care transitions.
The document discusses guidelines for patients leaving the hospital against medical advice (AMA). It defines key terms like leave against medical advice (LAMA) and against medical advice (AMA). It outlines steps providers should take to determine a patient's capacity to leave AMA and ensure they understand the risks. Providers are advised to document the discussion of treatment options, risks of leaving AMA, and patient's informed refusal. Special circumstances like suspicious situations or those lacking capacity require additional measures.
A patient undergoing blood transfusion experienced an allergic reaction after the nurse failed to properly monitor his vital signs as required every 30 minutes. Transfusion reactions can be life-threatening if not properly monitored and treated. Nurses have a duty of care to patients under their care. By neglecting to monitor the patient's vital signs as ordered, the nurse breached their duty of care, which likely contributed to the patient's adverse reaction going unnoticed and untreated. Strengthening nursing home staff training and increasing minimum staffing requirements could help avoid such medical errors and improve patient safety and outcomes.
This document discusses medical errors and increasing patient safety. It summarizes several studies that found medical errors are common, with rates of adverse events from around 3-17% of hospital admissions. Errors result in tens of thousands of unnecessary deaths annually. Most errors are due to cognitive mistakes and "system" failures rather than individual negligence. To improve safety, the document argues we must think of errors as systems failures and implement strategies like checklists, standardized procedures, training, and a culture where safety is a top priority and errors are reported to fix underlying issues rather than blame individuals.
An emergency department quality improvement projectyasmeenzulfiqar
The document discusses improving vital sign documentation during triage in emergency departments. It aims to investigate factors affecting vital sign data quality during measurement and documentation, and provide recommendations for improvement. A literature review found that timely and accurate vital sign documentation is important for identifying deteriorating patients. However, studies on nursing workflows and documentation of vital signs are limited. The objective is to study nurses' vital sign documentation process through a questionnaire of nurses and analysis of the data. Results showed teamwork and quality improvement efforts like education and training can enhance compliance with vital sign documentation standards during triage. Recommendations include departments addressing challenges in measurement time and reviewing results to improve performance.
This document provides instructions for a case study on fall risk assessment and prevention for an elderly patient. It includes background information on the patient, subjective data collected, nursing diagnoses identified, and next steps outlined. The CNS's next steps are to review additional interdisciplinary assessment data focusing on cardiovascular health, functional status, environment, and medication usage to fully understand fall risk factors and develop an evidence-based fall prevention plan.
1. The document discusses various methods that have been used to track and reduce medical errors, including chart reviews, self-reporting, and direct observation. Errors are often caused by systemic issues rather than individual mistakes.
2. A systems approach aims to identify error sources within healthcare systems and implement solutions like checklists, improved teamwork, and computerized physician order entry.
3. An individual approach provides education to improve cognitive skills and decision-making and reduce biases. Integrating systems solutions and cognitive training shows promise but requires more research.
PEER (Professionalism and Ethics Education for Residents) Project sponsored and organized by the Saudi Commission for Health Specialties (SCHS).
Definitions of terminology related to Medical Error (ME)
Levels of severity of medical error
Types & Examples of medical errors
Causes of ME
Disclosure of ME
Prevention of Medical Error
Medical errors represent a serious public health problem and occur frequently in various healthcare settings. They can involve medicines, surgery, diagnosis, equipment, or lab reports. Studies estimate medical errors may be the third leading cause of death in the US, resulting in between 200,000 to 400,000 deaths per year. Many common types of errors like misdiagnosis, unnecessary treatment, medication mistakes, and uncoordinated care have been reduced through standardized protocols and safety practices, but medical errors still frequently harm and kill patients.
1) The study reviewed 122 malpractice claims from 4 insurers involving missed or delayed diagnoses in the emergency department.
2) 79 claims (65%) involved missed ED diagnoses that harmed patients, with 48% resulting in serious harm and 39% in death.
3) The leading causes of missed diagnoses were failures to order appropriate diagnostic tests or perform adequate exams, incorrect test interpretations, and failures to order appropriate consultations. The most common contributing factors were cognitive errors, patient factors, lack of supervision, and excessive workload.
Archives of Physical Medicine and Rehabilitation 2013 BennettChristian Niedzwecki
This study analyzed data on over 21,000 children with traumatic brain injury (TBI) to examine factors associated with receiving physical, occupational, and speech therapy evaluations during hospitalization. The results showed that 41% received a physical or occupational therapy evaluation, while 26% received a speech or swallow evaluation. Older children, those with more severe injuries, fractures, and certain medical treatments were more likely to receive evaluations. Evaluations most commonly occurred around 5-7 days after admission. There was wide variation between hospitals, from 11-74% for physical/occupational therapy evaluations and 4-55% for speech/swallow evaluations, suggesting the need for evidence-based guidelines on initiating rehabilitation therapies after pediatric TBI.
This document discusses medical error and strategies to reduce it. It notes that error is common in healthcare due to complex processes and lack of standardization. Reporting and analyzing errors can help identify systemic issues, but error reporting is currently underdeveloped. Information systems could help by providing decision support and monitoring for errors, but must be carefully designed to avoid introducing new latent errors. Overall, reducing medical error requires a systematic approach across organizations to improve safety culture, implement decision aids, and continuously learn from reported errors and close calls.
The document discusses computer-based patient records for anesthesia. It notes that Cushing-Codman made the first ether chart for keeping anesthesia records. Computerization allows for easy retrieval of data which is an important advantage. Hospital information systems can have a monolithic or "best-in-breed" model. The monolithic system has smooth interoperability but some components may be inferior. Electronic health records provide tools for provider communication and access to population data for research. Specialty electronic health records have been developed including for anesthesia, emergency departments, and intensive care units.
Reducing Medical Error and increasing patient safety Reducing Medical Error...MedicineAndHealth
Medical errors are common and result in many deaths each year. Around half of adverse events in hospitals are preventable. Errors often occur due to systemic issues rather than individual negligence. To improve patient safety, healthcare systems must be designed with a focus on safety, adopting principles such as encouraging reporting of errors without punishment, and continual learning and improvement from past errors and near misses.
1) Patients leaving hospitals against medical advice (AMA) account for 1-2% of discharges annually in the US, totaling around 500,000 patients. These patients are often young, male, uninsured or on Medicaid, and treated at urban hospitals.
2) Contrary to common belief, insurance companies will often still reimburse hospitals for care provided to patients who leave AMA. A recent study found 100% of AMA patients from a Northshore emergency department were fully reimbursed.
3) Hospitals and doctors can take steps to reduce AMA discharges by educating staff, removing misleading forms, meeting with patients to address concerns, and arranging follow up care for patients who insist on leaving
Medical Errors within the U.S. Healthcare SystemTerry Coulon
The document proposes an "All Hands on Deck" plan to reduce medical errors in hospitals. The 4 part plan involves teams analyzing error data, implementing a voluntary reporting bill in all states, increased oversight of health business groups, and FDA approval of health IT systems. It aims to comprehensively target errors at state and federal levels. If rejected by Congress, an alternative plan involves information sessions at hospitals ranked high for errors. The plan's benefits include its collaborative approach across agencies and states. Its costs are under $1 million, but it does not address nursing home errors or ensure hospitals' budget support.
Nursing Diagnosis is second step of Nursing Process.which is very important and depend on your good assessment.you must make nursing diagnosis skillfully to meet patient's need.
Medical errors pose a significant burden globally. While they occur most commonly in hospitals and psychiatric units, with wrong-site surgery being the most frequent issue, they are a preventable ongoing problem. Effective prevention requires multiple coordinated solutions and systems that focus on continually learning from past mistakes, rather than blame, in order to reduce future risks and harm to patients.
A voluntary, Internet-based reporting system for neonatal healthcare providers recently revealed that a broad range of medical errors occur in the NICU.[3] The most frequent error categories reported were wrong medication, dose, schedule, or infusion rate (including nutritional agents and blood products; 47%); error in administration or method of using a treatment (14%); patient misidentification (11%); other system failure (9%); error or delay in diagnosis (7%); and error in the performance of an operation, procedure, or test (4%). Errors in patient misidentification, for example, were a common cause of feeding a mother's expressed breast milk to the wrong baby.[3]
The document discusses various types of medical errors, including failure to provide care leading to self-harm and errors leading to harm not caused by the patient. It emphasizes the importance of accurate assessment over time, noting that diagnoses can change in response to life events. The document recommends differential diagnosis, awareness of issues like medical complexity, pregnancy, and domestic violence, and implementing intervention and prevention strategies to provide ethical care.
Staff nurses' perception of medication errors, perceived causes, and reportin...Reynel Dan
The document discusses a research paper on staff nurses' perceptions of medication errors. Specifically, it examines their perception of errors, perceived causes, and reporting behaviors. The paper provides background on medication errors being a major cause of preventable deaths. It discusses theories that guide the study and defines key terms. Overall, the paper aims to understand nurses' views and behaviors regarding medication errors to improve policies and reduce errors and associated costs and deaths.
Medical negligence occurs when a medical professional deviates from the accepted standard of care in treating a patient, potentially causing injury. It is the basis for medical malpractice lawsuits seeking compensation. To succeed, a plaintiff must prove: (1) a duty of care was owed by the medical professional; (2) this duty was breached by failing to meet the standard of care; (3) this breach caused injury; and (4) damages resulted from the injury. Common types of negligence include misdiagnosis, surgical errors, medication errors, and failure to properly follow up on treatment. Plaintiffs can establish negligence through expert testimony on the standard of care and whether the medical professional's actions deviated from this standard.
This study analyzed 943 patients who left the hospital against medical advice at a cardiac teaching hospital in Iran over a 14-month period. The most common reason patients cited for leaving against advice was a lack of consent to surgery or other invasive procedures (31%), likely due to fear of such procedures. Women were more likely than men to cite this reason, while men more commonly cited personal or family issues. The average length of stay before discharge against advice was 5.5 days. About 19% of patients who left against advice were readmitted within the study period.
Informed consent is required for any medical procedure and involves educating the patient on the nature, risks, and benefits of the procedure. Key aspects of informed consent include voluntary agreement from the patient, disclosure of relevant medical information, and the patient's competence to consent. Exceptions may apply in emergencies or for therapeutic reasons. Standards for obtaining informed consent aim to respect patient autonomy while balancing ethical obligations of beneficence.
This document discusses engaging patients as partners in patient safety efforts. It notes that while traditional methods have focused on competent staff and well-defined systems, medical error rates remain alarming. The patient is often the only constant in their care, and can serve as an extra set of eyes to help catch potential mistakes. The document advocates educating patients on safety issues and their role, and empowering them with information to play a proactive role in reducing errors. It also acknowledges some patients may prefer a more passive role unless caregivers are supportive of their involvement.
This document summarizes the terms and conditions for using the Polity website owned by Creamer Media. It states that by using the website, users agree to the terms which include limited liability for Creamer Media, no warranty on website content, indemnification, and that unauthorized use is prohibited. The document also provides Creamer Media's contact and location information as required by law and describes the website's subscription and advertising services.
Este currículum vitae pertenece a Ramiro Urrutia Giaccarini, nacido en 1989 en Las Palmas de Gran Canaria. Actualmente está cursando la Licenciatura de Publicidad y Relaciones Públicas en la Universidad de Alicante. Tiene experiencia como becario en una agencia de publicidad, gestor y redactor en un medio deportivo online, y redactor de notas de prensa para un club de fútbol.
Valery Boronin presented on Application Inspector SSDL Edition, an application security testing tool. He began with an overview of common problems with application security like poor code quality costing over $500 billion annually. He then demonstrated Application Inspector SSDL Edition's capabilities like automated scanning, issue tracking, role-based access controls, and guidance for developers on fixing vulnerabilities. Benefits highlighted were helping develop more secure software through interaction with developers and automatic validation of fixes. Future plans include integration with build servers, IDEs, and providing more customization, compliance support, and analytics.
PEER (Professionalism and Ethics Education for Residents) Project sponsored and organized by the Saudi Commission for Health Specialties (SCHS).
Definitions of terminology related to Medical Error (ME)
Levels of severity of medical error
Types & Examples of medical errors
Causes of ME
Disclosure of ME
Prevention of Medical Error
Medical errors represent a serious public health problem and occur frequently in various healthcare settings. They can involve medicines, surgery, diagnosis, equipment, or lab reports. Studies estimate medical errors may be the third leading cause of death in the US, resulting in between 200,000 to 400,000 deaths per year. Many common types of errors like misdiagnosis, unnecessary treatment, medication mistakes, and uncoordinated care have been reduced through standardized protocols and safety practices, but medical errors still frequently harm and kill patients.
1) The study reviewed 122 malpractice claims from 4 insurers involving missed or delayed diagnoses in the emergency department.
2) 79 claims (65%) involved missed ED diagnoses that harmed patients, with 48% resulting in serious harm and 39% in death.
3) The leading causes of missed diagnoses were failures to order appropriate diagnostic tests or perform adequate exams, incorrect test interpretations, and failures to order appropriate consultations. The most common contributing factors were cognitive errors, patient factors, lack of supervision, and excessive workload.
Archives of Physical Medicine and Rehabilitation 2013 BennettChristian Niedzwecki
This study analyzed data on over 21,000 children with traumatic brain injury (TBI) to examine factors associated with receiving physical, occupational, and speech therapy evaluations during hospitalization. The results showed that 41% received a physical or occupational therapy evaluation, while 26% received a speech or swallow evaluation. Older children, those with more severe injuries, fractures, and certain medical treatments were more likely to receive evaluations. Evaluations most commonly occurred around 5-7 days after admission. There was wide variation between hospitals, from 11-74% for physical/occupational therapy evaluations and 4-55% for speech/swallow evaluations, suggesting the need for evidence-based guidelines on initiating rehabilitation therapies after pediatric TBI.
This document discusses medical error and strategies to reduce it. It notes that error is common in healthcare due to complex processes and lack of standardization. Reporting and analyzing errors can help identify systemic issues, but error reporting is currently underdeveloped. Information systems could help by providing decision support and monitoring for errors, but must be carefully designed to avoid introducing new latent errors. Overall, reducing medical error requires a systematic approach across organizations to improve safety culture, implement decision aids, and continuously learn from reported errors and close calls.
The document discusses computer-based patient records for anesthesia. It notes that Cushing-Codman made the first ether chart for keeping anesthesia records. Computerization allows for easy retrieval of data which is an important advantage. Hospital information systems can have a monolithic or "best-in-breed" model. The monolithic system has smooth interoperability but some components may be inferior. Electronic health records provide tools for provider communication and access to population data for research. Specialty electronic health records have been developed including for anesthesia, emergency departments, and intensive care units.
Reducing Medical Error and increasing patient safety Reducing Medical Error...MedicineAndHealth
Medical errors are common and result in many deaths each year. Around half of adverse events in hospitals are preventable. Errors often occur due to systemic issues rather than individual negligence. To improve patient safety, healthcare systems must be designed with a focus on safety, adopting principles such as encouraging reporting of errors without punishment, and continual learning and improvement from past errors and near misses.
1) Patients leaving hospitals against medical advice (AMA) account for 1-2% of discharges annually in the US, totaling around 500,000 patients. These patients are often young, male, uninsured or on Medicaid, and treated at urban hospitals.
2) Contrary to common belief, insurance companies will often still reimburse hospitals for care provided to patients who leave AMA. A recent study found 100% of AMA patients from a Northshore emergency department were fully reimbursed.
3) Hospitals and doctors can take steps to reduce AMA discharges by educating staff, removing misleading forms, meeting with patients to address concerns, and arranging follow up care for patients who insist on leaving
Medical Errors within the U.S. Healthcare SystemTerry Coulon
The document proposes an "All Hands on Deck" plan to reduce medical errors in hospitals. The 4 part plan involves teams analyzing error data, implementing a voluntary reporting bill in all states, increased oversight of health business groups, and FDA approval of health IT systems. It aims to comprehensively target errors at state and federal levels. If rejected by Congress, an alternative plan involves information sessions at hospitals ranked high for errors. The plan's benefits include its collaborative approach across agencies and states. Its costs are under $1 million, but it does not address nursing home errors or ensure hospitals' budget support.
Nursing Diagnosis is second step of Nursing Process.which is very important and depend on your good assessment.you must make nursing diagnosis skillfully to meet patient's need.
Medical errors pose a significant burden globally. While they occur most commonly in hospitals and psychiatric units, with wrong-site surgery being the most frequent issue, they are a preventable ongoing problem. Effective prevention requires multiple coordinated solutions and systems that focus on continually learning from past mistakes, rather than blame, in order to reduce future risks and harm to patients.
A voluntary, Internet-based reporting system for neonatal healthcare providers recently revealed that a broad range of medical errors occur in the NICU.[3] The most frequent error categories reported were wrong medication, dose, schedule, or infusion rate (including nutritional agents and blood products; 47%); error in administration or method of using a treatment (14%); patient misidentification (11%); other system failure (9%); error or delay in diagnosis (7%); and error in the performance of an operation, procedure, or test (4%). Errors in patient misidentification, for example, were a common cause of feeding a mother's expressed breast milk to the wrong baby.[3]
The document discusses various types of medical errors, including failure to provide care leading to self-harm and errors leading to harm not caused by the patient. It emphasizes the importance of accurate assessment over time, noting that diagnoses can change in response to life events. The document recommends differential diagnosis, awareness of issues like medical complexity, pregnancy, and domestic violence, and implementing intervention and prevention strategies to provide ethical care.
Staff nurses' perception of medication errors, perceived causes, and reportin...Reynel Dan
The document discusses a research paper on staff nurses' perceptions of medication errors. Specifically, it examines their perception of errors, perceived causes, and reporting behaviors. The paper provides background on medication errors being a major cause of preventable deaths. It discusses theories that guide the study and defines key terms. Overall, the paper aims to understand nurses' views and behaviors regarding medication errors to improve policies and reduce errors and associated costs and deaths.
Medical negligence occurs when a medical professional deviates from the accepted standard of care in treating a patient, potentially causing injury. It is the basis for medical malpractice lawsuits seeking compensation. To succeed, a plaintiff must prove: (1) a duty of care was owed by the medical professional; (2) this duty was breached by failing to meet the standard of care; (3) this breach caused injury; and (4) damages resulted from the injury. Common types of negligence include misdiagnosis, surgical errors, medication errors, and failure to properly follow up on treatment. Plaintiffs can establish negligence through expert testimony on the standard of care and whether the medical professional's actions deviated from this standard.
This study analyzed 943 patients who left the hospital against medical advice at a cardiac teaching hospital in Iran over a 14-month period. The most common reason patients cited for leaving against advice was a lack of consent to surgery or other invasive procedures (31%), likely due to fear of such procedures. Women were more likely than men to cite this reason, while men more commonly cited personal or family issues. The average length of stay before discharge against advice was 5.5 days. About 19% of patients who left against advice were readmitted within the study period.
Informed consent is required for any medical procedure and involves educating the patient on the nature, risks, and benefits of the procedure. Key aspects of informed consent include voluntary agreement from the patient, disclosure of relevant medical information, and the patient's competence to consent. Exceptions may apply in emergencies or for therapeutic reasons. Standards for obtaining informed consent aim to respect patient autonomy while balancing ethical obligations of beneficence.
This document discusses engaging patients as partners in patient safety efforts. It notes that while traditional methods have focused on competent staff and well-defined systems, medical error rates remain alarming. The patient is often the only constant in their care, and can serve as an extra set of eyes to help catch potential mistakes. The document advocates educating patients on safety issues and their role, and empowering them with information to play a proactive role in reducing errors. It also acknowledges some patients may prefer a more passive role unless caregivers are supportive of their involvement.
This document summarizes the terms and conditions for using the Polity website owned by Creamer Media. It states that by using the website, users agree to the terms which include limited liability for Creamer Media, no warranty on website content, indemnification, and that unauthorized use is prohibited. The document also provides Creamer Media's contact and location information as required by law and describes the website's subscription and advertising services.
Este currículum vitae pertenece a Ramiro Urrutia Giaccarini, nacido en 1989 en Las Palmas de Gran Canaria. Actualmente está cursando la Licenciatura de Publicidad y Relaciones Públicas en la Universidad de Alicante. Tiene experiencia como becario en una agencia de publicidad, gestor y redactor en un medio deportivo online, y redactor de notas de prensa para un club de fútbol.
Valery Boronin presented on Application Inspector SSDL Edition, an application security testing tool. He began with an overview of common problems with application security like poor code quality costing over $500 billion annually. He then demonstrated Application Inspector SSDL Edition's capabilities like automated scanning, issue tracking, role-based access controls, and guidance for developers on fixing vulnerabilities. Benefits highlighted were helping develop more secure software through interaction with developers and automatic validation of fixes. Future plans include integration with build servers, IDEs, and providing more customization, compliance support, and analytics.
148909 Anexa 8 raportare lunara locatii implementare activitati mai 2015Adrian Dan Pop
Raportare privind locațiile unde se desfășoară activitățile/subactivitatile relevante din cadrul proiectului POSDRU "Pași spre incluziunea profesională prin dezvoltarea economiei sociale" pentru luna mai 2015
La pandemia de COVID-19 ha tenido un impacto significativo en la economía mundial y las vidas de las personas. Muchos países han impuesto medidas de confinamiento que han cerrado negocios y escuelas, y han pedido a la gente que se quede en casa tanto como sea posible para frenar la propagación del virus. A medida que los países comienzan a reabrir gradualmente, los expertos advierten que es probable que se produzcan nuevos brotes a menos que se realicen pruebas generalizadas y se implementen sistemas de rastreo de contactos para identificar rá
El documento presenta información sobre el Centro Educativo Rural Puerto El Sol, incluyendo su ubicación, población estudiantil, planta docente, perfiles de estudiantes, directivos y docentes, proyectos educativos y estadísticas de matrícula y deserción escolar. El centro educativo atiende a 250 estudiantes en siete sedes rurales del municipio de San Miguel, Putumayo y busca brindar educación de calidad y prevenir la deserción escolar en la región.
DEXMA proporciona productos y servicios de gestión energética, incluyendo su software DEXCell Energy Manager, para ayudar a reducir el consumo y coste energético a través de la monitorización, análisis e informes. DEXCell Energy Manager es un software analítico de gestión energética multi-fabricante que se ejecuta en la nube y permite la monitorización continua, análisis de datos, generación de alarmas e informes para mejorar la eficiencia energética.
El documento describe la vida y obra del fabricante de violines Antonio Stradivari, nacido en Cremona en 1657. Stradivari aprendió el oficio bajo la tutela de Nicola Amati y luego superó a todos sus predecesores gracias a la perfección de sus instrumentos y su inigualable sonido. Sus violines, producidos entre 1680 y 1730, son considerados obras maestras y cotizan hoy en día por millones de euros, aunque el secreto de su calidad sigue siendo desconocido.
Version control for spreadsheets - Bjoern Stiel at Eusprig 2014eusprig
Version control and continuous integration have become de-facto standards in software engineering. Source control gives developers control over changes to their source code, removes the friction of team collaboration and is vitally important for locating and fixing bugs. For developers, it is unthinkable to work without revision control. Yet when it comes to spreadsheets, the best we seem to have come up with so far is file name timestamping and keeping long lists of file versions. This talk gives an overview of source control and collaboration concepts. We start off with a brief introduction to graph theory, cover basic version design concepts and move on to the question why spreadsheets are stubbornly tricky beasts to version control. We will cover practical examples and discuss how to integrate version control (and continuous integration) into our workflow.
Este documento proporciona un resumen de un informe sobre auditorías de seguridad vial realizadas por un equipo de la FHWA en Australia y Nueva Zelanda. Explica brevemente el objetivo de las auditorías, su historia y definición. Resume las principales secciones del informe, incluidas descripciones de los países visitados, el proceso de auditoría, los hallazgos clave y las estrategias para promover las auditorías en EE.UU. El documento ofrece una visión general del marco y aplicación de las auditorías de seguridad vial
Whorld Union of Wholesale Markets Congres in Mexico.
Developing network strategies to support wholasele market operations. How IP networks improve market operations
Este documento presenta una introducción histórica a la glándula pineal. Detalla las primeras referencias a la pineal en civilizaciones antiguas como Egipto y la India, y su estudio por anatomistas griegos como Herófilo. Luego describe los principales períodos en la investigación occidental de la pineal, desde la Edad Media hasta el descubrimiento de su función endocrina en el siglo XIX. Finalmente, resume los avances en el estudio de su anatomía, histología y posible papel en la regulación de la pubertad en el siglo XX.
Este documento describe los requisitos y procedimientos para que los estudiantes de tercer año de un liceo técnico-profesional realicen una investigación en una empresa como parte de sus estudios. Explica que los estudiantes deberán investigar la organización y estructura de una empresa asignada durante un período determinado, y presentar un informe escrito y una presentación oral que serán evaluados. También incluye los plazos, etapas, formatos y criterios de evaluación para la investigación.
Using ca e rwin modeling to asure data 09162010ERwin Modeling
Data profiling analyzes data content to infer metadata and increase the accuracy of data assets and models. It can help with data quality assessments, master data management, and reducing risks in data warehousing projects. The presentation provided examples of how profiling was used to uncover issues, validate models and requirements, standardize values, and reduce development times for various organizations.
The document provides information about traveling to Agra and visiting the Taj Mahal. It describes how to reach Agra by air, rail, road, and the upcoming Yamuna Expressway from Noida. It discusses the history of the Taj Mahal, how Emperor Shah Jahan built it as a monument to his wife Mumtaz Mahal. It also briefly describes the Islamic architecture of the Taj Mahal and provides information about tours that include visiting Agra and the Taj Mahal.
El perfil profesional presenta experiencia en gestión comercial y liderazgo de equipos multidisciplinarios. Cuenta con habilidades en dirección de ventas y marketing, administración financiera, y gestión de personal multicultural. Está titulado en Ingeniería Comercial y posee un Magíster en Marketing Comercial.
This document discusses the importance of collaborative care and care coordination for healthcare delivery systems. It notes that solo practice is no longer a sustainable business model and that fee-for-service payments have limitations. The document provides evidence that care coordination can reduce costs through fewer hospital admissions and readmissions without worse health outcomes. It also shows that patients experience a lack of communication and information sharing between their different doctors. To improve care coordination, mobile access to patient data and collaborative workflows are seen as critical, as mobile devices are increasingly how physicians access information. The right devices and secure mobile computing are needed to enable these new care coordination models.
Why Emplyers care about Pimary care 2008Paul Grundy
Employers have struggled with rising healthcare costs and uneven quality of care. Investing in primary care may help address these issues, as primary care is associated with reduced costs and better health outcomes. However, primary care faces a crisis in the US with a declining primary care workforce. Employers are well positioned to help strengthen primary care through initiatives that support primary care practices, payment reform, and advocating for policies that value primary care. By rebuilding the primary care system, employers can work towards stabilizing costs and improving employee productivity.
This document provides an overview of hospitalist careers, including definitions, history, workforce facts and trends, recruitment considerations, and factors influencing physician career decisions. It discusses the growth of hospitalists from a few hundred in 1996 to over 30,000 currently practicing in the US. Hospitalists typically work block schedules without taking call and have opportunities in clinical work as well as leadership roles. Recruitment and retention are influenced by lifestyle preferences of younger physicians as well as an aging physician workforce. The document outlines various hospitalist roles and recruitment programs to attract physicians.
The document summarizes information about patient-centered medical homes (PCMHs) and healthcare transformation efforts at the University of Utah and elsewhere. It discusses how PCMHs have led to reductions in emergency room visits, hospital admissions, and specialty care visits while improving outcomes for patients. The document also outlines the key principles of the PCMH model and how it can improve coordination of care, access, and overall population health while lowering costs.
The document summarizes key aspects of the physician market in the United States, including market structure, conduct, and performance. It notes that the US has a higher proportion of specialists compared to other countries, which may contribute to higher healthcare costs. Physician practices are increasingly moving to group models, which tend to be more productive and benefit from economies of scale. Managed care places pressures on physicians to control costs and modify behavior.
Dr. Edward Wagner, Director (Emeritus) MacColl Center, Senior Investigator, Group Health Research Institute addresses the 2014 Weitzman Symposium on The Future of Primary Care
Rob Reid: Redesigning primary care: the Group Health journeyThe King's Fund
Rob Reid, Senior Investigator at Group Health Research Institute, explains the journey taken by Group Health in support of integrated primary care. A case study in how primary care can be delivered effectively and efficiently to a population, Rob laid out the challenges facing general practice in the States, and how Group Health worked to improve the situation for both patients and the workforce.
Engaging your patients & community in healthcare reform effortsRenown Health
1⁄2 FTE
Programs: Monthly lunch meetings with speakers; social events; newsletter;
volunteer opportunities; recognition events.
Benefits: Sense of community, camaraderie, purpose, connection to BH.
Major benefit to Development, Volunteers, Community Relations
22
Mini-Medical School
Began: 2001
Goal: Educate the community about health and wellness in an engaging, fun way.
Format: 6 weekly 2-hour sessions with MDs, RNs, other clinicians.
Topics: Heart disease, cancer, diabetes, women’s health, men’s health, nutrition.
Participants: 150-200 community members per session.
Cost: $
This document discusses several enduring problems in healthcare systems including uncertainty about clinical effectiveness due to poor quality research, persistent variations in clinical practice, patient safety issues, reluctance to manage skill mix, and poor outcome measurement. It also outlines some achievements of the UK healthcare system such as the establishment of NICE to evaluate clinical and cost effectiveness, introduction of targets to reduce wait times, and beginning to benchmark safety incidents. However, it notes continuous reorganizations have not been properly evaluated and there is a need for greater focus on improving average performance and ensuring best practices are universally adopted.
· Psychiatric Mental Health Nursing. Scope and Standards of Practi.docxoswald1horne84988
· Psychiatric Mental Health Nursing. Scope and Standards of Practice.
Review the Scope and Standards of Practice from APNA (American Psychiatric Nurses Association). If you are an APNA member you can access the book free of charge. The link in this section will link you to the book but you will have to log in. It is a good idea to join APNA. You can also buy a print copy if you desire; it is inexpensive. The book is not a required reading. I have provided the standards here.
The standards are taken directly from APNA Scope and Standards of Practice 2ndedition (2014).
Assignment for this module:
Take each Standard and give several examples of how you will follow these standards in your practice. Please, only list just a few bullet points to address each standard. Ex: Standard 1: Assessment—what screening tools will you use? Will you meet with the pt and family together or separate or both? How much time will you allow for a new patient eval?
As a NP will need to know your scope of practice. You cannot rely on someone else to know your scope.
Standard 1: Assessment
· Collect and synthesize comprehensive health data that are pertinent to the healthcare consumer’s health and/or situation.
Standard 2: Diagnosis
· Develop standard psychiatric and substance use diagnoses
Standard 3: Outcomes Identification
· Identify expected outcomes and the healthcare consumer’s goals for a plan individualized to the healthcare consumer or to the situation.
Standard 4: Planning
· Develop a plan that prescribes strategies and alternatives to assist the healthcare consumer in attainment of expected outcomes.
Standard 5: Implementation
· Implement the identified plan
· Coordinate care delivery
· Employ strategies to promote health and a safe environment
· Provide consultation to influence the identified plan, enhance the abilities of other clinicians to provide services for the healthcare consumers, and effect change.
· Use prescriptive authority, procedures, referrals, treatments and therapies in accordance with state and federal laws and regulations.
· Incorporate knowledge of pharmacological, biological, and complementary interventions with applied clinical skills to restore the healthcare consumer’s health and prevent further disability
· Provide structures and maintains a safe, therapeutic, recovery-oriented environment in collaboration with healthcare consumers, families and other healthcare clinicians.
· Use the therapeutic relationship and counseling interventions to assist healthcare consumers in their individual recovery journeys by improving and regaining their previous coping abilities, fostering mental health, and preventing mental disorder and disability
· Conducts individual, couples, group, and family psychotherapy using evidence based psychotherapeutic frameworks and the nurse-client therapeutic relationship
Standard 6: Evaluation
· Evaluate progress toward attainment of expected outcomes
Standard 7: Ethics
· Integrate ethical provisions in all .
Provides an overview of wellness program trends, including a look at the role of prepaid wellness cards as a central component of employer wellness programs. We will also look at meaningful incentive thresholds and identify obstacles to program adoption.
The document discusses the patient-centered medical home (PCMH) model for healthcare delivery. It defines key principles of the PCMH model, including having a personal primary care physician, care coordination by an interdisciplinary team, and a focus on comprehensive, high-quality care. The document argues that the PCMH model should be adopted now because the current healthcare system is broken and unsustainable due to rising costs and quality issues. It also outlines how various stakeholders could benefit from the PCMH model through things like improved health outcomes, reduced costs, and enhanced care coordination.
2011 04 Sargen Hooker Cooper Gaps In Physician Supplyrodhooker
If current projections for training programs of advanced practice nurses and physician assistants are realized but physician residency programs are not expanded, the combined supply of advanced clinicians will be 20% less than projected demand in 2025. Increasing the number of first-year residency positions by 500 annually would narrow but not close the gap, which would remain above 15%. Efforts must be made to expand training of physicians, advanced practice nurses, and physician assistants, while also reforming clinical practice models to facilitate task sharing among a broader range of providers.
Patient Reported Outcomes (PRO) - Challenge and potential solutions.
Why and how can medical device and pharmaceutical companies, as well as the entire healthcare sector, leverage patient engagement with next-generation ePRO solutions?
Discover our white paper...
Clinical redesign aims to reduce costs through physician-led initiatives that improve margins while maintaining or enhancing quality. Hospitals continue facing financial pressures from weaker revenues, Medicare cuts, and increased spending needs. Summarizing a sample hospital's analysis, opportunities were found in provider productivity, compensation alignment, workforce optimization, and service portfolio review, with estimated annual savings of $3-4 million. Physician engagement is critical for successful clinical redesign.
Using Patient Registries and Evidence-Based Guidelines to Overcome Declining ...Phytel
Mankato Clinic implemented automated patient outreach to improve quality of care and address declining visit trends. Using patient registries and evidence-based guidelines, the outreach identified care gaps and engaged patients to schedule recommended visits. Patients responded quickly to the outreach, with 27% scheduling visits within 5 days. Following the outreach implementation, outpatient visits increased by 22%, demonstrating the program's ability to motivate patients and improve compliance with guidelines.
MSN 5650 MRU Reducing Hospital Readmission And Improving Quality Of.pdfbkbk37
This document discusses reducing hospital readmissions and improving quality of care. It identifies several key causes of hospital readmissions, including patient non-compliance, inappropriate transition procedures after discharge, complex medical conditions, and medication errors. Addressing these issues ethically requires ensuring patients receive clear discharge instructions, follow-up care, and avoiding harm from medical errors. Hospitals must provide high-quality care during and after a patient's stay to minimize preventable readmissions.
Similar to Engaging Physicians In Information Technology (20)
Lecture given as part of a healthcare leadership development course. Objective was to link the personal drive that brings a physician or nurse to pursue leadership opportunities with the reality of how to think about innovative change and healthcare transformation.
This document summarizes a presentation on positioning hospitalist programs for success. It discusses key drivers of health reform like value-based care and reducing costs while maintaining quality. Traditional drivers that helped growth of hospitalist programs are reviewed, like managing unassigned patients and primary care overload. Metrics to measure a successful program are outlined. Current challenges with primary care are described. The presentation positions hospitalists as integral in new models like Accountable Care Organizations that focus on coordinating overall patient care.
The document discusses coordination of care in hospitalist medicine. It provides background on Michael Wagner and his positions. It then discusses collaboration at different levels - 1st order collaboration involves direct patient care, 2nd order collaboration are relationships between hospitalists and other providers, and 3rd order collaboration is between hospitalist programs and other departments. Specific areas of collaboration discussed include communication with nurses, multi-disciplinary rounds, relationships with ED physicians, standardizing care expectations, and coordinating with primary care physicians. The presentation provides examples and best practices for enhancing collaboration at each level.
This document provides an update on the 2010 flu season. It reviews the 2009 H1N1 pandemic, symptoms of the flu, why it can be life-threatening, flu vaccination recommendations, treatments, and prevention methods. It highlights that certain groups are at higher risk for flu complications, including the elderly, young children, pregnant women, and those with chronic health conditions. People exhibiting warning signs like difficulty breathing or persistent fever and cough should seek medical care.
This document discusses the application of medical staff standards in an academic division of internal medicine. It outlines the organizational hierarchy, sources of data for practitioner evaluation, and methods of practitioner reporting. It describes the framework for quality and different cycles of practitioner evaluation, including continuous, ongoing, and focused reviews. An example is provided of proposed metrics for ongoing practitioner reviews in internal medicine and adult primary care.
The document outlines key principles from the Joint Commission regarding medical staff standards that clinical department chiefs should be aware of. It discusses the hierarchical structure of the medical staff and roles of the department chair. The chair is responsible for oversight of clinical and administrative activities, continuous surveillance of practitioner performance, credentialing and privileging recommendations, and assessing individual and aggregate quality metrics to improve patient and physician performance.
2. Biographical sketch
Michael Wagner, MD
Mi h l W
Dr. Michael Wagner is currently the Chief of General Internal Medicine at Tufts Medical Center in Boston
Mass. He has been practicing internal medicine for 19 years as a primary care internist and hospitalist. He
p g y p y p
received his undergraduate degree from Connecticut College and medical degree from Georgetown
University School of Medicine. He completed his residency at Dartmouth-Hitchcock Medical Center in New
Hampshire. He is board certified in internal medicine and is a fellow of the American College of Physicians.
Dr. Wagner has held numerous appointments, including his current role as the Chief of General Internal
Medicine at Tufts Medical Center, CEO of EmCare Inpatient Services in Dallas Texas, Regional Medical
Director for Cove Healthcare in La Jolla Ca. and Residency Program Director in Internal Medicine at St.
Mary’s Hospital/University of Rochester in Rochester NY.
Dr Wagner has focused his career on building and managing effective physician practices in community and
academic settings. His has been involved in many IT projects from naval underwater warfare simulation to
electronic medical records and large database analysis.
Dr. Wagner currently manages the clinical division of General Internal Medicine which provides primary
care to 33,000 patients in downtown Boston. The division also has an inpatient/hospitalist program,
consultative service and concierge practice. Dr. Wagner is actively involved in teaching medical students
and residents. He serves on many hospital committees and task forces including the Institutional Review
Board.
In addition to his academic work, Dr. Wagner has extensive experience with community based physician
practices and hospitals. As the CEO of a national physician practice management company, he built and
managed over 60 hospitalist programs in 16 states employing 385 physicians.
Today Dr. Wagner will be sharing his experience and insights on achieving physician buy-in for effective IT
adoption and engagement.
Michael Wagner, 2009
3. Goals of Session
Review the context of primary care practice
environement
Outline the framework for an IT implementation
Lessons learned from an EMR implementation
Questions and discussion
Michael Wagner, 2009
4. A little more detail…
4
Disclosures
Chief, General Internal Medicine Tufts Medical Center
Founding Member, Phoenix Group
Biases
Clinical – Internal Medicine/Hospitalist
Organizational – Academic and community based physician
practices
i
Geography – Northeast, but with national view
Goal
Leave you with a few insights and methods
Outline the transformative nature of IT adoption
September 2009 M Wagner MD
5. Biases - National experience
p
Review and/or design hospitalist program
Work as hospitalist
Review and/or design primary care practice
5 Jan 2009 M Wagner MD
7. Status report – Primary care physicians
p y p y
Physicians
Physicians’ Perspective study
Trends on where trainees are going
Burdens on primary care
Michael Wagner, 2009
9. The Physicians’ Perspective: Medical
Practice in 2008
Study outline
Survey on physician perspectives mailed to:
>270,000 primary care physicians
50,000 randomly selected specialty physicians
Survey completed and reported in 2008
Sponsored by “The Physician’s Foundation” a non-profit
p y y p
company promoting physician practices and competed by
Merritt Hawkins and Associates
Results ~12,000 respondents
~12 000
Margin of error of about 1%
The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”
10. The Physicians’ Perspective: Medical
Practice in 2008
Morale
Physician rated their colleagues morale
Positive – 6%
Poor o Very Low – 42%
oo or Ve y ow %
Self rating
78% of physicians said medicine is either “no longer
no
rewarding” or “less rewarding”
Capacity
76% of physicians said they are either at “full capacity” or
“overextended and overworked”
The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”
11. The Physicians’ Perspective: Medical
Practice in 2008
Paperwork
p
Impact on time spent with patients
63% of doctors said non-clinical paperwork h
fd d l l k has
caused them to spend less time with their patients
Amount of time spent on paperwork
94% said time they devote to non-clinical
paperwork in the last three years has increased
ki h l h h i d
The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”
12. The Physicians’ Perspective: Medical
Practice in 2008
Government
“Declining i b
“D li i reimbursement” highest rated problem and 82% said their practices
” hi h d bl d id h i i
would become unsustainable if Medicare cuts are made
Reimbursement fails to cover costs
Medicaid – 65% of practices
Medicare – 36% of practices
Closed practices
Medicaid – 33% of practices
Medicare – 12% of practices
Finances
Health and profitable?
17% of physicians rated their practices
Would you retire?
45% of doctors would retire today if they had financial means
fd t ld ti t d th h d fi i l
The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”
13. The Physicians’ Perspective: Medical
Practice in 2008
Impact on physician workforce
An overwhelming majority of physicians – 78% – believe there is
a shortage of primary care doctors in the United States today
49% of physicians – more than 150,000 doctors nationwide –
said that over the next three years they plan to reduce the
number of patients they see or stop practicing entirely.
p y pp g y
11% said they plan to retire
13% said they plan to seek a job in a non-clinical healthcare setting
20% said they will cut back
10% said th will work part-time
id they ill k t ti
60% of doctors would not recommend medicine as a career to
young people
l
The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”
14. Paperwork
p
Consult letters
Drug warnings
Medication substitutions
VNA forms
Oxygen orders
Notifications of PT-1 form
reauthorization requirements
Prior authorizations
Managed care patient lists
Refill authorizations
Letters from the division chief
Misc letters
Michael Wagner, 2009
15.
16.
17. Dissatisfaction with primary care
p y
17
Burden
Non-visit clinical work without support
Administrative paperwork
Technology 70
Compensation 60
50
Respect
40 General
G l
Role models Hospitalist
30 Subspecialty
Control 20
Medical school loans 10
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Source: Internal Medicine In-Training Examination Survey
M Wagner MD Jan 2009
18. Choices
18
Hospitalist Medicine Primary Care Medicine
The graduate
Michael Wagner, 2009
19. Choice: Primary Care vs. Hospital Medicine
Primary Care IM Hospital Medicine
Full time work commitment 18.75 days/month 15 shifts/month
Patient encounters per day 20-30 pts per day 15-18 pts per shift
Average compensation $150,000-$180,000/yr $180,000-$220,000/yr
Overhead Office, staff, equipment,
Office staff equipment Billing and medical
supplies, billing, medical malpractice
malpractice
Non-visit clinical work >100 documents/day Minimal
Administrative work Prior authorizations Inpatient payment
Referrals, FMLA, PT-1, denials
Disability forms, etc
Panel size 1,500 to 2,500 0
Schedule Monday - Friday On-off for blocks
Workday Controlled by schedule Controlled by patient
need, nursing, DC time
19 Michael Wagner, 2009
21. Strategic analysis
Strategic Drivers Responses
Aging and chronic illness Increasing visit and non-visit
burden increase clinical work
Shrinking MD workforce Increasing ratio of patients
per primary care MD
Reduction in health care Application of evidence
dollars/patient based care to make quality
and utilization more uniform
Michael Wagner, 2009
21
22. Transition Strategic Drivers
1. Aging and chronic illness burden increase
analysis 2.
3.
Shrinking MD workforce
Reduction in health care dollars/patient
22
Accelerants
1.Investment
1 Investment
2.MD workforce
3.Hospital medicine
Current state Future state
General Internist The New Internist
Concerns
• Vi it f
Visit focus • L d of t
Leader f team
1.MD-Patient relationship
• Space and staff • Population focus
volume focused • Employed in larger
• Solo Wildcards organization
g
1.Retailization
2.Health Care reform
3.Information technology
Michael Wagner, 2009
Wagner
4.Remote monitoring
4R t it i
5.Non-physician providers
6.Organizational acceptance
23. The patient – physician relationship
p p y p
23
Minimal
Radiology
Anesthesia
Episodic What is the value of a continuous
relationship between a patient and
Consultants physician?
Hospitalist
Urgent care
g
ED
Continuous
Internist
Pediatrics
Family Medicine
Some specialty care
p y
Michael Wagner, 2009 Jan 2009
24. Levels of Patient Engagement
g g
Highly engaged
Engaged
Engaged with normal prompts
Fragmented engagement
g g g
Disengaged
g g
Michael Wagner, 2009
25. Deconstructing Primary Care
g y
25
1.Visit and non-visit work
2.Disease/condition care 1.Visit based work
management 2.Access is essential
3.Multidisciplinary teams 3.Physical space designed
for urgent care
4.Triage and collaboration
with ED and hospital for
transfers
Chronic Urgent
Care Care
Health
Screening
1.Non-visit work is substantial
2.Screening based on accepted
guidelines
3.Requires
3 Requires coordination with
specific screening services
(Mammo, Endo)
Michael Wagner, 2009
26. The New Internist - Role
Expert in the care of the medically complex patient
p y p p
Manages patients with complex medical conditions
across the spectrum of healthcare services and over
time
ti
Team player
Works in collaboration with a multidisciplinary and
integrated team
Nursing
Social work
Home based services
Nutrition
Michael Wagner, 2009
27. The New Primary Care Physician – practice structure
Physician is part of the multidisciplinary team and is the medical leader
Direct patient care
Supervision of non-physician providers
Clinical guidelines, protocol development
Case review
Practice is structured to support visit and non-visit clinical work
Information technology
Integrated EHR, e-prescribing, patient portal
Staff
For visit work focused on efficient patient flow
For non-visit work – phone/electronic staff, case management
Space
S
Practice supports lifestyle needs of providers
Continuous professional development program
Transfer of care relationships with specialists/hospitals th t provide a hi h l l
T f f l ti hi ith i li t /h it l that id higher level
of care (applicable to rural and community facilities)
Michael Wagner, 2009
28. An Organizational Approach to
Primary C
Pi Care
Align patients with your healthcare organization through effective primary care practices
Create a platform for physician recruitment and retention by offering a stable employment
structure. Align compensation program with value based health care
Implement an electronic health record that is integrated with other information systems in order to
p g y
avoid duplication of data entry and facilitate access and transparency
Quality integrated into clinical operations with appropriate staffing and support
Reorganize staff to manage populations of patients in addition to managing visit based clinical
work. Augment with multidisciplinary team members for niche issues such as home bound patients,
hospice, etc.
Reconfigure space to handle visit and non-visit clinical work
non visit
Reorganize physician work schedule to account for non-visit work and team participation
Negotiate payer contracts to assume greater control over medical budget with appropriate
risk/reward
Michael Wagner, 2009
29. Review
Primary care is on the cusp of a major change
Current workloads and burdens are making the current
practice structure non-sustainable
In order to create sustainable models for primary care
care,
organizations or physician groups must rebuild the
infrastructure supporting physicians
IT can be transformative in this process
How d
H do you engage physicians t embrace an IT
h ii to b
implementation in the face of such a negative work
environment?
Michael Wagner, 2009
29
31. Components of an IT Implementation
p p
Providers/
Users
Project
Plan
Operations Technology
Michael Wagner, 2009
32. Technology - IT system invasiveness
gy y
Highly Invasive
• Electronic Medical Records The more invasive the IT system is in terms
• CPOE of daily workflow, the more MD engagement will
• Patient portal be needed to successfully implement the system
y p y
Invasive
• Billing / Charge entry
g g y
• Managed care registries
• Clinical information systems
Minimally Invasive
• Backend dictation systems
• Patient scheduling systems
• Order entry systems (non-CPOE)
Michael Wagner, 2009
33. Organizational factors
g
What are the drivers for the IT system?
Who is driving the program?
Have those who will be effected be engaged?
Have the goals of the project been clearly outline,
including:
What the system is designed to do?
What the system is not designed to do or fix?
Have resources been appropriately allocated?
Michael Wagner, 2009
34. Organizational - Recheck
g
What are the intended and unintended
consequences of the IT system?
Let s
Let’s recheck – do we have the right people and
resources?
Michael Wagner, 2009
35. Engagement is a state of mind…
g g
Respect
Communication The engagement and attitude of the
Interests leaders/drivers of the IT implementation
leaders/drivers of the IT implementation
will set the tone for the project. A challenge
Concerns for the executive team driving this project will
be to use these qualities listed to the left when
Intelligence
I lli interacting with the providers and staff using the
h h d d ff h
new IT system.
Data
Michael Wagner, 2009
37. Project p ( )
j plan(ner)
Experience and organizational skills matter.
Frequent organized meetings with project manager
to hold participants feet to the fire.
Action plans and minutes.
Experience with successful implementation of same
program in similar size organization.
Good sense of humor
humor.
Michael Wagner, 2009
38. Where to find Physician Leadership?
y p
Michael Wagner, 2009
39. Physician factors
y
Role of physician leadership
Nurturing future physician leaders
Scoping out your doctors
Avoid
A d
Nattering nabobs of negativism
Technocrati
Disorganization
Go for the silent, and usually appreciative, middle
Train h
T i the trainer model of education
i d l f d i
Behind the scenes lobbying, education and occasional
deals
Michael Wagner, 2009
41. Levers for transition
What is broken? What will be fixed?
What is in it for me?
How will this help the practice?
How will this help patients?
Michael Wagner, 2009
42. Strategies for Success
g
Have clear objectives that penetrate clinical work flows
Respect existing clinical work flows, but seize on
opportunity to re-work and fix what is recognized as
broken
Listen carefully to physician concerns and incorporate
suggestions when feasible – be gracious
Focus on the silent majority and build a system that will
work for them
Provide options and choices. Developing 3-4 well
p p g
worked out clinical work flows is better than forcing one
solution on everyone or keeping the 20 different ways it
is done todayy
Michael Wagner, 2009
43. Essential components
p
Engagement
g g
Planning that involves all parties
Training
g
Adjusting clinical volumes during implementation
Pre-loading data
g
Train the trainer model and super users
Phasingg
High touch and presence during GO-LIVE
Have Fun!
Michael Wagner, 2009
49. Transition Drivers
1. Risk management
analysis 2.
3.
3
4.
Drug recalls
Reports for Boston Public Health Department
R f B P bl H l h D
On-call access to patient data
49
Accelerants
1. MD leadership
2. Investment
Current state – Future state –
Paper based EHR
records
Concerns
1. MD-Patient relationship
2. Time
3. Productivity Wildcards
4. Computer skills 1. Vendor support
2. IT support
3. Administrative bandwidth
4. MD revolt
5. Patient acceptance
6. Budget hawk
Michael Wagner, 2009 Michael Wagner, 2009
50. Timeline
1999- Realization - practice must have EHR
April 2000 – Presentation to system RAC
Summer 2000 - Rejection by system RAC
Fall 2000 – Project approved under hospital RAC process
Late 2000 – Vendor selected – Medicologic “Logician”
product
Early 2001 – Project planning process begun with weekly
and bi-weekly meetings
Summer 2001 – Final testing – training begins
g g g
August 2001 – GO LIVE
January 2002 – Physician order entry initiated
Michael Wagner, 2009
52. Functionality
y
Appointment lookup – passive
Note writing – with options
Order entry
Results reporting
Lab
Rad
Path
Medication management
Meds
Prescriptions (does not meet e-prescribing standard)
Phone call management
ED and hospital notifications
Michael Wagner, 2009
53. Creating options – Note generation
g p g
Form
Transcription Quick Text Free form
Components
Final Note i
Fi l N in
Electronic Medical Record
Michael Wagner, 2009
54. Paper records
p
Paper based records
Destinations
1.
1 Clinic chart
2. Medical Record
3. Provider copy
Office visit
Our traditional view of what the output of an office visit has narrowed our
concept of a “medical record”. We have tended to focus on the note as
the physical structure that must be reproduced in electronic format.
Michael Wagner, 2009
55. EMR – not just a p y note writer
j pretty
Data repository Destinations
• Notes • Patients
• Labs / Rads • CHIN/Hub
• Phone notes • Hospital(s)
• Orders / sets • Registries
• Medications • Research
• P4P reporting
However, an EMR is the foundation of a data
repository and p
p y practice structure for
effective medical management of
individual patients and population of patients.
Michael Wagner, 2009
56. Loading the EMR
g
Demographic data is
easily added t EMR
il dd d to
through an interface
from scheduling system
Michael Wagner, 2009
57. Clinical data is added
Sample reports
p p manually and requires
constant attention to
ensure work is being
done.
Michael Wagner, 2009
58. Flu season 2001
In 2001, for the first time, we could track the actual
number of flu shots given and who got the shots
in real time
time.
Michael Wagner, 2009
59. Flu 2009
Flu Surge Data
Administrative and Logician
Data
9/23/2009 8:22
9/14 9/15 9/16 9/17 9/18 9/19 9/20 9/21
Human resources Goal Average Monday Tuesday Wednesday Thursday Friday Saturday Sunday Monday
Administrative staff out 0 1 1 1 3 3 3
Nursing staff out 0 0 0 0 1 0 0
MD staff out
MD t ff t 0 0 0 0 0 0 1
Practice capacity Urgent care capacity at 8AM 25 18 26 29 32 37 20
Appointments scheduled at 8 AM 244 411
Appointments completed 381 323 285 355 237 363
Historical daily
average*
Volume
V l
Phone notes 318 313 381 290 303 319 270 16 4 387
Office Visit notes 260 282 302 313 275 304 215 287
ED visits of patients in Logician 26 28 29 25 29 30 31 25 25 22
Hospital admissions of patients in Logic 11 14 22 14 14 15 18 5 9 15
Ordering Chest xrays 10 9 14 7 9 9 4 8
Flu shots (highlighted cell is to date)
Flu shots (highlighted cell is to date) >5000 1213 200 39 19 56 16 105
E&M codes with URI/Flu ICD9 code
*Average from 9/10/2008 ‐ 9/11/2009
In 2009, we can use a combination of information sources to prepare for a
possible flu surge Most of the data comes from our EMR
surge. EMR.
Michael Wagner, 2009
60. Typical questions to answer from the EMR
How many patients do we have in the practice?
How many seen in past three years?
How many diabetics?
What is average A1C?
How has highest A1C?
By PCP
How many diabetics?
How many have met process measures?
How many are meeting outcome measures?
Of the patients coming in today:
Who is diabetic?
What interventions need to be completed?
Michael Wagner, 2009
62. Creating a platform for sustainability
g p y
Issues
Issues •Upgrades
•Note structures Technology
•Problems
•User defined •Interfaces
tables
bl
•Patient lists
•Problem lists Issues
•Medication lists p
•Specialized
•Training and re- training
training •Providers tables
•New feature
Clinical work Product development,
development
flows customization testing and
integration
Michael Wagner, 2009
63. General Internal Medicine
One f
O of many practices at Tufts
ti t T ft
Tufts MC
Medicine Pediatrics Surgery
GMA Cardiology GI Renal … Gen Peds Ped GI … …
GMA has 60,000 visits,
but 240,000 visits were
happening in other clinics
Michael Wagner, 2009
64. Snapshot of work generated in the
EMR
Total number of Average number Ratio compared Number compared to
documents since per day for all of to office visit average volume of 20
Document type January 2008 GMA volume patients per day
Office Visit 63,932 256 1.00 20
Coumandin 9,058 36 0.14 3
Phone Note 75,103 300 1.17 23
Rx Refill
e 20,861
0,86 83 0 33
0.33 7
Letter - Results 39,310 157 0.61 12
Medication list 14,845 59 0.23 5
External Correspondence 18,726 75 0.29 6
Internal Correspondence 10,241 41 0.16 3
Other letter 39,543 158 0.62 12
Lab Report 258,036 1,032 4.04 81
Imaging Report 17,115 68 0.27 5
Pathology Report 4,052 16 0.06 1
Hospital Admission* 3,530 14 0.06 1
Emergency Report* 9,002 36 0.14 3
Totals (excluding office visit) 519,422 2,078 8 162
Other notes* 87,631 351 1.37 27
Based on Tufts GMA EMR data from January 15, 2008 to January 15, 2009
Michael Wagner, 2009
66. Avalanche of data
By the end of the week the
physician will have reviewed in
excess of 700 electronic
documents plus mail, fax and
email
Michael Wagner, 2009
67. IT overload and lack of integration
g
Logician / Centricity Clinic electronic health record
Soarian
S i Hospital li i l information
H it l clinical i f ti
PatientKeeper Physician billing system
RelayHealth Patient portal
QuantiaMD Physician education website
RCO/Envision Patient scheduling system
Standing Stone Warfarin management system
Dr. Quality Quality reporting website
Bed Board/ADT Inpatient bed tracking system
NEQCA registry Managed care quality monitoring
Mail Tradition mode of communication
Email General communication
Fax Legacy system
Phone Legacy system
Intranet (phone book, Up to Date) Information resources
Veriphy
p y Radiology critical result reporting
gy p g
SoftMed/ESA Electronic signature for dictations
Michael Wagner, 2009
68. Lessons earned
Like the field I showed earlier, an EMR needs constant
tending. The work flows may be automated, but the field
and hardware get old, broken and fail to keep up with the
changing landscape. Patient, problem and medication lists
need to be updated constantly.
dt b d t d t tl
Decisions must be made up front on who and how the
product will be maintained. Some of that maintenance will
need to b done by clinical people, so i
d be d b li i l l invest accordingly.
di l
Information systems are popping up everywhere and there
is little integrative analysis being done when a new system is
selected and implemented. The end result is clinicians
interacting in a fragmented digital landscape. Which will
only worsen physician satisfaction and increase patient risk
Michael Wagner, 2009