Hospitals and Health SystemsHospitals and Health Systems::Nurses and Physicians in the Implementation of the Nurses and Physicians in the Implementation of the

EMR at NYC Health & Hospitals CorporationEMR at NYC Health & Hospitals Corporation

Marie Marie AnknerAnkner, RN, MS, CNAA, HHC, RN, MS, CNAA, HHCAbhaAbha AgrawalAgrawal, MD, Kings County Hospital/HHC, MD, Kings County Hospital/HHCLouis Louis CapponiCapponi, MD, HHC, MD, HHCGlenn Martin, MD, Queens Health Network/HHCGlenn Martin, MD, Queens Health Network/HHCNadia Sultana, MBA, RN, BC, HHCNadia Sultana, MBA, RN, BC, HHC

HHC Mission StatementHHC Mission Statement

To extend equally to all New Yorkers, To extend equally to all New Yorkers, regardless of regardless of their ability to paytheir ability to pay, comprehensive health services of , comprehensive health services of the highest quality in an atmosphere of human care, the highest quality in an atmosphere of human care, dignity and respect; dignity and respect; To promote and protect, as both innovator and To promote and protect, as both innovator and advocate, the health, welfare and safety of the people of advocate, the health, welfare and safety of the people of the City of New York; the City of New York; To join with other health workers and with To join with other health workers and with communities in a partnership which will enable each of communities in a partnership which will enable each of our institutions to promote and protect health in its our institutions to promote and protect health in its fullest sense fullest sense ---- the total physical, mental and social wellthe total physical, mental and social well--being of the people we serve. being of the people we serve.

11 Hospitals11 Hospitals5 DTC’s5 DTC’s4 LTC’s4 LTC’s

100 Clinics100 Clinics

Home CareHome CareMetroPlusMetroPlus

www.nyc.gov/HHC

•Revenues totaled approximately $4.3 billion.•Nearly one million ER visits.•Five million outpatient visits

including 2 million primary care visits.•210,000 Hospital Discharges•The single largest provider of psychiatric

services in New York City•23,000 births

HHCHHC

HHC Organization ChartHHC Organization Chart

Board of Directors

Benjamin Chu, MD, MPHPresident

SVP SVP SVP SVP SVP(7) Networks

Facilities

Mayor Appoints

Mayor Appoints

HHC EMR TimelineHHC EMR Timeline1991 / 1997 2000 2002 2004 2005

HDS Pilot, Jacobi Medical CenterLabs, CPOE, Documentation

Installation throughout HHCLab, Lab Consolidation

CPOE

OPD Documentation/Coding

DC Summaries

Smart Cards

Disease/Pt. Registries

Medication Admin.

LTC

Portals

Vision for HHC Clinical SystemsVision for HHC Clinical Systems

Leaders in Clinical OutcomesLeaders in Clinical OutcomesReliably Support the Care TeamReliably Support the Care TeamComplete Information AvailabilityComplete Information AvailabilityPositive Fiscal ImpactPositive Fiscal Impact

Critical Success FactorsCritical Success Factors

Increase the Speed of InnovationIncrease the Speed of InnovationComplete ProjectsComplete ProjectsFacilitate System ConsistencyFacilitate System Consistency

Enhance Clinical Information AccessEnhance Clinical Information AccessRegistriesRegistriesClose the Data Warehouse LoopClose the Data Warehouse LoopEMPIEMPI

Successful 4.1/4.2 GUI implementedSuccessful 4.1/4.2 GUI implemented

Critical Success FactorsCritical Success Factors

Continuous EngagementContinuous EngagementSVP IT Steering CommitteeSVP IT Steering CommitteeNISA, PISA, DW Users GroupNISA, PISA, DW Users GroupIT Senior StaffIT Senior StaffFront Line StaffFront Line Staff

Provide Support, Resources & Provide Support, Resources & LeadershipLeadershipImprove Management of our PartnersImprove Management of our Partners

Using IT to Improve Patient Using IT to Improve Patient SafetySafety

Abha Agrawal, MDAbha Agrawal, MDChief Medical Informatics OfficerChief Medical Informatics Officer

Associate Medical DirectorAssociate Medical DirectorKings County Hospital, Brooklyn, NYKings County Hospital, Brooklyn, NY

HIT Summit, Oct. 2004. Washington, DC

Medication ErrorsMedication Errors

One million serious One million serious medicationmedicationerrors every year.errors every year.20% are life20% are life--threatening.threatening.7000 deaths annually.7000 deaths annually.$2 billion nationwide in hospital $2 billion nationwide in hospital costs alone.costs alone.

IT to Reduce Med. ErrorsIT to Reduce Med. Errors

Information Technology is Information Technology is a critical ingredient to a critical ingredient to

reduce medication errors.reduce medication errors.

Medication ProcessMedication Process

Medication Order CPOE

PharmacyPharmacy

ReviewDispensing

Nurse E- Med AdminAdministration

Physician

CPOE with Decision SupportCPOE with Decision Support

Electronic prescribing Electronic prescribing –– eliminates illegibility eliminates illegibility issue.issue.DrugDrug--allergy checking.allergy checking.DrugDrug--drug interaction checking.drug interaction checking.Coming up Coming up -- DrugDrug--lab checking.lab checking.Pharmacy review of meds Pharmacy review of meds –– matched against an matched against an electronic profile.electronic profile.

CPOE: Incorrect dose warningCPOE: Incorrect dose warning

CPOE: DrugCPOE: Drug--drug interaction drug interaction warningwarning

Electronic Medication Electronic Medication Administration Administration

Wireless network and mobile carts on wardsWireless network and mobile carts on wardsRealReal--time data entrytime data entryDecision support e.g. delayed med admin, too Decision support e.g. delayed med admin, too high dose etc.high dose etc.Error reportingError reportingNo errors during transcription from paper to No errors during transcription from paper to MAR sheetMAR sheetNext steps: BarNext steps: Bar--coded matching of patient and coded matching of patient and of medicationof medication

Med Admin: Info. available to RNMed Admin: Info. available to RN

Med Admin: Pharmacy Review Med Admin: Pharmacy Review WarningWarning

Med Admin: Incorrect Time Med Admin: Incorrect Time WarningWarning

Challenges in ImplementationChallenges in Implementation

Complexity Complexity –– interdisciplinaryinterdisciplinaryClinician buyClinician buy--in in –– MD, RN, PharmacyMD, RN, PharmacyCost of the software, even more Cost of the software, even more –– the cost of the cost of the implementationthe implementation

Putting this in perspectivePutting this in perspective

55--10% hospitals have adequate CPOE.10% hospitals have adequate CPOE.<10% hospitals have Electronic Med. Admin.<10% hospitals have Electronic Med. Admin.2003 HIMSS Patient Safety Survey2003 HIMSS Patient Safety Survey

Issues that IT can addressIssues that IT can addressTop issue Top issue -- Medication errors Medication errors –– 93% respondents.93% respondents.

1414thth annual HIMSS leadership surveyannual HIMSS leadership surveyProjected IT prioritiesProjected IT priorities

Top issue Top issue –– Reduce medical errors, promote pt safety Reduce medical errors, promote pt safety ––59% respondents.59% respondents.

It’s All About ResultsIt’s All About Results

1212--month Evaluation of CPOE at Metropolitan month Evaluation of CPOE at Metropolitan HospitalHospitalOverall Med. Error rate down by 40%Overall Med. Error rate down by 40%

Incomplete orders down by 70%Incomplete orders down by 70%Incorrect orders down by 45%Incorrect orders down by 45%Illegible orders virtually eliminatedIllegible orders virtually eliminatedErrors due to drug therapy problems Errors due to drug therapy problems -- unchangedunchanged

Igboechi et al. Hospital Pharmacy 2003

Nursing at New York City Health Nursing at New York City Health and Hospitals Corporationand Hospitals Corporation

Scope and InformaticsScope and InformaticsMarie Ankner, RN,MS,CNAAMarie Ankner, RN,MS,CNAA

Assistant Vice President , Nursing Assistant Vice President , Nursing Services Services

New York City Nursing ServicesNew York City Nursing Services

Each facility led by a Chief Nurse ExecutiveEach facility led by a Chief Nurse Executive6600 RNs located throughout the five boroughs6600 RNs located throughout the five boroughsNursing teams include ancillary personnelNursing teams include ancillary personnelInterdisciplinary approach to patient careInterdisciplinary approach to patient careUnionized environment Unionized environment

NYSNA, 1199, DC 37NYSNA, 1199, DC 37

Nursing Presence:Nursing Presence:

7 Networks7 Networks11 Acute Care 11 Acute Care Facilities Facilities 4 Long Term 4 Long Term Care FacilitiesCare FacilitiesDiagnostic and Diagnostic and Treatment Treatment Centers Centers Ambulatory Care Ambulatory Care SitesSitesHome CareHome CareTelemedicineTelemedicineMetroPlusMetroPlusChild Health Child Health ClinicsClinics

In the beginning …In the beginning …

RFP was developed and reviewed by an RFP was developed and reviewed by an interdisciplinary team representing all facilities interdisciplinary team representing all facilities (90’s)(90’s)Pilot developed at Jacobi Medical CenterPilot developed at Jacobi Medical Center

Initiative led by nursing and fostered Initiative led by nursing and fostered interdisciplinary screen building interdisciplinary screen building

Individualized Network /Facility expansionIndividualized Network /Facility expansion

Nursing ClimateNursing Climate

National Nursing ShortageNational Nursing ShortageAverage age of the RN in NYS is 48 yrs.Average age of the RN in NYS is 48 yrs.

Knowledgeable, aging workforceKnowledgeable, aging workforce

Workplace DriversWorkplace DriversIncreased patient complexityIncreased patient complexityDecreased length of stayDecreased length of stayNYS regulatory requirementsNYS regulatory requirementsFocus on access, health promotion and preventionFocus on access, health promotion and prevention

HHC EnvironmentHHC Environment

HHC RNs average age 48 yrs HHC RNs average age 48 yrs -- 60 % direct care providers have > 10 yrs of service60 % direct care providers have > 10 yrs of serviceNursing and the Electronic RecordNursing and the Electronic Record-- variation in templates and terminologyvariation in templates and terminologyInitiation of the NISA committeeInitiation of the NISA committeeIdentification of Nursing Informatics Educational NeedsIdentification of Nursing Informatics Educational Needs

Nursing Conference incorporated Nursing InformaticsNursing Conference incorporated Nursing InformaticsPre hire assessment of computer skills Pre hire assessment of computer skills

NISA GoalsNISA Goals

Identification and adoption of Best Nursing Identification and adoption of Best Nursing PracticesPracticesCollaboration of knowledge, expertise Collaboration of knowledge, expertise Work smarter not necessarily harderWork smarter not necessarily harderSafeguard patient care Safeguard patient care Assure professional practiceAssure professional practiceSupport Nursing and ITSupport Nursing and ITMaximize IT utilization to support patient careMaximize IT utilization to support patient care

Driving Force is Patient CareDriving Force is Patient Care

Cost effective, quality, safe patient careCost effective, quality, safe patient careProvide IT support for all health care providers, Provide IT support for all health care providers, including nursingincluding nursingComputerize Nursing ProcessComputerize Nursing Process

Literature reports that Nursing DocumentationLiterature reports that Nursing DocumentationUtilize13Utilize13--28 % RN time 28 % RN time

AchievementsAchievements

Online electronic medical recordsOnline electronic medical recordsPharmacy, lab and radiologyPharmacy, lab and radiology

Medication administration pilotsMedication administration pilotsPatient educationPatient educationHealth Promotion Health Promotion Immunization screensImmunization screensHome Care telemedicine programHome Care telemedicine programPaperless NICU at Jacobi Medical CenterPaperless NICU at Jacobi Medical CenterSmart CardsSmart Cards

The Nursing and Technology LinkThe Nursing and Technology Link

Nadia Sultana Nadia Sultana MBA RN,BCMBA RN,BC

Senior Director, Clinical Information SystemsSenior Director, Clinical Information SystemsNYC Health & Hospital’s Corporation NYC Health & Hospital’s Corporation

October 23,2004October 23,2004

Historically Historically

User Groups developed data collection screens separately to User Groups developed data collection screens separately to meet their immediate needs:meet their immediate needs:-- Physician Documentation screens Physician Documentation screens -- Physician Order Entry Physician Order Entry -- Nursing Assessments and Flow sheets Nursing Assessments and Flow sheets

Data collection screens lack Data collection screens lack standardization …standardization …impacting impacting Data Warehouse initiative andData Warehouse initiative andability to implement timely changesability to implement timely changesto CPR to CPR

Action Plan Action Plan

Formation of …Formation of …

NISANISA = Nursing Information System = Nursing Information System Advisory Group Advisory Group

…to promote dialogue, share best practices and…to promote dialogue, share best practices andfoster Nursing foster Nursing InformaticInformatic education education

NISA Framework NISA Framework

Network Nursing Service RepresentationNetwork Nursing Service RepresentationRegular Monthly meetingsRegular Monthly meetingsCoCo--chaired by Corporate Nursing and IT chaired by Corporate Nursing and IT Specific AgendaSpecific AgendaInitiation of an Issues List with FollowInitiation of an Issues List with Follow--upupGuest SpeakersGuest Speakers

Current ConceptsCurrent Concepts in discussionin discussion……

Development of standardized data collection screens Development of standardized data collection screens with data element identificationwith data element identification

Establishment of Change Control Procedures Establishment of Change Control Procedures

Identification of Educational NeedsIdentification of Educational Needs

Planning next modules incorporatingPlanning next modules incorporating“best practice”“best practice”

StandardizationStandardization

First attempt First attempt -- Development of the VISTA Desktop Development of the VISTA Desktop Nursing StandardNursing Standard

Outcome Outcome –– some variation continued post some variation continued post implementation …emphasized the need for implementation …emphasized the need for change control process…and need to change control process…and need to

continue to Standardizecontinue to Standardize

CONEY

High Issue - Block functions should appear as tabs. Substantial deviation from NISA standards.

Recommendation – Align desktop with NISA standards.

esponse – Rebuilding new desktop for April 18th.

tatus –verify with Misys analyst if this issue will be fixed on new desktop

ext Steps – Re-audit desktops when desktop build is complete

CONEY

Medium Issue -Redundant icon function

Recommendation –Remove icon

Response – Rebuilding new desktop by April 18th

Status - verify with Misys analyst if this issue will be fixed on new desktop

Next Steps - Re-audit desktops when desktop build is complete.

Non-Compliance IP Nursing Issues

WOODHULL

Medium Issue – Duplicate review queue functionality

Recommendation – Remove desktop shortcut

Status – IT rep will not sign off change control form or make changes until audit has been reviewed with NISA rep.

Next Steps – Review audit results with NISA Rep and IT.

Non-Compliance IP Nursing Issues

Change Control Procedures Change Control Procedures

…Experience with VISTA Desktop …Experience with VISTA Desktop Standardization and Phase I Development of Standardization and Phase I Development of Data Warehouse Reports highlighted need for Data Warehouse Reports highlighted need for Change Control Procedures to Decrease Change Control Procedures to Decrease variation of key data elements and terminology variation of key data elements and terminology

Change Control Process -CPR /DATA WAREHOUSE

Education efforts Education efforts

Development of Survey to assess needs Development of Survey to assess needs

Standardized CPR Modules Training and Standardized CPR Modules Training and issue CEUsissue CEUs

Perform “Gap Analysis” Perform “Gap Analysis” –– focus on focus on Nursing Documentation and CPR usageNursing Documentation and CPR usageto determine “best practice”to determine “best practice”

Medication Administration ExpansionMedication Administration ExpansionInterdisciplinary Documentation Interdisciplinary Documentation Clinical Pathways Clinical Pathways SMART CARDSSMART CARDS

Planning next modules incorporating“best practice”…

Glenn Martin, MDGlenn Martin, MDDirector, Medical InformaticsDirector, Medical Informatics

Queens Health NetworkQueens Health Network

Now that we have an EHR how do we use the data it generates?

Shift focus from process to outcomesShift focus from process to outcomesCreate clinical data repository and Create clinical data repository and management registriesmanagement registriesConvert data into useful information Convert data into useful information

Use data to segment patient populations according Use data to segment patient populations according to condition and acuityto condition and acuityDraw on clinical repository to measure indicators Draw on clinical repository to measure indicators and track improvement in patient health outcomesand track improvement in patient health outcomes

Report writer sits on QHN Intranet and Report writer sits on QHN Intranet and provides userprovides user--friendly query access:friendly query access:

•• Provides flexible parameters for Provides flexible parameters for key indicatorskey indicators•• Output can be saved for Output can be saved for retrospective review retrospective review •• Can sort data to facilitate patient Can sort data to facilitate patient segmentationsegmentation•• Includes patient telephone numbers Includes patient telephone numbers and primary care provider nameand primary care provider name

Diabetes Diabetes

Community providers can forward consultation requests and receive reports on-line quickly confidentially

And information needs to be coordinated and flow seamlessly to community providers who serve our patients outside the hospital

How do we plan to ensure that patients drive How do we plan to ensure that patients drive our services and make decisions about where our services and make decisions about where to get their care?to get their care?

Effectively make patients the owner of their information Provide patients the opportunity to carry their medical information at all timesOffers patient a vehicle for communicating current information to their provider of choice

Smart cards empower patients and connect providers empower patients and connect providers across communities and health systemsacross communities and health systems

Health Connection CardHealth Connection CardFunctions as Patient ID Functions as Patient ID Includes 64K chipIncludes 64K chipPatient summary updated at Patient summary updated at each encounter with:each encounter with:

Patient informationPatient informationEmergency contactEmergency contactProblem List and AllergiesProblem List and AllergiesActive MedicationsActive MedicationsComplete, relevant lab Complete, relevant lab resultsresults

6,000 patients own the Health Connection Card

Patients Name