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

Implementation of the EMR at NYC Implementation of the EMR at NYC Health & Hospitals CorporationHealth & Hospitals Corporation

Marie Ankner, RN, MS, CNAA, HHCMarie Ankner, RN, MS, CNAA, HHCAbha Agrawal, MD, Kings County Abha Agrawal, MD, Kings County Hospital/HHCHospital/HHCLouis Capponi, MD, HHCLouis Capponi, MD, HHCGlenn Martin, MD, Queens Health Glenn Martin, MD, Queens Health Network/HHCNetwork/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 their ability to payregardless of their ability to pay, , comprehensive health services of the highest comprehensive health services of the highest quality in an atmosphere of human care, quality in an atmosphere of human care, dignity and respect; dignity and respect;

To promote and protect, as both innovator To promote and protect, as both innovator and advocate, the health, welfare and safety and advocate, the health, welfare and safety of the people of the City of New York; of the people of 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 communities in a partnership which will enable each of our institutions to promote and enable each of our institutions to promote and protect health in its fullest sense -- the total protect health in its fullest sense -- the total physical, mental and social well-being of the physical, mental and social well-being of the people we serve. people we serve.

11 11 HospitalsHospitals

5 DTC’s5 DTC’s 4 LTC’s4 LTC’s 100 Clinics100 Clinics

Home CareHome Care MetroPlusMetroPlus

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 HHC Organization ChartChart

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 Vision for HHC Clinical SystemsSystems

Leaders in Clinical OutcomesLeaders in Clinical Outcomes Reliably Support the Care Reliably Support the Care

TeamTeam Complete Information Complete Information

AvailabilityAvailability Positive Fiscal ImpactPositive Fiscal Impact

Critical Success FactorsCritical Success Factors

Increase the Speed of InnovationIncrease the Speed of Innovation Complete ProjectsComplete Projects Facilitate System ConsistencyFacilitate System Consistency

Enhance Clinical Information AccessEnhance Clinical Information Access RegistriesRegistries Close the Data Warehouse LoopClose the Data Warehouse Loop EMPIEMPI

Successful 4.1/4.2 GUI implementedSuccessful 4.1/4.2 GUI implemented

Critical Success FactorsCritical Success Factors

Continuous EngagementContinuous Engagement SVP IT Steering CommitteeSVP IT Steering Committee NISA, PISA, DW Users GroupNISA, PISA, DW Users Group IT Senior StaffIT Senior Staff Front Line StaffFront Line Staff

Provide Support, Resources & Provide Support, Resources & LeadershipLeadership

Improve Management of our PartnersImprove Management of our Partners

Using IT to Improve Using IT to Improve Patient SafetyPatient Safety

Abha Agrawal, MDAbha Agrawal, MD

Chief Medical Informatics OfficerChief Medical Informatics Officer

Associate Medical DirectorAssociate Medical Director

Kings County Hospital, Brooklyn, Kings County Hospital, Brooklyn, NYNY

HIT Summit, Oct. 2004. Washington, DC

Medication ErrorsMedication Errors

One million serious One million serious medicationmedication errors every errors every year.year.

20% are life-threatening.20% are life-threatening. 7000 deaths annually.7000 deaths annually. $2 billion nationwide in $2 billion nationwide in

hospital costs alone.hospital costs alone.

IT to Reduce Med. ErrorsIT to Reduce Med. Errors

Information Information Technology is a critical Technology is a critical

ingredient to reduce ingredient to reduce medication errors.medication errors.

Medication ProcessMedication Process

Medication OrderCPOE

PharmacyPharmacy

Review

Dispensing

Nurse E- Med AdminAdministration

Physician

CPOE with Decision CPOE with Decision SupportSupport

Electronic prescribing – eliminates Electronic prescribing – eliminates illegibility issue.illegibility issue.

Drug-allergy checking.Drug-allergy checking. Drug-drug interaction checking.Drug-drug interaction checking. Coming up - Drug-lab checking.Coming up - Drug-lab checking. Pharmacy review of meds – matched Pharmacy review of meds – matched

against an electronic profile.against an electronic profile.

CPOE: Incorrect dose CPOE: Incorrect dose warningwarning

CPOE: Drug-drug CPOE: Drug-drug interaction warninginteraction warning

Electronic Medication Electronic Medication Administration Administration

Wireless network and mobile carts on Wireless network and mobile carts on wardswards

Real-time data entryReal-time data entry Decision support e.g. delayed med Decision support e.g. delayed med

admin, too high dose etc.admin, too high dose etc. Error reportingError reporting No errors during transcription from No errors during transcription from

paper to MAR sheetpaper to MAR sheet Next steps: Bar-coded matching of Next steps: Bar-coded matching of

patient and of medicationpatient and of medication

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

Med Admin: Pharmacy Med Admin: Pharmacy Review WarningReview Warning

Med Admin: Incorrect Med Admin: Incorrect Time WarningTime Warning

Challenges in Challenges in ImplementationImplementation

Complexity – interdisciplinaryComplexity – interdisciplinary Clinician buy-in – MD, RN, PharmacyClinician buy-in – MD, RN, Pharmacy Cost of the software, even more – Cost of the software, even more –

the cost of the implementationthe cost of the implementation

Putting this in Putting this in perspectiveperspective

5-10% hospitals have adequate CPOE.5-10% hospitals have adequate CPOE. <10% hospitals have Electronic Med. <10% hospitals have Electronic Med.

Admin.Admin. 2003 HIMSS Patient Safety Survey2003 HIMSS Patient Safety Survey

Issues that IT can addressIssues that IT can address Top issue - Medication errors – 93% Top issue - Medication errors – 93%

respondents.respondents. 1414thth annual HIMSS leadership survey annual HIMSS leadership survey

Projected IT prioritiesProjected IT priorities Top issue – Reduce medical errors, promote pt Top issue – Reduce medical errors, promote pt

safety – 59% respondents.safety – 59% respondents.

It’s All About ResultsIt’s All About Results

12-month Evaluation of CPOE at 12-month Evaluation of CPOE at Metropolitan HospitalMetropolitan Hospital

Overall 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 eliminated Errors due to drug therapy problems - Errors due to drug therapy problems -

unchangedunchanged

Igboechi et al. Hospital Pharmacy 2003

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

CorporationCorporation

Scope and Scope and InformaticsInformatics

Marie Ankner, RN,MS,CNAAMarie Ankner, RN,MS,CNAAAssistant Vice President , Assistant Vice President ,

Nursing Services Nursing Services

New York City Nursing New York City Nursing ServicesServices

Each facility led by a Chief Nurse Each facility led by a Chief Nurse ExecutiveExecutive

6600 RNs located throughout the five 6600 RNs located throughout the five boroughsboroughs

Nursing teams include ancillary Nursing teams include ancillary personnelpersonnel

Interdisciplinary approach to patient careInterdisciplinary approach to patient care Unionized environment Unionized environment

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

Nursing Nursing Presence:Presence:

7 Networks7 Networks 11 Acute 11 Acute

Care Care Facilities Facilities

4 Long Term 4 Long Term Care Care FacilitiesFacilities

Diagnostic Diagnostic and and Treatment Treatment Centers Centers

Ambulatory Ambulatory Care SitesCare Sites

Home CareHome CareTelemedicineTelemedicine

MetroPlusMetroPlus Child Health Child Health

ClinicsClinics

In the beginning …In the beginning …

RFP was developed and reviewed by RFP was developed and reviewed by an interdisciplinary team an interdisciplinary team representing all facilities (90’s)representing all facilities (90’s)

Pilot developed at Jacobi Medical Pilot developed at Jacobi Medical CenterCenter Initiative led by nursing and fostered Initiative led by nursing and fostered

interdisciplinary screen building interdisciplinary screen building Individualized Network /Facility Individualized Network /Facility

expansionexpansion

Nursing ClimateNursing Climate

National Nursing ShortageNational Nursing Shortage Average 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 Drivers

Increased patient complexityIncreased patient complexity Decreased length of stayDecreased length of stay NYS regulatory requirementsNYS regulatory requirements Focus on access, health promotion and Focus on access, health promotion and

preventionprevention

HHC EnvironmentHHC Environment HHC RNs average age 48 yrs HHC RNs average age 48 yrs

- 60 % direct care providers have > 10 yrs of - 60 % direct care providers have > 10 yrs of serviceservice

Nursing and the Electronic RecordNursing and the Electronic Record

- variation in templates and terminology- variation in templates and terminology Initiation of the NISA committeeInitiation of the NISA committee Identification of Nursing Informatics Educational Identification of Nursing Informatics Educational

NeedsNeeds Nursing Conference incorporated Nursing InformaticsNursing Conference incorporated Nursing Informatics Pre hire assessment of computer skills Pre hire assessment of computer skills

NISA GoalsNISA Goals

Identification and adoption of Best Identification and adoption of Best Nursing PracticesNursing Practices

Collaboration of knowledge, expertise Collaboration of knowledge, expertise Work smarter not necessarily harderWork smarter not necessarily harder Safeguard patient care Safeguard patient care Assure professional practiceAssure professional practice Support Nursing and ITSupport Nursing and IT Maximize IT utilization to support Maximize IT utilization to support

patient carepatient care

Driving Force is Patient Driving Force is Patient CareCare

Cost effective, quality, safe patient Cost effective, quality, safe patient carecare

Provide IT support for all health care Provide IT support for all health care providers, including nursingproviders, including nursing

Computerize Nursing ProcessComputerize Nursing Process Literature reports that Nursing Literature reports that Nursing

DocumentationDocumentation

Utilize13-28 % RN time Utilize13-28 % RN time

AchievementsAchievements Online electronic medical recordsOnline electronic medical records

Pharmacy, lab and radiologyPharmacy, lab and radiology Medication administration pilotsMedication administration pilots Patient educationPatient education Health Promotion Health Promotion Immunization screensImmunization screens Home Care telemedicine programHome Care telemedicine program Paperless NICU at Jacobi Medical CenterPaperless NICU at Jacobi Medical Center Smart 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 Systems

NYC Health & Hospital’s Corporation NYC Health & Hospital’s Corporation

October 23,2004October 23,2004

Historically Historically

User Groups developed data collection screens User Groups developed data collection screens separately to meet their immediate needs:separately to 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 to promote dialogue, share best practices andpractices and

foster Nursing Informatic education foster Nursing Informatic education

NISA Framework NISA Framework

Network Nursing Service Network Nursing Service RepresentationRepresentation

Regular Monthly meetingsRegular Monthly meetings Co-chaired by Corporate Nursing and Co-chaired by Corporate Nursing and

IT IT Specific AgendaSpecific Agenda Initiation of an Issues List with Follow-Initiation of an Issues List with Follow-

upup Guest SpeakersGuest Speakers

Current ConceptsCurrent Concepts in in discussiondiscussion……

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

Establishment of Change Control Establishment of Change Control Procedures 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 Development of the VISTA Desktop Nursing StandardVISTA Desktop Nursing Standard

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

•Response – Rebuilding new desktop for 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.

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 Standardization and Phase I Development of Data Warehouse Development of Data Warehouse Reports highlighted need for Change Reports highlighted need for Change Control Procedures to Decrease Control Procedures to Decrease variation of key data elements and variation of key data elements and terminology 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” – focus on Perform “Gap Analysis” – focus on

Nursing Documentation and CPR usageNursing Documentation and CPR usage

to determine “best practice”to determine “best practice”

Medication Administration Medication Administration ExpansionExpansion

Interdisciplinary Documentation Interdisciplinary Documentation Clinical Pathways Clinical Pathways SMART CARDSSMART CARDS

Planning next modules incorporating “best practice”…

Glenn Martin, MDGlenn Martin, MDDirector, Medical Director, Medical

InformaticsInformaticsQueens 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 outcomes

Create clinical data repository and Create clinical data repository and management registriesmanagement registries

Convert 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 acuity

Draw 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 user-friendly query access:provides user-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 times

Offers patient a vehicle for communicating current information to their provider of choice

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

Health Connection CardHealth Connection Card Functions as Patient Functions as Patient

ID ID Includes 64K chipIncludes 64K chip Patient summary Patient summary

updated at each updated at each encounter with:encounter with: Patient informationPatient information Emergency contactEmergency contact Problem List and AllergiesProblem List and Allergies Active MedicationsActive Medications Complete, relevant lab resultsComplete, relevant lab results

6,000 patients own the Health Connection Card

Patients Name