Physician Care Manager/Advanced Clinicals · 2014-03-07 · Physician Desktop / Work list Committee Project Leader: Core Team Medication Reconciliation Committee Physician on-Line

Physician Care Manager/Advanced Clinicals

“Achieving quality and cost-effective patient care using information technology.”

• Practice started in 1985

• Corporate office in Burlington, MA

• Dedicated to the healthcare industry

• Strategic Planning – aligning IT with business

strategies

• IT Project Implementations

• IT Operations

HealthNET Systems Consulting, Inc.

Chad Turner, Consulting Manager

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Getting Started

Eight factors of the Clotting Cascade

Physician Care Manager Project 4

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http://en.wikipedia.org/wiki/File:Classical_blood_coagulation_pathway.png

Factors of the Clotting Cascade



PCM et al

Topics of Discussion1. Orientation to Projects and

Components2. Project Scope3. Timeline and Milestones4. Organization

– Governance– Teams and Resources

5. Development Strategy6. Key Factors for Implementation7. Organization & Teams8. Development Strategies &

Guidelines9. Documenting development10.Meaningful Use11.CPOE

1. Outcomes & Measures2. Alerts/Rules3. Order Sets

12.eRx/Medication Reconciliation13.PDOC14.Medical Problem List

1. Nomenclature2. Timing

15.Hx – Med/Surg/Social/Family16.Communication and Marketing


VTE-6 (SQUARE PEG/ROUND HOLE ?)

9

VTE-6 (CONFIRMED)

10

PCM Project

• What’s PCM?– Physician Care Manager is Meditech software.– Suite of applications including CPOE that impacts

physicians and other care providers.– Integrated Meditech application

• Project scope can be variable based on organization• Goals & Objectives:

– Move further on the IT strategy toward an electronic health record (EHR).

– Improve quality and efficiency of care.– Meet “meaningful use” criteria for ARRA Stimulus

incentives.


Major Components– Computerized Physician Order Entry (CPOE)– On-line Documentation (PDOC)– Physician Desktop/Work list (Physician Workload Management (PWM))– E-Prescribing (eRX)– Medication Reconciliation (RXM)


Meditech PCM

CPOE

Ph

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ian

Do

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ing

Me

d R

eco

n

De

skto

p/W

ork

list

Physician Advanced Clinicals build upon one

another to enhance practice and quality

PDOC

eRx

MedRec

CPOE


STAGES & PLANNING

PCM Implementation – 2 Stages


• Integrated Design

• Staggered rollout due to resources


PCM Implementation – Multi-Stage

Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

CP

OE

Design, Build, Developing, Impact, testing

Workflow Current Future

Regulatory Requirement Plan

Planning & Prep

Design

Re-development

Order Set Development

Order and Order Set Favorites

Pharmacy (Order Strings, dictionary refinement, P&T approvals, etc)

Rules/Flags/Alerts

Nursing

Core Measure Development/Reporting Plan

Order Entry Dictionary refinement

Reporting

Training & Testing

Testing

Training

Re-Development

Go-Live & Reassess

Go-Live

Reassessment

eP

resc

rib

ing

Build, design, developing, Impact, testing


Dictionary Development

Dr.First Integration


Rules/Flags/Alerts

Training & Testing

Testing

Training

Go-Live & Reassess

Go-Live

Reassessment

Med

Re

c





Transfer Process Devel

Reporting

Training & Testing

Testing

Training

Go-Live & Reassess

Go-Live

Reassessment

PD

OC


Workflow



Discharge Planning

Problem List Development

Clinical Decision Support

Training & Testing

Testing

Training

Go-Live & Reassess

Go-Live

Reassessment

Physician Care Manager Project

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PCM Project Timeline - Detail

Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

CP

OE

Design, Build, Developing, Impact, testing



Planning & Prep

Design

Re-development

Order Set Development

Order and Order Set Favorites

Pharmacy (Order Strings, dictionary refinement, P&T approvals, etc)

Rules/Flags/Alerts

Nursing

Core Measure Development/Reporting Plan

Order Entry Dictionary refinement

Reporting

Training & Testing

Testing

Training

Re-Development

Go-Live & Reassess

Go-Live

Reassessment

eP

resc

rib

ing




Dr.First Integration


Rules/Flags/Alerts

Training & Testing

Testing

Training

Go-Live & Reassess

Go-Live

Reassessment

Med

Re

c





Transfer Process Devel

Reporting

Training & Testing

Testing

Training

Go-Live & Reassess

Go-Live

Reassessment

PD

OC


Workflow



Discharge Planning

Problem List Development


Training & Testing

Testing

Training

Go-Live & Reassess

Go-Live

Reassessment

Physician Care Manager Project

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PCM Project Timeline - Detail

PROJECT ORGANIZATION & TEAM

Impacted Areas & Resources

Function/ Application

Ph

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ns

Nu

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g/ P

atie

nt

Care

Ph

arm

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y

Reh

ab

Re

sp

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ry

Die

tary

Qu

ality

/ Ris

k

Me

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Rec

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Dia

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ostic

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CPOE 2 2 2 1 1 1 2 1 1 1

Physician Work List 2 1 2 1

e - Prescribing 2 2 1

Physician Documentation 2 1 2 2

Medication Reconciliation 2 2 2 2 1

Scoring Legend

None

Minor 1

Major 2


** NOTE: Information Systems will participate in each of the above

Function/Applications

Provider Advisory/Steering

Committee

Physician Desktop / Work list

Committee

Project Leader:

Core Team

Medication

Reconciliation

Committee

Physician on-Line

Documentation

Committee

Order

Sets/Rules/Alerts

Committee

Pharmacy

Operations

Committee

Nursing Focus

Group

Training

Committee

Hardware

Committee

Project Manager:

Advisors


Project Organization & Teams

- Multiple teams and work

- Some people on several teams

Project Governance• Med Exec Committee• Physician Advisory/Steering Committee• Core Team(s)

– Interacts with many other groups, individuals, and committees– Team composition may vary depending on what is being deployed (ie CPOE vs eRX vs PDOC)

• Clinical Advisory Committees– Nursing Focus Group– Pharmacy Operations Committee– Rules/Alerts Committee– Ancillary Development groups

• Policies & Procedures– Order set review and approval– Policy changes– P&T approvals – Process changes– Decision oversight


SYSTEM DEVELOPMENT –STRATEGIES & GUIDELINES

Development Strategies

• Focus on goals, outcomes and measurement

• Quality and process improvement opportunities

• Regulatory guidelines and requirements

• Efficiency

• Clinical decision support


Joint Commission Guidelines for Clinical Project Implementation (Condensed Checklist to be associated with the Project Plan)

• Examine workflow processes

• Actively involve clinicians

• Assess organizational technology needs

• Continuously monitor for problems

• Establish training program

• Develop and communicate policies

• Standardized order sets and guidelines are developed

• Alerts and rules

• P&T approval of electronic order sets

• Environment for data entry free of undue distractions

• Post go-live reassess and enhance as needed to maximize safety

• Continually monitor and report errors and initiate root cause analysis

• re-evaluate applicability of security and confidentially protocols


Action plan development and documentation


Key Goals for Implementation

Key Goals

Co

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Ord

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En

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ePre

scri

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Med

icat

ion

Rec

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n

Ph

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On

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Do

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Meaningful Use X X X X

Joint Commission Guidelines for Clinical

Implementation X X X X

Patient Safety X X X X

Improve Patient Outcomes X X X

Improve efficiencies X X X

Clinical Decision Support X X X X

Regulatory Requirements X X X X

National Patient Safety Goals X X

Quality Measures/Indicators X X X

Discharge Planning X

Increase Reimbursement X X

Decrease Physician Queries X X X


Additional Considerations

• CMS Never Events• Medicaid Hit List• Medicare Pay for Performance (P4P)• HMO Pay for Performance• IHI Initiatives• Surgical Care Improvement Project (SCIP)• Medication Safety Activities (Based on Joint Commission

National Patient Safety Goals (NPSG))• Department of Health (DOH)• Organizational QI Programs• ARRA/Meaningful use attestation


Meaningful Use – Stage 2 Criteria• Computerized Provider Order Entry (CPOE)

• Record Demographics

• Problem List

• Medication List

• Medication Allergy List

• Clinical Decision Support

• **New Transitions of Care - Transitions of care: Receive, display, and incorporate transition of care/referral summaries and create and transmit transition of care/referral summaries.

• Privacy and Security CC

• Clinical Quality Measures (No longer separate objective, mandatory)

• Drug-drug, Drug-allergy Interaction Checks

• Record Vital Signs, Body Mass Index, and Growth Charts

• Smoking Status

• Patient List CreationGenerate lists of patients by specific conditions

• Patient Specific Education Resources

• Electronic Medication Administration Record (eMAR)

• Medication Reconciliation

• Incorporate Laboratory Tests & Values/Results

• ** New View, Download, & Transmit

• Transmission of Reportable Laboratory Tests & Values/Results

• Transmission to Public Health Agencies- Syndromic

Surveillance

• Transmission to Immunization Registries

• 2014 Certification Criteria

• Drug Formulary Checks

• Imaging Results

• Record Patient and Family History

• Advance Directives

• e-Prescribing

• Transmission of Laboratory Test & Values/Results to Providers

• Electronic Notes


Meaningful Use – Stage 2 Criteria**Beginning in 2014, qualifying for an exclusion from a Menu Set Objective will no longer reduce the number of Menu set Objectives that an EP or EH must otherwise satisfy to demonstrate Meaningful Use for Stage 1. All the measures with metrics require a detailed metric report for the calculation. MEDITECH will provide this report out of Data Repository to ensure data integrity for 365 days of requirements in the following years.

Base EHR

Computerized Provider Order Entry (CPOE)

Record Demographics

Problem List

Medication List

Medication Allergy List


**New Transitions of Care - Transitions of care: Receive, display, and incorporate transition of care/referral summaries and create and transmit transition of care/referral summaries.

Core

Privacy and Security CC

Clinical Quality Measures (No longer separate objective, mandatory)

Drug-drug, Drug-allergy Interaction Checks

Record Vital Signs, Body Mass Index, and Growth Charts

Smoking Status

Patient List Creation - Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach.

Patient Specific Education Resources

Electronic Medication Administration Record (eMAR)

Medication Reconciliation

Incorporate Laboratory Tests & Values/Results

** New View, Download, & Transmit

Transmission of Reportable Laboratory Tests & Values/Results

Transmission to Public Health Agencies- Syndromic Surveillance

Transmission to Immunization Registries

Menu Set

Drug Formulary Checks

Imaging Results

Record Patient and Family History

Advance Directives

e-Prescribing

Transmission of Laboratory Test & Values/Results to Providers

Electronic Notes


Quality Measures


QUALITY MEASURESVTE-6 (SQUARE PEG/ROUND HOLE ?)

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VTE-6 (CONFIRMED)

33

CPOE - FACTORS FOR IMPLEMENTATION

CPOE Implementation Guidelines• What are we trying to accomplish?

– Best practices/Evidence Based Medicine– Improved communication – Financials

• Does it align with our “rules” and practice?– Policy changes– Medical practice changes– By-laws

• How will we measure it?– Defined Outcome measures and outcomes expectations– Reports

• How will we best get it done?– Project planning– Careful assessment and design

• What are the likely unintended consequences?Physician Care Manager Project

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Ten Commandmentsfor Effective Clinical Decision Support

(Bates et al)

1. Speed is everything

2. Anticipate needs and deliver in real time—deliver information when needed.

3. Fit into the user’s work flow

4. Little things can make a big difference—improve usability to “do the right thing.”

5. Recognize that physicians will strongly resist stopping—offer alternatives rather than insist on stopping an action.

6. Changing direction is easier than stopping—changing defaults (eg. dose, route, freq. of a medication) can change behavior.

7. Simple interventions work best—simplify guidelines to fit a single computer screen.

8. Ask for additional information only when you really need it

9. Monitor impact, get feedback, and respond—if certain reminders are not followed, readjust or eliminate the reminder.

10. Manage/maintain knowledge-based systems


Measuring CPOE• Measuring of CPOE is in terms of outcomes and other care

indicators– Quality Measures, CMS practice guidelines, etc.

• Use multiple measures wherever possible– # times alert is generated– # times alert is followed vs. ignored vs. override

• Subjective (ask the end-users)– End User surveys

• Can you tie to more global measure (eg. infection rate, ADE rate, etc.)?

• Can you tie to cost savings or increased reimbursement?– Improved specificity of physician documentation

• Will we meet Meaningful Use requirements?– CPOE Utilization– Medical Problem Lists


Outcomes and Outcome Measurement

• Outcome measures will be formulated throughout the implementation

• Pre and Post data will be collected as possible

• Outcome measure reports will be part of the project plan and measures will be monitored post live.


Examples of Outcome Measures

System Measures %downtime %orders done by CPOE % using order sets on admission # and percentages of various rules/notifications

Overrides Entered

Orders Erased

Orders Replaced

Doses Modified

Rules Closed

Total number of rules

Total number of orders processed using POM

LAB Rules invoked

OE Rules invoked

PHA Rules invoked

ITS Rules invoked % rules overridden # telephone/verbal orders % telephone/verbal orders signed within 24 hrs. Efficiency Measures # duplicate tests Time to physician consult completion # of physician consult sheets in record for consulting physician Admit Orders processing time

End-User satisfaction Physician satisfaction Nursing satisfaction Pharmacy satisfaction Hospital Process Measures Order Written to placed in computer system comparison % compliance with enter “Reason for Non-Formulary Medication” usage Pharmacy TAT Lab TAT Radiology TAT Hospital Outcome Measures %pts screened for DVT risk # medication errors Usage of unapproved abbreviations Orders signed off within 48 hours Documentation of PRN reason for PRN medications

39

Workflow Redesign

• Patient throughput

• Physician

• Nursing

• Pharmacy

• Medications

• Ancillary Orders (Lab, Radiology, Rehab Services, etc.)

• Dietary Management


(Current and Future Workflows)

For each patient type (INP, OPT, SDS, ED) it will necessary to evaluate ordering, process, care provider activity and processes, and communication needs related to each of the following:

• Emergency Department

• Medical Necessity

• Medication Reconciliation

• Patient Discharge and Discharge Planning

• Prescription Management

• Patient Education

• Physician Documentation

Development Considerations

• Avoiding Alert Fatigue• Standardization of order sets• Migration toward Evidence based medicine• Avoiding Unintended Consequences• Do no harm – assuring quality and safety to patients and patient care with thorough

analysis and extensive documentation• Benefits to medical staff (physicians and physician extenders)• Effective Clinical Decision Support• Improved communication amongst care providers• Financial benefits and impact• Appropriate specificity of physician documentation• Project Quality and Safety Assurance• Gaining buy-in from everyone• Achieving Outcome measures


Alert Fatigue

• Too many alerts can cause physicians to begin to ignore all alerts• The system should prioritize alerts by severity• Physicians can set own alert threshold (except for Level 1 alerts)• Alerts often more appropriately go to non-MD’s (nurses,

pharmacists, case managers, QI staff, etc.)• Use standardized order sets whenever possible to avoid need for

alerts


Rules, Alerts, and Flags

Benefits and Goals

• Provide Clinical Decision Support

• Avoid adverse drug events

• Auto reflex appropriate corollary orders

• Improve quality indicator adherence

Standardized Order Sets

• Ensures evidence-based care elements are remembered

• Patient safety tools• Streamlined order entry• Can be developed for multiple conditions or

multiple services• Use standardized order sets whenever possible

to avoid need for alerts


Key Decision: Build versus Buy

“Standardize and automate that which is routine about a patient’s care so the clinician can focus on what is unique about each patient”

Standardized Order Sets - Downside• Not all patients fit nicely into

standardized order set designed for one condition

• Order set for “all” patients may fail to take into account nuances for certain patients (eg. elderly or patients with Chronic Kidney Disease (CKD))


Key Decision: Developing method for management of Co-morbidities (CC) and Major Co-morbidities (MCC)

FACTORS FOR IMPLEMENTATION

Testing and Re-development• Medication order and administration testing and impact• Procedural orders testing and impact• Physician desktop and work list testing• ePrescription testing and validation• Medication Reconciliation testing• Clinical Documentation Improvement Program Development• Specificity Plan, ICD-10, Medical Problem List• Integrated testing – internal• Integrated testing – team with role playing• Redevelopment as needed based on outcomes of testing• Parallel Run


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Importance of Thorough Planning, Design, Development,

Testing and Training

What’s In It For Me? (Physician View)

• Better, safer care for my patients• Easy access to order entry and all clinical

information from one portal• Helps me remember all the things I could not

possibly remember• More up front work, but save time on the back

end• Fewer phone calls• Decrease in Coding query/clarification• Less time in Medical Records suite• Ability to access system remotely


Internal Marketing/Communication

• Need to communicate

• Need to gain momentum

• Branding

• Kickoff

• Multiple communication vehicles– Newsletters

– Posters/signs/plasma screens

– Screensavers


Other Areas for Development

• Issues project core team and development teams will face will not be limited to physician processes. – A number of Process Improvement opportunities for

Nursing and ancillary departments will become evident during implementation.

• Documenting Process Improvement opportunities is important

• Quality and Risk Management will play an important role throughout the project

• Administrative support is crucial to take advantage of perceived opportunities


ePrescribing/Medication Reconciliation - FACTORS FOR

IMPLEMENTATION

ePrescribing and Medication Reconciliation Issues

• Changes in process– Nursing– Physicians– Ancillaries– Out-patient areas– Clearly defining patient transfer and discharge expectations

• Dr. First Integration– Technical– Data Validation

• Scope of roll-out– In-patient only, Out-patient, ED, etc.– Defining the “Continuum of Care”


Impact Testing


Physician Desktop and Work List Issues

• Technology integration to workflow

• Process changes

• Policy changes

• Reconciliation processes that must be adopted (ie. Physician assignment, erroneous notifications, ability to set custom notifications)

• Remote access


Physician On-Line Documentation (PDOC) - FACTORS FOR

IMPLEMENTATION

Physician On-Line Documentation

• Approach will emulate the CPOE implementation process

• Medical Problem list development will use Physician development team, coding, and IS resources

• Integration of medical problem list and prescription writing tool (ie IMO, DR FIRST, etc.)

Key Decisions: Data sharing between disciplines, data sharing between patient visits, problem list

nomenclature


Goals & Measures• Decrease Turn-around-times

• Fewer coding queries

• Improved Legibility

• Auto insertion of the provider pager/Identifying data

• Electronic access to documentation

• Formatted/Auto data incorporations

• CDI - Clinical Documentation Improvement

• CCD Timing/Impact

• Quality Measures

• Standardization of nomenclature

• Revenue cycle enhancement

• Crosswalk to Medical Problem List processing by medical staff

• Inclusion of reference ranges & Abnormal flags in the documentation

• HIE/Partners electronic transmission of data

• Patient Departure Times

• Admission Bottle Necks

• Transcription costs

• Decrease time for MedRec and Allergy processing by auto populate

• Addendum versioning in outside systems




What can we accomplish?


Tracking Development, Decisions, and Issues


Staging/Roll Out Plan


Roll-Out Order:

1. Infectious Disease2. Pediatrics3. OB/GYN4. Pulmonology5. Cardiology6. Neurology7. Hemotology/Oncology8. Transitional Care Unit9. Nephrology

10. Urology11. Interventional Radiology12. Orthopaedics13. Surgical Services14. Plastics15. Bariatrics16. Opthomology17. Pediatry18. Ear/Nose/Throat

Setting and Meeting Milestones


Support, Assessment, and Communication


Documentation time/measurement/management


Data Sharing (Interdisciplinary)

• Meaning and Value

• Documentation Redesign

• Nursing Documentation

• Respiratory

• Consultants

• Rehab Services


PDOC – Clinical Decision Support (HIMSS Analytics)

Options:

• Protocols

• Goto Logic

• Quality Measures/Documentation

• Risk Scoring


Clinical Documentation Improvement Program (CDIP)

Clinical Documentation Improvement• The purpose of the Clinical Documentation Improvement program

is to create a clear picture of the patient’s hospital stay to anyone who picks up the chart, to accurately code the chart, and to capture CCs and MCCs that are appropriate for your patient while they are in the hospital.

Medicare reimburses on a 3-tiered system: – No CC– With a CC– With an MCC.

• CC – co-morbidity/complication. Impact reimbursement on a chart, justify length of stay, impact mortality rates and increase case mix index.

• MCC – major co-morbidity. Significantly impact reimbursement and length of stay.


Discharge Plan & Summary

• Discharge Planning

• Discharge Routine

• Discharge Instruction

• Discharge Summary


Medical Problem List/Problem Management

Nomenclature and Ease of Use

• SNOMED

• ICD9

• ICD10

• DSW4/DSW5

• IMO

• Specificity

• Ease of Use


Who, What, When, and Where – What is the purpose of a Medical Problem List

• Billing

• Communication between care givers

• Differential Progression

• Rule Out vs Diagnosis

• Problem Statuses

• Onset/Present on admission

• Medical Necessity (Patient Status vsoutpt MN)


IMO vs Build


Medical, Surgical, Family, and Social History

Medical, Surgical, Family & Social History

• Meaningful Use Menu Set

• Regulatory requirements and clinical value

• Workflows for capturing information– Transcription by Unit Secretary

– Nursing Input

– Physician Input/Review

• Data Sharing

• Migration to new method/documentation tool

• Causative factors documentation (value vs need)


Relation Detail


Specificity vs value (When is too much too much?)


Redundancy and Timing


Diagnosis & Procedures


Current vs Past History


Associating Diagnosis/Causative Factors to Procedures

(Value vs Need)


Communication & Marketing

Communication• All decisions related to the implementation

should be communicated and documented before, during, and after go-live.

• Go-Live and Post go-live support should be agreed to and communicated throughout the duration of the project.

• All concerns and recommendations are always welcomed

• Communication plan can be a static or constantly evolving


Communication Plan


Communication Topics/Types• Coming Soon• Did You Know • Learn More About PCM• News Bulletin• PCM Features Benefits • PCM Kickoff Meeting• Readiness Assessment • Process Analysis Redesign• PCM Team Meeting• Physician Advisory Meeting • MD Training Schedule

• PCM Going LIVE

• Did You Know• Learn More About PCM• News Bulletin• PCM Features Benefits• PCM Kickoff Meeting• Readiness Assessment• Process Analysis Redesign• PCM Team Meeting • MD Training Schedule • PCM Going LIVE


Staff Involvement & Communication

• Publish an electronic or paper newsletter• Show software demonstrations • Involve nurses and physicians in the selection of

hardware devices• Network with other MEDITECH customers • Create media buzz• Utilize staff/provider surveys• Incorporate project updates into other organizational

meetings.• Create a project homepage on social networking sites

such as Twitter or Facebook.


Marketing & Communication

• Identify and communicate goals.• Utilize your marketing department.• Choose a theme, logo, or catch-phrase • Use branding to create a unique and memorable

identity for your MEDITECH system.• Signage is an important communication tool for

medical staff• Post an implementation timeline for everyone to see• Develop flyers or posters for patients• Recruit hospital volunteers• Promotional Events and Activities


Going Over the Top

• Hold a kick-off party• Organize an information fair• Have giveaways• Contact local newspapers and radio stations to

raise awareness in the community• Arrange for internal site visits to Departments

already Live with MEDITECH• Talk Process Improvements coming• Hold workshops or retreats for core teams and

implementation support staff


Summary

Summary

• PCM Project Scope with the Implementation of:– CPOE– ePrescribing– Medication Reconciliation– Desktop/Work List– On-Line Documentation

• Time & Resource Commitments– Phases – Large amounts of resources – leadership, design, decisions and

work

• Design & Implementation Mantra– Quality and outcome measures are built in– Efficiency and ease of use will be key to provider acceptance


Discussion & Questions


Documents

Physician Care Manager/Advanced Clinicals · 2014-03-07 · Physician Desktop / Work list Committee Project Leader: Core Team Medication Reconciliation Committee Physician on-Line