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Stage 6 and BeyondSt. Michael’s Hospital
Michael Freeman MDMedical Director Heart and Vascular Program
Director of Medical InformaticsDirector of Nuclear Cardiology
St. Michael’s HospitalAssociate Professor of Medicine
University of Toronto
Stage 6 and Beyond
• Where we have travelled• Structure• Case study of CPOE• What follows after Stage 6
St. Michael’s Hospital: Toronto’s Urban Angel
• A leading academic health sciences centre, fully affiliated with the University of Toronto
• Recognized as a provider of compassionate care• Provide primary and secondary care to the region’s
largest homeless and inner city health population• Major tertiary referral and regional trauma centre• Strong focus on research and education
Innovations 2011 – Clinical Solutions 3 - Session # 5 – IT Adoption Hat Trick
Phase 1 Master Plan Limitations
St. Michael’s: An Academic Health Sciences CentreLi Ka Shing Knowledge Institute
Education
Patient Care
Research
Keenan Research Centre
Li Ka Shing International Healthcare Education Centre
Bridge to St. Michael’s Hospital
Knowledge Translation
Information Management Vision
•Recognizing:• Health care is knowledge based• Extends beyond the boundaries of the hospital
•Information Systems:• Patient-focused• Enabler for quality and safety • Support business processes through information access and flow• Enable process improvement through inquiry and change• Enable practice excellence
Delivering the right information, right person, right time
A History Lesson
• 2001- SMH has new IM strategic plan that sets the stage for an integrated clinical system
• Perceived to be behind peers• Clinical results viewing available; no other legacy
applications except in diagnostic departments (Lab, DI, Cardiology)
• Siemens contract signed 2002
Project Gemini
•Twinning of transformation and technology
•Clinical transformation as the underpinning to the project
•Harness power of workflow technology to enable practice and process change
Project Gemini Goals
• Improve access to health services• Improve clinical outcomes for patients• Increase patient safety; reduce risk of error• Improve coordination of care• Increase patient satisfaction • Improve the quality of worklife• Reduce overall delivery costs
And the best laid plans….
• SARS• Immature product• Expansive scope and short timeline• Unprepared clinicians
How will we achieve adoption?
1.Build and Demonstrate Value
2.Build Partnerships to engage clinical leadership
3.Innovation- leverage technology and tools with an emphasis on workflow enabled process
Articulate a Shared Vision
•The vision for clinical transformation at SMH is about much more than simply automating our existing paper systems.
•
•It is about carefully designing a patient centered, best-practice framework for implementation. – That is based on a model of interprofessional practice– Includes the use of evidence based care processes and
decision-support systems to achieve the best outcomes for our patients.
1. Value
• Understand the needs of clinicians
• Clinical user group
• Push the envelope with the design teams
• Participation in validation sessions
• Engagement with the vendor
• Define benefits and share with clinicians
2. Delivery
• Provide stability
• Act, respond
• Thoughtful, detailed planning for implementations
• Understand, anticipate and redesign the workflow
• Active and visible issues management
3. Innovation
• Be creative• NO is not in our
vocabulary ..
Enabling Infrastructure for Adoption
• People / Processes– Interdisciplinary culture / model– Workflow redesign expertise
• Technology– Design of technological tools– Access devices to bring technology to the point of care– Software - user centric design with clinical
decision support
Results of Demonstrating Value
CPOE Project Scope
•Electronic ordering of all
diagnostics, medications,
treatments and care orders
for Inpatient units
•Electronic MAR with bar code
closed loop administration
5
Learning's From our Launching of CPOE
1 Governance and organizational models are required to support complex clinical system implementations
2
Enabling roles, processes and evaluation necessary to successfully promote clinician adoption of CPOE/eMAR
3
Strategies are required for a phased-in implementation approach for CPOE/eMAR and the successful transformation of a patient centered care delivery model
6
CPOE/eMAR & MAK Scope
All patient care orders, non-medication orders and medication orders are placed by an MD or resident
To dispense medications, Pharmacists validate all electronic medication orders
Nurses chart all medications administration electronically
All providers can view medication history
7
CPOE/eMAR Committee & Team Structure - Planning
Content Development Subcommittee
eMAR Subcommittee
Design/Build Subcommittee
Change Management / Education Subcommittee
Design/Build TeamEducation/Support Team
Operations Committee
eHealth Executive Committee
CPOE/eMAR Advisory Committee
Physician Leads
8
Moving from Planning to Implementation
• Planning structure created ‘Silos’ that challenged the teams working relationships
• Implementation required greater co-operation and ownership between these ‘Silos’
• Performed an analysis of project structure and identified the needs for implementation
Conclusion:The CPOE/eMAR Project Structure needed to CHANGE
9
CPOE/eMAR Project Team Structure - Implementation
Operations Committee
Soarian Development
Education & Support
Unit Engagement
Technical
CPOE Leadership Team
Professional PracticePharmacyInformation Technology
Medical InformaticsClinical InformaticsProject Management
CPOE Project TeamProject ManagementChange ManagementClinical Informatics
Clinicians including RNs, Pharmacists and OthersCommunication
Content Development
Order Sets
Medications
Non-medication
CPOE Advisory
Design
Build
Test & UAT
Workflow & Practice
Change Management
Impl. Scoping
Wo
rkst
ream
sP
roje
ct S
tru
ctu
re &
Co
mm
itte
es
Devices
Release Management
Interfaces
Content SubCommitee
Medication Management
CPOE Project SponsorCIO & CMO
Metrics & Evaluation
Rx Team
Clinical Unit Team
Physician Leads
ICT Team
Key Partners
eHealth Executive
10
Our Implementation Approach – How?
Demonstration Unit12 bed Medical Unit
Validation Unit 130 bed Medical Unit
Validation Unit 2 36 bed Surgical Unit
Go-Live Day 1
& MAK LiveSoarian CPOE
Go-Live Day 1
MAK
Go-Live Day 1
Soarian CPOE
Soarian CPOE
MAK
Go-Live Day 10Go-Live Day 14
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Implications of Different Day 1 Go-Lives
Big Bang – CPOE & MAK on Day 1•Initial chaos on the unit; complete transfer from paper to electronic
environment•Many different users to support (i.e. MDs, RNs, HDs, etc); fewer support
team members to users•Move directly from current state workflows into future state workflows
Phased Approach – CPOE or MAK on Day 1•Focus the changes on one key process (order entry/management vs.
medication administration)•Support team members can focus “at the elbow” training with key users
of the process•Users must adapt to interim processes before fully transitioning into
future state processes•Significant workload impact on pharmacy to bring MAK live first pre-
CPOE.
13
What was included with each implementation?
Scoping & Engagement
Design, Build & Testing
Education & Training
Post Live Support
Key Activities:•On unit observations and interviews with key stakeholders
•Understanding patient/information flow and unique workflows (i.e. self medication program)
•7 week engagement sessions focusing on processes, changes, Soarian/MAK functionality, considerations for clinical team, etc.
14
What was included with each implementation?
Scoping & Engagement
Design, Build & Testing
Education & Training
Post Live Support
Key Activities:•Collection of unique content (i.e. care
orders, predefined medications, etc.)•Analysis of content and order sets•Design and development of new
electronic orders and orders sets•Testing of new electronic content•Migration from DEV to TRAIN to
PROD
15
What was included with each implementation?
Scoping & Engagement
Design, Build & Testing
Education & Training
Post Live Support
Key Activities:•Documentation of unique workflows•7.5 hour RN training session (in
classroom)•2 hour MD/resident training (in
classroom)•2 hour HD training (in classroom)
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What was included with each implementation?
Scoping & Engagement
Design, Build & Testing
Education & Training
Post Live Support
Key Activities:•24/7 on unit support for 4 to 5 weeks•Command centre to log, triage and
resolve issues•Daily status meeting with Project
Leadership, Team, Unit leaderships and end users
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Driving Clinical Adoption – Physician Perspective
• Ensuring future state process fit with physician workflow
• Clear and consistent communication regarding the benefits of the changes
• Engaging physicians to develop orders sets which incorporate evidence-based, best practice guidelines
• Providing flexibility for training sessions
• Leveraging Physician Leads role in key clinical areas as champions
• Enabling multiple Soarian access points – remotely from home and through various devices (iPhones, blackberries, computers on wheels, iPads, etc.)
• Leveraging existing structures for communication, input into key decision points and project updates (i.e. Medical Advisory Committee)
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Driving Clinical Adoption – Staff/Unit Perspective
• Understanding a clinical unit’s culture, practices and flow to define an implementation scope that most appropriate for the unit
• Ensuring transitions function as smoothly as possible (i.e. OR transfer workflow, ED admissions, etc.)
• Focus on creating shared ownership of the project between the project team, stakeholders and clinical unit
• Tackling less than desirable practices and processes;
•Frequency of telephone and verbal orders
•Using physician order sheets as a communication tool
•Minimizing incomplete orders
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Driving Clinical Adoption – Challenging Processes
• Consult Orders • Suggest orders from a consulting MD that require review and
acceptance from the MRP• Transfers of Care
• From service to service or one level of care to another• Increased complexity when transferring from paper based area to
electronic unit• Supporting SMH’s educational mandate
• Organization trains over 300 nursing students, 150 medical students and 400 residents
• Currently, no safe electronic solution is available to support medical student workflows
• Enhancement Requests/Content Change Requests• Clear downtime procedures
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Where we are today…..all med/surg beds are live!
• All staff physicians,nurse practitioner’s and residents enter orders electronically
• 215 physicians, 650 residents have been trained
– >2,500,000 medication, investigations, diagnostics and care orders have been placed
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Right Drug = Drug Type + Dose + Route + FrequencyEach alert (incorrect drug, dose, or route) helps avoid a potential medication error
* Reporting period: March 9, 2010 to March 31, 2011, Source: Siemens MAK
Our 360 CPOE Trained RNs received 3694 Medication Alerts
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Pre-CPOE Post-CPOE
# o
f B
ioch
em
istr
y T
est
s Ordering efficiencies are improving lab test utilization
Comparison of Biochemistry Lab Test Volumes – Pre & Post CPOE
• The real value has been on the integration of the process analysis methodology with the implementation. We have uncovered many “hidden gems” in the implementation
Unanticipated Workflow Changes
•Self administration policy on CF unit. Partnership of RN and patient
•Eliminated “take own meds”
•Standardized transfer order sets from critical care to floor
•Nurse patient assignments changed to geographic
•MDs have changed their rounding practices
•And we have over 95% orders entered directly by MDs
Implications
• Engaging clinicians is about driving value. Workflow can be a key asset in demonstrating early wins.
• Workflow analysis and technology, combined with advanced clinical information systems can be a mechanism to:• Deliver information to the clinician desktop• Assist organizations to transform practice• Facilitate knowledge translation from bench to bedside
The Result – SMH is now a leader in EMR deployment
• Over 30% of Ontario hospitals are between Stage 0 and 2
• Only TWO Ontario Hospitals have reached Stage 6.
What’s Next?
• Enabling the Emergency Department and Critical Care
• Adoption Sustainability Strategy & Optimization
• Implementation of Embedded Analytics (business analytics tool)
Road to Stage 7
Challenges to Attaining HIMSS 7
• Physician Documentation• Interoperability• Changing technologies• Financial Pressures• People• Competing organizational priorities
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Questions
Michael Freeman, MDDirector, Medical InformaticsSt. Michael‘s [email protected]
Purvi Desai, MBASenior Clinical Project ManagerSt. Michael‘s [email protected]
Anne Trafford, BSc. RN
Vice President, Information Management, St. Michael’s Hospital
