QUEENS HEALTH NETWORK
HEALTHCARE
INFORMATION SYSTEM
A MODEL FOR
ELECTRONIC PHYSICIAN ORDER ENTRY
SUMMARY
AND OVERVIEW
The requirements of a rapidly
changing, competitive marketplace have amplified an existing demand for
improved clinical information within the healthcare organization, and focused
increasing attention on the expansion of ambulatory care services, especially
primary care. Additionally, recent
population-based “disease management” efforts by health systems directed at
major chronic illnesses have increased the emphasis on safe, efficient and cost
effective means to enhance patient care and measure outcomes. At the Queens Health Network (QHN), the
consolidation of operations and regionalization of services compels the sharing
of patient data throughout a multi-hospital system. Quality care for patients across a variety of
settings, whose locus is no longer the inpatient hospital, requires the ever
more rapid retrieval of longitudinal, integrated patient information at the
point of service.
In the spring of 1996, implementation of a computerized medical record was proposed by senior administration to the medical staff as an integral component of the Queens Health Network=s strategic and business plans. The decision was made to implement the New York City Health and Hospitals Corporation=s software choice, Ulticare/ Patient 1, by Per Se Technologies (formerly Health Data Sciences). Assistance with database design and development, as well as implementation support, is provided by Negley, Ott and Associates.
At QHN, the registration and visit scheduling systems (Seimens, formerly SMS) feed admission, discharge and transfer data to Ulticare/ Patient 1, which then transmits charge data to the billing systems for procedures performed in radiology, cardiology and the laboratories. Laboratory tests are ordered online, and results are imported via bi-directional interfaces to instruments or reference laboratories. Ulticare/ Patient 1 serves as the hub of the radiology system, transmitting orders to both the voice recognition system, Talk Technologies, and the AGFA PACS, and storing and transmitting reports received from the voice recognition systems to the PACS. With the exception of mammography, QHN is filmless.
Computerized physician order entry (CPOE) has been a reality in the Queens Health Network since January 1997. Currently, doctors throughout Ambulatory Care document about 3,000 patient encounters online every day, and inpatient physicians place orders and review results for thousands more. Physicians, nurses, social workers, nutritionists and other patient care providers enter and retrieve data (test and consult orders, assessments, progress notes, history and physical examinations, medication orders, patient education) in Ulticare/ Patient 1 at nearly 3,000 personal computers located in exam rooms, ancillary departments and on inpatient units across the Queens Health Network.
The result is an integrated, interdisciplinary electronic patient record located at the point of care used by physicians and other clinicians to enter and retrieve patient data. Because of this strong patient information infrastructure, the Queens Health Network is well positioned to re-engineer care processes, coordinate patient care across the continuum of time and location, sustain multidisciplinary team functioning, and facilitate performance and outcomes measurement necessary to improve health care quality in the 21st century.
A member of the New York City
Health and Hospitals Corporation (HHC) and an affiliate of the Mount Sinai
School of Medicine, the Queens Health Network is the major healthcare provider
in the borough of
(See APPENDIX I:
MANAGEMENT
Goals of the Healthcare Information System (HIS)
Project objectives are shared by the medical staff and administration. These include: 1) to support the improved quality of patient care through access to and availability of patient information; 2) to facilitate and improve the documentation of clinical data throughout the lifetime of the patient, and across the continuum of care; and 3) to integrate clinical information available from various legacy systems.
Project Planning and Leadership
Initial efforts were launched at Elmhurst Hospital Center (EHC). A Project Implementation Team was recruited from within the organization, and an ambitious timetable outlined. A senior administrator, responsible for the provision of clinical services in the inpatient hospital, the operating rooms, and the emergency department, was relieved of those duties and designated as the Project Manager. A strategic management expert, she has the skill sets which allow her to effectively negotiate competing priorities, and direct the implementation process. The Project Manager was partnered with a data analyst with expertise in outpatient operations, who assumed the title and responsibilities of Technical Director. Other Project Team members included the Chief Information Officer, Information Systems (IS) analysts responsible for the existing lab and registration systems, the radiology system administrator, and IS technical and communications experts. The Project Team immediately assumed high visibility in the organization, as the project was given priority status and support.
The HIS Steering Committee, comprised of senior clinical and administrative leadership, was created to institutionalize the project, and establish clinical and operational priorities. This group includes: the medical directors of each primary care, as well as key specialty care services and the emergency department; the associate dean of the medical school, the nursing executive, the senior network vice president of the Queens Health Network, the directors of quality assurance and health information management, and administrators responsible for the clinical and ancillary services in Ambulatory Care.
The HIS Development Committee, comprised of senior administrators, was commissioned to research issues prior to consideration by the Steering Committee, and keep implementation on track. Both groups are chaired by the HIS Project Manager and meet regularly.
To commence the project, every clinical and administrative department in the hospital was given a brief demonstration of the project and informed of its goals and objectives. In August, 1996, the HIS Design Team was established, and a hospital wide informational session, with participation by all department heads, was presented by the Project Team to introduce and encourage support for the endeavor. Members of the Design Team are recruited based on their ability to provide clinical or systems expertise and participate in the development of applications specific to their service or department (See APPENDIX II: HIS QHN Organizational Structure).
Implementation: From Paper to CPOE in Six Months
Because the success of the project was determined to be time critical, various application modules are implemented in phases, in a continuous cycle of design and development. This approach is in lieu of “building the perfect beast”, which would require the commitment of significant resources over a number of years, before providing any value for patient care activities.
The execution of an aggressive project time line necessitated the compression of numerous complex tasks into a series of parallel, concurrent phases, all of which were completed within six months. These initial phases included:
§
Creation of a physical infrastructure
- Identify, design and renovate space
-
Design and build
- Relocate Project Team
§
Creation of a data communication infrastructure
- Design and build a local area network
- Design and build a wide area network
- Plan and install hardware
§
Clinical work flow analysis, including process redesign
§
Software customization
§
Project Team training
§
Development of system documentation
§
Development of training program and documentation
§
Implementation of provider training program
§
Transition plan development and implementation
§
Establishment of a HELP DESK
§
Software implementation and support
A
hospital wide data infrastructure, including Level 5 communication network, FDDI
ring technology, mainframe computers, and terminal servers were installed
during the fall. Over four hundred personal computers and two hundred fifty
laser printers were located in exam rooms throughout the
Implementation of the electronic medical record was initiated in Ambulatory Care in January, 1997, with the development of interfaces to the existing, electronic registration (ADT), laboratory and radiology systems. The immediate effect was to integrate and allow the retrieval of clinical test results by the physicians at their desktops. Physicians began placing test orders on the system, and documenting problems on the patient problem list.
In order to continue to add immediate value to patient care activities, enhanced documentation features are added to the system as they are developed. Continuous project design and development cycles require ongoing implementation phasing as new functions are introduced. Each phase involves:
§
Analysis of patient and work flow, with suggestions of improvements
§
Application design by an interdisciplinary team of users
§
Customization of application software
§
Interdisciplinary feedback sessions to refine the product
§
Development of system and training documentation
§
Provider / user training
§
Testing of application; assessment; improvement
§
Software implementation and support
The Queens Health Network has established a model for the design and development of a computerized patient information system which is collaborative and interdisciplinary, in function and in form. Physicians, nursing and other patient care providers assist in establishing priorities for system development, and participate in every step of the design and implementation process. As a result, the HIS reflects the variation in the manner in which physicians take care of patients, and captures data particular to specific patient populations, while allowing the sharing and dissemination of data across all areas. Physician participation in development efforts also contributes to the high level of system utilization across the Network: recent analysis indicates that every physician logs on to the CPR, for an average of 43 hours per month.
Point of Service Computing to Gain Physician Support
The HIS was conceived of as a way of providing essential patient information to physicians throughout a high volume, geographically dispersed service delivery area. Doctors were frequently unable to obtain timely patient information, and once they did so, documentation of care might be illegible or incomplete. Tracking and providing the paper medical record to scores of primary and specialty care services, no less the emergency department and inpatient units, was a logistical ordeal. Reviewing patient test results required physicians to queue up in front of application specific computer terminals, first, for example, at the lab terminal, next, at the radiology terminal.
The goal of the initial software implementation was to gain the support of the medical staff by resolving the most glaring issues for doctors. For the first year of the project, attending physicians, as well as residents and midlevel providers directly supervised by attendings, were the only users of the system, with other staff trained solely in a support capacity to the physicians.
Clinical documentation required by payors and regulatory authorities was arduous and time consuming. For example, a physician is required to note the patient=s diagnosis three times: once in the physician=s progress note; a second time, on the summary required by JCAHO for patients receiving continuing ambulatory care services; and again, on the billing form. Physicians under pressure to see a high volume of patients were loath to duplicate efforts seen as bureaucratic and of little value to patient care.
The Project Team customized the electronic patient problem list to automatically capture appropriate ICD-9 and CPT-4 codes as the physicians document the patient=s problem and the care provided at each clinic visit. In one automated process, the documentation of diagnoses and procedures is completed, and physician and hospital billing is enhanced. The linking of the financial to the clinical documentation not only streamlined both processes, but guarantees that the clinical information is entered at every encounter: physicians are required to complete the encounter (billing) form.
In turn, this ensures that the clinical data from each primary care or specialty visit is available and accessible to the doctor, at the point of service, for the lifetime of the patient. By December 1997, physicians throughout ambulatory care were documenting online significant diagnoses, conditions, procedures, drug allergies and writing online prescriptions for patients.
Today, a network comprised of nearly 3,000 personal computers with printers, located in examination rooms, ancillary departments and on inpatient units throughout the Queens Health Network has been created. The HIS has become an integral part of the practice of providing quality patient care for 1,625 different doctors, nurses, social workers, dieticians, lab and radiology technicians each day. This integrated corp of care givers spend an average of four hours daily accessing the clinical record and documenting clinical findings in the electronic chart. Analysis shows that an average of 579 physicians and 1,046 allied health professionals access the HIS on a daily basis.
Development of an
Electronic Primary Care Chart
Priority for system development and implementation was given to outpatient services generally, and primary care services, in particular: Medical Primary Care (adult), Women=s Health Services, and Pediatric Primary Care, including Adolescent Health Services. During the summer of 1997, the HIS Project Team assessed the patient and work flow in the various primary care clinics, and developed a statement of work for those areas. These were approved by the clinical and administrative department heads, and then presented to an interdisciplinary work group. Included in the group were several representatives of the Medical Records Committee, the Director of Health Information Management, the medical directors of the primary care services, as well as Ambulatory Care nurses and administrators.
A document describing the
proposed components of an electronic, primary care patient record was presented
to and modified by the group. The work
document included descriptions of the types of information to be entered into
the system; who the data would be entered by; how the information would be
presented, and where the information would be stored. This effort was an
initial part of the process of supporting the medical staff and administrators
to conceptualize the interactive process required to design and develop a
product which would meet their clinical and informational needs. Discussions were focused on assuring that
system implementation would augment rather than disrupt patient care. Core record elements were defined as
essential for providing patient care, and certain financial and clinical
process elements were identified as those that could be incorporated at a later
date. The proposal was then modified and
finally approved by the HIS Steering Committee (See TABLE 1: Elements of an Electronic Primary Care
Chart).
Once the overall framework and its components were approved, design teams from the various services were convened to define and approve the details of their particular applications. Each module was tested and piloted on a controlled basis before being implemented service-wide. Prior to implementation, the appropriate documentation was written by the Project Team, and training provided to the staff.
By the middle of 1998, interdisciplinary patient assessments had been implemented in various primary care and specialty care clinics; by February 2001, the primary care services were “practically paperless”, with physicians documenting patient histories and physical examinations, progress notes, assessments and plans online; nursing picking up doctor’s orders and documenting their assessments, patient/ family education and screenings for interventions by ancillary services online; and social workers, dieticians and health educators reviewing online referrals and documenting all progress notes for new and established patients.
TABLE
1
ELEMENTS
OF AN ELECTRONIC PRIMARY CARE CHART
User Training and Support
User training is coordinated with the clinical and ancillary departments, and scheduled at the convenience of the caregivers. Training is provided by the Project Team whenever a new feature or function is introduced; at any time upon the request of the user or user=s supervisor; and to all new employees whose patient care functions require documentation on the HIS. In 2001, a computer based training (CBT) program was installed, in a hugely successful effort to provide increased access to training for all levels of staff in the system’s Chart Review features.
Ongoing training of physicians and other patient care providers is required because: 1) Continuous system design and development guarantees that the HIS is constantly changing, to reflect users= needs and priorities. New functionality is continually being requested, tested, piloted and implemented; 2) The needs of the various primary care and specialty care patient populations, inpatients and outpatients, have widely disparate requirements; 3) Each month, medical and surgical residents rotate into the network from its medical school affiliate; and 4) The transformation of physician practice patterns, and the integration of new technology, requires constant reinforcement. Emphasis is always on improving support for patient care providers, to enhance the quality of patient care.
Today, the HIS has become ubiquitous to the point that training must be provided on one or both campuses every day, sometimes in large groups, sometimes on a one-to-one basis. The training program has evolved into a highly structured, formalized endeavor, with class rosters used to register students in advance, and customized training documents for every application. Instruction and support materials are service specific, as well as discipline specific: pediatricians, for example, are trained to document age-specific milestones in their progress notes, while internists learn how to access a diabetic protocol to guide management of this chronic disease. Nurses learn how to document patient/family education, while lab and radiology technicians learn how to process tests. Last year the HIS Project Team trained nearly 3,000 employees throughout the Queens Health Network.
Training and support is provided by the staff of the HIS Help Desk, who triage calls, and walk users through the applications when needed. If the problem cannot be resolved over the phone, a Help Desk member is immediately dispatched to the clinic to address the software issue, or replace hardware, as appropriate. This immediate response is essential in a busy patient care environment, where no system down time or delay is acceptable. It is also key in gaining the support of the medical staff and other clinicians for whom the use of paper has become anathema. Electronic call logs are maintained which help to identify application features which require reinforcement and/ or redesign.
OPERATIONS
System Security/Patient Confidentiality
Access to the electronic medical record is limited to those employees who require specific patient information, and level of access varies dependant upon an individual=s discipline or work function. For example, clerical and administrative staff, physicians/ midlevel providers, RNs and various other nursing personnel, have different security levels, and see varying amounts and types of information. Access is restricted on a Aneed to know@ basis.
Users are issued an electronic key at training, and must choose a system password which changes every three months. At the initial training session, every employee signs a confidentiality statement. Both the physical device (key) and the electronic password are required to sign on to the HIS every time. Every admission to any patient=s Chart Review is recorded automatically. The system generates an audit trail which shows who viewed and/or added to each patient=s file, with a record of the date and time.
Maintaining
Operational Activities Throughout Continuous Development Cycles
An ongoing needs assessment process defines the efforts of the HIS Project Team. Requests from all levels of clinicians and administrative staff for new features or system enhancements are forwarded to the Project Manager. As appropriate, group or individual meetings are held to refine issues, which are then referred to the regularly scheduled Development Committee and Steering Committee meetings for consideration and prioritization. Competing needs are juggled and progress is monitored. Improvements and further changes are implemented as required.
While the timetable for meeting project objectives is strictly adhered to, priorities may be modified according to market needs. For example, development of the final module of the Ambulatory Care chart, the design and installation of specialty consultations, was postponed due to national emphasis on patient safety, and the organization’s desire to mitigate errors through installation of order entry on the inpatient units.
It is the expectation of the Steering Committee that all functions performed in the targeted area by all employees will be automated to the greatest extent possible. In order to accomplish this, detailed workflow analyses of departmental processes are prepared by the HIS Project Team through direct observation, interviews with departmental leadership and staff, and interviews with representative caregivers who review and rely on the patient data provided by the department.
Preparation of a proposal to replace the current workflow often reveals work processes that are redundant or conflict with other departmental practices. At times, the needs of caregivers reviewing the data and those providing the data may conflict. These issues are analyzed thoroughly and recommendations for resolution are prepared.
A prototype of the new system is presented to the department, which includes a written document as well as a demonstration of CPR functionality. The current and proposed work processes are described in the document. The prototype presentation allows the targeted department to confirm that current processes and problems have been accurately defined, and to validate the proposed workflow for appropriateness. Implementation objectives are prioritized, and the expectations of the users are clarified and refined.
At times, it may not be possible to meet every objective identified as desirable, because of resource constraints or technology limitations. A thorough review of the prototype provides an initial glimpse of the impact of the implementation and the likelihood of achieving the department’s local objectives. The department and the HIS Project Team may also begin to identify and prepare to mitigate any potentially adverse effects of the implementation.
As the CPR develops, documentation and decision support features are customized to serve the needs of the different patient populations, then modified and improved after feedback from the physicians and other care providers. For example, an initial intake tool for adult primary care patients was implemented, including a nutritional screen performed by nursing staff. The system calculates a score based on the patient=s responses to a series of screening questions. When the score reaches a defined threshold, the patient is electronically referred for a full nutritional assessment. The clinical information is then routed to an electronic work queue to be reviewed and augmented online by the dietician assigned to that patient population. As the information is updated at subsequent visits, or by other care providers, the computer screens are refreshed, eliminating the need to repeat efforts by staff or patients to communicate.
The paper form that was in use in the primary and specialty care services provided the basis for the development of the electronic intake tool. Based upon user feedback, changes were made to the calculations used to determine nutritional risk in the adult population. Additional work with physicians and other clinicians made it clear that the nutritional requirements for obstetrical and pediatric patients varied from the general adult population, and required additional sets of calculations to support their particular patient care needs. Pediatrics oversaw the design and inclusion in their progress note of age specific interval histories, including diet.
As the utilization of various documentation tools are expanded, providers will continue to be polled to determine their effectiveness. Changes will be made as necessary and appropriate to improve the data collection process and patient care.
Evaluation
of Management of the CPR Effort
- The most important rule to be followed as the CPR is planned and implemented is the simplest: Listen! Listen to physicians to learn what they need to take care of patients. Listen to explanations of patient flow and paper flow to understand how to develop CPR tools to expedite these processes. Listen to users and creators of clinical information to understand what is essential and what wastes time.
§
Physician order
entry is a realizable goal if a partnership is created between the medical
staff and the Project Team. A return on
the investment of learning a new system must be realized as quickly as possible
in the demonstrated value of electronic patient information (timeliness,
availability, legibility).
§
While pilots are
important for gaining trust and testing functionality, successful
implementation of a comprehensive, interdisciplinary patient record requires a
“Big Bang” implementation strategy. The
department or service will suffer the same period of upheaval regardless of
whether the new application is rolled out to 20 or 200 or 2,000 users. Furthermore, integrated functionality must be
simultaneously implemented across disciplines in order to provide its full
capabilities and benefits to users.
§
The process of
automating the clinical patient record is less about technology and more about
change management. People generally have
a fear of the unknown, and often prefer “the devil they know over the devil
they don’t”. Users learn at different
rates: “superusers” aren’t always super, even if
they’ve attended multiple classes. They
also have varying degrees of tolerance for change. Some who are initially CPR enemies eventually
come around.
§
Use of the CPR
has moved the organization into the information age. Ironically, due to the priority given to
physicians in CPR development, support and implementation, the medical staff
are often more expert at the language, complexities and capabilities of the
system than the support staff. The
organization has insisted that the clinicians work toward a paperless environment,
while many of the mid-level managers continue to resist the role of “superuser”
essential to provide the first line of support for clinicians.
§
The importance of
physician leadership to the successful implementation of the CPR cannot be
overstated. Lack of enthusiasm for the
project from the chief of service will guarantee limited satisfaction with and
utilization of the CPR within a service.
Differences are apparent across campuses and within services, where the
application and the technology are exactly the same.
§ System integration is the key to providing clinical information in the easiest, most expedient format possible. Foreign system interfaces require maintenance, troubleshooting and inevitably cause data integrity and reliability issues for clinicians.
§ The development of clinical practice standards requires hard work and compromise, and they must be agreed to prior to system implementation. The CPR cannot be programmed to follow certain rules, providing decision support in the process, unless consensus is reached by the medical staff.
- At this point in development, some paper remains part of the chart that the Ulticare/ Patient 1 software cannot accommodate. This includes images, e.g., consent for treatment and other signatures, the pediatric growth chart, and EKG strips. In addition there are a few applications that have not yet been converted (blood banking), or developed (specialty consult reports).
- Keeping
it simple and quick, especially for physician order entry functions is
another key to success. The Project
Team must remember that there are multiple customers for each application
under development. It is important
for system efficiency not to allow extraneous questions, inconsistent
displays, and flashing reminders to clutter screens.
Functionality
Targeted Processes
From the beginning, development of the CPR was given
priority within the organization, due to its anticipated impact on key systems
which support patient care. It was
expected that implementation of an electronic patient record would go far
toward improving the quality of healthcare provided by the Queens Health
Network, especially with regard to:
§
Patient safety,
as physician order entry eliminates transcription errors made by caregivers who
serve as intermediaries between the physician and the patient; legibility of
prescriptions, progress notes, care plans, assessments is improved; and
medication errors may be reduced through use of computerized alerts regarding
dosing, allergies, and adverse drug reactions.
§
Efficiency of
care can be improved by reducing redundant laboratory and other testing,
improving multidisciplinary communication by integrating patient assessments,
and making all patient information immediately accessible at the point of care.
§
Effectiveness of
care may be enhanced through use of automated decision support features, such
as electronic reminders of health maintenance testing and immunizations,
displays of certain test results and measurements trended over time, and
automatic notification of a patient’s condition to providers at other care
venues.
§
Timeliness of
patient information is improved by providing real time availability of clinical
information, diagnostic tests and treatment results across the continuum of
care.
QHN CPR Data
& Data Entry
In
general, patient information is entered into the CPR by physicians or other
clinicians, or captured by instrument or foreign system interfaces. The Queens Health Network’s CPR laboratory
application includes forty-four laboratory instrument interfaces, a
bidirectional interface to the organization’s primary reference laboratory, and
an interface to another HHC facility for whom QHN serves a reference laboratory
for cell immunology tests. The CPR also
supports bi-directional interfaces to two PACS systems, one mammography system,
and the voice recognition systems for the radiology departments, as well as
patient registration and billing systems.
The software allows field level data control
in both the order entry and result entry processes. At a macro level, the Project Team can define
who can order a test and who may need to countersign the order; who can cancel
or result a test. The real uniqueness
lies in the ability to prevent certain users from accessing, editing, or
viewing certain data (down to the field level) based on system security access
or data documented in another field in the patient’s record. Creative
combinations of existing system tools are used to minimize the number of tests,
order and result profiles, menus, etc.
The Project Team builds one assessment, for example, with built in
logic, rather than replicating it numerous times, thereby minimizing the
database links to be maintained or updated as the CPR expands
Extensive
system audit trails also help to promote the use of the fewest number of data
elements possible. There is no need to
over-engineer minor differences (in fact, it may not be necessary to suppress
fields as described above) because it can always be determined retrospectively
exactly who did what. If at the time of
the application development, nurses’ aides are not permitted to perform hearing
testing on children, but are permitted to do so following a training program
the next year, the Project Team doesn’t have to alter a set of complicated
rules to enable this functionality. This
also permits users sharing a common title but performing different duties in
different services the latitude authorized by or within their service.
Duplication
of data entry has been eliminated due to system functionality allowing patient
information to be displayed in order entry screens, in result entry screens,
and in multiple display functions. The
system’s event architecture also allows a single event to seamlessly display in
multiple intrafacility and interfacility work queues (e.g., a lab test ordered
at
Controlling
the input of patient information at its source is a powerful mechanism to
ensure quality. Fields in order and
result screens can be created from user defined or system defined data
elements. Fields can be displayed based
on the definition of customized field specific logic, called Data Element
Dependencies (DEDs). Interactive entry
of information as well as historical patient information can trigger the
display or suppression of fields. In
addition, user security levels can be used as criteria to determine the display
of fields. Display, edit and required
field functionality have been used to compel users to enter complete
information, promoting to a safer environment for patient care.
Multiple
views of data allow visual validation of information across venues, another
vital mechanism to ensure data quality.
The same patient information can be viewed in work queues, review
queues, result verification queues, face sheet display screens, order and
result screens and across multiple functions designed to process events.
For
instance, in the laboratory module, culture reports contain organism and
sensitivities results from the microbiology analyzer with required fields to
ensure completion. Non-reportable
sensitivities are marked for suppression so caregivers cannot view them. Results go into culture-specific queues for
review by supervisors, regardless of the origin of the order (i.e., acute care
hospital or off campus clinic). All
processing activity on a culture can be reviewed online by medical
technologists and supervisors. Reports
identifying organisms, diseases and patient conditions that must be reported to
regulatory agencies can be reviewed online.
The control in the input of patient information and the numerous review
mechanisms ensure quality and consistency of the patient data.
The
following table demonstrates the types of data captured in the QHN CPR, how it
is entered and who places the order and/or documents the information, and the
mechanisms for controlling the reliability and validity of data capture. This table demonstrates the scope and breadth
of the QHN longitudinal patient record.
Every effort is made to capture data in the CPR at the point of care by
the person providing the care.
TABLE
2
QHN
HEALTHCARE INFORMATION SYSTEM
CLINICAL
DATA CAPTURE MODEL
|
Function |
Order Entry/ Data Capture
By |
Data Entry Controls /
Notes |
|
Allergies |
ALL, RPH |
Standardized
prompts; searches for exact medication names against CPR copy of commercial
drug database |
|
Problem
List |
ALL |
Standardized
lists; searches against CPR copy of ICD9 database |
|
Outpatient
Prescriptions |
MD |
CPR
requires some fields in order process and provides standardized dose and
route lists; searches for non-formulary medications, drug info, and ADR info
against CPR copy of commercial drug database. |
|
Inpatient
Medications |
MD, RPH |
CPR
requires some fields in order and result processes and provides standardized
dose and route lists; searches for non-formulary medications, drug, and ADR
info against CPR copy of commercial drug database. |
|
Vital
Signs & Measurements |
ALL |
Range
limited fields; abnormal & critical value markings |
|
Head
Circumference Percentile |
--- |
Controlled
by security position of user: MDs,
NPs, and PAs only enter data. CPR automatically calculates the percentile for
the patient’s age. |
|
Coding
Sheet (encounter billing data) |
MD |
CPR has
built in alerts indicating wrong specialty, old visit, or discharged visit.
Searches for procedure code against CPR copy of CPT4. |
|
Telephone
Triage |
NSG |
CPR has
standardized pick lists with built in logic that prints select encounters to
appropriate locations upon completion. |
|
Diabetes
Protocol |
MD |
CPR
displays results for diabetes management tests and links to order entry
functionality to allow quick ordering of missing tests. |
|
Pediatric
Immunizations Results |
ALL |
N/A CPR
controls data entry with standardized pick lists for vaccine types (e.g. DTP,
DT), manufacturer names, etc., and for users to explain why an immunization
will not be done (e.g. contraindicated).
The CPR speeds and controls the data entry process by giving users
their own database of commonly used vaccines.
E.g., users can pre-define the manufacturer, lot number, and
expiration dates for the Hib vaccine they are
using, which will automatically pull into the fields each time that they
document administration. |
|
Pediatric
Immunization Reminders |
--- |
Reminders
display on a report to the screen.
This display grid shows the AAP immunization recommendations for that
patient’s age. The CPR fills in
vaccinations given, then displays documented reasons why an immunization will
NOT be done, leaving blanks only where items are due. |
|
Health
Maintenance Tests Results |
MD, ALL |
CPR
controls data entry with standardized pick lists for why a test/procedure will not be done (e.g.
contraindicated), and range limited prompts (e.g. for BP). The CPR’s lab and radiology departmental
processing performs multiple controls for test results and, as these are
pulled automatically, rather than transcribed, those controls positively
affect the HMTs as well. The CPR speeds and controls data entry of
immunizations for adults in the same way as for pediatric immunizations (see
above). Users do not have to maintain this record of
HMTs separately; it is built into their work
process. They must indicate when they
will NOT perform a test/procedure.
Otherwise, they merely order the test or do the procedure, and the CPR
recognizes it. |
|
Health
Maintenance Test Reminders |
--- |
N/A Reminders
display on a report to the screen.
This display grid shows the recommendations for that patient’s age and
sex. The CPR fills in laboratory (e.g.
Pap), and radiology tests (e.g. mammogram), and documentation by caregivers
(e.g. BP value or Hepatitis vaccination), leaving blanks only where items are
due. |
|
Psychosocial
Screening |
NSG |
CPR
pulls in information about patient’s abuse history and substance use if it
has already been entered on any visit (the screener may overwrite this). The
screener accesses prompts with structured pick lists as reminders, then
determines appropriateness of a referral for social work services. The CPR then prompts with the list of
social work groups for the screener to select. |
|
Social
Worker Assessment |
MD, SW |
The
social worker is notified both via a paper request and an online work
queue. The CPR pulls information
entered during the screening forward into the social worker’s
assessment. Once documentation is
complete, the CPR changes the status of the assessment from ordered/pending
to complete and removes it from the worklist. |
|
Nutritional
Screening |
NSG |
CPR
pulls in height and weight if it has already been entered on any visit (the
screener may overwrite this). It then
calculates the desirable body weight (DBW).
The screener enters information about the patient’s relevant history
and risks using structured pick lists.
The CPR then checks against predefined rules regarding DBW
calculations/diet risks and automatically generates a referral for assessment
if appropriate. CPR prints a copy of the referral for the patient, and routes
it to an online work queue for the appropriate dietician. |
|
Dietician
Assessment |
MD, DIET
|
The
dietician is notified both via a paper request and an online work queue. As the dietician documents the assessment,
the CPR calculates fields, e.g., number of Kcal and grams of protein needed
per day based on patient’s size (previously entered by screener) and entries
by the dietician to standard questions.
The CPR then changes the status of the assessment from ordered/pending
to complete and removes it from the worklist. |
|
Specialist
(Consultant) Referrals |
MD |
CPR
requires certain information from the orderer, and provides standardized pick
lists to indicate subspecialty and number suggested of visits. As doctor places the order for a specialty
referral, the CPR checks which insurance plan is paying for the visit. If it finds a defined managed care plan, it
retrieves the rules for this payor and type of referral from another internal
CPR database and displays it to the user.
Regardless of the payor, it generates a specialty referral form used
to move the patient through the system. |
|
Managed
Care Authorization & Forms |
MD |
CPR
automatically generates a managed care authorization form as a byproduct of
every specialty referral order for a managed care patient. It also checks several internal databases
to determine (and print on the referral) the patient’s plan ID number, an
authorization number from the appropriate plan’s pool, the name of the PCP,
checks whether the author is authorized to sign for the PCP (in the same
practice group assigned to the patient), and the plan ID number of the
PCP. If the orderer is the PCP or an
authorized provider, it prints a message that the referral has been
electronically signed, otherwise it prints a signature line. As
another byproduct of the online order entry of specialty referrals, the
network’s managed care office receives daily reports listing which patients
had referrals and restricted procedures ordered. This gives them the lead time necessary to
make sure the signed form is submitted to the plan in advance of the pending
appointment or test. |
|
Cytopathology |
MD, LAB |
CPR
requires several fields to order the test, and provides standardized pick
lists for specimen type and body site.
CPR flags all non-Gyn cytopathology orders as STAT. It controls lab data entry and processing
by lab staff through security positions – restricting some staff to
accessioning or initial slide creation documentation. CPR controls data entry with standardized
pick lists of diagnoses and symptomology per |
|
Surgical
Pathology |
LAB |
Orders
are placed by the surgical pathology lab staff only. The CPR controls this access by security
position. Pathologists code in SNOMED
in the CPR by accessing the CPR’s SNOMED database. |
|
Chemistry,
Immunology, Hematology, Microbiology |
MD, LAB,
IF |
CPR
requires certain information in the order and result process, prompting with
standardized pick lists. Some
processing is performed manually, but most data is passed back and forth
between the CPR and the accessioning robot or instruments via interfaces. |
|
Radiology |
MD, RAD,
IF |
CPR
requires certain info in the order and result process, and provides
standardized pick lists for view, type, and body site. The CPR supports bi-directional interfaces
linking together the Radiology departments’ PACS and voice recognition
systems, checking patient and visit identifiers during these
transactions. The CPR auto-schedules
these procedures. |
|
Obstetrical
US & testing |
MD, OBS |
CPR requires
certain information in the order and result process, and provides
standardized pick lists for view and type.
It provides standard pick lists of diagnoses and range limited fields
for measurements. The CPR
auto-schedules these procedures. |
|
Non-Invasive
Cardiology |
MD, CAR |
CPR
requires certain information in the order and result process, provides
standardized pick lists for type of study, and restricts the ordering of
certain procedures to Cardiologists only.
It provides standard pick lists of diagnoses and range limited fields
for measurements. CPR auto-schedules
these procedures. |
|
Cardiac
Catheterization |
CAR |
CPR
requires certain information in the order and result process, and provides
standardized pick lists for type of study.
It restricts the ordering of all procedures to Cardiologists only, and
provides standard pick lists of diagnoses and range limited fields for
measurements. |
|
Resource
Scheduling |
RAD,
CAR, OBS, CC |
CPR
automatically schedules tests based on timeframe indicated by the orderer and
with definitions/rules about which procedures can be done where, test
duration, etc. Department and clinic
clerks can also manually perform the function but the CPR controls them by
only displaying appropriate room and time slots. |
|
Triage
Note |
NSG |
Standardized
prompts, required fields, range limited fields. |
|
History |
ALL |
Standardized
prompts with pick lists, range limited fields. |
|
Physical
Examination |
MD |
Standardized
prompts with pick lists (especially for body system symptoms), range limited
fields, abnormal & critical markings. |
|
Assessment
& Plan |
MD |
Standardized
prompts with pick lists, required fields. |
|
Nursing
Notes |
NSG |
Standardized
prompts with pick lists, required fields. |
|
Pediatric
Milestones & Guidance |
ALL |
Standardized
prompts with pick lists. |
TABLE KEY
QHN HIS CLINICAL
DATA CAPTURE MODEL
|
|
|
---
= Not applicable |
CC
= Clinic clerks |
|
MD
= MDs, NPs, CNMs, and PAs |
LAB
= Laboratory clerks, technicians, supervisors, physicians/PhDs |
|
ALL
= MDs, NPs, CNMs, PAS, and nursing staff |
RAD
= Radiology clerks, technicians, radiologists |
|
NSG
= Nurses |
OBS
= Obstetrical ultrasound clerks, technicians, maternal/fetal physicians |
|
RPH
= Pharmacists |
CAR
= Cardiology clerks, technicians, cardiologists |
|
DIET
= Dieticians |
IF
= Data/information provided to CPR via interface |
|
SW
= Social workers |
|
The above
table does not include the approximately 250 new processes that physicians have
recently begun ordering online on the inpatient units. They include orders for nursing procedures,
and requests to various departments for services like Social Work and Discharge
Planning, Food and Nutrition, and Respiratory Therapy. Additionally, physicians have recently begun
ordering all online department services (lab, radiology, cardiology, neurodiagnostic
testing, Obstetrical ultrasound, and all medications) for inpatients, which
they were accustomed to doing for outpatients.
As of April 2002, all patients seen in any EHC inpatient or ambulatory
care delivery setting benefit from the application of consistent rules based
clinical decision support for CPOE.
Availability of the Electronic Patient Record
There are
CPR PCs in every location where clinical documentation is performed at all
Queens Health Network care sites, including all outpatient examination rooms,
outpatient nursing, social worker, dietician, and telephone triage nurse
offices. PCs are also available at all
workstations in the departments processing online which include all Laboratory
sections, Radiology, non-invasive Cardiology, Neurology and Rehabilitation
Neurodiagnostic testing areas, the Pharmacies and Obstetrical testing
units. There are terminals on every
inpatient unit, and scattered throughout the emergency departments, as well as
in Health Information Management (HIM), Quality Assurance (QA), Finance and other
departments for review of patient information.
The
larger offsite clinics access the CPR directly on the Wide Area Network (WAN),
but the smaller school based clinics dial up to the servers located at
EHC. The reference laboratory dials into
its own PC on the network, which then communicates with the CPR. The other
HHC hospital laboratory sends select specimens for processing and pushes
transactions to the Queens Health Network CPR via the corporate network.
CPR
Features Facilitate Access to Clinical Information
The CPR
provides immediate access to patient specific information, and allows the
extraction and aggregation of data.
Integrated displays present data regardless of whether they are
documented by a physician as part of a clinic visit, by laboratory instruments,
spun off by the CPR as an order. The
integration of patient information processing and display in the CPR has
provided significant benefits for patient review and processes, and for
intradepartmental processing of tests, treatments and activities.
§
The Ulticare / Patient 1
Chart Review function provides summary level, detailed, longitudinal and
encounter specific data review for each patient. User specific, customizable Chart Review
screens display patient data grouped into categories for ease and precision of
review. Categories may be created based
on data provided by a specific department, or based on a clinically relevant
event time, or based on the data’s relevance to medical body systems or disease
paradigms. These data can be provided in
summary, detail, trended or graphed formats.
Users may select by category (e.g., all Hematology
results), by test (e.g., all Chest X
rays), or for all activity for a specific date and time (e.g., yesterday
morning at
Most users across the Network share the same Chart Review display
screen, but some are restricted based on job function to their own department’s
activity, e.g. Cardiology clerks can only see Cardiology testing, not physician
notes.
§
A clinician may wish to check a previous value while
in the middle of performing documentation (e.g. a BP result). S/he can obtain previous test results and get
to other data reviews with one keystroke, without losing his/her place in the
current, unsaved documentation.
§
The software allows the creation of “data review
groups”, screens containing various data elements in sequenced displays, as
defined by individual services. For example, the CPR has specific review
mechanisms for the medication administration record for data captured in
patient care assessments.
§
To satisfy a physician’s need to see the result of a
specific test in the context of other results (i.e., trended with other
values), the test can be defined at the level of the database. For instance, select the most recent Fasting
Blood Sugar result to review not just today’s value, but the patient’s most
recent FBS by nursing, chronologically interspersed with the most recent
laboratory glucose levels.
§
The software provides a User Defined Database (UDD)
tool which can be programmed to display a snapshot of data according to various
rules defined by individuals or departments.
Reports may be generated by users from a specific menu point, system
generated from within Chart Review, or for specified users, printed to paper. Some useful informational displays currently
in use include the “Patient Summary Report”, “ACOG Summary Report”, and
“Pediatric Visit Summary Report”.
Integration
of patient data is transparent to users of the CPR. All patient data obtained from the two acute
care hospitals and the seventeen clinics in the Queens Health Network display
in the electronic record. The user need
not specify the particular facility, or often, the encounter in which the data
were collected or documented. Summary,
detail, trended and graphed data display in an integrated manner across the
continuum of care. In addition, the
source of the data is collected in the CPR and can be viewed by users when
encounter specific review is required.
DECISION
SUPPORT, WORKFLOW AND COMMUNICATIONS
The most successful functions in the QHN CPR integrate
the operational with the clinical, yet the multiple needs they serve are often
transparent to the user. Many are global
in nature, and users see the results employed throughout the CPR. The design objective is to examine clinical
work processes and creatively combine the available software tools, using good,
old fashioned management techniques to create real, integrated solutions.
Because of the high level of system integration, most
key functions defy classification into one category or another. For instance, when the physician orders a
specialty consultation online, the CPR simultaneously provides decision
support, communication between services, and support for administrative
processes. The CPR integrates the
processes of alerting caregivers that they are ordering for a managed care
patient, displays appropriate plan specific rules regarding care, issues a plan
authorization number and generates the caregiver’s plan identification numbers
or name of the primary care provider, then prints notification to the Managed
Care office. The QHN CPR includes many examples of this integrated approach:
Embedding Real Time Alerts and Information
into the Order Entry Process. An integral
component of the software is the ability to check during medication orders for
drug-drug interactions, drug-allergy interactions, and correct dosing.
Additionally, duplicate order alerts are built into the order entry process for
departmental tests, medications and specialty referrals. These are knowledge based and defined in the
database on a test by test basis. For
instance, if a caregiver is ordering a second urine culture test within an hour
s/he is alerted to the fact that one is already ordered, while multiple orders
for MI Panels within an hour do not trigger alerts.
Embedding Real Time Alerts into the Order
Result Process. Test results which
fall outside of normal defined ranges are highlighted as “abnormal” or
“critical” values in Chart Review. Billing rules are based on the care setting,
e.g., outpatient caregivers are prevented from selecting emergency, inpatient,
or ambulatory surgery visit types as they proceed through functions performed
from the outpatient menus. Additionally,
built into each specific coding sheet is logic defined by DEDs which link the
appropriate codes in the ADT interface to alert the provider that they have
chosen a visit for another clinic, or an old or discharged visit.
Changing the Way Physicians Receive and Review Results. Prior to the implementation of the CPR, departments (laboratories, radiology, cardiology, etc.) printed at least two paper copies of every patient result. The first was sent to HIM to be filed in the paper chart. The second was printed in batches by ordering location, and then either delivered, or left in mailboxes to be picked up. These efforts caused delays that could be measured in days, not hours. Printouts might be delivered to the wrong location and were not sorted by, or delivered to, the specific caregiver who ordered the test. Normal results were not filtered so staff were forced to review one hundred percent of results.
The Ulticare/ Patient 1 Physician Review Queue returns the
results of tests ordered to each physician who ordered them. The queues populate in real time so that as
soon as the first results of a lab panel are documented, the information begins
to stream into the order author’s Review Queue.
To expedite review of important results, data filters block certain
items from appearing in the queues. For
example, at the request of the Steering Committee, normal laboratory results
don’t display in the queue, but abnormal, critical, or unmarked results
do. The Project Team can define at the
test level which results should display immediately, and which should be
suppressed until verified by department supervisors or physicians (e.g.
Cytopathology results will not display in physician review queues or Chart
Review until the required pathologist verification has been performed). The system also allows filtering by visit
type: clinic patient and inpatient results display in the review queues,
emergency patient results do not.
The
Review Queue allows the medical staff to define the manner in which they review
results, for example, STAT results first, or a summary list of abnormal and
critical results. Data may be trended or
graphed. The CPR logs an entry in the
event audit trail which contains a permanent record of all processing and
review activities. Providers spend less
time looking for critical patient data and more time analyzing and acting on
it.
Applications are
Customized by Service, Yet Standardized Across Services. The QHN
electronic Ambulatory Care chart consists of co-located functions and review
displays, menus, and securities customized for each service. They also share common characteristics and
components which support standardization of care across services. The applications provide almost paperless
record keeping for patients seeking care at any of the QHN sites, are shared
across the continuum of care, and eliminate duplicative documentation. Primary care chart functionality includes:
§
Extensive well patient notes, which are population
specific. In Pediatrics, for example,
the note prompts for age specific developmental milestones. If the child has not achieved certain
milestones by the appropriate age, the CPR assigns a score to the overall delay
and makes a referral recommendation in accordance with New York State
Department of Health (DOH) policy. The
CPR also calculates the population percentile for height, weight, and head
circumference as it is documented online, and prompts with age specific
anticipatory guidance topics recommended by the
§
Obstetrical progress notes include extensive
documentation of menstrual, contraceptive, and pregnancy history. These data are stored and redisplay at future
visits, so that they may be reviewed and appended easily. The Obstetrical note also includes measurements
taken at every visit: e.g., fundal height, fetal lie, fetal heart rate, mother’s
weight, which are displayed in a trend so that patterns may be more easily
identified.
§
All primary care progress notes contain patient
history and physical examination findings by body system, as well as
caregivers’ assessment and plan. Records of multiple pregnancies are kept
separate, driven by patient’s first treatment date.
§
Patient intake screens include nutritional and
social screenings. The CPR includes
rules that calculate and identify threshold scoring which vary depending on the
population, and refer patients for support services based on score and
location.
§
Grid displays of health maintenance tests and
immunizations. These are driven by the
patient’s age and sex, and provide a snapshot of both what has been done and
what needs to be done for the patient.
§
Triage notes for sick patients include chief
complaint, history of present illness, and vital signs which subsequently
display to the physician as s/he examines the patient.
§
Orders placed by physicians pull forward to display
in nursing notes documented later in the visit.
This allows nurses to quickly determine their responsibilities for the
patient, and eliminates transcribing orders, improving patient care and patient
safety.
§
Attending physicians expediently document their
supervision of and concurrence with residents’ examinations and findings in
notes utilizing options approved by Finance and clinical leadership.
§
Interdisciplinary patient/family education is
accessed by all medical, nursing, and many ancillary staff. The initial screens prompt for documentation
of patient’s preferred language, barriers to learning, clinical teaching
priorities, etc. Subsequent screens
prompt for JCAHO required encounter specific criteria, including topic, method,
and patient comprehension.
Electronic Work Queues Reduce Reliance on
Paper and Speed Turn Around Time.
Ulticare’s unique event architecture can
create multiple events from one order (e.g. tid) and
then process each as separate entities. The software has been customized to
move events from one user’s processing queue to the next as work proceeds. The
work queues aid in work management, from order through completion, in the way
that a paper tickler file might. Once
one part of the process is completed, the event will disappear from that
queue and move into the next one in the process.
§
Medications ordered for inpatients are
electronically routed to pharmacy worklists.
Sophisticated algorithms route different types of orders to different work
queues, as appropriate. For instance,
discharge medications are needed now, not in the next scheduled cart fill; TPNs or chemotherapy require a third level of review and
processing.
§
If a STAT CBC is ordered at
§
Events change “status” in the CPR, which are defined
primarily at the test level in the database.
For example, a laboratory event will first appear in a work queue to be
collected by a lab phlebotomist, or in another queue for collection by
nursing. Once the phlebotomist or nurse
has documented that the specimen has been collected, it moves to a list to be
accessioned, then to a dispatch work queue (if it is to be sent to another
facility – this is also defined at the test level), then received and
re-accessioned, then to a specific instrument work queue (there are forty-six
possible destinations, plus manual resulting work queues). If all required
result fields have not been completed, it will move to a “partial” work queue,
and when all required fields have been satisfied it will finally fall out of
every work queue as “completed”.
§
The Microbiology workcard
functionality in the CPR allowed for the phasing out of paper workcards.
Complicated culture processing is performed online for all cultures
including wound, tuberculosis and fungus cultures. Complex processing algorithms which guide
culture activity processing were implemented, automating the organism identification
process. Free-text data entry is
minimized, permitted only when online functionality is insufficient to
accommodate highly variable result responses (such as is found with parasitology result processing).
§
Online documentation of critical test results has
been improved through an integrated display of patient location with the actual
laboratory test results. This
facilitates communication of critical results from lab to caregiver with one
phone call.
§
The EHC Radiology Faculty Practice group codes study
supporting diagnoses after the Radiologists have finished reading by using a
customized work queue, accessing an online ICD-9 database.
§
Result verification queues push billing encounter
forms documented online by residents to the supervising physician for
verification prior to billing.
CPR Minimizes Work Duplication and Maximizes
Interdisciplinary Communication.
Data elements with specific storage locations and characteristics are
defined to facilitate the sharing of information. These include: non-historic data elements,
which are never shared. (i.e., each caregiver must take the same measurement
and record it every time e.g., fetal lie); visit historic, i.e., saved for the
duration of one visit (e.g., LMP, which will display to multiple caregivers
throughout the visit); or patient historic, which are saved for the patient’s
lifetime (e.g., the age at menarche). This functionality is widely used in the
primary care chart. For example:
§
Once the triage nurse documents the patient’s
complaint in the triage nursing assessment, it will appear in subsequent
physician progress note screens to validate or edit, not retype.
§
While writing the progress note the physician
documents specific orders for the nurse to carry out, e.g., “FBS”, or “educate
on medications” in the Orders to Nursing field.
Later, as the nurse writes his/her nursing note, the CPR displays these
nurse specific orders along with other orders the physician has placed online
(for labs, radiology, prescriptions, specialty consults, etc.). The nurse is
aware of the full care plan and can “pick up” his/her orders.
CPR Maximizes Communication Across
Departments. Utilization of software features such as UDDs, DEDs, and reporting
tools have improved communication across departments.
§
The Managed Care office receives daily reports of
specialty consults and specified procedures ordered the previous day, allowing
staff to proactively obtain the necessary PCP signature or plan
pre-authorization.
§
CPR tools have been used to create real time
printing of telephone triage documentation to the appropriate location (for
example, the pediatric emergency room), under specific conditions. The triage nurses merely document their calls
online, consequently alerting other staff of the pending arrival of urgently
ill patients.
§
Referrals for Ambulatory Surgery, which generally
require financial clearance, are printed directly from the ordering surgeon to
the Admitting Department, alerting them to begin the clearance process.
§
The CPR communicates specific ordering information
to caregivers. For instance, when a
barium enema is ordered, the CPR requires certain questions to be answered,
prompts the caregiver to prescribe certain medications to be taken the night
before, and prints a set of patient instructions in English and Spanish.
CPR is Designed to Ensure that Regulations
Are Met. Workflow analysis
for each new application includes the definition of all applicable standards
and required regulations by the department.
The database is then constructed to meet these requirements, for example:
§
The “Patient Summary Report” was written to satisfy
the JCAHO standard requiring that patient problems, allergies, significant
medical and surgical history, and medications known to be taken by or
prescribed for the patient are available in one location in the chart.
§
The Obstetrical record was designed to meet American
College Of Gynecologists (ACOG) and New York State Prenatal Care Assistance
Program (PCAP) requirements for documentation.
§
The Pediatric Immunization Recommendations adhere to
the AAP standard.
§
The Pediatric Milestones & Guidance follow the
AAP standard, and generate referrals for Early Intervention according to New
York City DOH standards.
§
Age-specific head circumference, and height and
weight percentiles calculate according to
§
The Cytopathology laboratory processing utilizes the
§
All applications are constructed to generate the
correct charge or prompt for manual coding, and require the appropriate
verification signatures to support accurate billing per state and federal
reimbursement regulations.
CPR Maximizes Organizational Quality Checks.
Department specific quality assurance tools have been created to identify
issues across care venues. For example:
§
The laboratory commissioned detailed reports that
identify specific organisms and infection control patterns.
§
Radiology utilizes a report that scans Surgical
Pathology reports for occurrences of cancer related strings, then searches for
Radiology reports for the patient within a three month window prior to the
Surgical Pathology finding. An outside
Radiologist consultant then compares both the body of Surgical Pathology report
findings and the Radiologist findings to determine clinical appropriateness.
§
Laboratory quality control processing and analysis
is consolidated into the CPR utilizing online QC data capture and review
functionality, eliminating manual or standalone QC programs, and incorporating
electronic signature for QC data review.
Data from quality controls and instrument/equipment preventative
maintenance can be reviewed simultaneously, and functionality for online
trending and graphing of QC data is available.
TECHNOLOGY
The computerized patient record deployed in the Queens
Health Network supports the clinical activities of 2,800 clinical staff
members, including nearly 800 physicians who access the CPR on a regular basis to
retrieve patients’ diagnostic data.
These clinicians treat over 3,000 patients each day at two acute care
hospitals and in over 600 clinics, offsite satellite facilities and school
based programs. The Queens Health
Network supports integrated care delivery across all venues through the sharing
of all clinical data relevant to caregivers.
In order to get clinicians to use the CPR, the electronic data must have
more value, i.e., be more convenient, more timely and more relevant than the
data when it resides in the paper chart.
Scope and Design
of the CPR System
The primary system used at QHN for the CPR is the
Ulticare/Patient1 system developed by Per Se Technologies. This system offers the ability to manage
clinical data in all care delivery venues while maintaining data
integrity. The focus on a patient
centered record is important in a municipal health system where service
offerings are constantly scrutinized to insure that quality care is delivered
by the most efficacious provider.
Clinical data must flow seamlessly from the service provider to the CPR
and back to the clinician. All textual
clinical data that has been automated resides in this CPR and is accessible
from any of the nearly 3,000 PCs across the QHN. Radiographic, MRI and ultrasound images are
available at any clinical desktop via a PACS system developed by AGFA. Full diagnostic quality images are available
on high resolution monitors in key areas:
the Emergency Department, intensive care units and Orthopedics). Compressed images are available via a Web
browser from any desktop in the organization.
Clinicians can also access databases/medical libraries and Internet
clinical content providers via the clinical desktop (See APPENDIX III: Queens
Health Network Health Information System).
The Ulticare/Patient1 system is hosted on a
multi-processor ring using a proprietary fail-soft technology developed by the
vendor. There are two quad processor
AViiON CPUs that act as the primary and secondary clinical data gateway
processors. Each processor supports dual
controller, mirrored, RAID5, hot swappable disk storage. There is currently 240 GB of clinical data
which is mirrored, RAID5'd and stored on two separate disk arrays. These two processors act as mirror images of
each other and offer the users connected via the application servers instant
access to the entire clinical database.
The architecture provides four copies of redundantly stored clinical
data in the mirrored environment. The
architecture allows these mirrored processors to be remotely sited without
degrading performance as long as there is fiber in place to run the FDDI
network (See Appendix IV: QHN HIS Enterprise Network).
Clinicians log in from their PCs via an enterprise
network using redundant local and wide area network technologies with auto
fail-over to the CPR. Once connected
through the remaining six Data General CPUs (AViiON 3700R dual processor
machines) they can access clinical data from today through the beginning of the
implementation in 1997 and may also access data that pre-dates the
implementation due to its conversion from legacy systems. All of the CPR servers in the processor ring
are connected via a redundant FDDI inter-machine network. The architecture can support the loss of
multiple processors, disk towers and fiber links without failing. The architecture accommodates up to 5,000
concurrent users with sub two second response times.
The file storage system used in the CPR is a vendor
developed proprietary unified inverted binary tree structure that offers fast
data access and storage times. This
proprietary structure cannot be accessed by external users for other
purposes. The CPR takes textual data
feeds from internal functional modules as well as external systems that conform
to the HL-7 and ASTM communications protocols.
The CPR accepts registration, admission, discharge and transfer data
from two Seimen’s (SMS) Unity systems using a
proprietary interface. Charge
information is passed back down these SMS interfaces. In addition, patient registration can be done
directly on Patient 1/ Ulticare if the SMS systems are down, and will
synchronize when restored.
Clinical data entry is performed in a variety of
ways. The primary method is the use of
the keyboard and mouse to interact with extensive menu driven screens that are
module, clinic, provider and activity specific.
These menus include templates, macros, hot keys and table driven
selections. The software offers
extensive tool kits to pre-load data for clinical validation through defined
rules and templates and to collect data from diverse caregivers to consolidate
into a final clinical note for physician review and annotation. The software interfaces with voice
recognition systems used to dictate all radiology reports. The system also accepts data feeds from
reference laboratories and other feeder systems that conform to the HL-7
standard. Finally, the system is
interfaced to forty-six laboratory instruments to transport clinical data in
real time into the CPR.
Clinicians access the CPR from 3,000 PCs connected via
the enterprise network. These PCs log-in
through a locked down desktop so that viruses cannot be introduced to the
network and unauthorized programs and functions cannot be used on the
system. QHN has also deployed wireless
network technology on the inpatient units to support mobile devices in addition
to the current hardwired devices.
Linkages with outside customers are provided through
user specific formats that are uploaded to external systems, and managed by real
time interfaces conforming to the protocols above, while ad hoc data needs are
met by extracting data using a robust data mining tool that creates data sets
that can be FTP’d to other external users.
The Ulticare/Patient 1
software was purchased by HHC in 1992, primarily due to the scalability of the
product, its patient centered architectural focus, fail-soft technology, the
integrated nature of the application module set and the robustness of the
toolkit. The CPR supports a
multi-facility care delivery model which characterizes the HHC environment, one
of the largest municipal hospital systems in the United States. Within the Queens Health Network, a patient
centered CPR has become a necessity to meet the needs of the patient community,
since patients may be seen in a clinic at one facility one day and be admitted
via the emergency room at the other hospital the next day. The emergency room physician needs access to
the clinic physician’s notes and the clinic physician, upon the patient’s
return to clinic, needs access to the data generated during the emergent
episode of care. In addition, clinical services have been regionalized, so that
patients, for example, are always sent to Queens Hospital for MRIs, and to
Elmhurst for radiation therapy. The data
must not only be accessible, but must be within a context and continuum that
makes clinical sense and is not arbitrarily determined by system
architecture.
Patient confidentiality is protected more effectively
through the utilization of an electronic patient record than on paper. All clinical data is stored centrally in a
server farm which is physically protected and monitored. There is no segregated data that resides in
disparate servers in isolated corners of the health system. This centralized
database model not only improves integration of clinician views, but also
insures that no clinical data is ever at physical risk. The architecture of the system does not use
the local hard drive of any PC for any clinical data storage, permanent or
temporary. This means that if a PC is
ever stolen (although all of the PCs are physically locked down), the thief
steals only hardware, not data.
The CPR uses a
closed proprietary data structure that cannot be accessed or manipulated by any
user of the system. To an external
viewer, the data structure is a single large locked file that is 240GB
big. Users have no ability to manipulate
data at the file level in the application.
All user access to data is controlled by CPR application functions and
these are set to view or view and edit.
If a user has security to make an entry in a record, it is audit trailed
with their user ID, a date and time stamp and the device location. Users cannot erase or manipulate this audit
trail. Finally, if the user is modifying
previously input clinical data, then the prior copy is stored and the new
version is marked as supplemented or corrected data.
The system has security controls that allow QHN staff
to limit access to certain patient populations or segments of the chart on a
per provider basis. Physicians can be
limited to their own patients only, patients in their service or group,
patients on which they are officially consulting, or a larger universe of
patients. Other care givers can be
limited to patients that they are directly assigned to, to patients with
studies being performed in their work area, to patients on a specific unit or
clinic, to patients checked into a specific location, or by visit type or other
criteria. In all cases, every patient’s
record accessed by any clinician or user of the system is logged in a file
which is used to generate chart access reports for privacy audits. QHN management actively monitor these
reports and use approved employee templates when setting up new users to insure
that patient access and clinical data access is clinically appropriate and
meets management promulgated standards.
The definition of the data model in the QHN CPR has
been facilitated by the flexibility of the Ulticare/ Patient 1 software. The system comes with all of the standard
nomenclature and coding models (CPT, ICD, SNOMED, ACR, etc.) but there are
aspects to all clinical implementations that create situations where clinical
judgment and systems analysis must be applied to previously unstandardized
clinical documentation. The system
supports standards by allowing analysts to build clinical documentation tools
using standard clinical objects and pull clinical data forward from one care
delivery setting into another.
The CPR has a full set of functional and clinical
tools that insure that clinical data is not only presented in a meaningful
fashion to each clinician, but can be acted on in real time without having to
switch systems. If the functionality
resides in the CPR, then its use is required for clinical documentation by all
caregivers. Currently, the CPR is not
only used for data review, but is also the vehicle for all major ancillary
clinical documentation, all physician order entry, and is the primary clinical
documentation vehicle for most ambulatory care and inpatient services.
Where the CPR does not offer comparable functionality,
interfaces have been developed, based on two principles. First, if it is clinical data, then it must
be available in the CPR in real time.
Clinical data loses its value to the clinician if it is delayed at the
source system. Second, the official
record for text based electronic clinical data is the CPR. The CPR never purges data, so once it is
migrated from the source system into the CPR, the CPR becomes the permanent
storage location for that information.
The CPR at QHN creates an integrated clinical data continuum that allows
caregivers in any venue to view data appropriate to their needs from across all
of each patient’s individual episodes of care.
The clinicians cannot tell if the clinical data they are accessing was
generated from a foreign system or generated by the CPR modules.
Ulticare/Patient 1 is scalable in the number of additional
application processors that can be assigned to the system, as well as the total
amount of disk storage allowed. The
multi-processor design and data storage architecture of the CPR make the
process of adding additional users and modules as easy as adding hardware and
the infrastructure to support it. The
database tools and programming capabilities organic to the application allow
the Project Team to add new departments and services on demand.
The Ulticare/Patient 1
software includes a proprietary report programming tool. Analysts knowledgeable about the QHN data
model may extract data for any external party using this report writer. QHN currently extracts data for professional
billing, quality monitoring, DOH immunization reporting, payor population
quality indicators and health maintenance testing quality reporting. The Project Team has developed numerous
statistical and quality reports for review of online departments and
processes. Since the data model is a
proprietary one, the system does not offer an extensive ad hoc reporting
capability.
Security and Data
Integrity
The Queens Health Network utilizes a LAN design model that emphasizes backbone redundancy as to ensure maximum availability. The design incorporates a collapsed backbone topology using a combination of Gigabit and 100FX uplinks to ensure maximum throughput and performance. Both Elmhurst and Queens Hospitals incorporate redundant core switches that are connected together via a gigabit connection with a combination of gigabit and 100FX uplinks to the edge device switches. Using Wireless 802.11b (11MB), with future support for 802.11a (54MB), QHN is preparing the core hospital facilities to fully support wireless within the LAN environment.
Queens Hospital Center, which has been recently upgraded, has incorporated a Cisco solution that includes dual Catalyst 6509 switches at the core and Catalyst 5500/6009 switches as edge devices. Each edge switch has a primary and redundant gigabit connection connected to each core switch. All core and edge switches have redundant supervisors, switching engines and power supplies to further ensure maximum availability. The fiber infrastructure includes two separate 18-strand multi-mode fiber cables run in two physically diverse paths. VLAN and trunking technologies have been implemented for network segmentation purposes as to ensure adequate network utilization on the backbone. A structured horizontal wiring solution has been implemented using CAT5e.
Elmhurst Hospital Center has implemented an Enterasys solution that incorporates dual SRR-8600 core
switches with (3) primary switch locations.
All Elmhurst core, primary and back-end edge switches have redundant
supervisors, power supplies and up-link ports.
Elmhurst is currently in the process of upgrading its
infrastructure. The (3) primary switch
locations will utilize dual SSR-8600 switches each with a gigabit uplink to
each core switch. The back-end edge
switches utilize a combination of gigabit and 100FX uplinks to the primary
switches. The plan is to establish a
primary and redundant uplink connection to each primary edge switch and
implement VLAN technology. A structured
horizontal wiring solution has been implemented using CAT5.
The current WAN is based upon a HHC standard design.
The design utilizes ATM, Frame Relay and ISDN type communications and Cisco
routing hardware. All packets that are
routed within the HHC WAN are encrypted to ensure privacy of information moved
between networks and corporate offices.
For the two core hospitals, there are two redundant
Cisco 7206 routers at each location connected to the LAN backbone via Fast
Ethernet and to the AGFA LAN via Gigabit.
The design has incorporated a mesh topology to ensure maximum network
availability. The routers are running
HRSP (Hot Standby Protocol) which if one router fails the standby Fast Ethernet
port becomes the primary. HRSP uses a
floating default gateway address that allows devices to continue to function
without changing default gateway settings/addresses. Between the two core hospitals are (two) OC3
ATM connections, scaled down to 45MB per connection. And there is a 6MB OC3 ATM and a 3MB OC3 ATM
connection between each core hospital and the Corporate Data Center. The ATM circuits are configured for a primary
and secondary connection. This provides
for more than sufficient bandwidth for moving information between Queens,
Elmhurst and other HHC locations.
The off campus locations utilize Cisco Catalyst 24
Port Switches on the LAN side and Cisco 3600 series routers for the WAN
connection. The sites are connected to
the WAN via Frame Relay with ISDN backup.
The frame circuits are either 56K or 384K depending upon network design
and size of facility.
Data integrity is maintained using a combination of
system and management tools. The system
maintains four redundant RAID5 copies of the clinical data across the mirrored
servers. Full backups of the system are
done on a weekly basis with daily incremental backups. In between the
incremental backups, transaction logging is performed to an automated log file
so that if a data recovery from back up is required, data stored since the last
back up is not lost, and can be applied from the log file. Backups are performed while the CPR is up and
available for use. The backup process
uses a multi-pass algorithm that will make up to eight passes through the
entire database to back up data blocks that have changed during the
backup.
Due to the multiple data redundancies in the
architecture, system failures resulting in data loss have been non-existent
during the five years that the CPR has been live at QHN. Even so, clinical data is moved in real time
to a relational database that recycles every three days. This downtime system is designed to offer
clinicians access to clinical data required to support continuity of care while
the CPR is recovered and restored. The
downtime system is enabled on the clinical desktop should the CPR fail. The CPR is brought down on a quarterly basis
for approximately six to eight hours for software and database upgrades. The downtime system is accessible from every
desktop in the network, and only enabled by the Project Team during scheduled
and unscheduled downtimes to maintain record confidentiality.
The CPR operates in a multi-server ring. The data is mirrored across two quad
processor data storage servers and the users access the CPR via six other dual
processor application servers. All of
the servers have redundant power supplies, FDDI controllers, disk controllers,
and TCP/IP connections to the enterprise network. The architecture is designed so that up to
one of the data storage servers and all but one of the application servers can
fall out of the network without preventing users from accessing the CPR.
Servers can be
lost for software, hardware or environmental reasons. When an application server falls out of the
network, users accessing the CPR via that server are logged off. To get reconnected they re-insert their data
key and type in their password. This process
takes less than 5 seconds. The system
also sends a warning via the internal e-mail system to any user who initiated a
job on the failed server (i.e., the Project Team) to alert them that it did not
complete and to check their recent work.
QHN staff then contact the vendor and initiate a
recovery plan. In most cases, the server
can be re-booted and returned to the CPR network within an hour. The application servers do not maintain
patient clinical data. They do contain
tables and files that support operations that are re-synchronized with the data
storage server automatically when the server is restarted. Losing an application server degrades system
performance only to the extent that the users that were accessing the CPR are
now redistributed to the remaining servers.
Response time may not be significantly affected, depending upon the
number and type of processes in use as the server fails.
While losing an application server is generally
transparent to the users, losing a data storage server would not be. Therefore the CPR has quadruple data
redundancy across physically distinct hardware platforms. Should one fail, the risk has increased
significantly. The CPR continues to operate, but it is imperative to get the
full redundancy back as quickly as possible.
Any failure of a data storage server for any reason automatically
triggers the IS staff to immediately start a full back up of the remaining data
storage server. The vendor is also
contacted and the cause of the failure of the server is determined and
remedied. Once the data storage server
is brought back into the network, the entire CPR database must be synchronized
from the data storage server that remained operational. This process takes approximately eight
hours. During this time, the clinicians
notice a slight degradation (2-3 second response time) in system
performance. However, while one of the
data storage servers is out of the network or being synchronized, clinicians
can continue to access the system.
If the CPR is brought down in an orderly fashion, then
the CPR can be restarted with minimal disruptions and users can be logged back
into the system within one or two minutes.
If the CPR fails abnormally, or is not brought down in an orderly
fashion, then data integrity of the CPR clinical data cannot be guaranteed. In that event, the vendor recommends that the
CPR be restored from back up. This
process takes approximately eight hours once the tapes are retrieved from off
site storage. The presence of an
alternative system to allow access to clinical data is imperative to support
continued clinical operations in the Network.
QHN is in the process of obtaining a full disaster
recovery solution which will provide a real time copy of the database (using
Storage Area Network (SAN) technology) available at an offsite data center.
This disaster recovery solution will provide for the full resumption of system
activity in less that two hours during a hardware or environmentally caused
system failure.
Standards
The QHN has adopted HHC wide security practices that
include such areas as server & network equipment security hardening,
desktop standards, anti-virus protection and intruder detection/secure access
solution. The following is a brief
description of each area:
Intruder
DeTEction/Secure Access:
HHC has contracted with a security vendor to handle
all aspects of security related to technology and LAN/WAN. The vendor is responsible for developing and
managing policies related to the HHC WAN and enforcing such policies using
various types of monitoring and security technologies. Through such technologies and systems, the
vendor is able to proactively monitor the network for potential security
threats related to unauthorized access, viruses and other abnormal network
activities. There are routine network
scans run to determine potential security holes and sensors that monitor the
network 24x7 for abnormal or inappropriate activities. Using a solution that combines Cisco Secure
PIX firewall, Cisco Secure IDS Director/Sensors, Cisco 3640 Routers, Cisco 3005
VPN Concentrator, Cisco Catalyst 2924 Switches, and Cisco Secure Access Control
Server, QHN has built a secure zone that restricts access, monitors abnormal
network behavior and provides secure remote vendor/user access.
Server & Network Equipment Security Hardening:
Using HHC security hardening policies, QHN is
proactively performing hardening services as indicated for all server
platforms, including Windows NT, Windows 2000, Unix, Netware and others. Similar policies are in place for securing
networking equipment such as switches and routers. Routine network scans are performed to
determine potential security holes.
Anti-Virus System:
QHN has adopted the McAfee Anti-Virus
solution/products that include desktop anti-virus (Virus Scan & Vshield),
server anti-virus (Netshield) and a centralized management system for updating
anti-virus software on managed devices and actively monitoring for viruses (EPO
Server & EPO Agent). The EPO agent
is installed on all desktop computers and servers. The agent actively communicates with the EPO
Server for pushing out anti-virus software updates and detecting viruses. The EPO Server also provides reporting
capabilities for both virus detection events and anti-virus software coverage.
Desktop Standards:
Using Novell ZEN Works, QHN enforces desktop lockdown policies based on an individual network login and associated network permissions. This allows QHN to secure computer desktops to limit access to administrative tools and authorized applications, prevent access to changing computer settings and prevent installation of software.
The clinical desktop provides all clinicians with a
common look and feel from any device in the health system. Once in the CPR, each clinician can have
individualized tools to support the review and processing of clinical data
consistent with their needs and securities.
This means that a radiology technologist will have the same access
whether they are in the department or on the floor doing a portable exam, but a
physician accessing the CPR from the same device on the floor will have a different
view which is consistent with their clinical data needs. Doctors who treat patients in ambulatory
care settings as well as on the inpatient units have access to different
functions depending on their location, but can always access the functions associated
with the care delivery process in the other venue. In addition, the system allows the Project
Team to configure various data views to optimize the presentation to clinician
groups.
Data content and vocabulary standards are supported by
the system based on the use of clinical data objects that offer consistent
presentations of terms and vocabulary.
These objects are not required for use by individual clinicians, but are
available. An example is found in the
area of patient problem management. The
physicians are responsible for managing and maintaining a problem list on every
patient. These problems are defined
using the ICD-9 table. The physician can
select a defined problem from the table, or can free text a problem and
correlate it to an existing ICD-9 code.
The system supports a database tool kit that allows for the development
of modules to support clinical documentation in any care delivery venue. This means that QHN has the ability to create
unique clinical data and vocabulary objects.
QHN convenes a multi-disciplinary group from across each provider
service, IT, and HIM when deploying new modules to insure that nomenclature and
vocabulary meet the clinical standards mandated by QHN and outside review
organizations.
At a system communication layer, QHN prefers to use
HL7 and ASTM communications protocols when communicating with foreign
system.
Performance
The CPR operates 24 hours a day, seven days a
week. There is no downtime required for
back ups. Scheduled downtimes occur
three or four times per year when the software is updated. These downtimes are scheduled during off
hours to afford minimal disruption for clinicians and ancillary
departments. While the CPR is down for
these scheduled downtimes, the clinicians can access recent clinical data using
the downtime system.
Response time on the system is normally less than two
seconds. When a data storage server is
being synchronized after failure, this time will increase to three or four
seconds. Filing times for orders and clinical
documentation average five or six seconds.
This makes clinical data immediately available to all caregivers in the
enterprise within six seconds of it being input and approved.
The multi-server environment makes hardware upgrades
relatively painless for the clinicians.
QHN has taken servers out of service individually and in batches to make
hardware and operating system upgrades while leaving the remaining servers up
allowing clinicians to access the CPR.
The vendor releases software updates after an internal QA to all of
their clients. QHN does not load this
software to the development environment until it has successfully been
installed by several other clients and by at least one other client in the NYCHHC
network. While on the development system,
the software is tested against a series of scripted scenarios to insure that
existing functionality has not been damaged by the new software. All new application development performed by
the QHN analysts is QA’d by senior clinical staff from the areas being
implemented and is reviewed for proper functionality, gap identification,
standards compliance, and operational appropriateness.
QHN recognizes
that a CPR can never be a static tool.
Clinicians and departments are always adding new tests and services,
modifying standards and procedures, responding to the paradigm shifts that
affect the healthcare delivery market place.
In order to be an effective tool for the clinicians the CPR must be
flexible and responsive to these needs, and the IT team tasked with its
deployment must be eager to embrace and codify these changes. QHN’s CPR and Project Team meet that
challenge every day.
VALUE
The need to keep patients well and keep patients well
served has never been greater. In an era
of cost constraints and performance expectations imposed by purchasers,
regulators, and an increasingly informed public, the challenges are formidable.
The expectations of the QHN Medical Board and senior administration regarding
an electronic patient record were that:
§ Documentation of clinical data throughout the lifetime of the patient, and across the continuum of care, would be facilitated and improved.
§ Improved quality of patient care would be supported through access to and availability of patient information.
§ Clinical information from various legacy systems would be integrated into one CPR.
The successful evolution of an expanded and
decentralized primary care network seemed predicated on the development of an
electronic patient information system.
The logistics of the exchange of patient records among numerous patient
care locations seemed insurmountable, especially when viewed in the light of
the problems inherent in providing paper charts to existing locations. The decision was made to begin CPR
implementation in the ambulatory care setting, where the pressing need to
provide solutions to encumbered processes was obvious, then proceed through
conversion of diverse legacy systems, and on to the inpatient setting. Applications and functionality would continue
to be added to the CPR in continuous development cycles.
Success would
be measured by creation or improvement of processes that impact patient care:
improved access to patient information; complete, legible clinical
documentation to support quality patient care and promote a safe environment;
and timely and accurate patient data provided at the point of service
throughout the Queens Health Network.
Design and implementation of an electronic medical record was viewed as
essential to the development of an effective infrastructure from which to
support the reorganization of care, the design and refinement of quality
measures and reporting processes, and the practice of evidence-based medicine
to improve management of chronic disease.
Process Reengineering through Creation of a CPR
The CPR has become the primary source of clinical
information for caregivers and ancillary departments in a complex, municipal
healthcare network that serves a high volume of patients across a diverse
ethnic and geographic region. In the process,
it has transformed the way clinical information is recorded and shared.
Implementation of the CPR requires a series of activities to be defined, executed and quantified in a way that had not been done before. Dimensions of certain processes of medical care generally accepted as basic prerequisites of good care have been automated and, in the process, improved upon. One way to quantify the contribution of the CPR to improving patient outcomes is through an interactive process of defining and transforming various operations. Process improvements can be measured by analyzing various actions, and their impacts on practices that affect patient care.
One example is the installation of nutritional
screening tools for new patients in Ambulatory Care (See TABLE 3: Development
of Ambulatory Care Nutritional Screens).
In response to JCAHO requirements to compile and share nutritional
assessment information, nutritional screening was initiated on paper in Medical
Primary Care, then expanded to the medical and surgical subspecialties. An online nutritional screen, complete with
decision support, became available in March 1998. Another tool, developed for
the obstetrical population, was implemented in June 2000.
TABLE 3
DEVELOPMENT OF AMBULATORY CARE
NUTRITIONAL SCREENS
|
Opportunity for Improvement |
Action(s) Implemented |
Indicator |
Measurement |
Impact on Processes/Patient Care |
|
JCAHO
Type I Recommendation: nutritional assessments incomplete |
·
Interdisciplinary work group convened. ·
MPC nutritional screening criteria refined and built as component of
electronic primary care chart. ·
Nurses, health educators, physicians trained. ·
Screening process implemented on HIS. |
·
On-line screening tool designed, demonstrated, revised. ·
Curriculum written. ·
Training completed. ·
Number of screens completed by nursing staff in MPC and Medical
Specialties. ·
Support for and monitoring of tool utilization. |
·
Interdisciplinary group and HIS Steering Committee approved. ·
Curriculum and training completed for 100% of current staff. ·
Number of screens completed will increase until 100% of new patients
is achieved. ·
On demand training of new staff; continuous training of all staff. ·
Ongoing HELP DESK support for all users. |
·
Patient screening information readily available to all patient care
providers. ·
Data serves as foundation for nutritional assessment to be completed
by dietician. |
|
Need
screens appropriate for Obstetrics
population |
·
Interdisciplinary work group convened. ·
WHS nutritional screening criteria defined, then built on HIS. ·
Nurses, physicians trained. ·
Screening process implemented on HIS. |
·
On-line screening tool designed, demonstrated, revised. ·
Curriculum written. ·
Training completed. ·
Number of screens completed by nursing staff in WHS. ·
Support for and monitoring of tool utilization. |
·
Interdisciplinary group and HIS Steering Committee approved. ·
Curriculum and training completed for 100% of current staff. ·
Number of screens completed will increase until 100% of new patients
is achieved. ·
On demand training of new staff; continuous training of all staff. ·
Ongoing HELP DESK support for all users. |
·
Patient screening information readily available to all patient care
providers. ·
Data serves as foundation for nutritional assessment to be completed
by dietician. |
The development of the electronic nutritional
assessment is one component of an incremental process of improving care
delivery in Ambulatory Care. The
electronic screening tool is an indicator that a series of measurable actions
have been taken: the refinement of nutritional screening criteria, curriculum
development and staff training, user support and monitoring utilization of the
tool. Patient information that was
fragmented and incomplete has been improved by making patient screening
information readily available to all caregivers, and providing data to
dieticians to serve as the foundation for the patient’s nutritional assessment.
Opportunities for improvement may prove possible in an
electronic world and replace limited capabilities with ones that did not previously
exist. For example, gestational age is
automatically calculated in the QHN electronic prenatal record, replacing
manual calculations made at each visit prior to the CPR. Patient information has become dynamic, e.g.,
every screen in the electronic patient record reflects in real time the aging
of the patient, and the display of health maintenance test alerts will change
across time to reflect the age of the patient. The characteristics of the
medical record are being transformed from those of a static medium to an
interactive one.
It has taken some time for the organization to
recognize that the electronic media is intrinsically different from paper. The
electronic media is, by definition, interactive. It requires interaction initially to design
and develop and then, in its final stage, to interpret. Even the name for the paper media, “hard
copy” illustrates the difference: paper is static and tangible, electronic
information fluid and reactive. The
process of transferring manual processes to computer is at its core different
from replacing one paper form with another.
The traditional method where the Medical Records committee approved each
piece of paper for insertion into the chart, with minimal consideration of the
associated work processes, has been transformed through an interactive process
where redundant and useless activities and paper are replaced or eliminated all
together.
It has become necessary to examine the assumptions
that underlie quality care, and consider which elements must be maintained or
may be improved upon. The CPR has served as a focal point for discussion and
compromise regarding operational and clinical practices. A rigorous methodology
for consideration of these issues is adhered to by the HIS Project Team, and
respected by the clinicians. Determinations are made regarding what information
is needed to perform tests, satisfy clinical pertinence, auditors, or
third-party payers, meet or exceed professional peer standards, as well as
regulatory authorities. Efforts are made to include variations in practice from
one service to another, and one campus to another. The system then is
programmed to apply certain standards, even if the user is unaware of
them. For example, the CPR prompts
physicians ordering specialty consultations with rules appropriate to the
various participating managed care plans. This standardization occurs
regardless of the user’s awareness of changing regulations or protocols.
The CPR serves as a catalyst for the development of
clinical practice standards across services and departments, both within the
hospitals, and across the Network. Although the Queens Health Network delivers
more babies than any other provider in Queens, nearly 7,000 each year,
individual practices may vary from site to site, and even from doctor to
doctor. All adhere to the ACOG practice
standards. However, within the Elmhurst group, it took an extensive discussion
among several attending physicians, the chief of service and a physician’s assistant
to define the algorithm to electronically calculate EDC, with each caregiver
explaining their preferred method of twirling the pregnancy wheel, and citing
academic textbooks before coming to agreement.
QHN’s commitment to institutional change extends beyond the
CPR to entire operations, as opposed to piecemeal, incremental changes to paper
forms. Re-engineering processes to foster improvements and access to patient
care has been the hallmark of the design and development of the CPR. Now all staff manage patient information, and
this is not an easy concept to grasp and actualize. Every individual has an
enhanced capability to collect and interpret patient information that did not
formerly exist.
Physician Data Entry
In 1996, there were no personal computers in exam
rooms, and patient information was often difficult to get and incomplete. Currently there are almost three thousand
PCs, with local and wide area networks to support them. A walk through any clinic, department or
inpatient unit shows nurses and doctors, dieticians and social workers,
physician assistants and nurse midwives, lab and radiology techs all busy
documenting their work in the CPR.
From the start, physicians, nurse practitioners,
certified nurse midwives, and physician assistants have been required to place
their own orders, write their own prescriptions, and document their own
encounters in the CPR. This work is not
written on paper and then transcribed by less medically qualified staff. While it may be true that support staff are
often more amenable to computer work (not to mention faster typists!), the CPR
contains and presents real time clinical information which only the medical
professional can interpret and respond to.
To that end, the system privileges of nursing and support staff do not
allow access to the computer screens necessary to perform these functions.
Furthermore, for a CPR to communicate and guide
practice patterns, for instance, by alerting the provider that a test has
already been ordered, or that prescribing a drug will create an interaction
with a previously prescribed medication, the most sophisticated users must
interact with the system. This requires
the direct involvement of those who are authorized and able to make medical
decisions.
Utilization of the QHN CPR by all staff has been required
throughout all phases of the project, beginning in Ambulatory Care. Monthly snapshots of usage statistics
indicate there are more users logging onto the CPR, and spending more hours in
the CPR every year.
Table 4 Utilization of the QHN CPR, indicates that in
January 2002, every physician in the Queens Health Network logged on to Ulticare at least once.
In the past year, the number of log ons to the
CPR more than doubled, and the number of users of the system was increased by
83 % (due to the lab conversion in April 2001).
These statistics show utilization of the CPR at a consistently high
level across the organization.
TABLE 4
UTILIZATION OF QUEENS
HEALTH NETWORK CPR
*Increase in Logons vs. decrease
in Average Hours Logged On due to lab conversion, with more users quickly
reviewing results.
Online documentation by physicians and midlevel
providers has paid big dividends in quality and completeness of clinical
documentation. Queens Hospital Center
reports a 50% decrease in the number of pharmacist interventions in medication
orders in Ambulatory Care due to improved the system alerts, and the improved
legibility and completeness of the prescriptions. By 1999, the completion in
the electronic medical record of certain performance indicators, e.g., patient
problem lists, orders/ referrals for mammography, Pap smears and diabetic
retinal examinations had reached 100% (See TABLE 5: Impact of Online Documentation on Performance
Improvement Indicators).
As CPR functionality is implemented, paper forms are removed from the clinical areas in an attempt to force the medical and support staff to use the CPR. Of course, there are still some resistant but resourceful staff who manage to find old forms. Ancillary departments generally accept the paper orders for a brief period, but eventually inform the staff that they will no longer perform tests not ordered online. By January 2002, the number of coding sheets (encounter billing forms) documented online each week had reached nearly 15,000 across the Network.
There has not always been a high level of enthusiasm
among doctors for doing their own online documentation. At one Steering Committee meeting, one chief
of service complained that the business of an academic medical center was to
teach doctors to practice medicine, not to practice typing. This was challenged
by her counterpart, who asserted that the skills required of any professional,
including physicians, in the 21st century must include mastery of the personal
computer. Complaints about caregivers
spending more time with the computer than their patients have decreased as
facility with the system has improved, and the investment of entering data pays
dividends in real time access to patient information.
There has been a gradual acceptance of the fact that indeed, computer
proficiency is a skill to be developed. Throughout the project, there have been
complaints that the system is not intuitive.
This claim from medical professionals whose careers are devoted to
keeping up with changes in the techniques and technology that comprise the art
and science of medicine seemed contradictory.
Indeed, a large part of CPR development is communicating how to use the
system. This includes writing specific
training documents for each application and updating the documents
periodically, group instruction in the classroom, one-on-one training, and
on-the-job training if necessary. It
also includes listening to user feedback to determine whether the system training
and functionality is effective.
Not only is the learning process continuous, it must be interactive.
For instance, the Chief of Pediatrics turns over his monthly luncheon
conference to the Project Team several times a year to discuss CPR concerns. The Women’s Health Services caregivers on
both campuses have held regularly scheduled meetings to reinforce training in
new applications and work out system issues. These meetings have become
informal educational sessions where users answer each other’s questions,
explaining the keystrokes that they use to perform the task in question. At times, one of the physicians may “drive”
the PC, demonstrating options as the session progresses.
Complaints that online documentation takes longer have
been carefully analyzed. If, for
instance, the caregiver filled out on paper only those elements that s/he
thought pertinent to the visit, and must now complete all fields in the online
history and physical examination, it does take more time. The Director of Ambulatory Care has also
suggested that online documentation requires a different approach than
scribbling on paper. He says that the
process of completing neatly typed fields that prompt for information
encourages complete clinical documentation and clear thinking. Rambling progress notes that reiterated
unnecessary patient information have been replaced with succinct and pertinent
notes that support better patient care.
In a survey of Primary Care physicians conducted in February, 2002, physicians reported that the CPR saves them time (See TABLE 6: CPR Survey Results February 2002). Ordering of tests is quick and easy, and the multiplicity of colored requisition forms has been eliminated. Medication renewals, especially for the elderly and chronically ill, who require a multitude of medical equipment and supplies along with their medications, have been streamlined. In addition, 73% of EHC and 85% of QHC caregivers surveyed report that access to and availability of patient information has been improved with the CPR.
TABLE 6
CPR SURVEY RESULTS FEBRUARY 2002
Percentage in Agreement
Question: The CPR
Saves Me Time When…
|
|
|
Reviewing
pt's record |
Seeing
other's pt |
Writing Rxs |
Renewing
Rxs |
Looking
up labs |
Looking
up Radiology |
Ordering
tests |
Ordering
consults |
|
EHC |
Pediatrics |
60 |
41 |
47 |
89 |
92 |
93 |
70 |
57 |
|
|
WHS |
77 |
62 |
58 |
70 |
100 |
94 |
65 |
77 |
|
|
MPC |
68 |
84 |
71 |
79 |
91 |
88 |
88 |
88 |
|
|
ALL |
66 |
63 |
58 |
80 |
94 |
92 |
75 |
74 |
|
|
|
|
|
|
|
|
|
|
|
|
QHC
|
Pediatrics |
9 |
27 |
27 |
91 |
91 |
100 |
18 |
18 |
|
|
OBS/GYN |
53 |
59 |
89 |
100 |
100 |
82 |
89 |
82 |
|
|
ALL |
36 |
47 |
64 |
97 |
96 |
89 |
60 |
57 |
|
|
|
|
|
|
|
|
|
|
|
There is acceptance of the CPR as a continuously
developing system. Transition periods
may be difficult, as users are forced to straddle the two worlds of paper and
electronic data. Installation of new functionality always requires a learning
curve and a related commitment of time and effort on the part of the users.
Regardless, improvements in quality of care have caused the CPR to gain
acceptance among the medical staff. In
addition, its pervasiveness has convinced all but the staunchest opponents that
it is here to stay.
The CPR
and Cultural Change
At all levels of the organization, resistance to computer automation is
being confronted and transformed. Staff
who had never approached a computer have become competent consumers of technology. Their language when calling the Help Desk has
evolved. They have learned some PC and
network terminology, and make the kind of diagnostic associations formerly
consigned to the IS Department. For
instance, they often know when rebooting will solve their problem, and can
convey information about which network server they are logged onto. These new skills have transformed the way
that staff at all levels manage patient information.
As the CPR has evolved, so too has the HIS training program. It has become specialized due to the variety
of departments now using the system to perform departmental processing. The training for a hematology supervisor is
far different from that of a pharmacist or a radiology technician. It is also broad based: nearly 3,000 physicians, nurses and other
clinicians and administrative staff were trained in 2001. CPR training also includes a computer based
training program (CBT), evolving in tandem with the system, which teaches a
variety of formats and topics tailored to the needs of the clinicians.
Clinical staff throughout the organization have
learned to speak a common technical language, although they may perform
disparate functions in the CPR. Because
staff use one, integrated clinical system, clinic clerks, lab phlebotomists,
and attending physicians all know which function the Ulticare/
Patient 1 keys perform, how to save data, and can determine whether a test was
completed. Integrated data views provide
consistency in test markings and other documentation which present a single,
shared view of the patient’s condition.
Staff are not only working towards a shared goal of providing quality
patient care, but are doing it using the same tools and language across
nineteen sites and thousands of visits each day.
The organization’s physician leaders have grown into
the role of technology partners. The HIS
Steering Committee has been institutionalized as a strategic decision making
group within the Network. In addition,
the tone at these meetings has changed dramatically, from disagreement from
some members regarding the basic premises of the project, to consideration and
management of the changes related to its expansion. The committee has increasingly become a true
partner in examining technology issues, assessing associated clinical risk, and
proposing creative solutions.
The organization as a whole has developed higher
expectations regarding the availability and transfer of information. Reflective of life in the Information Age, a
seemingly insatiable demand for electronic data has developed. For example, once online documentation of
pediatric immunizations began, only a short time passed before the Project Team
was asked to FTP these data to the New York State Department of Health,
replacing an arduous process involving the patient registration system. Likewise, it was not enough that the doctors
were completing electronic coding sheets at the close of every clinic
encounter. The faculty practice billing
group next requested summary data on disk to replace the mountains of
individual coding sheets that were collected from the clinic, manually
collated, reviewed, discarded and followed up for inaccurate or incomplete
coding. And the bar has been raised: the
five seconds that it takes for information to paint the computer screen may
seem like an eternity, while it could have taken hours to produce the patient
chart in the paper world.
The Importance of Integration
The system was purchased at a time when the major
ancillary departments (laboratory, radiology, pharmacy) utilized standalone
systems. Caregivers were required to
learn the log in, password, and keystrokes for several different systems and
queue up at specially designated terminals to look up results. Worse, several departments which used their
own best of breed systems did not provide look up terminals at all. Caregivers in Women’s Health Services, for
instance, were forced to telephone various departments to obtain the results of
tests performed for every pregnant patient throughout the prenatal period of
care: the Cytopathology lab for Pap
smear results, reference labs for HIV and genetic test results, and the
Obstetrical testing unit and/or Radiology department for ultrasound and
non-stress testing results.
Integrated views of patient data allow caregivers to
process information and make clinical decisions faster and easier. The CPR has so far replaced a total of nine
electronic and five paper departmental systems.
Online Radiology, non-invasive Cardiology, Cytopathology, and Pediatric
Immunization systems, and two Obstetrical Ultrasound, two pharmacy, and one
online Laboratory system have been retired; as well as manual Radiology,
Cardiology, and Pediatric Immunization systems, and two paper Surgical
Pathology systems.
Initially, interfaces were employed to import data
into the CPR until these systems were replaced with the Ulticare/
Patient 1 system modules. Inevitably,
interface errors affected the reliability of clinical data. In addition, caregivers’ access to data not
yet migrated to the CPR remained limited to different views of patient
information accessed by various system logons at inadequate numbers of
terminals.
As legacy systems are retired, departmental processing is integrated
into the CPR, replacing best of breed systems.
In the process, there may be apprehension about whether or not CPR
functionality will adequately satisfy local users as well as regulatory
requirements. For example, the best of
breed Cytopathology system containing five years of gynecological and
non-gynecological test results was not Y2K compliant and had to be retired in
1999. The Project Team developed a
cytopathology module in collaboration with the department, configuring generic Ulticare/ Patient 1 tools to perform all of the critical
test processes. Specimen identification
numbers are generated according to the prescribed format; supervisor and/or
pathologist review and sign-off are forced for certain specimens based on
complex rules and technologist documentation (including the existence of
historical abnormal results uploaded from the one of the two million records
from the retired legacy system); counts of normal specimens are calculated and
supervisory review is forced of every tenth specimen resulted as normal by each
technologist; and preliminary results are suppressed until finalized.
The CPR not only presents all of these data consistently at each
clinician’s desktop, it provides customized views of data across time, e.g.,
prenatal flow sheets. The CPR allows caregivers to quickly retrieve information
from a single source, so they can review patient diagnoses and problems,
allergies and adverse drug reactions, significant past medical and surgical
history, vital signs and other measurements, and in the primary care services
extensive intake information, interdisciplinary education records, patient
histories and physicals, and progress notes.
These data are displayed together with medication information and test
results, while system decision support tools display alerts that reduce the
rate of medication errors. The graphic
system display of lab tests across time insures that trends are immediately
apparent to the caregivers, and that certain values are not missed.
The QHN CPR includes digital radiography and a Picture Archiving and
Communication System (PACS), as well as voice recognition, at both hospitals.
The Elmhurst Hospital Radiology Department has been filmless, replacing film
with digital images available at the clinical desktop, since November 1999. This has dramatically reduced the percentage
of studies never read, as well as the time required to issue radiologists’
reports. The result is 100% image availability to clinicians, faster
interpretations, less repeat xray exposure to patients due to misplaced films
and duplicate procedures, faster patient discharges, and better teaching
opportunities for residents and fellows (See TABLE 7: Summary of PACS Impact on
Availability and Turnaround Time).
TABLE
7
SUMMARY
OF PACS IMPACT ON AVAILABILITY AND TURNAROUND TIME
|
Elmhurst
Hospital Center Radiology Department |
Oct
1997 Traditional
Radiology (film and dictation to transcription service) |
Jan
1999 (Film,
using voice recognition system) |
Jan
2000 (Digital
images, using voice recognition system) |
|
Unread
studies |
24% |
12% |
2% |
|
Studies
read within 12 hours |
8% |
40% |
97% |
Patient Safety and Quality Care
Development of the CPR has led to increased standardization of data,
resulting in more reliable data.
Utilization of multiple clinical systems and paper records may result in
discrepant data values. For example, the
registration system and the radiology system may indicate a different location
for the same patient, or the pharmacy system may show the patient is allergic
to codeine, while the LIS indicates “no known allergies”. Information is fragmented and may lead to
disparate views of the patient’s condition. Because the systems are
independently fed by various departments and users at different intervals,
determining which is the correct information is difficult for the caregiver and
may prove dangerous. Integrated CPR
functionality minimizes discrepancies and ensures better data integrity, e.g.,
utilization of a single format for each data element, and updates across the
record as appropriate by the user with the most recent clinical information,
along with electronic audit trails clearly displaying edits and editors.
At about the same time as the CPR was in initial
development, the QHN began to deploy a decentralized model of care, as well as
the consolidation of redundant services. The integrated CPR has been implemented at
every site, on campus and off, allowing providers to create records for new
patients and access records for patients previously seen at the hospital. The same functionality supporting care
delivery is available at all nineteen locations, across the continuum of
patient care. For instance, if patients
followed in the community medical centers need to be referred for specialty
care, the specialists at the hospital can view the entire patient record
online. Information is available in real
time, at all times, saving time and reducing opportunities for error.
According to the Director of Ambulatory Care, the
impact of the CPR on patient care has been enormous. Compare the Ambulatory Care 60% to 70% paper
chart retrieval rate prior to system implementation, to 100% availability, 100%
of the time for the CPR: immediate access to patient information. Patient care has improved as access to
information has improved. A gynecologist
recently said “the HIS makes me a smarter doctor”. Care need not be deferred until an
appointment can be made and the record located, and the patient’s entire
history is available for review. Because
the physician has immediate access to the patient’s blood pressure and
medications, for instance, adjustments to outpatient prescriptions can be made
for patients with cardiac and other chronic conditions during a telephone call
with the patient. Because the system provides checks against tests previously
ordered, duplicate testing has been reduced, and the patient may no longer be
required to make numerous treks to the hospital.
The CPR supports primary care physicians with age and
sex specific health maintenance reminders.
Reminders include Pap smears, mammograms, sigmoidoscopy,
blood pressure checks, lead levels, and vaccinations. Online tools are also available to help
caregivers determine if the minimum testing and required referrals have been
made for obstetrical and diabetic patients.
Communication has been improved between doctors and nurses. The primary care progress notes have been
designed to pull the complete set of orders placed by the physician for the
patient in order entry and care planning into the nursing note for sign off. Nursing staff pick up orders electronically,
without the need to transcribe them from one paper form to another, with the
resulting opportunity for errors. The
electronic patient record is interdisciplinary.
All clinicians document patient care on the same system, with data
deemed appropriate automatically shared in other screens. For instance, the nursing staff’s
documentation of vital signs, immunizations, finger stick glucose testing, PPDs, etc. are available online at all times across the
continuum of care. This helps eliminate
duplication of effort, and, more importantly, encourages users to read what the
other caregivers have documented.
Paper prescriptions are often illegible, which can
cause any number of patient safety concerns.
Electronic prescriptions are always legible and complete, as the omission
of certain required fields when ordering a medication will prevent it from
printing. In addition, the CPR displays
alerts to potential drug-drug interactions, drug-allergy interactions, and
dosing errors during the writing of the prescription to reduce medication
errors. Additionally, pharmacists required to verify the physicians’ orders
prior to dispensing medications can also review patient’s diagnoses and lab
values if they think that an incorrect medication or dose has been ordered.
Legible, complete documentation improves patient
safety and quality of care. Because availability of online patient information
is assured at all times, fewer departments feel a need to hoard charts, or
maintain “shadow charts” locally. In the
past this practice lead to problems with HIM’s
ability to certify that the chart was, in fact, complete. With paper, there was
always a chance that the test value or note had been misplaced. Currently, if the application exists online,
and certain elements of patient care are not recorded in the CPR, it is clear
that the documentation was not done.
Documentation
in the CPR has improved the completeness of patient records. Data entry screens
are easily updated to include new questions required by practice or policy
changes, and users are automatically migrated to the new screens. Additionally, data fields can be “required”
so that users cannot skip important questions.
And medical records, billing and quality management experts may easily
review records, from any of the 3,000 PCs available in clinical and
administrative areas, to determine the quantity and quality of data and advise
clinicians accordingly. The Faculty
Practice group, for example, no longer reviews every coding sheet individually
for the primary care services; they are correct and complete, due in part to
the formatted attending note which prompts for clinical information required to
support reimbursement.
Access to care has been improved by the CPR. Prior to deployment of the CPR at EHC, for instance, patients were required to carry a paper request form from the referring physician to the department and wait in long lines to make an appointment for a radiology study. Worse, reception was closed on weekends and evenings, with the operation supporting neither off hours nor offsite practices. Continuing with the best practices model that guides QHN CPR installation, the Project Team implemented Ulticare’s automatic scheduling feature during conversion of the best of breed radiology system to the CPR. Now, when a study is ordered, the system automatically searches the various modality schedules for available slots and schedules the patient for the next available. It then prints patient instructions pertinent to the study (in English and Spanish) along with an order request displaying the date, time, and location of the radiology appointment issued. Clerical staff in the clinics have been given the system privileges to move or reschedule a study without the intervention of the radiology department. With the exception of STAT tests and other outliers, there are no longer patients waiting for appointments in the radiology reception area.
Care availability, timeliness and appropriateness have
been improved with the implementation in the CPR of an integrated telephone
triage application. Nurses take calls
from patients to determine acuity and level of care required, then document
details of the encounter and advice to the patient in the patient’s electronic
record. The system automatically routes
paper notification to a printer in the location the patients have been
instructed to present to. If the triage
nurse instructs a patient to go directly to the emergency room, for instance,
the staff will be expecting the patient, as notification will have printed to
the triage area of the ER prior to the patient’s arrival. The application also supports the telephone
triage units with a tickler list of patients to call back a few hours later, or
the next day. Documentation of the
triage encounter is permanently stored in the CPR, a permanent record of the
telephone encounter and the patient’s disposition.
Cost Impacts
An objective of CPR development is the integration of clinical information formerly available from various standalone systems into one CPR. In the process, Information Systems has reduced the number of disparate servers, maintenance contracts, and dedicated hardware required of best of breed systems. The cost of maintaining myriad systems also includes a human component: the integrated CPR no longer requires the allocation of analysts who specialize in each of these tangential systems, but is now comprised of one project team, cross-trained to utilize a common set of tools across multiple applications. Additionally, supporting multiple systems usually meant that IS had to create and maintain essentially the same database tables in multiple systems. Often standalone systems cannot access the master charge table, for example, but need their own replica: the retired Radiology, Laboratory, and Cardiology systems all had their own copies of the bed table. IS now has fewer interfaces to maintain and troubleshoot. The CPR allows analysts to use a common knowledge base, minimizes rework and database maintenance, and reduces the time spent supporting foreign interfaces.
In addition to the care quality and process improvements generated by
the installation of the PACS and voice recognition systems, these advances have
generated a savings of approximately $993,000 per year at Elmhurst Hospital. This includes savings for film, supplies,
fileroom space, personnel services for scheduling, filing, making appointments,
and relaying results, length of stay reductions, and improved throughput in
clinics. The conversion to the CPR with digital images in EHC Radiology has allowed
a reduction of 5 FTEs and virtually eliminated phone calls to the department to
obtain results. The department saves
$164,000 per year in transcription costs at EHC and $206,200 at QHC, and no
longer distributes four copies of each test result: to the ordering location,
to Medical Records, to Faculty Practice, to the filmroom in the film jacket.
There is an improved return on billing due to
standardized order prompts, more complete documentation, and more timely
coding. Improved documentation to support
claims and coding has resulted in additional reimbursement/ or avoided costs
for penalties from lack of documentation.
For example, Elmhurst Hospital Radiology Faculty Practice revenue rose
$306,000 in the year following installation of the CPR/PACS/Voice Dictation
system combination.
The online CPR means that there is less paper written,
printed, distributed, filed, and retrieved to support patient care. Savings from the reduction in the amount of
paper forms printed for orders and charting have been achieved. Less paper has allowed the diversion in
Ambulatory Care to financial counseling of 1.5 FTEs who formerly prepared
charts for caregivers in clinics. IS
staff no longer print and distribute paper results, for a savings of $20,550
per year in paper costs. The
laboratories have also reassigned staff who used to distribute results to
caregivers on inpatient units and in clinics.
In the Health Information Management Department,
resources formerly assigned to filing mountains of loose paper in patient
charts have also been reassigned to other duties. Purges of old records are no longer
outsourced, as resources have become available to allow the department to focus
on internal file management in compliance with mandated record maintenance and
retention schedules. In addition, time
spent in HIM searching for loose sheets of patient information required for
patient care have been eliminated. Economies of scale have been created,
allowing the addition of numerous off campus locations without requiring
additional HIM staff to support the filing and production of patient
charts.
The CPR underlies the expansion of the Queens Health
Network, supporting the regionalization of services and the evolution of two
separate hospitals into an integrated healthcare delivery system. Because patient records are available in real
time at all locations, the CPR supports the queuing of lab specimens from each
ordering location to the correct hospital’s departmental work lists. In a process that is transparent to providers,
orders are placed online from anywhere in the Network, and the CPR routes
orders, results, and corrections appropriately to the patient’s chart. This process supports the regionalization of
laboratory services: all routine
Chemistry, Hematology, Immunology, and all Microbiology tests are sent to
Elmhurst, while Cytopathology exams for the Network are performed at
Queens. The CPR also supports a highly
advanced level of laboratory automation, utilizing HHC’s only accessioning
robot to process most of the 3,800 specimens each day. MRIs are only performed at Queens hospital,
but EHC patients’ results are immediately available to caregivers at
Elmhurst. All Pediatric Orthopedic and
Cardiology referrals are automatically sent to Elmhurst hospital. This allows the organization to employ
specialists to provide excellent care efficiently and effectively.
The CPR
also supports the Queens Health Network service as a reference lab for flow
cytometry, performing specific tests for another HHC healthcare network. The strategic business plan of the
Corporation is advanced by consolidating services, while providing an
additional source of revenue.
IMPROVING HEALTH CARE IN THE 21ST CENTURY
By April 2002, the QHN Healthcare Information System included an extensive
array of personal computers with associated peripherals, used daily in
examination rooms by physicians, nurses, mental health providers, social
workers, health educators and dieticians to document integrated patient
assessments. Patient care providers
throughout Ambulatory Care, the inpatient areas and the ancillary services
departments enter and retrieve patient data at the point of service. Myriad standalone departmental systems have
been retired, and clinical data converted to the integrated CPR. The electronic
medical record has become an essential component of managing patient care
across the Network, with ever increasing demands for its enhancement and
expansion.
Laboratory and radiology results are integrated, timely, and accessible in exam rooms in offsite and on campus clinics, and in school based health centers across the Queens Health Network. The widespread availability of these and other clinical data support ongoing efforts in the continued regionalization of duplicative and competing clinical services, and the decentralization and expansion of others. The HIS allows real time access to patient information anywhere in the network. Consider an Elmhurst patient referred to Queens Hospital for a head MRI. The radiologist can now review prior visit history and diagnoses, results of general diagnostic radiography and CT scans, BUN, Creatine and other recent lab values, and ensure that the patient does not have a contrast allergy before the technologist performs the test. That the patient is followed at another facility in the Network is no impediment to access to vital information. Availability of clinical information online surmounts one of the biggest obstacles to integrated, seamless care across the entire spectrum of healthcare services.
The QHN CPR positions the organization to provide patient care that is safe, effective, timely and efficient. Real time data regarding individual patients and populations of patients with chronic conditions can be aggregated and analyzed to develop population-based approaches to disease management. Currently, a disease registry is being established for patients with diabetes, in an effort to facilitate access to information about the performance and results of certain elements of care. Patients with congestive heart failure have also been targeted as a population whose outcomes can be improved with patient-specific data to assist clinicians and patients in making diagnoses and evaluating treatment. The CPR is providing the foundation for the Queens Health Network to make the comprehensive changes associated with better patient and system outcomes.
APPENDIX
I
APPENDIX II
Healthcare Information System
Queens Health Network
Organizational Structure
