# Presentation: 091687

## Debbie McQuay
Director of Quality Improvement 
Information Systems Steering Committee Member
Long Term Care Implementation Team Member

- Director of Quality Improvement
- Information Systems Steering Committee Member
- Long Term Care Implementation Team Member

- Implementation and Benefits of an Electronic Health Record

- Citizens Memorial Healthcare

## About UsCitizens Memorial Healthcare – 25 Years

- 5 Long Term Care / 1 Residential Care –     588 Beds
- 74 Acute Care Beds / ICU / Outpatient / ASC
- Emergency Room / Ambulance Services
- 19 Clinics
- Home Care Services / Hospice
- Davies Award 2005
- Most Wireless/ Most Wired 2005 & 2007

**Notes:**
Part of the Challenge was we are very spread out

## Project Infocare Vision

- Citizens Memorial Healthcare will implement Meditech to _enable a patient to enter anywhere into our continuum of care and have a personal identity_ that is maintained across that continuum.
- Physicians and other caregivers will have _access to all of that patient’s medical information_ within the healthcare system.
- Health care providers will be able to _document efficiently_ within the software system. Providers will be able to spend more time with their patients. Time will be spent providing patients with that human touch of care, rather than spent completing forms and paperwork.
- We will _realize the benefit of our investment_ of time, talent and money in Meditech by enabling Citizens Memorial Healthcare to become a technologically advanced health care organization that is _poised to grow to meet demand and offer new services to our current patients and to the community_ at large.

**Notes:**
The vision of having access everywhere was a challenge.

## Project Infocare Timeline

- 2000 – IS Strategic Planning
- 2001 – Vendor Search & Selection
- 2002 – Implementation Began
- 2003 – September – MDS & Care Plans
- 2004 – February 1st – First LTC (110 bed)
- 2005 – Feb – All 5 LTC/SNF - Implemented
- 2006 – July – Residential Care
- 2007 – Jan BMV – Completed Aug 2007

**Notes:**
2006 – Residential Care 
	Delay in implementation
	huge update to the software
	the facility added 18 rooms, 

## Project Infocare Costs

- Total Project = $6,000,000
- Software (Meditech & other)
- Computers and network structure
- Staff implementation time & benefits
- Travel & training costs
- LTC Costs = $650,000
- $130,000 per facility, or
- $1,365 per licensed bed

**Notes:**
Costs of technology is always a challenge, we had some help with Grants

## Patient Centered

**Notes:**
We wanted the project to of course be patient centered. 

## Getting Started

- Team Diversity
- Clinical team included Administrators, DON’s, Charge Nurses, Ward Clerks, Med Techs, MDS Coordinators
- Financial Team included Director of Finance, Billing Personnel, Business Office Clerks, Admissions Coordinators
- 6 month implementation schedule for Admissions/Billing, MDS and Care Plans (all facilities live at once)
- 1 year implementation for Physician Orders, Nursing Documentation, Electronic MAR (one facility at a time-21 day in-house live coverage by Team members)

**Notes:**
Everyone believed there part of the project was the most important. Challenge to get everyone to look at the big picture. 

## Training

- Initial Training Course
- RN’s and LPN’s 16 hours
- RMT’s 12 hours
- C.N.A’s 8 hours
- Continued Education
- LTC Specialist provide continuing education through scheduled and requested in-services
- On Line Education – HealthStream
- Challenge
- Some Staff Never Used a Computer

**Notes:**
Challenge was determine exactly what we needed to teach. 
We started teaching what we knew, we even recapped how you could build an assessment, and the multiple ways it could be built, maybe more than they needed to know.

## Security Features	

- We have the ability to tailor access levels to what is appropriate for a specific job class. This applies to both the parts of the system they can document in and the portions of the Electronic Medical Record that they have access to.
- Records are secure from falsification. All documentation is date and timed stamped.
- Tracking mechanism in place to track edits to documentation.

**Notes:**
Did a lot of education about not sharing passwords and closing out the computer when you left it. 

## Status Board

**Customize** to display pertinent information by type of caregiver
- List of _**residents by location.**_** **
**Sort**  by any field.
- Provides **critical info** such as Resuscitation Status, new Lab results, Allergies, latest Vital Signs at a glance. Also specific treatments (like Accu-checks)
- Alerts caregivers of Medications or Interventions that are **due**
- Alerts caregivers to **New Orders**
**Physician Contact info** available with one click.

**Notes:**
As we look at different areas of our system there were different challenges. 

Customizing is a wonderful feature
The challenge was deciding what is the most relevant information for each discipline and each shift. 

## Worklist	

- Provides an electronic              “To Do” list
- Assessments built to our specifications.
- Ability to add descriptor text to assist clinicians
- Ability to _attach our protocols_ or policies and procedures  to individual assessments
- For easy access to click on view protocol

**Notes:**
One of the best things about the system is you can build your own assessments.

Also a major Challenge – started out putting everything anyone would ever want to document.

Then had to go back and make it what  you really wanted documented with areas for them to be able to comment on the abnormal. 

## View Protocol

- Assist care providers with meeting nursing care standards.

## POM (Physician Order Management )  

_**Benefits**_
- Increased Safety
- The orders are clear and concise.
- Orders are automatically checked against the residents allergy and adverse reaction information.
- Medications are checked for duplicate therapy and drug to drug interaction, as well as for food to drug interaction.
- Able to chose medications, Procedures, or I.V.’s

**Notes:**
Physician order entry, do you think that was a Challenge??? For some of the physicians it was instant buy-in and then there were the others. Some also not computer savvy, so it slowed them down more than they felt was necessary. 

We still get a fair number of orders per fax, that have to be enter by the nursing staff, then the fax is scanned into the record, but there is a continual increase in the number of orders physicians input.

## Labs

- Labs can be ordered for one time or set up for a routine basis. i.e. Every 30 days.
- Reports available to ease the difficulty of managing routine lab orders
- Use of Medication

**Notes:**
Probably the biggest challenge still exist, phlebotomist come to the facilities specific days of the week, the system does accommodate orders for once a month on the second Tuesday, the order has to be entered for every 30 days, therefore it requires have someone in each facility to run reports and pay close attention to the orders and when the phlebotomist will be in the facility. 

Before req was maybe taped to the desk

We have worked on this process a couple of times and we think at this point we finally have worked out the best process. 

## Medications 

- Able to chose from thousands of medications – 1st Data Bank
- Orders follow the Medication Rights
- Order is editable changes can be made to the start date, dose, frequency, etc.
- Dose instructions and comments can be entered

**Notes:**
This was probably the biggest improvement for Long Term Care. No longer did the paper MARs have to be generated and checked and put in the books.

The biggest challenge was the dictionaries and building the numerous medications to fit our organization, as well as the over the counters and vitamins that were not included in the 1st data bank. We didn’t have a pharmacy we use the numerous retails in the area.

## eMAR(Electronic-Medication Administration Record )

- Provides **Detailed Information**
- To improve efficiency and safety
- Start and Stop Dates
- List Trade and Generic name
- List dosage, route, and frequency.
- List when the medication was last given.
- List when the medication is next scheduled.
**Associated Data**
- The user can access related information from nursing assessments and labs.
**Monograph**
- Detailed  information regarding the use of the medication.

**Notes:**
The biggest challenge especially for the first facility. The MAR is not viewable until 24 hours prior to a scheduled medication is to be given. Therefore we had build the dictionaries and entered all the orders, took the team of about 8 -10 people about a week.

But it wasn’t until Sat before go live on Sunday Midnight (Super Bowl Sunday) that we knew how the MAR would really look. We came into look it over and freaked out. _(Need more here about what we found___) So we re-entered multiple medications and finished somewhere around 11pm for our go live at midnight. But we learned a lot.

Our most valuable lesson we learned was work on test a lot more. Trial – test – trial some more. 

The first pass for the nurses and med techs was a challenge, one nurse who had never used a computer took her the first pass about 45 minutes longer that usual. But within a week was shorter than when using paper

Cause and effect is huge. Best thing integration and worst thing integration 

## Monograph

- Provides information regarding medication such as...
- Side effects
- Precautions
- Drug Interactions
- Missed doses
- Medical Alerts

**Notes:**
Like having a drug book with you all the time. 

## Why BMV – Resident Safety 

- BMV decreases errors
- Opportunity for errors
- 588 Residents / 10 meds per day / 5880 med per day
- 2,146,200 Meds per year
- Average Medication Error Rate 6%
- What if we only have 1% = 21,462 errors per year
- 0.1% = 2146 Errors
- Noted through observation - Errors Prevented
- Wrong dose errors prevented
- Wrong medication errors prevented
- Wrong resident errors prevented

**Notes:**

ICU- Wrong Medication nurse pulled ASA EC order was for plain. 
Ltc- Wrong Med nurse pulled Ibu order was for ASA. Just grabbed the wrong med out of cart 

Acute- Wrong med pulled from Pyxis caught with BMV
LTC- XR ordered but resident was getting plain medication. 

Acute/LTC – Wrong patient eMAR open.

## BMVBedside Medication Verification

- BMV in LTC Gave Us Some “Opportunities” to be Creative
- Eleven Retail Pharmacies in 3 Counties
- Partners in Medication Safety
- Provided each pharmacy with the software and hardware to produce a bar code

**Notes:**
As previously discussed we didn’t start with BMV. 

And each has a pharmacist with their own ideas

New Slide – Initially slowed but now back to standard times

Bracelets to identify – Picture in the med cart in front of each med

## LTC BMV Improvements to Process

- Further Automated ordering process
- Order is placed in POM
- Fax is generated to the residents pharmacy
- The fax prints with the details of the medication including a bar code of the Rx number.

**Notes:**
Less for the nurse to do 

Another level of safety – decreases transcription errors

## BMV

- Hardware issues
- Not all Scanners are created the same.
- Power issues
- Battery management
- Power settings
- USB Port Issues
- Make sure that there are enough ports for all for the hardware

**Notes:**
Need module numbers of scanners we are using 
What kind of cart are we using? 
Label and bar code printers? 
Re-packager machine
Bartender  - Bar coding – manually produce bar codes if needed

## EMR ( Enterprise Medical Record )

- Replaced paper chart
- Resident data stored in electronic form.
- Provides storage of all residents visits, LTC, Hospital, Clinics.
- Automatic, incremental tape backup every day
- Weekly back-up placed in hospital vault, as well as monthly and annual back-ups.
- 2006 – Image Now – Paper is all scanned into EMR

## Visits Panel

- With appropriate access, providers can view multiple visits within the organization.

## Notes

- Provides a listing of all notes that have been entered regarding the resident.
- Can selected by specific providers i.e. Nurses, Therapist, Social Services, etc.
- Notes can be viewed individually by clicking on the magnifying glass
- Notes can be sorted by date, provider, type, and text.

**Notes:**
Built templates into the system for things such as communication with physician. If a resident has a fall the nurse can fill out the assessment and then when she pulls the template, note for post fall communication essential information is pulled into the form.   

## Order History

- Provides a listing of all the orders placed on the resident.
- Can be sorted by category, procedure, status, etc.
- Can provide an audit trail regarding who placed the order, made edits, or discontinued the order.

**Notes:**
Therefore the clinic physicians can see the history of orders when the residential care resident goes to see him. 

## Allergies 

- Provides a listing of the residents allergies.
- Shows the severity of each allergen.
- Allergies and Adverse reactions are checked against medications.
- Can view details of the allergies by clicking on the specific listing

## Summary

- Tabs on this screen include:
- Providers
- Allergies
- Visit Specific Info
- Risk/Legal Info
- Diagnoses
- Contact Info
- Insurances
- Demographics

## Management Benefits

- Reports – Vioxx Example
- Access from any computer in the organization
- Increase in documentation from direct care givers
- D.O.N’s and Administrators can easily monitor resident care.
- Status board management allows easy viewing of interventions or medications that are due.
- Reports are available for several medications. More efficient means of monitoring residents that receive psychotropic medications, antidepressants, etc.
- Reports available for resident interventions. Provides more effective way of tracking residents with specific needs such as Restorative Care

## Future Expansion

- Functionality to further streamline communication between facilities and the physician (2007-2008)
- PDA functionality will allow caregivers greater mobility (2008)
- Interface Vital Sign Machines with Computer System

**Notes:**
Karrie

## Challenges

- Staff who had never used computers
- Want to write on paper and transfer to chart
- Correspondence / Printing of Medical Record
- How to affix the Computers to the Med Carts - Velco
- COWS (Computers on Wheels) – How many do we need? What kind of carts should we purchase?

## Wonderful Things 

- Never have to look for a chart
- Never have to wait for someone to finish with a chart
- Can View from Anywhere
- Can Build Reports to Assist Caregivers
- Residents are Safer
- Support for Clinical Decisions