# Presentation: 181820

## Comprehensive IT Solutions for Quality & Patient Safety

- Reporting on early successes in implementing a pharmacy order entry system in a pediatric hospital system

- AHRQ Annual Conference
- June 9, 2005
- Paula J. Edwards
- pedwards@isye.gatech.edu
- Georgia Institute of Technology

## Comprehensive IT Solutions for Quality & Patient Safety

- Research funding is graciously provided by AHRQ and Children’s Healthcare of Atlanta
- The presenter has no conflicts of interest related to this research

## Agenda

- Project overview
- Impact on patient safety
- Ensuring successful implementation
- Next steps

## Project Overview

- Children’s Healthcare of Atlanta
- Scottish Rite- private community hospital
- Egleston- academic teaching hospital
- Implementing technology
- Inpatient pharmacy system, eMAR, clinical documentation, CPOE, bar coding
- Staged Implementation
- Vendor: Epic
**Goal:** *Reduce medication errors and increase quality of patient care*

**Notes:**
CHOA is the merged entity of two pediatric hospitals.  After competing for 50 years, they merged 6 years ago, and now have more than 430 licensed beds and 450,000 patient visits/year.  Children’s is known for cancer, cardiac, neonatal, transplant orthopedic care, and many other specialties.  They were ranked in the top 10 children’s hospitals nationwide by Child Magazine.
Children’s has committed and invested heavily in HIT.  They are part of the way through a staged implementation of a complete integrated electronic medical record over the next 18 months.
Inpatient Pharmacy System, Epic Rx,
electronic Medication Administration Record, eMAR
Clinical Documentation
Bar Coding System
Computerized Provider Order Entry System, CPOE

The vendor chosen is Epic.  Epic, known for their mature ambulatory heath record, is now making strides in the r inpatient product.  There is significant customization and flexibility in tailoring the product to the pediatric inpatient setting.

## A Collaborative Effort

**A Collaborative Effort**

**Children’s**
**Healthcare of Atlanta**

**Ga Tech**
**Industrial Engineering**

**Emory University**
**Public Health**

- Technical Implementation

- Workflow Redesign

- Operations
- Efficiency

- IT usability

- User
- Satisfaction

- Patient Safety Impact

- Culture
- of Safety

- Change
- Management

## Desired impact on patient safety

**Objective:** Reduce medication errors by implementing IT to support each step in the med order fulfillment process

## Potential impact on patient safety

- EMR and CPOE have proven potential for improving patient safety...
- e.g., In Vanderbilt Pediatric CCU, potential ADE’s reduced by 40.9% (Potts, et al., 2004)
- ... but implementing the technology doesn’t guarantee a positive impact on patient safety
- e.g., recent JAMA article on new CPOE errors creating a potential for medication errors (Koppel, et al., 2005)
***How can we ensure that our EMR & CPOE will have a positive impact on patient safety?***** **

## Where we are now

- Vendor
- Selected:
**Epic**

-  Online
-  Lab
-  Results

-  Inpatient
-  Pharmacy
- (EpicRx)

- eMar &
-  Clinical Doc

- CPOE

- Bar
- Coding

**Successful**
**Go-Live!**

- Fall
- ‘05

- Spring
- ‘06

- Winter
- ‘06

- How are we ensuring success?
- Getting stakeholders involved
- Redesigning work practices to include use of new technology
- Learning and change management
- Evaluating & improving IT usability
- Measuring achievement of goals

## Get stakeholders involved!

**   ****Front line**
**involvement in **
**all aspects of**
**design, build,**
** ****& test!**

**Notes:**
To assure front line involvement in all aspects of designing, building, and testing of system:
Determined departments impacted by Epic and requested delegates from manager/director
Departments selected computer literate, front line staff with detailed knowledge of workflows and good relationships within their teams
Teams of ~15-20 meet monthly for 2-3 hours- review build, provide input, communicate back to staff in departments
Function as super users in departments during and after implementation
Exec Steering Comm – bimonthly
Clinical Oversight – monthly
Physicians – Ad Hoc/quarterly
Manager Teams/SDM Councils – consulted on major operations changes

## Redesign work practices

- Study workflows effected by IT system implementation
**Field observations** and **staff interviews**
- Flowchart current workflows
**Identify best practices**
- Literature reviews, peer input from other hospitals
- Leverage tools available within EMR/pharmacy system
**Standardize** future state workflows
- Work with Department Champions / Oversight teams
**Identify gaps** between current and future state workflows
**Plan for transition** from current to future state
**Educate** staff and leaders on gaps and transition plan

**Notes:**
Clinical informatics team – former clinicians with 10-20 years at CHOA, 11 total

## Learning & change management

- Understand readiness to change through surveys of directly impacted staff
- Prior to implementation, assess **perceptions and expectations** regarding the HIT & training
- Responses shared with the training team
- Training materials and plans revised (crucial to rapid change)
- After implementation assess perceptions regarding **impact** of the HIT on **work practices**, **satisfaction** with the HIT and HIT rollout
- Responses used to **iteratively improve** rollout & training for future stages
- Future work will examine factors influencing readiness to change and acceptance of new technology

**Notes:**
.Evaluation of staff readiness & acceptance of EPIC and Survey of staff perceptions of safety - Baseline staff readiness and safety surveys were developed, distributed and completed (pharmacy staff, patient care staff, and physicians). Post-Pharmacy implementation surveys are underway. These will be compared by groups (e.g. pharmacy, nursing and provider) for common themes and issues specific to groups.
Findings(selected)
Pharmacy Staff Readiness Survey Findings (109 distributed, 33 returned completed, response rate = 30.3%)
Most agree (54.5%) or strongly agree (30.3%) that people who learn the new system will be more valuable to the organization.
39.4% agreed they had been informed/updated throughout the implementation process, while another 39.4% disagreed with this statement. (definitely has room for improvement).
Most believe that Epic can assist them in improving quality of care (21.2% strongly agree, 54.5% agree, 18.2% neither agree nor disagree) and reducing medical errors (6.1% strongly agree, 60.6% agree, 27.3% neither agree nor disagree).
Most felt that Epic would fit into their workflow (63.6% agree, 33.3% neither agree nor disagree). Also 30.3% felt that using Epic would reduce their administrative workload and 66.6% felt that Epic would enable them to complete tasks more efficiently; 
Most feel that it will be easy to learn Epic (3% strongly agree, 54.5% agree, 24.2% neither agree nor disagree), but 15.2% are concerned that it will not be easy; however many are concerned that it will be difficult to schedule time (54.5%) to complete Epic training.
Pharmacy staff (78.9%) indicated that if resources were available, they would spend additional time to get familiar with Epic. 

## Evaluate and improve IT usability

- Output:
- Suggested changes to improve ease of use
- Input to training needs

***Usability Goals***
***Make system easy to use from day one***
***Reduce potential for errors***

## Measure achievement of patient safety goals

| Goal | Measurement Method(s) |
| --- | --- |
| Reduce medication errors | Self-reported medication-related errors
Trigger-based chart review of adverse drug events |
| Promote ‘culture of safety’ in hospital personnel | Survey on perceptions regarding patient safety
Survey on perceptions of EMR/CPOE system’s impact on work & safety |
| Improve turn-around-time on first-dose medications | Field study of pharmacy order fulfillment process |

- Measure baseline prior to go-live and measure after go-live of each major phase (e.g., pharmacy, eMAR, CPOE)
***   ************ ******Demonstrate impact of sequential IT initiatives***

**Notes:**
Measuring errors
Identify clinically significant medication processes and medication errors that can be used to monitor improvement 
Pharmacy interventions; prescriptions with missing, illegible or erroneous information; administration errors
Use IHI “trigger” methodology to identify adverse drug events with chart review in both general pediatric and ICU wards
Team of clinicians will review and vet “triggers” for pilot testing in June
Sampling strategy designed to allow hospital-wide estimates as well as site specific estimates of errors

## Measure achievement of goals: Stage 1 - Online Lab Results

| Goal | Measured by | Pre-Live Value | Post-Live Value |
| --- | --- | --- | --- |
| Increase satisfaction of users accessing results through web based application by 5% | Survey users of MDAccess who become users of EpicWeb pre- and post live. | 3.48 | Phys survey 3.94
Phys office staff 4.25
Combined 4.01
Increased by 15% |
| Decrease time to access results by 20% | Studies pre- and post- implementation related to the number of steps it takes to look up lab results in SMS versus Epic | 12 steps in SMS
 | 7 steps in Epic
Decreased by 42%  |
| Increase # of locations with access to results by 20% | Number of new workstations placed in clinical areas for Stage I go live / # workstations available pre- implementation | 527 | 114 added
(641 Total)
Increased locations by 21.6% |

## Our lessons learned

- To ensure implementation meets goals for improving patient safety
- Get users involved and keep them involved!
- Don’t just design the technology, design the work practices and technology to work together
- Train on the technology *and* work practices
- Iteratively improve the implementation process *and* the system
- Communicate tangible results achieved toward goals

## Comprehensive IT Solutions for Quality & Patient Safety

- Reporting on early successes in implementing a pharmacy order entry system in a pediatric hospital system

- AHRQ Annual Conference
- June 9, 2005
- Paula J. Edwards
- pedwards@isye.gatech.edu
- Georgia Institute of Technology

## References

- Potts, A. L., Barr, F. E., Gregory, D. F., Wright, L., & Patel, N. R. (2004). Computerized Physician Order Entry and Medication Errors in a Pediatric Critical Care Unit. *Pediatrics, 113*(1), 59-63.
- Koppel, R., Metlay, J. P., Cohen, A., Abaluck, B., Localio, A. R., Kimmel, S. E., et al. (2005). Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors. *JAMA, 293*(10), 1197-1203.

## Approach to measuring medication errors

- Identify clinically significant medication processes and medication errors that can be used to monitor improvement
- Pharmacy interventions; prescriptions with missing, illegible or erroneous information; administration errors
- Use IHI “trigger” methodology to identify adverse drug events with chart review in both general pediatric and ICU wards
- Team of clinicians will review and vet “triggers” for pilot testing in June
- Sampling strategy designed to allow hospital-wide estimates as well as site specific estimates of errors