EMR Tools as Agents of Change
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1 EMR Tools as Agents of Change Elizabeth Clark, MD Division of Geriatrics Albert Einstein College of Medicine Amy R. Ehrlich, MD Division of Geriatrics Albert Einstein College of Medicine Paul Douglas Ossman, MD, MPH Section of Hospitalist Medicine Division of General Medicine and Epidemiology University of North Carolina Chapel Hill
2 Objectives Outline innovative geriatrics EMR tools which facilitate clinical care and training Discuss strategies for development, implementation and evaluation Share pitfalls and lessons learned
3 Workshop Structure Introduction & Presentations: 10 minutes CPOE: Geriatric Order Set Hip Fracture Admission Template Advanced Care Planning Small Group Discussions: 50 minutes Focus: CPOE or Template Please join the appropriate table for your interest
4 Rapid Cycle Quality Improvement: Plan Do Study Act Identify a problem in delivery of care Conduct small local test cycles Learn from taking action Encourage systemic improvement Gauge effectiveness of interventions DM Berwick, 1998
5 Computerized Physician Order Entry (CPOE) Paul Douglas Ossman, MD, MPH Section of Hospitalist Medicine Division of General Medicine and Epidemiology University of North Carolina Chapel Hill
6 UNC Hospitalists: The Stakeholders 20 Internal Medicine faculty 3 midlevel providers 5 active inpatient services 3 hospitalist services 2 teaching services 50 Internal Medicine Interns and Residents
7 Order sets Are Paired With Templates Geriatric Order set: Geriatric Consult note Geriatric Admission note Hip Fracture Admission Order set Hip Fracture Post Op Day 1 Order set Hip Fracture Admission note All include: Baseline functional capacity Mini Cog score, Healthcare proxy, Code Status DVT prophylaxis, bowel regimen Delirium prevention
8 ACTIVITY x x Geriatric Order set OOB to chair with meals PASSIVE EXERCISE to all extremities with AM and PM care AMBULATE WITH ASSISTANCE Daily NURSING x Assess Orientation to Person, Time and Place QAM and PRN Reorient patient when necessary x Note: Open blinds every AM x Note: Minimize disturbances at night, Turn off television when pt asleep or when not in use x To Bedside: Glasses, hearing aid, and pt s own shoes. Make available to patients when possible and encourage use x Encourage po fluids, keep fluids within reach GENITOURINARY Remove: indwelling urinary catheter RN/HUC D/c order in CPOE when completed. Bladder Scan post void residual after first void or if no void in 6 hours Call HO for PVR > 200 ml or if no void in 6 hours MD NOTE: For acute medicine floors, order: Remove indwelling catheter per protocol. Discontinue catheter per policy NURS 0143 (For medicine acute floors only)
9 Hip Fracture Order set
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12 Measuring Success P Chart of Proportion of Patients Having Vitamin D Checked 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Internal discussion and literature review Intervention Sample Number (Consecutive Samples of 15 patients) Proportion D Mean Getting Hip to Vitamin D: A Hospitalist Project for Improving Assessment of and Treatment for Vitamin D Deficiency in Elderly Patients Undergoing Hip Fracture Surgery, John Stephens, MD; Chris Williams, MD; Eric Edwards, MD; Paul Ossman, MD; Stephanie Flecksteiner, MD; E. Allen Liles, MD; Jonathan Kirsch, MD UCL LCL
13 EMR Template: Advance Care Planning (ACP) Discussion Progress Note Elizabeth Clark, MD, FACP Division of Geriatrics Montefiore Medical Center Albert Einstein College of Medicine
14 VA QI Project: Advance Care Planning (ACP) in EMR Objective: Implement EMR ACP documentation Setting: 2 urban VA Medical Centers Methods Development of user friendly EMR tool Multi modal educational programs Assessment VAMC 1 & 2: Total number of ACP notes written VAMC 2: 200 ACP notes reviewed for Effect of ACP on rates of Advance Directive (AD) completion End of Life (EOL) care preference documentation for patients w/o capacity Quality of ACP notes before and after training Evidence of ACP discussion as ongoing process
15 th
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17 Implementation Methods VAMC 1 ( ) VAMC 2 ( ) Champions 6 physicians, 9 NPs 2 physicians, 1 APN Settings for Clinician Modeling Interventions NH, geriatrics clinic, home based primary care, geriatrics & palliative care consults Role modeling: clinic, hospital, NH Noon conferences Intense training for geriatrics /palliative care fellows and rotating residents Monthly orientations Performance improvement initiatives Geriatrics & palliative care consults Role modeling: clinic, hospital, consult, Noon conferences Intense training for geriatrics /palliative care fellows Large group lectures Provider detailing
18 Results: ACP notes completed Fiscal Year VAMC 1 VAMC
19 Results: Impact of EMR tool and training (VAMC 2) Increased rates of Health Care Agent designation AD completion increase from 38% to 53% 1 EOL wishes recorded for patients w/o capacity 11 21% of ACP discussions with surrogates 1, 2 Training improved quality of ACP documentation Goals/values, desired care settings, and reasons for not expressing care preferences 2 ACP became on ongoing process after training 21% of notes documented follow up ACP discussions 2 1) Awan K, et al., AGS Annual Meeting, ) Nakagawa S, et al., AGS Annual Meeting, 2012
20 Breakout Session # 1: Stakeholders Discussion (10 minutes) Identify stakeholders Obtain buy in Moving the product through the system Report back (5 minutes)
21 Breakout Session # 2: The Products Discussion (20 minutes) Are there already established products? What is in development? Pitfalls and lessons learned Report back (5 minutes)
22 Thank You Contact Information: Elizabeth Clark, MD Albert Einstein College of Medicine Amy R. Ehrlich, MD Albert Einstein College of Medicine Paul Douglas Ossman, MD, MPH University of North Carolina Chapel Hill
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