Clinical Safety & Effectiveness Cohort # 10
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- Kristin Spencer
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1 Clinical Safety & Effectiveness Cohort # 10 Implementation of an Electronic Medical Record in an Obstetrics Emergency Room /Triage Setting DATE Educating for Quality Improvement & Patient Safety 1
2 Disclosure Mark S. Funk, MD has not relevant financial relationships with commercial interests to disclose. 2
3 The Team Physicians CS&E Participant Mark Funk MD Medical Director Women s Ambulatory Service Team Members Elly Xenakis MD Chief of Maternal Fetal Medicine Tiffany Remsing MD Chief Resident Ob/Gyn Brian Szender MD PGY3 Ob/Gyn Bernard Lynch MD PGY1 Ob/Gyn 3
4 Nursing The Team (cont.) Chris Hallgren RNC PCC Labor and Delivery Data Collection Camerino Salazar MS Director Quality and Outcomes, UHS Information Technology Irene Puente MSN RN Clinical Informatics Specialist UHS Sponsor Department Robert Schenken MD Chair Department of Ob/Gyn 4
5 A Special Thank You Camerino I. Salazar, MS Director, Quality and Outcomes, Texas Diabetic Institute, University Health System Hope Nora, PhD Clinical Data Coordinator, Center for Patient Safety and Health Policy Leticia Zuniga Bresnahan, MBA Project Coordinator, Center for Patient Safety and Health Policy 5
6 What We Are Trying to Accomplish? Aim Statement: Develop an electronic documentation tool to be used in the University Health System obstetrics emergency room (OB Triage) and achieve provider acceptance of using the electronic documentation tool from 0% to 75% over a period of 4 months. 6
7 Project Milestones Team Created January 2012 AIM statement created January 2012 Team Meetings Monthly Background Data, Brainstorm Sessions, March April 2012 Workflow and Fishbone Analyses Interventions Implemented April 1, 2012 Data Analysis May 25, 2012 CS&E Presentation June 15,
8 Background Providing appropriate communication in an emergency room setting in consideration of patient safety, provider satisfaction, and continuity of care Physical locations of concern: UHS OB Triage Labor and Delivery Antepartum/postpartum wards Ambulatory Clinics 8
9 Background (Cont.) OB Triage Emergency room setting which was dependent on paper documentation as the main communication tool. Paper documentation flows with the patient to use on the labor deck, antepartum/postpartum and a copy sent to referring provider/clinic 9
10 Background Multiple UHS Clinic Locations All Clinic Locations are Sunrise Compatible 10
11 OB Triage/Admissions Note Paper Document 11
12 QI Tools Utilized Brainstorming Flowchart Fishbone Pre and Post Surveys 12
13 Patient in OB Triage Pre Project Flow Diagram Paper OB Admission History and Physical Dispostion Outpatient Clinic Labor and Delivery Antepartum/ Postpartum Copy/Fax/On Base Paper OB Admission History and Physical Paper OB Admission History and Physical) 13
14 Fishbone Diagram Cause and Effect System Technology Time required to get logged into system System maintenance lack of computer stations Limited IT Programming Provider resistent to change No multiple oversight of notes Loss of team approach of triage At elbow support Cumbersome entry fields Improvised technology for report Standard note requirements vs free text Lag in data entry and retrieval times Missing notes/filing errors Illegible handwriting Data entry/field issues Unable to identify missing information readily Potential for Compromised Patient Safety and Continuity of Care Human Resources Human Error 14
15 Baseline Readiness for Process Change Assessment Determined satisfaction level with current paper based process Based on responses, determined what aspects of paper tool needed to be addressed in the electronic tool Assessed readiness for a conversion to an electronic tool Results drove the design of the electronic tool Assessment conducted via web representative sample of the targeted end users was surveyed as reflected on following two slides 15
16 Figure 1: Clinical Characteristics of Survey Respondents 12.80% 10.30% NP CNM 76.90% Physician ource: OB HPI Electronic Documentation Survey 16
17 Figure 2: Clinic Locations of Survey Respondents 7.70% 7.70% 10.30% 15.40% 5.10% 74.40% UFHC NW UFHC SW UFHC N UHS RBGC UFHC SE KWC N PC ESBC WEC SFC ZC Source: OB HPI Electronic Documentation Survey 17
18 As a provider in Labor and Delivery I feel that the paper based OB Admission History and Physical can easily be referred to when the patient is on the Labor Deck. Not Applicable 10.50% Strongly Agree 50% Agree 31.60% Disagree 2.60% Strongly Disagree 5.30% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 18
19 As a provider in Antepartum/Postpartum Services I feel that the paper based OB Admission History and Physical can easily be referred to when the patient is in the OB Ward. Not Applicable 23.70% Strongly Agree 11% Agree 34.20% Disagree 18.40% Strongly Disagree 13.20% 0.00% 10.00% 20.00% 30.00% 40.00% 19
20 The information necessary for appropriate follow up and care found within the paper based OB Admission History and Physical is complete Hardly ever 5.60% Some of the time 16.70% Most of the time 77.80% 0.00% 20.00% 40.00% 60.00% 80.00% % 20
21 The information provided within the paper based OB Admission History and Physical to referring clinic/provider either through fax or provided to the patient directly is clearly written or legible... Hardly ever 19.40% Some of the time 41.70% Most of the time 38.90% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 21
22 I believe implementing or putting this form in the Electronic Medical Record can help clinical providers /staff to Avoid injury to patients from the care that is intended to help them Strongly Agree 35.1% Agree 67.60% Disagree 16.20% Strongly Disagree 0.00% 0.00% 20.00% 40.00% 60.00% 80.00% 22
23 I believe implementing or putting this form in the Electronic Medical Record can help clinical providers /staff to Reduce patient wait time Strongly Agree 35.1% Agree 21.60% Disagree 45.90% Strongly Disagree 18.90% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 23
24 I believe implementing or putting this form in the Electronic Medical Record can help clinical providers /staff to Improve efficiency of care Strongly Agree 18.9% Agree 40.50% Disagree 32.40% Strongly Disagree 8.10% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 24
25 I believe that having an electronic version of the paper based OB Admission History and Physical in the Electronic Medical Record will provide the opportunity to improve care coordination between providers and the patient. Not Applicable 0.00% Strongly Agree 35.1% Agree Disagree Strongly Disagree 0.00% 5.40% 56.80% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 25
26 I believe implementing or putting this form in the Electronic Medical Record can help clinical providers /staff to Provide a standardized level of care Strongly Agree 25.0% Agree 69.40% Disagree 5.60% Strongly Disagree 0.00% 0.00% 20.00% 40.00% 60.00% 80.00% 26
27 I would support replacing the current paper based version of the OB Admission History and Physical with one developed for use with the Electronic Medical Record.. Not Applicable 0.00% Strongly Agree 35.1% Agree Disagree 16.20% 37.80% Strongly Disagree 10.80% 0.00% 10.00% 20.00% 30.00% 40.00% 27
28 Intervention Keeping in mind the features of the paper based tool that were important to the target audience, we worked with IT to design a tool that incorporated these features Anticipating that as long as the paper based tool was available that it would continue to be used, we removed this option and only the electronic tool was made available After 8 weeks of use, a survey was distributed to assess level of acceptance 28
29 OB Triage/Admissions Note EMR Full Text 29
30 OB Triage/Admissions Note EMR Report 30
31 Patient in OB Triage Post Project OB Triage/Admission Note Flow Diagram Dispostion Outpatient Clinic Labor and Delivery ANtepartum/Postpartum EMR Full Text OB Triage/Admission Note (REPORT) EMR Full Text EMR Full Text 31
32 Post Intervention Survey Impact/Results Overall, I believe with continued improvements the EMR OB Triage/Admission Note will strengthen delivery of quality care and safety for patients that present in OB Triage. 32
33 Figure 3: Impact/Results Percent Acceptance 4.20% Sales 16.70% 41.70% Strongly Agree Agree Disagree Strongly Disagree 33.30% Source: OB HPI Electronic Documentation Survey 33
34 Costs: Return on Investment Upfront development of electronic tool by IT Time and effort of the team Survey Monkey Savings: Mitigation of errors due to delay in access to electronic chart Impact on decision making due to immediate access to OB report Medical error reduction thus savings in unnecessary care, potential litigation, hospital and provider reputation 34
35 Lessons Learned/ Next Steps Importance of IT support Validation of hypothesis through needs assessment survey Learning curve with implementation of electronic tool Counter balance measure Track effect of change in process on patient wait time/work flow of providers 35
36 THANK YOU! 36
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