Transition to the Electronic Patient Record (EPR) Successes and Lessons Learned University Health Network

Transition to the Electronic Patient Record (EPR) Successes and Lessons Learned University Health Network Tim Tripp Diamond Watson-Hill Katherine Henning October 28, 2010

University Health Network (UHN) Three Hospitals One Vision The SIMS Partnership Toronto Western Hospital Toronto General Hospital Princess Margaret Hospital Fast Facts: ~750 beds ~257,000 patient days ~943,000 ambulatory visits ~10,856 employees ~3,488 students ~573 active staff ~1,741 volunteers ~ Budget $1.4 billion Data Source: Fast facts Fiscal Year 2008/09, UHN Intranet 2

Agenda The SIMS Partnership UHN IM Background and Strategy EPR Adoption Model Medication Order Entry/Medication Administration Record Electronic Discharge Summary Advanced Clinical Documentation 3

UHN IM Background and Strategy 4

Information Management Strategies at UHN Taking Charge Integrating Care Systems Integration (PMH) Y2K readiness Customer service Systems reliability care@uhn Clinical content CDS Telecommunications Internet/Intranet Community integration Information Enabling Care Access Patient Safety Accountability Patient Experience Community Focus Information Enabling Care 2009 IM Strategy 2014 Transforming Care Provide Safe, Quality Care Ensure Business Continuity Integrate Care Environments IM Strategy 2014 Transforming Care care@uhn 1995 1998 2000 2003 2008 2014 5

Schematic of EPR Environment The SIMS Partnership Inventory Chart Locator PYXIS Pharmacy TLC Management PHS Medispan Microbiology OTTR CancerFacs Finance Medical Imaging EPR GRASP ORSOS Apollo Cath Lab Med2020 Nutrition Scanned Documents Labs Endoscopy Blood Bank 6

EPR Development at UHN: A Snapshot The SIMS Partnership PHARMACY STD CLINICAL DESKTOP RADIOLOGY SYSTEM ED WHITEBOARD LABS & PATH ECHO & ECG SYSTEM DIAGNOSTIC ORDERS & RESULTS SCHEDULING SCANNING MEDICATION OE/MAR EPR Cache Upgrade PROBLEM LIST PILOT enotes & ADV. CLIN. DOC. 2001 2002 2003 2004 2005 2006 2007 2008 2009 7

UHN EPR Volume The SIMS Partnership 2009 data: Mysis Modules University Health Network Reg/ADT Accounts 3+ Million Processed Visits (monthly avg) 120,000 Order Entry - Labs, Radiology, DT 24,000 Procedures* Chart Review - Onsite Access Chart Review - Remote Access MOE MAR All Patients Height, Weight, Allergy, Clinical Documentation Admission Assessment Physician Inbox Privacy Lock Box *2007 data 8

The Future of EPR within UHN The SIMS Partnership Upcoming initiatives: Blood Transfusion CPOE Advanced Clinical Documentation RN/Allied Health Focussed Assessment Facility Merge Positive Patient Identification (ID) Opportunities: Problem List / Controlled Medical Vocabulary (CMV) empi duplicate records Integrated Scheduling 9

EPR Adoption Model 10

EPR Adoption Model The SIMS Partnership 11

EPR Future Development Certification ARRA Ambulatory Certification Downtime Data Access SQL Reports Package PHI Portability Integrated Medication Management The SIMS Partnership ARRA Hospital (Stage 2) Interoperability Advanced Clinical Documentation Rx Inventory Retail OP Pharmacy eprescribing Integrated Med Reconciliation Med Order Entry Pharmacy Processing Med Admin Physician Doc Template Mgmt Interactive Whiteboard Order Entry CPOE Evidence Based OS Integrated Pt. Education Problem List Immunizations Monitor Data Capt Bio-Surveillance Department Solutions Ancillary Services Radiology Clinical Lab Patient Record Access Control Lockbox: Patient; Visit; Problem Patient Mgmt Workflow Management Order Mgmt Condo Support Sequestration Data Review CDS Results Mgmt QuadraMed Integration - Affinity - QES - Acuity Plus French Lang Support Enhance M34 Postal Code Configuration Content - Core - Rehab Security Services Enterprise Auth (LDAP) Event Scheduler Clinical Alert Engine Advanced Drug Knowledge Services (Incl. Canadian Drug Files) Controlled Medical Vocabulary / Clinical Concept Layer Production Database Caché Shadow Database 12

EPR Future Development The SIMS Partnership Initial data mapping to a Controlled Medical Vocabulary Clinical Concepts Focus on Continuity of Care Document creation (CCD = structured data = key to interoperability) Benefits: The foundation for interoperability and standardized reports that can be shared across multiple sites The foundation for concurrent coded documentation based on the codified procedures and terms utilized within the templates 13

Clinical Concept Layer (An Enabling Technology) The SIMS Partnership Advanced Clinical Documentation Interoperability (5.2) Physician Doc (5.3) SQL Reports SQL Queries General Data Services / API s (3 rd Party Content Conduit) Clinical Concept Layer CMV Data Map (5.2) Clinical Concept Observation Table QCPR Customer Configuration A QCPR Customer Patient Data A Caché Database 14

EPR Future Development The SIMS Partnership 2011: Fully codified problem list with CMV utilizing appropriate coding schemes including the ability to transition to ICD-10 Allows the clinician the ability to contribute and obtain a complete view of the patients medical history across the continuum of care 2012: Implementation ready documentation templates based on best practice reducing implementation time quicker to production. Increased clinician satisfaction with efficient documentation tools including ability to modify / create custom templates ProVation Order Sets: based on evidence & best practice 15

Medication Order Entry / Medication Administration Record (MOE/MAR) 16

Our Objectives The SIMS Partnership Eliminate medication transcription errors. Ensure complete and legible medication orders. Introduce clinical decision support alerts. Eliminate pharmacy order entry and introduce online verification of medication orders. Introduce point-of-care medication administration documentation. Standardize order sets and order screens. Reduce reliance on the paper health record. Improve clinical processes and policies. 17

100 % of eorders are Legible & Complete Paper Order Sheet Nurse Medication Order Administration Screen 100% of orders are complete and legible 18

100% of Drugs and Order Screens Are Standardized The SIMS Partnership Standard Order Screen (Online) 130 Common order and Standard Order screens Over 10,000 typical orders built Pre-Printed Order Sheet (Paper) Pre-Printed Order Sheet (Online) 19

100% Standardized emar The SIMS Partnership Paper MAR Electronic MAR 100% Standardization of medication administration times No Transcription Required (for most medications) Immediate electronic access to MAR and medication history at the point of care 20

Results Realized UHN experience published in 2006 Provides insight into implementation processes, clinician experiences and overall successes of the initiative 21

Electronic Discharge Summary 22

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Evolution The SIMS Partnership Handwritten Dear Doctor Letter +/- Discharge Summary Electronic Dear Doctor Letter Electronic Discharge Summary Discharge summary with medication reconciliation and decision support 25

Enable the creation of high quality discharge summaries The SIMS Partnership Note completed prior to discharge Documents: Allergies presented with specific reaction All discharge medications with name, dose, frequency and duration Results of normal and abnormal hospital investigations pertinent to presenting complaints Arranged medical follow-up Pending laboratory results Uses a structured format vs. a letter style What Is Necessary for High-Quality Discharge Summaries? van Walraven AJ of Medical Quality.1999 26

Data Elements in UHN s Discharge Summary Discharge and Diagnosis Admission date and location* Discharge Date* Discharge Disposition Most Responsible Diagnosis Pre and Post Co-morbidities Procedures Physician Notes Patient History Course in Hospital Labs (initial, latest)* Radiology* Allergies and Medications Allergies and Reactions* Discharge Medications* e Prescription Follow-up Plan Lab Work Radiology Future Appointments Physicians to receive a copy* * Pre-populated from EPR 27

Electronic Patient Record Family MD HL7 Patient Demographics ADT & Allergies Completed note Data repository Medications Labs, Radiology Discharge Summary Application 28

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Results Currently, 70% of discharge summaries produced using the electronic discharge summary Significant savings on transcription achieved with this implementation Technical issues currently being addressed to allow us to move to 100% 33

Advanced Clinical Documentation Expanding the use of electronic synoptic notes at UHN 34

Current Use of Electronic Synoptic Notes at UHN UHN is actively promoting the adoption and implementation of synoptic notes as a standard to improve the quality of care ecancer Tools Depict CAIS Bladder Kidney Testes Clinical Anaesthesia Note Surgical Synoptic Patient Note EPR Operative Note CPAC Ovarian Surgical Note Procedure Note Legend In Use In Development AFP Innovation Fund Bronchoscopy Upper GI endoscopy Colonoscopy Cystoscopy Data repositories & reporting Clinical Research Interdisciplinary care teams UHN extended care team CPAC Other provincial jurisdictions UHN Registries e.g., staging, tissue banks Referring/ Family physician Provincial Registries 35

Benefits of an Ambulatory Synoptic Note Patient Care Seamless flow of information across the continuum of care Acces s to realtime test results Struct ured reporti ng Pointofcare docum entatio n Advan ced Clinica l Docu mentat ion Stand ard forms + templa tes Education Documentation standards for clinical notes Teaching and training tool for medical students, residents, and fellows Integr ation with resear ch Integr ation with referra ls The SIMS Partnership Research Structured data capture Clinical trials information tracking 36

Surgical Synoptic Note Information Flow Physicians access the Surgical Synoptic Patient Note through the EPR EPR Inbound HL7 Clinic Note - discrete data elements The SIMS Partnership Web-based synoptic note application Outbound HL7 Patient Demographics ADT Notes are auto-faxed to community physicians SNOMED CT vocabulary database 37

Surgical Synoptic Note History of Present Illness Benefits Single streamlined process for capturing consult and clinic information Smart navigation shows only pertinent servicespecific templates Automated import of patient demographics data saves time Powerful communication tool linking acute care and primary care physicians; auto-faxing of patient notes to primary care physicians EPR integration note available real-time in chart review Eliminate dictation and transcription 38

Surgical Synoptic Note - Annotation Tool Clinicians often use freehand drawings to supplement their clinical documentation and communications with patients The ambulatory documentation tool provides clinicians with the ability to draw and store these drawings as part of the clinical record 39

Surgical Synoptic Note - SNOMED Integration The Surgical Synoptic Note project uses SNOMED CT to model diagnoses, physical exams, chief complaints, procedures, diagnostic tests etc. Over 1300 terms have been directly mapped to SNOMED CT The application s search functionality uses special ranking algorithms to provide users with a simple, intelligent interface for accessing clinical concepts 40

Surgical Synoptic Note Outcomes The SIMS Partnership The application was developed to provide 4 ambulatory surgical clinics (General Surgery, Orthopaedics, Plastics, and Urology) with a method to document consultation and follow-up notes. System went live on June 25 th, 2009. Surgical Synoptic Patient Note is a patient-focused initiative that offers: Patient Benefits Supports better-informed, safer and more timely clinical decisions Reduces the delay between surgical documentation completion and availability in EPR chart review Improves quality of care by adhering to best practice guidelines, improving disease management and reducing medical errors Electronic tool allows documentation to be captured by clinicians at the point of service Provider Benefits Assists healthcare professionals to make critical decisions on patient treatment and follow-up effectively and efficiently Standardization and improvement in the quality of notes Reduces time and effort to access patient information from multiple sources A training and teaching tool for medical students, residents and fellows; guides them through the consultation and followup process Synoptic data captured as part of routine standard care can be easily extrapolated for secondary use: Outcomes and organizational planning Research System/Sector Benefits Greatly improves access to usable electronic data for patient care, research and reporting, and organizational planning Provide structured evidence-based medical content to ensure optimal patient outcomes A centralized electronic library of highquality clinical templates Hard dollar savings derived from the elimination of dictation and transcription Improved communication across the continuum of care No transcription or scanning delay after documents are completed Direct data capture will improve the quality of data transferred to cancer registries, tissue banks, and research databases 41

Surgical Synoptic Note The Road Ahead Complete functional enhancements: Automated billing Lab and radiology results pulled from EPR Physician to-do list Enhance integration with EPR: Send patient vitals to EPR via an HL7 assessment interface Expand to other services and areas at UHN Surgical and non-surgical, inpatient, ambulatory etc. Align with the EPR clinical documentation roadmap 42

EPR Referring Physician The SIMS Partnership Synoptic Reporting Emerging Opportunities Existing Dataflows Supported by the Surgical Synoptic Patient Notes Surgeon enters data, at the point of care, into a synoptic template that captures data in a structured & standardized manner: Patient demographics Chief complaint Past medical history Physical assessment Impression & Plan Meds & Allergies Surgeon Clinic Note Faxed Information Flow Future Benefits of Synoptic Reporting to Provincial Healthcare Expansion of Synoptic Reporting Benefits Local Database CCO Data Repositories Research Clinical Trials H I A L L R S Ancillary Data & Services Health Information Data Warehouse EHR Data & Services Registries Data & Services SNOMED CT Tissue Banks Benefits Structured data helps establish standards of care & reduces medical errors Positively influences practice as new techniques and information are rapidly disseminated Seamless integration of clinical best practice guidelines Synoptic template is an education tool that reminds clinicians of the steps & details of the event (reason for referral, surgery, etc.) for optimal quality control Synoptic reporting enhances the clinicians & care teams ability to measure & monitor the process of care and assess impact on outcomes Improved accuracy & completeness of clinical documentation Improved workflow by a) auto faxing clinic notes to referring physicians & b) making information immediately available to other care providers with access to the EPR Eliminates costly dictation, transcription, and scanning expenses Benefits Benefits Direct data capture improves the quality Data available for surgical outcomes of data sent to cancer registries, tissue studies & information surrounding banks, & research databases variations on practice and outcomes Allows for accurate collection & Data can be used to monitor the quality comparison of cancer data which of reporting in Ontario & to support directly impacts cancer screening & service planning & research treatment protocols Synoptic reports will enable the Biobanking allows for integration of collection of surgical, clinical, pathology clinical and biological profiles & outcomes data for quality monitoring Accurate diagnoses & staging to guide & improvement treatment planning & to make informed Clinicians get real-time practice patient care decisions comparisons to provincial averages Structured reports have high integrity Integration of data with provincial EHRs as a research tool 43

The Future Stage 1 Pharmacy, Radiology & Lab Info Systems The SIMS Partnership UHN s goal is to have complete and accurate clinical documentation to enhance patient care and facilitate the reporting of vital health information that is critical to optimal management of Ontario s healthcare system The electronic health record of the future will be one that requires structured data as a standard of practice Providing clinicians UHN with the tools to Stage 6 Surgical Synoptic Patient Note, deliver outstanding Discharge Summary, OR Notes patient care is an Stage 4 essential part of emoe, Allergies documentation, Insight alerts UHN s Information Management Stage 3 RIS PACS, etriage, emar, Strategy and the Drug-drug Checking reason why UHN is Stage 2 a Canadian leader in Digital documents, QCPR EMR adoption Clinical Outcomes Data from HIMSS Analytics 2010 44