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Sir William Osler, the Canadian physician frequently described as the Father of Modern Medicine, was an innovator in medical training. He created the first residency program for specialties and introduced bedside clinical training as part of physician education. He once said:
Observe, record, tabulate, communicate. Use your five senses…Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.
Though Osler said this more than 100 years ago, the principles are still relevant today. Observe, record, tabulate, communicate – modern clinical informatics strives to help clinicians with all of these foundational aspects of medicine. Allscripts is working with world-class Canadian education organizations to create additional opportunities in this field.
Partnering with Dalhousie University to improve healthcare IT education opportunities
Dalhousie University is known for providing its researchers and students with real-world opportunities to apply their learning. Dalhousie and Allscripts have formed an academic alliance to ultimately improve health care.
In January 2016, Dalhousie University’s Health Informatics Group brought together students from medical and computer science disciplines for a two-day code-a-thon to equip students with the knowledge and tools to build new applications on top of electronic health records (EHRs). During the hands-on workshop, the Allscripts Innovations team educated Dalhousie members on the developer toolkits and Open APIs available to clients that wish to integrate third-party applications.
“When you look at something as complex and large-scale as health IT, it’s not one little piece of software, but a whole environment,” Dr. Andrew Rau-Chaplin, Dean of the Faculty of Computer Science, said. “Partnering with companies is an opportunity to connect the academic setting to concrete examples in a number of dimensions.”
Supporting Canada’s first scholarship in nursing informatics
Nursing Informatics is the “science and practice (that) integrates nursing, its information and knowledge, with management of information and communication technologies to promote the health of people, families, and communities worldwide.” (IMIA Special Interest Group on Nursing Informatics 2009).
To help ensure that Canadian nurses are highly trained in this discipline, the Canadian Nurses Foundation recently established the Dr. Kathryn J. Hannah Nursing Informatics Scholarship, named after a pioneer in the field.
“Advancing nursing knowledge is crucial to every aspect of patient care and health service delivery for all Canadians,” Canadian Nurses Foundation CEO Christine Rieck Buckley said. “We need more nurses prepared at the graduate level with experience in health informatics. As Canada’s only national nursing foundation, we are delighted to work with corporations like Allscripts in this valuable scholarship fund.”
Investing in tomorrow’s clinical informatics leaders
When I meet with healthcare leaders around the country, I’m inspired by their dedication to continuous improvement of care. I think Osler said it best when he said:
The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.
I’m encouraged to know there are brilliant minds at work in the field of clinical informatics. There’s also a passion for helping others that is second to none. The future is in good hands.
The Hospital for Sick Children (SickKids), affiliated with the University of Toronto, is the largest organization dedicated to improving children’s health in Canada. These clinicians provide the best in complex, specialized care for some of our country’s youngest patients.
We’ve always been impressed by the compassionate team at SickKids, but perhaps never so much as when we collaborated with them to complete five successful Allscripts Sunrise™ activations in 2015. We recently spoke with Steven M. Schwartz, M.D., FRCPC, FAHA, who led the implementation of Sunrise™ Acute Care in the Cardiac Critical Care Unit (CCCU), about the effort.
Describe your department and what prompted you to move to Sunrise.
The Department of Critical Care Medicine at SickKids is responsible for both the Cardiac Critical Care Unit (CCCU) and the Paediatric Intensive Care Unit (PICU). Between us, we have 41 beds to care for these critically ill infants, children and adolescents.
Our hospital has been using Allscripts [electronic health record (EHR) system] since the 1990s, and other parts of the organization had moved to Sunrise (Clinicals) years ago. It was time to upgrade the ICUs, to have the same modern functionalities as everyone else, particularly with regard to computerized order entry.
What did you do to prepare for the switch to Sunrise?
Getting to successful implementation was years in the making, but there are a few things that worked really well for us. First and foremost, we had clinician engagement at every level. This was very much a clinician-led implementation.
Next, we approached the project as a team. We had a large working group of about 20 people representing technical, clinical, operational and educational disciplines. We met every week for about a year before go-live day to look at everything as the system was being developed. It worked better for us than having smaller, separate teams. With a larger group, we were able to make things happen quickly, with everyone in the room at the same time.
I think it also helped to go live in the neonatal intensive care unit (NICU) first. That unit has fewer orders and less technology with which to interface than the CCCU and PICU. We were ready for activation a couple of months later.
On “go-live” day, the CCCU and PICU were operating beyond full capacity. How did you manage the activation during such a busy time?
We always must be prepared to care for patients in over-capacity situations. It was important that the implementation did not interfere with patient care.
We had trained several nurses to be Sunrise “super users” to answer questions, but we needed them at the bedside instead. Allscripts was able to provide extra people to make sure the activation went smoothly.
Implementation isn’t the end – training and support have to keep evolving. We have a terrific educator group at SickKids that provides a lot of our ongoing training needs.
What can you do with Sunrise that you couldn’t do before?
The absolute biggest change is Computerized Physician Order Entry (CPOE). It provides us with the same benefits as the rest of the organization. It helps improve continuity of care, because when kids leave our unit for the ward, those clinicians can find our notes and flowsheets in the same system that they are using on their wards. With the new system it’s easy to navigate to things like X-ray and test results. Our teams are learning the advantages of electronic medication reconciliation and clinical documentation.
Is there anything else you’d like to share about your experience?
It’s been a good team effort. The big lesson we learned is that, to be successful with an activation, you need to have everyone at the table, including the vendor. It helps to have people who have been through this before to help solve problems quickly.
Fraser Health Authority (Surrey, British Columbia, Canada) uses multiple clinical systems to deliver patient care to more than 1.6 million patients annually. Connectivity across care settings is important, as is connecting with provincial repositories of clinical data.
Fraser Health recently used Allscripts dbMotion™ Solution to achieve a milestone in its progress toward better connectivity. As of January 2016, Fraser Health clinicians can query the Provincial Laboratory Information Solution (PLIS) for patient lab test results.
The first pilot group includes 650 clinicians, and the capability will eventually be available to 15,000 users over the next several months. Clinicians can access test results from other providers, which will help enable more complete clinical information at the point of care and reduce unnecessary test duplication.
The change is simple for the user. From within the dbMotion document domain there is now an additional checkbox to “search for external data.” With just one click, it puts provincial lab results at the clinician’s fingertips.
As simple as it looks, this capability represents a significant technical achievement. It is the first time Fraser Health has accessed a database that sits behind Canada Health Infoway’s Health Information Access Layer (HIAL). The HIAL helps organizations sharing information by providing common services, such as user authentication, and logging and auditing accesses.
PLIS is one of many provincial repositories that sit behind the HIAL. Now that Fraser has successfully connected to PLIS, it will be easier to connect to other provincial databases, such as Pharmanet.
The integration at Fraser Health continues, both through adding sources within the organization, and connecting with additional provincial databases.
Our annual user conference, Allscripts Client Experience (ACE), draws thousands of clients and industry leaders each year. We’re already gearing up for ACE 2016, August 9 – 11 in Las Vegas, Nevada, U.S.A. It’s a large event with lots of opportunities to learn, network and share experiences with other clients.
ACE may seem overwhelming to a first-time attendee. We talked with Lori Lee Bereti, RN, a clinical informatics specialist at Regina Qu’Appelle Health Region (Regina, Saskatchewan, Canada) about her first experience at ACE last year. She offered some helpful tips about how to prepare, including these:
- Talk to people who have been there before.
“I knew what to expect because my colleagues prepped me and helped me understand what parts of the event would be most valuable to me…our Allscripts Outcomes Executive was also helpful.”
- Go in with a plan for educational sessions.
“You have to go in with some idea of what you’re hoping to find. Use the mobile application ahead of time to go over the sessions and narrow it down. There are so many opportunities, you need to go in with a plan….dive into the sessions that will have the most application for you.”
- Think about who you’d like to meet.
“I really enjoyed putting names to faces for many of the Allscripts contacts who I do so much business with over the phone…If I have one disappointment, it’s that I didn’t realize some people were attending, and I missed them. Next time I will know where to look.”
- Find new people facing similar challenges.
“At ACE, our Allscripts Outcomes Executive was able to introduce us to other Canadian clients. It’s so helpful to see where everyone is at – some are ahead of us, some are catching up – but it makes you feel better to know there are other people facing the same challenges we are.”
- Share your own successes.
“We were both excited and a little bit nervous to present at ACE this year. We talked about our community-based hip and knee clinic, which is a brand new center that opened up with Allscripts Sunrise™. We presented about our client focus and how it’s been a good project for us and our healthcare community. It was great to talk with others about it.”
(Are you a client with an ACE presentation idea? The ACE 2016 Call for Papers is now open*.)
- Open your mind to new ideas.
“My favorite seminar was about troubleshooting with end users who are adapting to clinical documentation…It helped me see where we were on the right track for helping users, and gave us new ideas we could bring back to our organizations. I’m always looking for ideas to manage the challenge of helping people adapt to new environments.”
Thanks to Lori Lee for sharing this helpful advice. Registration is open for ACE 2016; we hope to see you ther
*Editor’s note 5/4/2016: The deadline for the ACE 2016 Call for Papers was March 31, 2016.
Regina Qu’Appelle Health Region (RQHR) employs Allscripts Patient Flow™ to automate the process of turning over and assigning beds for better occupancy management and higher staff productivity. More efficient and accurate bed assignments helps reduce length of stay by an estimated 42%, saving the organization $400,000 annually.
RQHR offers a full range of hospital, rehabilitation, community, public health, long-term and home care services to the more than 260,000 residents of southern Saskatchewan, Canada. It faces the same occupancy management challenge as many other healthcare organizations.
Better processes with automation
In October 2013, RQHR went live with Patient Flow’s bed management component for inpatient services. With processes in place, the organization uses Patient Flow to manage the work flow of bed turnover and match patient needs to available capacity.
“Discharge triggers the dirty bed notice right away, that’s huge,” said Wendy McCrystal, senior business analyst from RQHR. Visibility eliminates the need for multiple calls for staff to identify dirty beds or available beds for new patients. Now staff can see exactly when the bed was left dirty and made clean.
RQHR also uses Allscripts Sunrise™ Acute Care to manage and forecast patient discharge dates to calculate bed availability. Sunrise helps RQHR track estimated discharge dates and highlight them on unit display boards. Built-in flags indicate when a patient is three days or less away from discharge.
“We’re able to get a better picture on every unit when patients are scheduled to leave, which helps us with discharge planning,” said John Ash, acting executive director of patient flow, pharmacy and respiratory services for RQHR. The housekeeping team also uses the data to adjust work schedules or adjust rotations to increase staffing for late afternoons or evenings.
Reducing surgery wait times with more efficient bed management
When RQHR relied on a paper process to manage bed turnover, caregivers occasionally had to cancel surgeries, place patients in hallways or inpatient units, and use overflow space to hold patients until beds were available. The emergency room (ER) sometimes had 15 or more admitted patients waiting for a new patient bed, which negatively impacted the flow of the ER. Occupancy of core beds approached 120%.
By automating bed management with Patient Flow, RQHR is now able to assign new patients to beds within 15 to 20 minutes, which is in the 90th percentile for similarly sized hospitals.
Patient Flow has reduced the number of complaints about notification times or unclean beds, which previously resulted in two or three labor-intensive searches through paper records each month.
Real-time data about bed availability also means patients are placed on appropriate floors for their care needs. According to Ash, “Previously, we sometimes had to put medical patients on surgical floors while we tracked down bed availability in the right area.”
Financial and operational benefits
In addition to the estimated $400,000 in savings, a base-line analysis of phone volume in the organization shows a 50% drop in calls after Patient Flow went live. Staff is more productive because they no longer spend time tracking down open beds. Data entry requirements are minimized because Patient Flow shares data with Sunrise.
RQHR continues to monitor and evaluate ways to improve bed management with Patient Flow. The organization is also in the early stages of implementing other modules in Patient Flow and Sunrise which will enhance work flows, including patient transport, patient registration and physician order entry.
According to Ash, one thing is certain,“Patient Flow is intuitive and very easy to use. Our staff would never let us take it away now that they see what Patient Flow can do.”
Fraser Health Authority (Surrey, British Columbia, Canada) uses Allscripts dbMotion™ Solution to make all relevant clinical information from multiple source systems available at the point of care. A recent case study shares how Fraser Health is currently using dbMotion to exchange information across its continuum of care from acute to community settings.
It will expand interoperability to the ambulatory setting in 2015, with the integration of data from clinical systems supporting community care. At that point, more than 2,600 physicians in British Columbia will be able to view and exchange interconnected patient data without leaving their home clinical system, which will enable Fraser Health to better coordinate care for its patients and reduce duplicative services.
In its first phase of dbMotion implementation, Fraser Health enabled 100 early adopters to have access to the system in December 2014. “Our early adopters have had a high level of satisfaction,” Convey said. “They don’t have to get frustrated with having to go to multiple sources anymore.”
One early adopter, a nurse in Fraser Health’s Mental Health and Substance Abuse department, remarked, “Love it! I have only used [dbMotion] a couple of times but it was useful.”
Early clinical benefits from dbMotion
One example of clinical benefits comes from the Psychosis Treatment Optimization Program (PTOP). Its treatments often include Clozapine, which aids clients with psychosis who have not previously responded well to other psychotropic drugs.
The dbMotion-powered clinical network enabled the PTOP pharmacy to review the latest lab results for three clients. After discussions with clinical staff, they determined that decreases in white blood cell counts and absolute neutrophil counts were not related to Clozapine. Patients remained on the drug, avoiding potential adverse reactions to being removed and/or restarting the medication.
“Using dbMotion enabled the Clozapine program to reduce hospitalization and emergency room visits by up to an 80% savings, or about CA$30,000 per patient,” said Senior Consultant for eHealth Aneet Sahota. “Most importantly, it dramatically improves the lives of these clients.”
To learn more, download a free case study.
Alberta Children’s Hospital (Calgary, Alberta, Canada) uses Allscripts SunriseTM to improve care and free its clinicians from tedious “detective work” and calculations. In a recent case study, physicians describe how they’ve applied intelligent order sets to pediatric diabetes management and infant Total Parenteral Nutrition (TPN).
Solving the mystery of insulin management
According to pediatric endocrinologist Dr. Jonathan Dawrant, managing insulin has three main challenges:
1) Even though diabetes is a growing health concern, not every clinician has enough exposure and expertise to manage insulin.
2) Insulin has no clear dose range; it’s different for every patient. This ambiguity is especially challenging for growing children.
3) To determine the appropriate dose of insulin requires input from various sources. Dawrant observed, “Doing rounds was like doing detective work…you have to gather different pieces of paper, which are located in different places, then manually calculate doses and next steps. The process repeats itself daily.”
Now Alberta Children’s Hospital uses Sunrise to gather insulin information – clinician’s orders, actual doses and patient reaction – into one display. Clinicians can more easily recognize patterns and make better decisions.
Automating complex TPN calculations
Neonatologists must carefully calculate TPN, or intravenous nutrition, for their tiny patients. According to Alberta Children’s Health neonatologist Dr. Jack Rabi, they need to review and adjust orders based on clinical concerns, lab results and the patient’s weight. And all of this needs to happen every day for 40 babies.
Sunrise order sets have significantly simplified the process. “Prior to the [TPN] order set, it would take five or ten minutes for each baby, but now it takes less than 30 seconds to order,” Dr. Rabi said.
Taking pediatric care to the next level
Alberta Children’s Hospital recognizes the value of using technology to free clinicians from tedious information-gathering and calculating tasks. Instead, pediatricians can use reports in strategic ways to improve care for their patients.
To learn more about Alberta Children’s Hospital’s experience with Sunrise, you can download a free case study.
As of June 2014, St. Joseph’s Health Centre (Toronto, Ontario, Canada) is live on its new eCare inpatient electronic patient record (EPR)*, powered with Allscripts SunriseTM. We’re shining a spotlight here because it’s a great example of a successful implementation.
Throughout the project, patient care remained top priority, which shows in a video St. Joseph’s developed:
St. Joseph’s Chief Information Officer, Anne Trafford, is truly in a class by herself. She and her team employed several approaches worth sharing:
1. Let the clinicians drive
The St. Joseph’s implementation team emphasizes that health IT system deployments should be clinically driven, not “just an IT project.” Keep the EPR in perspective; it’s an important tool to help clinicians deliver better patient care at the bedside.
2. Incorporate electronic medication reconciliation
St. Joseph’s is one of very few hospitals in Canada that is performing electronic medication reconciliation during transitions of care. The organization is tracking rates of completion for Best Possible Medication History and Admission Reconciliation and has a multi-disciplinary team focused on process and system improvements.
3. Communicate consistently and intentionally
Goals for eCare started at the very top levels of the organization, and the implementation team communicated regularly to staff about how the new system would improve patient care. This thoughtful communication continued throughout the entire project
4. Expect to optimize
Some hospitals want a perfect EPR configuration before launching, which is an unrealistic expectation. At St. Joseph’s, the team managed the scope well to ensure it started with a solid foundation that they could continue to evolve and optimize. It’s an extension of the organization’s commitment to continuous improvement.
5. Gain more functionality with a comprehensive approach
While St. Joseph’s is a long-time user of Sunrise solutions, it rolled out its first electronic tools for CPOE and documentation within the last 12 months. The first inpatient unit went live in November 2013 and rolled out to all inpatient and critical care units by June 2014.
6. Build in multiple training options
A comprehensive training strategy for 200 physicians and 800 other clinical users helped smooth the switch from paper to electronic orders. A combination of e-learning and role-based classroom training received positive feedback. The team also engaged clinicians as “super users” to build in-house capacity for after the rollout.
7. Use the data
Beyond the day-to-day improvements in clinical decision support, St. Joseph’s will mine the data to feed strategic planning efforts and new models of care. It’s also participating in a provincial project to share EPR data with an Ontario repository, scheduled to be live within the next 12 to 18 months.
These strategies worked well. Between March and June 2014, physicians directly placed more than 90% of orders in Sunrise and completed nearly 200,000 entries into nursing and health discipline flowsheets. Between March and June 2014, the clinicians verified 4,000 medications and Sunrise fired 974 alerts for ordering providers to indicate potential drug-to-drug interactions or allergies.
Thanks to the team who shared their thoughts with us, including Chief Information Officer Anne Trafford, Deputy CIO Purvi Desai, Director of Information Technology Liz Goff, Chief of Staff Dr. Ted Rogovein, and Director of Interprofessional Practice and Chief Nursing Officer Jenni Glad Timmons.
* Editor’s Note: Electronic Patient Record (EPR) is another term for Electronic Medical Record (EMR) or Electronic Health Record (EHR).
Emergency Departments (EDs) do their best to minimize wait times, and technology is increasingly becoming part of that effort. At our annual user conference, Allscripts Client Experience (ACE), the team from Alberta Health Services talked with us about how the organization uses data to manage EDs efficiently.
Alberta Health Services (AHS) Calgary Zone provides 480,000 visits each year through its EDs, which include four adult sites, one pediatric site and two urban urgent care centers, all using SunriseTM Acute Care and SunriseTM Emergency Care.
The Alberta government sets targets to ensure the quality of emergency care. For example, patients must be seen by an MD within one hour of triage, discharged with four hours and/or admitted within eight hours. A new guideline requires all patients to be seen within an hour of arriving at the ED.
To meet government targets and minimize wait times, AHS takes a three-pronged approach:
1. Input: Balance patient loads
AHS developed an early warning system to help distribute the number of patients equally among ED sites. Pre-hospital and acute care data from Sunrise feeds its third-party Real-time Emergency Patient Access and Coordination (REPAC) system. The dashboard considers patient volume, acuity and staffing patterns to project wait times at each ED facility, which AHS publishes online*. While it’s hard to judge how the public is using this information, it does help the city’s ambulance service provider determine which hospital to go to.
2. Throughput: Track real-time progress
AHS uses Sunrise Emergency Care tracking boards to help clinical teams track how long patients are waiting. Every end user has a different view, task lists and alerts, based on role, to help manage their work. Visual cues and alerts help the team stay coordinated as patients are seen, assessed, admitted and discharged.
3. Output: Measure performance
With data from Sunrise, AHS was able to determine that some of the delays were coming from patients waiting for consultations or available hospital beds. Now ED clinicians can proactively address these issues. For example, a new custom “bed huddle” report aggregates data to help stakeholders anticipate where delays might occur and to better manage the flow of patients.
Dr. Tom Rich, MD, CCFP-EM, FCFP clinical informatics, shared a specific example of how data shed light on a simple change that helped reduce wait times:
“It’s amazing when you show the data how motivating that is, because they actually don’t believe it until you show them. Like, if your average length of stay for every patient you see is 14 hours, and this consulting service can do it in eight, what’s your issue? And then you go back and look and it’s something as simple as the surgery service is doing service and they’re on call [for ED consulting]. Well, they’re in the OR with a case for six hours when a request comes in…so one of the [ED] sites said, ‘that’s not appropriate’ and they now have an on-call surgical team that is not doing the operating…it’s a pretty powerful tool for us to use.”
Thanks to Dr. Rich, Kim Jessen, RN, clinical information systems specialist, and Kelsey Kiapatuik, clinical information systems specialist, for sharing the AHS story at ACE.
*A recent study found AHS’s proactive EMS destination selection through a real-time integrated electronic surveillance system enhances regional capacity and flow management while significantly reducing ambulance diversions.
One benefit of automation you might not expect? Improving morale.
At our annual user conference, Allscripts Client Experience (ACE), we talked about this benefit with Terri Carlson, executive director of support services, Jeanette Harkness, manager of portering, and Wendy McCrystal, senior business analyst from Regina Qu’Appelle Health Region (RQHR). The largest healthcare system in southern Saskatchewan, Canada, RQHR uses SunriseTM by Allscripts and Patient Flow.
Patient Flow helps hospitals automate bed management and patient transport, which leads to better care coordination and efficiency. The system also offers transparency that hospitals don’t have with manual and paper processes.
Better transparency improved trust between departments
When using a paper system for bed management and bed turnover, RQHR did not have transparency. Housekeeping staff would walk the halls looking for beds ready to be cleaned. Clinical staff assumed that housekeeping staff weren’t cleaning beds fast enough, leading to shortages. A lack of information caused mistrust between teams.
“There was a lack of trust in the organization,” Carlson said. “It was believed that the inpatient units were hiding beds and, in turn, that beds and rooms weren’t being cleaned fast enough.”
In October 2013, RQHR went live with Patient Flow’s bed management component for inpatient services. It hasn’t changed the cleaning process, but information is more consistent, efficient and accessible across departments. Teams are better able to quickly place patients from the emergency department and surgical units due to real time bed availability being accessible.
Patient Flow improved the paper process in several ways. For example, “Discharge triggers the dirty bed notice right away, that is huge,” McCrystal said. “And the other thing is that there aren’t as many phone calls between units.” Visibility eliminated multiple phone calls for staff to identify dirty beds or available beds for new patients. Now staff can see exactly when the bed was left dirty and made clean.
“It hasn’t changed the housekeeping process, it’s just made everything more out in the open,” Carlson said. “It’s been validating…We’ve elevated the perception of the need for housekeeping.”
Patient Flow has reduced the number of complaints about notification times or unclean beds, which previously resulted in two or three labor-intensive searches through paper records each month. Since the new system has been in place, Carlson has not had to investigate a single complaint.
Staff has come to depend on Patient Flow and appreciate the way it helps coordinate care. RQHR is looking forward to expanding the solution to its transport processes in the near future. As usage expands, RQHR expects Patient Flow to continue to improve communication and build trust among departments.
To learn more about Patient Flow, you can watch a recent video featuring Allscripts solution director, Bob Oakley.