Honoring Industry Leaders Stage 7 - HIMSS Analytics

ProfileThe ChallengeThe Centre for Addiction and Mental Health (CAMH) isCanada’s largest mental health and addiction teachinghospital, as well as one of the world’s leading researchcentres in the area of mental health and addictions.CAMH combines clinical care, research, education,policy development and health promotion to helptransform the lives of people affected by mental healthand addiction issues. A wide range of clinical programs,support, and rehabilitation services are provided thatmeet the diverse needs of people who are at riskand are at different stages of their lives and illnesses.Services include: assessment, early intervention,residential programs, day treatment, continuing careand family support in both an inpatient and outpatientenvironment.It was identified that to provide our patients withthe best possible care, an integrated solution tostreamline workflows and provide standardizedaccess to information and care pathways wasrequired. Prior to the implementation of our clinicalinformation system, I-CARE,CAMH had disparateand standalone systems including paper, paperhybrid, and computerized systems. This standaloneapproach resulted in challenges including duplicatedocumentation, adverse drug events, difficultyaccessing patient and clinical information, and theinability for clinicians to effectively collaborate tosupport the best patient outcomes. The three maingoals of the transformation were to:CAMH staff work with family doctors, home supportservices, community agencies and other healthcareproviders to make sure that clients and their familiescan receive assistance in their own communities andhomes if possible. Additionally, CAMH addresses largerissues that arise from four major factors affecting health-- housing, employment, social support and incomesupport. Standardize and integrate patient information Improve process efficiency throughout theorganization Utilize data to drive performance improvementStage 7 Achievements, HIMSS Global Conference 2018

Implementation OverviewCAMH implemented the clinical information systemusing a big-bang approach with the support of anintegrated team of clinicians, information technology,and other CAMH staff. A two-year transformationreadiness initiative engaged all these teams and patientsacross CAMH to identify current-state processesand define requirements for the clinical informationsystem. This phase was completed with the purchaseof the current system. A two-year design, build, and testphase commenced where project team and subjectmatter experts tailored the system to CAMH needs.Clinical staff guided the development of future-stateworkflows and system testing once the final designwas completed. The final design included sManagement, Reporting, Laboratory, Pharmacy, Legal,and many other modules. The big-bang implementationprovided a single source of client / patient informationand a robust electronic medical record system.Approximately 3,000 staff members were trained overa two month period on the new clinical informationsystem. Early adopters trained prior to go-live andproject team members provided 24/7 on-site supportfor clinicians in each service area for six weeks followinggo-live. After a five-month period in which supportactivities were transitioned to operations, a concertedOptimization Project was launched to evolve thesystem to improve support for better patient outcomesand further standardize processes. Increased reportingand data quality projects and implementation of furtherclinical decision support systems also highlighted theOptimization Project. One of the guiding principlesfor the Optimization Project was ensuring CAMHleveraged the HIMSS EMRAM criteria and subsequentlypositioned to achieve HIMSS Stage 7, building upon theachievement of HIMSS Stage 6 in June 2015.HIMSS Stage 7 preparation included the implementationof performance improvement strategies to increaseand sustain the rates of Computerized Provider OrderEntry and Closed Loop Medication Administration in acomplex mental health setting. CAMH embarked on apatient engagement research strategy to understandthe specific needs of their patient demographics.This led to the development of novel strategies forpatient identification and perceptions of medicationadministration, which have been published. Capacitybuilding and ongoing refinements to the CIS allowedfor the targets of 1% scanned clinical documentationto be achieved.Key participants involved in the process: The coreplanning and implementation team for CIS implementationincluded an interdisciplinary group of 120 staff fromacross the organization. After implementation, 7members focused upon improvements culminating inHIMSS Stage 7 achievement.Resulting Value / ROIClinicians have reported time savings during the clinicaldocumentation process as a result of standardized andstreamlined assessments and documentation types. TimeClinicians have reported time savings during the clinicaldocumentation process as a result of standardized andStage 7 Achievements, HIMSS Global Conference 2018

streamlined assessments and documentation types.Time savings have been reported when accessing clinicaldocumentation, lab results, and other clinically relevantinformation due to the standardized folder structure andconsolidated storage environment. These traits havealso led to a decrease in documentation duplication andaccess to accurate information at point of care as theresult of the clinical information system being the onesource of truth for clinical information at CAMH.Lessons LearnedPatient outcomes have been improved due to thestructure of the system workflows and facilitation ofcollaboration. Interdisciplinary care and communicationare enhanced through tools built into the system andfacilitate collaboration and access to information allowingthe development of more effective treatment plans. Onaverage, 954 patient identification errors are caught by thesystem prior to medication administration per month. Eachidentification error represents the possibility that a patientwould have been administered the wrong medication if theclinical information system was not utilized. An example ofclinical supports includes improvements to the Clozapineorder set, which has prevented 17 patients from developingmyocarditis, a potentially fatal condition, since June 2015.Standardization has ensured a consistent experiencefor clinicians who are able to leverage the system inways that truly support best practice adoption andimproved patient care for all individuals.In addition to the value added to front-line clinicalprocesses, the clinical information system has supportedthe Information Management Group and Research teamsat CAMH. Access to advanced reporting functions andcustomizable data retrieval has resulted in access to highquality data. This data has been used for performanceimprovement opportunity identification and trackingof initiatives through intuitive dashboards for hospitalexecutives and front-line clinicians.Engagement of clinicians was the most crucial aspectto success. CAMH made a point to engage cliniciansand front-line staff early and often throughout thedesign, build, test, and implementation stages of theclinical information system. Operations since go-liveare supported by committees with extensive clinicalrepresentation and backed with the support of clinicalleadership.Workflow-based training with competency completioncomponents have been paramount to the success ofthe clinical information system implementation andcontinue to be an important process for CAMH.“We take great pride in being a globalleader in healthcare informationtechnology. As a complex care hospital,it is vitally important that all our clinicalstaff have access to all the medicalrecords at their disposal at all times.Better, faster and easier access toinformation means better patient care.”- CAMH President and CEO Catherine Zahn.Stage 7 Achievements, HIMSS Global Conference 2018

ProfileThe ChallengeSince 1964, Children’s Hospital of Orange County(CHOC Children’s) has been steadfastly committed toproviding the highest quality medical care to children.Affiliated with the University of California, Irvine, ourregional pediatric healthcare network includes a stateof-the-art 316-bed main hospital facility in the City ofOrange, and a 54-bed hospital-within-a-hospital inMission Viejo. CHOC also offers many primary andspecialty care clinics in Orange County and beyond;more than 100 additional programs and services;residency programs in Pediatrics, pharmacy andnursing; support for several fellowship programs; andfour “Institutes” in cardiovascular care, neurosciences,orthopedics and pediatric cancer.Safe handling and preparation of breastmilk withinthe hospital setting is often taken for granted and,as with many performance improvement initiatives,the process is not scrutinized until problems arise.Historically, the handling of infant feedings hasnot received the same level of attention as thatof medications. However, the concept of usingquality improvement measures with regards to safebreastmilk handling is not new and current emphasisthroughout the industry has been focused onpreventing breastmilk misadministration (when thewrong milk reaches the wrong patient). Such errorsare considered bodily fluid exposures, which areconcerning from a medical standpoint as well as aneconomic standpoint because such exposures arereportable to the state and can result in fines to theorganization.CHOC Children’s Hospital began its journey to a fullyimplemented Cerner Millennium EMR in 2002. TheHospital’s dedication to patient safety was evident inthe acronym chosen for CHOC’s EMR, “CUBS,” whichstands for Connecting Users and Building Safety. Today,CHOC Children’s dedication to safety, quality, andthe patient experience is supported by over fourteenensuing years of patient-centered Healthcare IT design.These efforts led to our recognition as a Stage 7 HIMSSAnalytics Inpatient awardee in 2015.Between May 2010 and May 2012, CHOC Children’sreported 3 incidents of the wrong breastmilkreaching the wrong patient and 16 incidents wherethe breastmilk was labeled incorrectly but did notreach the patient.Stage 7 Achievements, HIMSS Global Conference 2018

Implementation OverviewPhase I (centralized breastmilk handling) was launchedin January 2013. In March 2013 a breastmilk bar codescanning project team, led by the Director of ClinicalNutrition & Lactation and an Information Technology (IT)Project Manager – also including a variety of clinical andIT team members – was created. The team selectedTimeless Medical Systems because it offered greaterfunctional capabilities than other systems evaluatedand the vendor would accommodate full customization,allowing the system to fit into the existing workflow,rather than forcing the workflow to fit with the system.There were two primary system end-user groupsidentified. The breastmilk technicians, while a smallgroup, would actually be the individuals using thesystem for more than 50% of their workday and woulduse the majority of the system’s features. To determineand validate design decisions pre-implementation,the Clinical Nutrition & Lactation department obtaineda demo version of the Timeless system to use inconjunction with mock breastmilk preparation. Specificchanges that would enhance workflow (such as havingcertain fields default or having the system automaticallymove to the next screen instead of having to click thenext button) were identified, built and tested.The second end-user group of bedside nurses wouldprimarily use the system to scan prepared feedingsagainst a patient’s armband before administration,a process almost identical to the in-place barcodemedication administration (BCMA). As such, it wasdetermined those features in the system did not requiresignificant modification.The project goals were to automate all calculationsand use the barcode scanning for positive patientidentification rather than the two-person double check.All changes were implemented to reduce the risk ofhuman error with calculation and identity confirmationand, ultimately, improve patient safety. Increased staffefficiency was an additional consideration and goal.Resulting Value / ROIWhen evaluating whether to implement breastmilk barcode scanning, we considered the potential costs of notimplementing scanning. Those costs included: Regulatorycitations for breastmilk errors, HIPAA fines up to 25,000per incidence for errors considered HIPAA breaches, labcosts of 500 per incident when a baby received thewrong breastmilk to test the donor mother and recipientbaby, and loss of family confidence or satisfaction, whichcould result in families seeking care elsewhereWe considered that each misadministration error wouldcost anywhere from 500 to 25,500 and could leadto lost revenue if families turned to other organizationsfor care. Therefore, the initial start-up costs would bepotentially less than 6 breastmilk administration errors.We felt the implementation costs were well justified toprotect our patients as well as for avoidance of costsassociated with breastmilk errors.We purposefully sought a system that was compatiblewith our current bedside hardwired and mobilecomputers with regards to the type of scanner andlabel printer. This resulted in only needing to purchasehardware for the centralized preparation area.Stage 7 Achievements, HIMSS Global Conference 2018

Through the barcode scanning implementation, wewere able to eliminate a 20-hour per week tech positionsaving 30,000 annually and save one hour per day oftechnician time that could be used for other duties.Lessons LearnedBreastmilk administration errors are likely much morecommon than suspectedThe biggest lesson we learned was that breastmilkadministration errors are likely much more common thanorganizations realize. At the start of the project, our PIteam did recognize that 55% of errors were unlikely tobe detected by the previous systems in place; however,110 wrong milk to wrong baby near misses and 193expired breastmilk near misses during the first year postscanning implementation far exceeded the suspectednumbers. Concrete data supports that errors are unlikelyto be consistently detected without automated systems.Regular reinforcement and education is necessary toensure safety and complianceWe found that during the 16 months post-scanningimplementation, some staff had developed inconsistentscanning practices. For example, some bedside staff werescanning before warming the milk instead of followingthe policy to always scan immediately before feeding,thus increasing the risk of error. This inconsistency inpractice resulted in two breastmilk administration errorsin 2015, one in 2016, and one in 2017. After each error,a root cause analysis was conducted and follow upeducation provided to all bedside staff. Two computerbased-learning modules on breastmilk scanning weredeveloped in fiscal year 2018—one for onboarding ofnew hires and the other for use as an annual competency.Formula preparation and administration errors mayalso be commonWe acknowledged that there was the potential formathematical calculation errors when formula recipeswere manually calculated as well as the possibility ofutilizing the wrong formula product. Consequently, ateam was created to expand the use of the TimelessMedical bar code scanning system to include infant andenteral (tube feeding) formulas. The formula scanningportion of the system, Formula Trak , Phase I (go-live dateof January 17, 2018) utilizes an order interface betweenthe EMR and the Timeless system for formula orders,which will result in the Timeless system automaticallycalculating all recipes for infant and enteral formulas.A technician is also required to scan the bar code onthe formula product prior to preparation to ensure theproduct scanned matches the order from the EMR. If anincorrect product is selected, the system will alert thetechnician and not allow the user to proceed.Phase II will involve the bedside nurse scanning thepatient armband and the formula (as is done withbreastmilk) at the time of administration to ensure thecorrect feeding is going to the correct patient.“As one of only a handful of pediatric hospitals to achieveHIMSS Stage 7 and HIMSS recertification, we arehonored to receive this recognition. The collaboration andpartnership of our clinicians, physicians, and IT to deliversolutions that drive improvements in clinical outcomesat the bedside is what we strive for each day and thisaward exemplifies our commitment to nurture, advanceand protect the health and well-being of children.”– John Henderson, Vice President and CIOStage 7 Achievements, HIMSS Global Conference 2018

ProfileImplementation OverviewChildren’s Mercy Hospital (CMH) is located in KansasCity, MO with two hospitals, one in Kansas and onein Missouri. 367 beds 352,286 outpatient visits (9 metropolitan ambulatorysites of care and two distant ambulatory sites of care) 191,500 ER/UC visits 14,190 admissions 20,188 surgeries 5,586 transports1. The Cardiac High Acuity Monitoring Program(CHAMP) idea came from their Clinical Director. Fromthere, the IS team worked with the clinical team todevelop the app. The CHAMP app started trial usein March 2014 at CMH for all HLHS patients. Using aMicrosoft Surface Tablet with Windows 10 operatingsystem that is connected to a database that sits in theMicrosoft cloud, the family enters information that isanalyzed real time in the cloud. Any measurementthat is outside the healthy cardiac parameters willalert the medical team.The ChallengeHypoplastic left heart syndrome (HLHS) is acongenital heart anomaly with the highest mortalityrate of all congenital heart anomalies. Babies bornwith a single ventricle (HLHS) are at an increasedrisk of mortality between the first and second stageof a multistage surgical repair. The first interstagebrings a risk of mortality of 10-25%. There has beena standard of monitoring nationally which involvesthe parents having a scale to weigh the baby, anoxygen saturation monitor, and a three ringed binderto document things as well as some red flag signsto look for at home. This process has not shown tohelp with decreasing mortality.2. This was presented to other centers who care forthese HLHS patients and Seattle Children’s began usingin January 2016. Seven children’s hospitals enrolled bythe end of 2017 with a goal for 12 by the end of 2018.Resulting Value / ROI1. The result is a 2% mortality rate at CMH with a0% rate since March 2017. For all sites together, themortality rate is 4%, which is down from 20%.2. Real time changes result in cost reduction.Treatments can be modified while the baby is at hometo avoid trips to the hospital. CMH also documenteddecrease in readmissions overall.Stage 7 Achievements, HIMSS Global Conference 2018

Lessons Learned1. Working in a true team partnership with clinical and information systems staff, an ideacan become a reality.2. Don’t wait for it to be perfect, trial and retrial. No population is too small to trial whenit comes to patient care for quality improvements.3. Listen to parents and families.“This case study proves the direction that healthcareis moving with an omni-channel experience and thepatient/customer as the primary focus.”David Chou, VP, Chief Information and Digital Officer, Children’s Mercy Hospital.“The CHAMP app and the CHAMP program has takena group of high risk congenital cardiac patients andincreased

highest level on the EMR Adoption Model (EMRAM) and the Outpatient EMR Adoption Model. The EMRAM identifies and scores hospitals and clinics using a progressively sophisticated eight-stage model that charts the path to a fully paperless environment. This prestigious industry award was introduced in 2009 by honoring 15 organizations that had .