Meaningful Use 2 Preview

Eligible Provider Core Objectives

Eligible Hospital Core Objectives

Medication Reconciliation: Entropy v. Order II

To follow-up from last week's post, I'd like to review the med rec workflow.

As I previously mentioned, it is critical to review the patient’s medication list at the time of admission.  Cancel medications that the patient is no longer taking. Add any medications not already on the list. If specific information about dose and frequency are unknown – add the medication name through the “document by history” tool.

You will frequently find that there are old and irrelevant medications on the list. Customizing your list view to include “start” and “compliance status” can help you filter the list.

Admission medication reconciliation can begin as soon as the medication list has been reviewed and updated.

Select “Continue”, to convert the ambulatory Rx to an inpatient medication order

Select “Do Not Continue”, to keep the Rx on the patient’s list as a Prescription without ordering for inpatient use.

Apart from facilitating a safe and accurate transition from home to hospital, admission med rec is not only required, but make discharge med rec a breeze.  It also promises correct formatting of discharge paperwork that the nursing staff uses for education and distribution.

“Do Not Continue After Discharge” - While these meds will not be prescribed at discharge, the inpatient medications will stay on the list of active medications until the patient until then, after which time it will drop off the list of active medications. 

“Continue After Discharge” is used to designate home medications that you want the patient to continue, but no new Rx is required.

“Create New Rx” for medications that you want the patient to take at home that do require a new prescription.  These can be electronically transmitted to the patient's pharmacy of choice, printed in the event of a scheduled agent, or prescribed but not sent in the event that a written Rx is preferred (a last and anachronistic resort).

Here's another version, another presentation mode:

Medication Reconciliation on Prezi

Medication Reconciliation: Entropy v. Order

A few weeks ago, the Depart Process was rolled out across the three Baystate hospitals.  The "depart" is basically a revamping of the discharge process that accounts for all pieces of information that need to be shared with the patient or transmitted to the patient's next care provider at the time of discharge.  This new method is comprised of a variety of tasks, but the most fundamental is one that has always been part of medical practice: Medication Reconciliation.  

When challenged about the importance or ownership of med rec, I've always responded that this is one of the cornerstones of being a good doc.  How can I provide even adequate care if I don't ask, record and reconcile what medications my patient is taking?  

So what is med rec?  It's a rather straightforward process that makes patient care more efficient:

1. At the time of encounter, whether the office or the hospital, review the list of current medications in the EMR and by asking your patient.
• REMOVE any medications no longer taken using Cancel/DC in the medication list or Do Not Continue in the Med Rec tool.
2. Document those medications, vitamins, supplements that the patient reports as active but not previously prescribed or documented.
3. Determine what new medications required for treatment of your patient, whether in the hospital or in the office, and prescribe accordingly.
4. Review the list and provide a copy to your patient, or enter orders per routine.

NB:  If the patient isn't taking the medication, then the medication does not belong on the list.  Do not hesitate to remove (unless these are protocol meds, e.g. chemotherapy cycles)

Next post: a pictorial review of hospital-based med rec

Sites & Apps

As anyone who knows me knows, I love gadgets.  I don't think it would be to my benefit were I to admit to all of the wasted dollars on the folly of early adoption.  However, I am glad to let you know of a few cool virtual things I've come across while playing with whichever web device I happen to have handy.

For those of you who have never come across zite, don't wait any longer.  Go straight to your iPad, iPhone or Android device and download immediately.  Zite is the ultimate news and information aggregator that is designed to be made in your own image.  While the Home page offers dozens of front page news, its customize functionality can't be beat. And yes, I also have StumbleUpon, Flipboard, and the second best info app, The NYT, but zite wins the game.

Here are my Sections:  Film & TV, Food & Cooking, Health & Exercise, Apple News, Philosophy & Spirituality, Politics, Sports, Technology, Wine & Mixology, World News, Analytics, Cult of Mac, eHealth, Infographics, Informatics, Information Design, Medicine, New York Knicks, Visualization, Social Media

I've been spending a lot of time in the second half of this list and have found some extraordinary sites, blogs, and tools.  And when I don't have the time or patience to read articles in their entirety, I save them instantly to Pocket, a web- and device-based app that holds and archives articles as you like them.  Check out the app or the website at http://getpocket.com.

And for your musical entertainment, check out the local talent - Gracie Vengco!  Soon to be found on:

http://femaledrummernewsletter.blogspot.com/p/top-100-greatest-drummers.html

Chart Search - from Cerner.com

As mentioned previously, BH's EHR, CIS, underwent a code upgrade that will enable the incremental addition of tools designed to enhance the user's experience.  I've been piloting Chart Search for the past few months and have discussed its utility with CMIOs at other Cerner sites.  My goal is to deliver this tool to you before the end of the calendar year.
_____________________________________________________________

From cerner.com:

Harnessing the power of semantics to improve care

By: David McCallie, Jr., MD, Vice President, Medical Informatics

In this data-driven age, the ability to quickly search and find pertinent information is invaluable. The fact that more than 50 percent of Internet users begin with a search gives a hint of the role that search can play in navigating the clinical record. Within health care, where clinicians collect information over a patient’s lifetime, the ability to quickly search through the patient’s record is imperative. New techniques, like performing a semantic search using Cerner’s Chart Search, are making it easier for clinicians to quickly find the information they need.

Because Cerner’s Chart Search uses semantic technology, it can understand the contextual use of each indexed clinical concept, and can intelligently match and rank the documents so that that the most important and useful documents will move to the top of the result list, reducing the time it takes to locate key pieces of clinical data. This allows clinicians to spend more time providing the best care for their patients.

A physician clinic note on heart disease management displays as the most relevant document following a Chart Search.

Chart Search was announced at the 2010 Cerner Health Conference. Dr. Karl Kochendorfer, director of clinical informatics at University of Missouri Health Care, captivated the audience with speed and accuracy as he searched for patient data. Fast forward to today—Dr. Kochendorfer is using Chart Search to make a difference in his practice. Here is a recent example from Dr. Kochendorfer:

“I recently saw a patient who was describing dizziness over the past two years while seeing another provider. The patient was very frustrated about these symptoms but couldn’t recall all of the details associated with his previous care. I was able to use Chart Search to find all instances of when he had it, when it started, what the specific symptoms were and what meds were changed because of them. It helped me to get an entire picture of the patient’s symptoms over the past two years within a matter of seconds, and then assisted me in providing the best care for the patient.”

David McCallie, Jr., MD, Vice President, Medical Informatics, is director of the Cerner Medical Informatics Institute. He is responsible for a research and development team focused on developing innovations at the intersection of computer science and clinical medicine. Prior to joining Cerner in 1991, McCallie was director of research computing at Children’s Hospital in Boston, Mass., and an instructor in neurology at Children’s Hospital and Harvard Medical School. McCallie earned a bachelor’s degree in electrical engineering and computer science at Duke University. He earned his medical degree at Harvard Medical School. McCallie has published numerous articles and presented frequently on the subject of healthcare informatics. He is a member of the American Medical Informatics Association.

Healthcare Informatics Primer

Prezi.com has become my new virtual toy.  It's an eye-popping way of creating presentations for audiences large and small, not only outdoing PowerPoint in terms of creativity, but also by allowing the user to swallow up and integrate .ppt files directly into the prezi template.  Here is how the folks at prezi describe their goods: 

Prezi is a cloud-based presentation software that opens up a new world between whiteboards and slides. The zoomable canvas makes it fun to explore ideas and the connections between them. The result: visually captivating presentations that lead your audience down a path of discovery. 

Yesterday, I had the opportunity to lead a 3 hour seminar at UMass's Isenberg School of Business at the invitation of a good old friend of Baystate's (and a new friend of mine), Eric Berkowitz, PhD.  His group of students consists of both MBA and MHP students as well as an organizational engineering student.  They were super-bright and engaged, curious to hear about the current state of healthcare.  We chewed on the business, policy and politics of the nation's predicament.  I was most gratified to hear that they were especially interested to hear how challenging it is to deliver high quality care to diverse populations while being mindful of cost, communication, and satisfaction.  

Now... to connect the dots... here is the prezi I used to drive the discussion:

UMass/Isenberg on Prezi

New Sets of Eyes on CIS

CIS was first implemented at Baystate Health in 2004, first in the hospitals and then followed by an incremental rollout across over 70 Baystate Medical Practices.  To date, Baystate has achieved many successes with our electronic medical record.   We have been recognized as a HIMSS Level 6 organization, a measure of EMR implementation shared by only 4% of hospital systems across the nation.  And Baystate Health was one of the first integrated delivery networks in the country to have demonstrated Meaningful Use of the electronic medical record. 

But these are laurels bear no meaning as we work hard taking care of our patients day and night.  Just this week, many of us have been challenged with a new means of discharging patients from the hospital.  While the introduction of the Depart Process has bolstered completion of Medication Reconciliation, it has also added to the heap of EMR skills required to get our work done.  And these new tasks seem to come out of nowhere and without explanation or negotiation.  I wouldn't argue that this isn't stressful, but I do believe in the value of this new workflow.  I can only say that with time and proficiency, the logic of their necessity will be revealed. 

I recently started Rob Smith’s Mindfulness-Based Stress Reduction program, one that is specifically designed for physicians.  During both the introductory session and the first official session, the misery of the EMR was reported by more than a few colleagues when asked for their reason for enrolling.  While not all who shared this sentiment are CIS users, their preponderance was not lost on me. 

The clinical milieu is bogged down by administrative and data-driven tasks, often a result of electronic inefficiencies or shortcomings.  And, while we truly have had outstanding success with CIS, there is no doubt that your experience leaves much to be contented.  So, in an effort to improve these circumstances, we recently engaged the services of Aspen Advisors, a consulting firm with expertise in Cerner, to help us identify how best to optimize our automated electronic systems.  

A team of consultants spent a number of hours visiting four BMP practice sites:  South Hadley Adult Medicine, General Pediatrics at 3300 Main St., the Wesson Women's Clinic, and Thoracic Surgery.  I also escorted them through a number of BMC wards, including medical, surgical, pediatric and critical care units. In the practice sites, providers and staff were asked to both demonstrate current methods of use and also help to define the benefits as well as the weaknesses of CIS.   I also provided Aspen the complete set of results from the CIS Users Satisfaction Survey that over 1000 CIS users completed, including 75 pages of your comments.

It is our expectation that these visits, in addition to the dozens of spontaneous conversations held with house staff, physicians and nurses throughout BMC, will culminate in a constructive analysis of our EMR and a forward-thinking strategy to improve the usability of CIS for all patient care and clinical practice needs.  I will surely report on those results when they become available.  In the meantime, I invite you to contact me by whatever means of your choice with questions, comments and concern. 

The Golden Spike - The Commonwealth's Entry into Health Information Exchange

Today was truly a monumental day for Baystate Health as well as all patients, providers and health systems across the Commonwealth of Massachusetts. At about 11:30 this morning, Gov. Deval Patrick gave his consent for the private and secure transmission of his personal health information from MGH to Baystate Health. On the receiving end awaiting the receipt of this EHR-to-EHR communication stood our CEO and President, Mark Tolosky, our Chief Quality Officer, Dr. Evan Benjamin, and our new leader of IS and Chief Information Officer, Joel Vengco.  (Me?  I would've loved to have worn the white coat, but I was rescued from the bright lights and TV cameras by attending a Premier conference in Phoenix.  Too bad I can't stand 95 degrees, humid or dry!)

The establishment of secure delivery of patient health information between disparate electronic health record systems holds the potential of providing the right information at the right time and to the right providers for each and every patient, regardless of where they receive their care.  Even more importantly, HIE will play a major role in meeting the Triple Aim, not only by delivering data expediently to improve the care and "experience" of the patient, but by facilitating the identification and care of high risk populations and by decreasing the duplication or incidence of inappropriate clinical services.  (I'll have more to say about what I believe should be the Quadruple Aim, that fourth target of improving the physician/provider experience of our profession.)

I will surely be posting more about HIE in the coming weeks and months since we will be venturing into something considerably more robust that the state's point-to-point delivery of information.  In the meantime, check out the following:


Officials launch statewide health info exchange - CBS 3 Springfield - WSHM

CIS 2012 Upgrade and The Depart Process

While I write this, the IS team is at work upgrading CIS to the 2012 code. It has been 3 1/2 years since we've had a major upgrade, (March 2009 Enhanced View led to integration of ambulatory and inpatient EMR) and this morning's is unlikely to rock anyone's world. There is a color scheme change that might take some adjustment, particularly for those of us who enter orders while wearing progressives or "cheaters". The user interface displays individual orders in gray, suggesting that the order is inactive. It's not and it should only take a moment to get over. But the text is gray on gray background. This didn't make me too happy, particularly since we weren't given a choice. I've spoken with CMIOs and medical directors at other Cerner sites who have had this installed for a while and they were reassuring. We will soon have the opportunity to judge. The 2012 upgrade is necessary because it is required for our transition to ICD-10 next October. In the near term, we will roll out a new tool, Chart Search, that will allow a Google-type search through an individual patient's chart. So, for example, you can search for documents that refer to a particular condition in Clinical Notes, easing chart navigation. This won't be ready this coming week; we are aiming for December if all else goes smoothly. I've heard that docs love it, especially for those complicated patients with hundreds of notes and results documents stacked in the database. Stay tuned for a tool so many of us have been waiting for - the ability to upload and integrate photos into the patient record and documents... What is coming our way, and hopefully without too much disruption to workflow, is the new inpatient Depart Process/Patient Education modules. The key to success is to perform Med Rec at admission which facilitates discharge Med Rec which, in turn, allows the Depart Process to be set in motion. Here is a brief video I created that covers the basics of this process:

CPOE and PPID Implementation today:

Congratulations to Chestnut Surgery Center at BMC and the Ambulatory Surgery Center at BMLH for implementing CPOE (order entry) and PPID (Medication Barcode Scanning) today!  Thank you to the entire Team for all your efforts in making this implementation a success!!

PACS Image Viewing

Ever expanding...

Hi! 
Welcome and thanks for checking out our blog. The Clinical Informatics Teams have been involved in many projects to expand electronic documentation at Baystate Health over the last few months. Here is a quick list of what the inpatient team has been up to and may be coming to a computer near you in the future:

• Interactive Flowsheets (IView) and Progress notes for APTU/ MHU
• Sally Irelan
• Patient Education (Krames material) and Depart for all inpatient units
•  Nicki McAvoy
• CPOE(order entry)/ PPID (med scanning) for Ambulatory surgery at all 3 facilities
• Steven Downs and Sally Irelan
• Expansion of forms library to include ED and Surgical units
• Steven Downs
• Nursing Communication Mpage
• Sally Irelan

Ever expanding... and always optimizing: We also continue to work with staff to make what already exists in CIS to be easier to access and help staff provide safer care:

• Concentrated Potassium replacement in NICU - nurse witness task and care set
• Nicki McAvoy
• Standard Interventions in Nursing Care Plans 
• Sally Irelan
• Redesign of Skin/ Wound Documentation screens
• Sally Irelan

This is of course a very short list of the projects and requests we are working on. Please feel free to contact any of us with questions or comments.

Preliminary Survey Results

Cerner Regional CIO/CMIO Meeting

I am sitting in a conference room in the Hyatt Harborside in Boston amidst 100 or so titled folks from a few dozen Cerner client sites and from Cerner itself.  Thus far, we've heard a bit about future state which is intended to leverage mobile technologies, i.e. iPad, not only for viewing, but for documenting too.  It's interesting that the feedback from CMIOs in particular has more to do with current state and optimizing the EMR experience as it exists today. This brings me a jolt of pleasure since I generally assume the gadfly role when I attend these meetings.  It had been my experience in the past that most clients were Kool-Aid addicts, but not today.

Workflows, documentation, orders, user interface, even the Mpage; all the usual suspects of discontent are being brought to Cerner leadership in full force.  And I intend to share some of the preliminary results from the CIS User survey many of you performed with Cerner folks.

A most worthy read...

You may have already read this piece in today's message from Evan Benjamin MD, our Chief Quality Officer and a colleague of Dr. Berwick's. Evan shared this with me last week and I have been doing the same with friends and colleagues since. As I said in an email to my colleagues in Clinical Informatics, "This talk speaks to where my heart and soul live and why I do the work I do." ---- Berwick to HMS 2012

Brief news

I feel a bit like a spammer, (though without any inchoate intentions a la any relatives I might have in Nigeria), having sent two pan-provider emails in the past 24 hours.  I've actually held back a couple since I don't want to overwhelm/bore/incite my colleagues.

In the event that you overlooked or have an Outlook rule that deletes all emails from me, here is what you missed:

• A hearty and earnest invitation to reply to the CIS User Survey  (Please do! Honestly.)

and...

• a few words about the new Radiology PACS (again, Picture Archiving & Communications System) that will be available on Tuesday morning July 17.

And, not quite my final act of the week last Friday, I sent out the post of an imminent vacancy in the Division of Clinical Informatics.  Many of you know the talented Dr. Talati will be moving on up to the north to assume the physician leadership role in the Baystate Franklin Emergency Department.  Great get for BFMC and our patients.  While this notice was sent only to BMP physicians, I would be remiss were I not to accept applications from outside the group.  If you are not a BMP doc, but are interested in a great job and know Cerner's EMR, don't hesitate to contact me.  

More news to come...

Transparent Informatics Redux

The last post to the first effort to communicate to our BH colleagues via this "web 2.0" platform, aka blog, was just about 2 years ago when Tom Higgins wrote a great post on the iPad.  Since then, we've gone dark, leaving nothing to transparency.  A lot has changed since July '10 and we are once again ready to reveal ourselves through posts, actions and deeds.


The first order of this blog is for us to solicit your opinion.  As we begin our planning for FY13, we, the Division of Clinical Informatics, need to know what you're happy with and what you just can't stand any longer.  Follow the survey link below and, in five minutes or less, let us know what prize we should have our eyes on.

CIS User Survey