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Ministry Health Care. A values-driven health care network of aligned hospitals, clinics and other providers based in Wisconsin and Minnesota15 Hospitals Ministry Medical Group with more than 150 physicians serving out of 25 locationsAffinity Medical Group with nearly 200 physicians serving out of
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1. IT Successes and Challenges in Opening an All-Digital Hospital Larry T Hegland, MD, MMM
Chief Medical Officer
Saint Clares Hospital
The Diagnostic and Treatment Center
Weston, WI
2. Ministry Health Care A values-driven health care network of aligned hospitals, clinics and other providers based in Wisconsin and Minnesota
15 Hospitals
Ministry Medical Group with more than 150 physicians serving out of 25 locations
Affinity Medical Group with nearly 200 physicians serving out of 17 locations
Health insurance plan
Hospice care, long term care, dialysis services and home health services
3. Saint Clares Hospital 86-bed community hospital opened in October 2005 and currently providing general medical and surgical services
Built for a new market and not as a replacement facility
All-digital facility (paperless) with a comprehensive electronic medical record and physician order entry system (CPOE)
Electronic ICU using VISICU via a telemedicine service
Medical staff of over 300 providers primarily from the Marshfield Clinic, a 740-physician multi-specialty practice located across north central Wisconsin
4. Diagnostic and Treatment Center Joint venture between Ministry Health Care and the Marshfield Clinic providing outpatient services and ancillary services to Saint Clares Hospital and other entities on campus
Radiology and womens imaging services
Heart services including cardiac testing and catheterization
Radiation oncology services
Laboratory services
Physical, occupational and speech therapy services
Ambulatory surgery
5. IT Strategy Best of breed approach with numerous interfaces required
EMR provided by Marshfield Clinic and Ministry Health Care allowing access to almost 30 years of physician office records
Tight integration of clinical and administrative practices to IT systems
Convertible tablet PCs used by practitioners with full system access available in the hospital, office, home or anywhere a high speed Internet connection is available
Extensive planning for system redundancy and downtime including multiple backup strategies
Comprehensive staff and physician training program using classroom, on-the-job and other approaches to learning
6. Key IT Clinical Successes Access to patient records in both the hospital and office setting has resulted in numerous benefits, especially in the emergency room
Highly stable network with easy accessibility from any location with Internet access
All-digital world with virtually no paper, avoids problems of dual systems
Electronic patient records are immediately available to clinicians and staff
Has contributed to an extremely low rate of delinquent or incomplete medical records (<3.5%)
Allows concurrent record review for performance improvement, case management, patient safety and other support staff
7. Key IT Clinical Successes Clinical testing results immediately available to the clinician
Successful integration of VISICU e-ICU technology with hospital IT structure and service implementation with full access to hospital IT system by telemedicine intensivists
Successful deployment of telemedicine capability in hospital emergency department
Successful deployment of smart IV pumps and PYXIS machines as part of our IT system
8. Key IT Clinical Successes Introduction of decision support and best practices to medical care helps reduce unexplained variation in treatment approaches
Mandatory CPOE system has markedly reduced the most common medical errors seen in the paper world (but new risks created)
CPOE has increased the speed with which medical therapy is initiated
Time of order to release of medication on med-surg unit medication dispensing devices is less than 15 minutes on average
Similar results seen in response times for laboratory testing
9. Planning Phase Culture design
Management team brought in up to 2 years prior to opening
Personalysis personality assessment tool
Team building and culture development meetings
Selecting Winners employee selection tool
Customer service program
Benchmarking
All-digital facilities
Top performing clinical facilities
Joint Commission Resources
10. Planning Phase Project management
Facilitation
Barrier identification
Consistency
Deadline management
Coordinated 89,000 man hours in formal project plans
Process mapping
Over 8400 detailed process maps developed
Teams included IT, clinical and administrative members for integrated process mapping
Process maps reflect clinical processes and/or operational workflow, with links to the appropriate IT systems
11. Planning Phase CPOE development
CPOE team meetings
Over 1000 order sets created
Incorporated evidence based, best practices
Failure modes and effects analysis (FMEA) to anticipate and prevent potential CPOE associated medical errors
Physician champions
Active participation of system Chief Information Officer and Director of Information Technology
Involved in clinical and IT process mapping and barrier removal
12. Planning Phase Education/Communication
Extensive staff training sessions (4 weeks for new hires)
Customized physician training
Medical staff communications via meetings, e-mail and newsletter
Manage expectations and do not over promise
Patient simulations
Actively tested clinical and IT systems via numerous patient simulations
Requires involvement of clinical, administrative and IT staff
13. Opening Phase (months 1-3) Clinical and IT SWAT teams
For the first month, entire clinical and administrative management team, IT staff and clinical managers met daily
Later, clinical and IT SWAT teams were created to deal with day-to-day problems as they arose
Inpatient and Combined Operations Groups
Inpatient Operations Group (IOG) focused on more complex problems derived from the Clinical and IT SWAT teams for the hospital
Combined Operations Group (COG) focused on more complex problems derived from Clinical and IT SWAT teams for both the hospital and the Diagnostic and Treatment Center
14. Opening Phase CPOE/EMR team
Ongoing order set development and order set refinement
Processing of suggestions and complaints regarding IT issues
Leader rounding
Issue identification
Maintain high visibility
Blue Shirt IT support program
24/7 in person physician and staff support provided by large number of specially trained staff
Got questions? campaign
IT Command Center for coordination of staff and immediate problem solving
15. Opening Phase Communication/Education
Focus shifted to communication of IT system updates and changes via e-mail and newsletter
Development of advanced refresher training
Staged opening
Medical-surgical floors (3) opened at 0, 3 and 6 months
Interventional cardiology and cardiac surgery planned opening in summer of 2006
All other services available at time of opening
Staging was needed to accommodate difficult recruiting environment and extensive training requirement of all new hires
16. Operations Phase(months 4-present) Transition process to operations
Ongoing CPOE, Clinical and IT SWAT teams , IOG and COG meetings
Super-users IT support program
24/7 service to replace bulk of contract Blue Shirt staff
Consists primarily of highly proficient front line staff who go through a 1 month training program to give even greater proficiency
Focused on physician support, especially the low volume user
17. Operations Phase Clinical Applications Coordinators
Highly trained IT/Clinical specialists with in depth knowledge of applications
EMR System and customer champions
Liaison between IT analysts and clinical users
MD and other user training and support
Downtime procedures support (flexible schedule and on-call) and security requests
Work with users to identify future system improvements
Integration testing and testing of new functionality
18. Operations Phase Education/Communication
Ongoing communication of IT system updates and changes via e-mail and newsletter
Development of lunch and learn training
Leader rounding
Post-implementation learning
Extensive, facilitated survey of system users regarding experience and suggestions for future improvement
Lessons learned meetings to provide system guidance for future all-digital hospital projects
Comprehensive report produced to encapsulate critical learning derived from this process
19. Planning Phase Challenges Lack of road map in building all-digital hospitals
Limited benchmarking opportunities and few best practices available
Architects never come back
Lack of a medical staff prior to opening
Building consensus difficult
Physicians joining staff over period of six months created education and communication difficulties
Staged opening
Increases difficulty of consistent staff training
20. Planning Phase Challenges Operational talent does not always translate into planning/implementation talent
Vendor failures
Project management helped surface vendor failures
There is never enough time
Weekends are workdays without meetings
21. Post-Opening Challenges There is never enough time
Weve discovered the eighth working day of the week
Be prepared for meltdowns within the leadership team
It is easy to become trapped in the moment and feel overwhelmed by problems
Physicians have one commodity to sell
time
The all-digital world makes physicians feel less efficient despite some of the benefits the system creates for them
Planning/implementation talent does not always translate into operational talent
22. Post-Opening Challenges It is difficult to overestimate IT training and support resource requirements
Long term commitment to IT resources being available on 24/7 basis is required
Telephone support is frequently inadequate
Low volume users of the system are extremely difficult to make successful the personal handlers solution
IT training needs never go away and it is very difficult to deploy additional training to physicians
Physicians frequently feel dumb in the all-digital world
Need someone dedicated to communicating system improvements to users
23. Post-Opening Challenges Benchmarking all-digital staffing needs to the paper world is futile
The all-digital environment slows everyone down in terms of documentation
It appears that all-digital environment increases staffing time requirements about 10-15% (much higher at opening)
Process mapping cannot be too detailed
Gaps in process map details created early breakdowns in several care systems such as heparin and insulin drip protocols
The interface back to the paper world can be difficult
Complaints from long term care, rehab and other facilities
24. Post-Opening Challenges All-digital systems are fragile
Problems need to be analyzed systematically for software, hardware and network related causes
A single malfunctioning wireless system antenna caused a two month search for hardware/software related problems that did not exist
Patient registration systems must accurately capture key patient demographic data
Even with excellent network stability, downtime procedures must be clearly specified and simulated
25. Post-Opening Challenges CPOE related problems
Order sets often not intuitive and require too many clicks (the problem of ADCVANDISSEL)
Constant modification of system to address physician concerns creates training/communication problems and a sense of perpetual change
CPOE facilitated errors
Selecting wrong patient, drug, dose, etc.
Assuming computer is doing more than it is really is
Alert fatigue
Undetected errors in order sets and software bugs
Difficulty with very complex or if-then orders
26. If you are thinking of doing this
27. For more information contact:
Larry T Hegland, MD, MMM
Chief Medical Officer
Saint Clares Hospital
The Diagnostic and Treatment Center
3400 Ministry Parkway
Weston, WI 54476
(715) 393-2487
larry.hegland@saintclareshospital.org