Building Effective Tools for Donor Management in Electronic Medical Records

1. Michigan Health & Hospital Association and Gift of Life MichiganWelcome to the MHA Keystone: Gift of Life WebinarWednesday, June 27, 20121:00 pm – 2:00 pm

2. Today’s topic: Building Effective Tools for Donor Management in Electronic Medical Records Introductions: • Ashley Renkes Hospital Services Associate, Gift of Life Michigan Questions: • Please type questions into the chat box. • A question and answer session will take place at 1:45 pm. • If you prefer to pose your question anonymously, please direct the chat to the “Host and Presenter” so that your question is sent only to them.

3. Building Effective Tools for Donor Management in Electronic Medical Records Gift of Life / Keystone Webinar Series June 27, 2012

4. W E L C O M E ! 2012 Webinar Series • Partnership between MHA and Gift of Life Michigan • Today’s speakers: Ashley Renkes Hospital Services Associate, Gift of Life Michigan Carol Schindler, RN, MSN, MA Clinical Transformation Specialist, Sinai Grace Hospital Julie Pfeiffer, RN, BSN, CPTC Donation Coordinator, Gift of Life Michigan

5. Questions to Run On… • What are the basic elements of donation that a hospital EMR should consider? • Why are hospitals implementing EMR systems, and what is the future of EMR? • How can hospitals integrate organ, tissue, and eye donation into EMR systems? • What can you learn from hospitals that are in the process of integrating donation into their EMR systems?

6. Getting to Know Donation: Crucial Information to Consider Ashley Renkes Hospital Services Associate Gift of Life Michigan

7. What is Gift of Life? • Federally designated organ and tissue recovery organization for Michigan since 1971 • Liaison between 175 critical-care hospitals and eight transplant centers • Independent, non-profit based in Ann Arbor • Maintains the confidential Michigan Organ Donor Registry in collaboration with the Secretary of State • Open 24/7, 365 days a year

8. Regulatory Agencies Joint Commission (JCAHO) and CMS require hospitals to notify OPO: • Within 1 hour of meeting clinical triggers • Within 1 hour of death Hospitals are required to collaborate with Gift of Life to ensure that the family of every eligible decedent is offered the option of donation.

9. What are Clinical Triggers? • Clinical Triggers: • Specific medical parameters which prompt hospital staff to make a referral to Gift of Life on a potential organ donor. • Notifying Gift of Life is a “heads up”. It does not mean that patient is going to be an organ donor or that Gift of Life is going to come onsite and interact with the family.

10. When Must I Call Gift of Life? • Within one hour of patient meeting clinical triggers. Every patient on a ventilator with: • A Glasgow Coma Scale (GCS) of 5 or lower • Being evaluated for brain death • Being considered for withdrawal of support • Being considered for a change of resuscitation status • Hospitals must also report every death within one hour after death

11. Who are Candidates? Organ Donation: All patients who meet certain criteria or “clinical triggers” should be referred to Gift of Life. Tissue Donation: All patients who die and are issued a death certificate should be referred to Gift of Life Michigan.

12. Federal Regulations • 2001 Health Information Portability & Accountability Act (HIPAA) • Allows hospitals to release information to facilitate donation. • Section 164.512: “consent and authorization…is NOT required…” • Gift of Life is allowed access to a referred patient’s medical record.

13. Donation Process Overview Every Screening Specialist takes approximately 100 calls each day from hospitals reporting imminent deaths and/or deaths.

14. Donation Process Overview Gift of Life will determine, based on the call, what the appropriate response should be to the hospital: Immediate on-site response, delayed response, follow by phone, or case is closed for donation. A clinician’s access to the medical record is crucial during the evaluation stage.

15. Donation Process Overview Potential organ donor cases are coordinated in-house by Donation Specialists. They access the national organ transplant waiting list, arrange for transplant surgeons to recover organs from the donor patient, and support on-site Donation Coordinators throughout the donation process.

16. Donation Process Overview Donation Coordinators work with the medical staff on-site at the donor hospital to offer the option of donation to the donor family. They help facilitate donor management, the allocation of organs, and the recovery process. Donation Coordinators require frequent access to the donor’s chart in order to place organs and write orders.

17. Donation Process Overview If a patient is donating tissue and eyes, but not organs, Screening Specialists will require a copy of the patient’s medical chart, or need a nurse to review the chart verbally with the Screener before the recovery process can begin. The Food and Drug Administration (FDA) requires this information.

18. Donation Process Overview Gift of Life has its own laboratory, to determine compatibility between the donor organs and the potential transplant recipients. Gift of Life tests for the health of the donor, by looking for viruses that might make the recipient ill.

19. Donation Process Overview The donation surgery happens at the donor hospital or one of the Gift of Life Surgical Centers located in Southfield or Grand Rapids, Michigan Once organs are recovered they are transported to the transplant hospital for the transplant surgery.

20. Donation Process Overview After a referral or donation occurs, Hospital Services Associates review medical records, compile reports, and run statistics on hospital performance. The Hospital Services Associates also follow-up with donor hospitals with the results of recent donations.

21. Clinical Transformation…Transforming Patient CareCreating ripples of change in Clinical Practice Electronic Medical Record -GOLM

22. Definition of EMR • Healthcare Information Management System Society • Electronic Medical Record • System used by the health care institution; information is shared by computers. • Electronic Health Record • Record of patient health information generated by one or more encounters (hospitalization, outpatient visits, ambulatory surgery). • Patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, etc. Electronic Medical Record -GOLM

23. Why are Hospitals Implementing EMR Systems, and What is the Future of EMR? • The Institute of Medicine (IOM) is an independent, nonprofit organization that works outside of government to provide unbiased and authoritative advice to decision makers and the public.  • Recommendation: Healthcare Industry provide a systematic approach to decrease patient errors (2000). • Safety • Effectiveness • Patient centered • Timeliness • Efficiency • Equity Electronic Medical Record -GOLM

24. Components of Computer Information System in Health Care • Financial Information System (FIS) • Clinical Information System (CIS) • Pharmacy Information System (PIS) • Nursing Information System (NIS) • Laboratory Information System (LIS) • Radiology Information System (RIS) • Picture archiving and communication systems (PACS) Electronic Medical Record -GOLM

25. WHY NOW? • In February 2009,the President signed the American Recovery and Reinvestment Act (ARRA), allocating over 19B under the law’s HITECH Act (Health Information Technology for Economic and Clinical Health). • Accelerate adoption of Electronic Health Records. • Provide incentives to hospitals and physician offices. • Addressing key objectives know as “meaningful use”. Some of the objectives: • Demographics • Problem list and diagnosis • Active medication and medication allergy list • Patient copy of electronic medical record to patient • Drug-drug and drug-allergy checks • Report clinical quality measures to CMS or states • Incorporate lab values into EHRs • Build a national infrastructure for health information exchanges (HIE’s). Electronic Medical Record -GOLM

26. 2006 Computerized Provider Order Entry (COPE) Order Sets Nursing Documentation Interfaces Lab Radiology Alerts Allergy Drug-Drug Interactions Electronic Prescriptions Scanning of medications and patient wrist bands 2007-2012 PowerPlans SurgiNet Rehab PowerNotes Interfaces Wound Expert Teletracking E-Quality M-pages Inpatient Summary VTE Summary Trauma Summary Expansion to non-DMC health providers to document in EMR Hospice Gift of Life DMC Experience with EMR Electronic Medical Record -GOLM

27. Benefits of EMR • Orders will be legible and can be viewed by all health care providers (HCP) in real time; no missed orders. • RN able to view status of medication order on the MAR (electronic medication administration record) and MAR Summary. • Prescriptions entered on line, printed for patient. • Alerts for nursing on eMAR when administering medications. • MAR and MAR Summary allows all HCP to see the meds which have been ordered, administrated, or not given since the point of entry into the hospital. Electronic Medical Record -GOLM

28. Benefits of EMR • Medication reconciliation will be done by the physician as the patient cross levels of care and the orders not wanted will be discontinued by the provider. • Alerts will fire when a patient has an allergy. • Evidence based knowledge is available as a resource for physicians and nurses. Electronic Medical Record -GOLM

29. How can Hospitals Integrate Organ, Tissue, and Eye Donation into EMR Systems? • Develop a plan for key Gift of Life Staff to access to the electronic record. • Chart review of labs, progress notes, physical exams, radiology and EKG reports • Design Orders Sets (group of evidence based orders in one location) • Process for registration of the outpatient encounter • Document on the inpatient chart • Document on the outpatient chart Electronic Medical Record -GOLM

30. The Inpatient Summary is focused on providing a summary view for clinicians that includes access to several components of the patient’s chart from a single page. Clinicians are also able to place orders and document directly from the summary. Examples of information found on the Inpatient Summary includes: Patient Information; Diagnoses; Problems; Allergies; Medications; Procedure History; Past Medical History; Vital Signs; Diagnostics; Documents; Labs; Intake & Output; Measurements & Weights; Visit History; Orders Electronic Medical Record -GOLM

31. Example of Order Catalog for GOL Orders Electronic Medical Record -GOLM

32. Gift of Life Pre Assessment: the provider whoplaces the order details can make changes if necessary. Electronic Medical Record -GOLM

33. Gift of Life Brain Dead Donor Orders: the provider whoplaces the order details can make changes, if necessary. Electronic Medical Record -GOLM

34. Gift of Life Brain Dead Donor Orders: the provider whoplaces the order details can make changes, if necessary. Electronic Medical Record -GOLM

35. Gift of Life Brain Dead Donor Orders: the provider whoplaces the order details can make changes, if necessary. Electronic Medical Record -GOLM

36. Gift of Life Brain Dead Donor Orders: the provider whoplaces the order details can make changes, if necessary. Electronic Medical Record -GOLM

37. Accomplishments Gift of Life has access to the electronic record; patient’s clinical history is viewable. ICU physicians and nurses can care for the patient instead of placing orders. Management of the patient is more effective and timely. Issues Registering the Outpatient Encounter too early GOLM cannot see the previous clinical information. The story is lost. Radiology, lab, and other services cannot find the patient because the patient is removed from the inpatient bed to outpatient location. How is it Working? Electronic Medical Record -GOLM

38. Future of EMR: Communication Between Systems • Common language so each computer system can share information. • Michigan Database Advanced Directives. • Gift of Life Registry. • Personal Electronic Health Records. Electronic Medical Record -GOLM

39. References Lillian Burke and Barbara Weill,” Information Technology for Health Professionals”, Third Edition; Chapter 2: Medical Informatics: The Health Information Technology Decade; Prentice Hall, Inc. A Pearson Education Company, https://ecampus.pheonix.edu/content/eBookLibrary/content.e/Re (accessed6/15/2012) Blumenthal, David. MD. M.P.P. Tavenner , Marilyn. R.N. M.H.A. “The “Meaningful Use’ Regulation for Electronic Health Records, N Engl J Med 363;6 August 2010; Downloaded from nejm.org on June 15, 2012 Carolos Palacio Jeffrey P. Harrison David Garets Benchmarking Electronic Medical Record Initiatives in the US: a Conceptual Model Journal Medical Systems 2010 34:273-279 DOI 10.1007/s1096-008-9238-5 accessed June 15, 2012 Electronic Medical Record -GOLM

40. Building an EMR Team: Getting Results through Multidisciplinary Collaboration Julie Pfeiffer, RN, BSN, CPTC Donation Coordinator & Ashley Renkes Hospital Services Associate Gift of Life Michigan

41. Developing a Coalition • Choose key players in EMR design, implementation, use, process improvement, and access. • Users: Nurses, Physicians, Donation Coordinators, HSA • Designers: EMR team members • Implementation and access: Information Technology, Finance • Improve processes: Hospital Services and Liaison(s)

42. EPIC EMR: Building from the Ground-up • Starting with existing paper forms and processes: • Certification of Death by Neurological Criteria • Find a way to force use and complete documentation. • Gift of Life progress note “Green Sheet” • Implement timed “task list” items for clinical trigger notification. • Provide quick, easy way for units to track calls to GOL and plans made. • Order sets • Provide quick and easy way for donation coordinators to order medications, procedures, etc. • “Dr. Gift of Life” • Flag GOL charges for billing purposes. • Allow GOL to write orders without re-admitting patient (Hurley currently discharges and re-admits patients due to limitations with their admitting software package).

43. Death by Neurological Criteria • Policy is quoted with each step. • At end of document, physician selects “consistent” or “not consistent” with BD; electronic signature with auto-fill date and time (may be manually adjusted).

44. Death by Neurological Criteria • Developed from existing form by GOL/EPIC team, with key physician partners. • Electronic signature designed to meet transplant center requirements. • Helps physicians follow medical center policy, and standardizes the documentation process.

45. Gift of Life Progress Note • Nurse or physician documentation triggers timed “task list” item. • Nurse or physician documents call to GOL and plan for response. • Gift of Life fills out note while on-site…many auto-fill responses available: • “Please call with changes…” “Thank you for this referral…” • Possibility: Add date and time of consent to trigger billing for DCD donors.

46. Gift of Life Progress Note • Note for RNs includes date and time of call, clinical trigger met, person contacted, drop-down/clickable plans (follow by phone, coordinator ETA, not suitable for donation, etc.) • Indication of whether or not family has been approached, and the outcome of any approach. • GOL coordinator fills out note upon arrival, allows staff and future coordinators to follow plan for patient’s care under GOL and identify previous interactions.

47. Clinical Trigger Notification • Documenting a clinical trigger with automatically place a timed “task” on the nursing task list. • GOL will be able to run reports to identify patients with documented clinical triggers. • Task will automatically link to GOL progress note.

48. Order Sets

49. Order Sets • Developed from current clinical practice. • Includes relevant medications, tests, labs, procedures…nothing pre-selected to allow for flexibility (saves $). • Coordinators will order under “Dr. Gift of Life” for brain dead donors, hopefully will build a billing flag into the progress note for DCD donors (2013?) • Hurley Medical Center is granting access to all North Central Gift of Life coordinators, will facilitate additional access if needed. HMC staff will be trained to enter orders for coordinators without access and for DCD donors.

50. Reporting and Training • EPIC reports: • Deaths on a vent under the age of 71. • Patients meeting clinical triggers. • Patients with a GOL progress note. • Untimely notification per GOL progress note. • Routine notification logs of inpatient and ER deaths. • Training • Abbreviated sessions for coordinators to learn GOL specific screens. • HSA trained for initial responding/support/death record review.