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“Reports: A Critical Task for Implementation The Importance of Reports for Supporting Implementations and “Reports: A Critical Task for Implementation The Importance of Reports for Supporting Implementations and Improvements in Healthcare HIMSS Nursing Informatics Quarterly Webinar Wednesday, April 5, 2006 1: 00 – 2: 30 p. m. Central/2: 00 – 3: 30 Eastern

Objectives • Describe a model to guide evaluation of clinical information system (CIS) implementations Objectives • Describe a model to guide evaluation of clinical information system (CIS) implementations • Identify uses of data and reporting: – as a structured methodology for monitoring progress – as a strategy to increase user acceptance – as feedback to vendor future enhancements • List examples of reports for CPOE and other implementations

Outline • Data to Wisdom Continuum • Reports – System performance monitoring – User Outline • Data to Wisdom Continuum • Reports – System performance monitoring – User acceptance – Vendor • Recommendations

Zen Story The world of a successful CNO had fallen apart at work and Zen Story The world of a successful CNO had fallen apart at work and at home. The CNO traveled around the world to find the Master who was known to hold the secrets to happiness. Mapes, J. (2003). Quantum leap thinking. Naperville, IL: Sourcebooks, Inc. Schlender, B. (2004).

1 st Secret: Pay Attention 1 st Secret: Pay Attention

2 nd Secret: Pay Attention 2 nd Secret: Pay Attention

3 rd Secret: Pay Attention 3 rd Secret: Pay Attention

DIKW Continuum Ackoff, Russell, DIKW Continuum Ackoff, Russell, "From Data to Wisdom", Journal of Applies Systems Analysis, Volume 16, 1989 p 3 -9. Bellinger, G, Castro, D. , Mills, A. , 2004 Data, Information, Knowledge, and Wisdom http: //www. systems-thinking. org/dikw. htm

Data Rich Information Poor • Collect large amount of data, but data used for Data Rich Information Poor • Collect large amount of data, but data used for D R I P – financial reports – reports for outside agencies: Core measures (AMI, CAP, CHF), APACHE, NSQIP, UHC clinical database (CDB), AHRQ indicators, IHI 100 K Lives • Many data resources, but not readily accessible • No project resources to collect & analyze data • Project members lack expertise in data collection & analysis • Data not used to set priorities or fuel change • Not part of the vendor project plan

Extreme IT Implementation Projects Traditional PM Planned Result Build Test Train GO LIVE Start Extreme IT Implementation Projects Traditional PM Planned Result Build Test Train GO LIVE Start Plan Test, retest Build, rebuild. . Train, retrain, update…. . GO LIVE Workflow Desired Result Infrastructure Copyright: Doug De. Carlo Communication Evaluate –Revise – Evaluate – Revise Evaluate - Revise…. .

Outline • Data to Wisdom Continuum • Reports – System performance monitoring – User Outline • Data to Wisdom Continuum • Reports – System performance monitoring – User acceptance – Vendor • Recommendations

CIS Project Examples 1. Clinical viewer implementation 2. Computerized prescriber/provider/physician order entry (CPOE) implementation CIS Project Examples 1. Clinical viewer implementation 2. Computerized prescriber/provider/physician order entry (CPOE) implementation

#1 Project: Clinical Viewer #1 Project: Clinical Viewer

Technology Acceptance Model Perceived Usefulness Computer Experience Job Title Reported Gender System Usage Age Technology Acceptance Model Perceived Usefulness Computer Experience Job Title Reported Gender System Usage Age Perceived Ease of Use Davis, F. (1989). Perceived usefulness, perceived ease of use and user acceptance of information technology. MIS Quarterly, 13(3), 319 -340. Davis, F. , Bagozzi, R. , & Warshaw, P. (1989). User acceptance of computer technology: A comparison of two theoretical models. Management Science, 35(8), 982 -1003.

Web survey distributed Sept, 2003 Responses- 269 Web survey distributed Sept, 2003 Responses- 269

Survey Conclusions • High level of user satisfaction with Clinical Viewer • People who Survey Conclusions • High level of user satisfaction with Clinical Viewer • People who used the system the most were more satisfied with usefulness and ease of use • Physicians were more satisfied than nurses • No difference in usage between physician and nurses or between male and female • Computer experience may be an influencer on different perceptions between physicians & nurses. • Younger age group reported higher usage • Novice group reported less usage

Study Implications • Provided input for CPOE project, both + and - – Remote Study Implications • Provided input for CPOE project, both + and - – Remote access……. Too many passwords – Information in one system …. . Missing results – Quick……Slow response time • Encourage general computer usage • Users probably will not feel comfortable until after they use new systems at least 5 times and will become more comfortable after 10 times • Experts may have higher system expectations or are more critical of systems • Web is a viable way to obtain feedback on computer program • Evaluation can be included as part of system implementations

CV Usage Today CV Usage Today

#2 Project: Inpatient CPOE • Order entry for 22 departments • Results review: Lab, #2 Project: Inpatient CPOE • Order entry for 22 departments • Results review: Lab, Rad, Path, Endo • Selected Transcriptions: ED, Operative, Discharge Summary • Order sets and order pathways • Decision support: allergy, drug-drug, drug -food, dose range • Rollout July 2004 – August 2005

CPOE Usage Report Total # of orders 2004 Aug 11, 444 Sept 16, 062 CPOE Usage Report Total # of orders 2004 Aug 11, 444 Sept 16, 062 Oct 26, 338 Nov 42, 171 Dec 44, 203 2005 Jan 46, 178 Feb 41, 103 March 135, 945 April 125, 517 May 131, 648 June 154, 956 July 185, 795 MD 92% 74% 68% 64% 61% 64% 60% 59% 58% 60% 66% 73% Written 2. 6% 14. 5% 17. 3% 16% 17% 15. 7% 17. 3% 22. 6% 21. 7% 17. 1% 10. 7% Verbal 3. 4% 4. 8% 6. 9% 16. 7% 11% 10. 4% 12% 6. 1% 5. 9% 5. 1% 5. 5% Phone 1. 9% 6. 2% 6. 7% 7. 8% 8. 6% 9% 11. 6% 10. 1% 9. 8%

CPOE Usage CPOE Usage

Performance Measurements Telephone and verbal orders Performance Measurements Telephone and verbal orders

Top 25 providers volume of telephone orders Jan, 2006 T e l e p Top 25 providers volume of telephone orders Jan, 2006 T e l e p h o n e o r d e r s # Providers

Acceptance Model Implementation of New Care Delivery System Clinical Population User Acceptance Formative Evaluation Acceptance Model Implementation of New Care Delivery System Clinical Population User Acceptance Formative Evaluation FOCUS Patient Outcomes

Acceptance Determinants* • Performance Expectancy: the degree to which an individual believes that using Acceptance Determinants* • Performance Expectancy: the degree to which an individual believes that using the system will help him/her to attain gains in job performance. (Perceived usefulness) • Effort Expectancy: the degree of ease associated with the use of the system. (Perceived ease of use) • Social Influence: the degree to which an individual perceives that important others believe he or she should use the new system. • Facilitating Condition: the degree to which an individual believes that an organizational and technical infrastructure exists to support use of the system. *Unified Theory of Acceptance and Use of Technology (UTAUT) Venkatesh, Viswanath, Morris, Michael G. Davis, Gordon B. Davis, Fred, MIS Quarterly, 2003

Acceptance Model Components Characteristics of users • Gender • Age • Educational level Determinents Acceptance Model Components Characteristics of users • Gender • Age • Educational level Determinents • Performance expectancy (usefulness) • Job Role • Effort Expectancy (ease of use) • Unit • Social Influence • Training User Usage Acceptance • Facilitating Conditions • General computer expertise • Prior CPOE experience • UK CPOE experience Outcomes

Performance Expectancy • Acceptance survey = 5 (1 -7 scale) – Liked: “the timeliness Performance Expectancy • Acceptance survey = 5 (1 -7 scale) – Liked: “the timeliness of order execution”; “Not having to read scrawled, illegible notes” – Disliked: “People don't complete their orders”, “When doctors put orders in incorrectly and we are expected to fix them” , “Takes too much nursing time” • Actions – Duplicate alert

Effort Expectancy Survey • Disliked “difficult to find specific items”, “the lab slip printing Effort Expectancy Survey • Disliked “difficult to find specific items”, “the lab slip printing system”, “MAR checks” • Liked: “easy to do chart checks/MAR checks” ; “flags for new lab results”; “The labels are much easier to use” Other • Number of clicks: – Ran reports on most common diagnosis by service and most common orders: used to help identify need for prefilled order sets, orders for rounds, commonly used orders, etc. • Response time: help from IT for ongoing monitoring • Quality of use by physicians: report that lists use of a “non specific order”

Lab Label Printing TAT Pathology labels – Label study of 21 valid labels – Lab Label Printing TAT Pathology labels – Label study of 21 valid labels – Minimum of 0 min – Maximum of 4 min – Total Average 1. 1 min Lab labels – Label study of 35 valid labels – Minimum of 1 min – Maximum of 9 min – Total Average 3. 7 min

Response Time Response Time

“Special Order Nursing” • Month Total 3, 331 orders • Who: – 399 were “Special Order Nursing” • Month Total 3, 331 orders • Who: – 399 were entered on behalf of the physician – 2, 932 entered by physician • What: – 271 medication orders – 31 labs – 7 blood bank orders – 1 allergy to latex

Social Influence Survey • “most physicians do not want to enter orders” Actions • Social Influence Survey • “most physicians do not want to enter orders” Actions • Ongoing work with physicians: newsletters, dog & pony show, added 2 new physicians to the team

Facilitating Condition Survey • “No on-site backup on weekend” Others – Device access – Facilitating Condition Survey • “No on-site backup on weekend” Others – Device access – Downtime – Help desk responsiveness

HELP DESK HELP DESK

Clinician Support Identify common problem themes: • by service • by units • by Clinician Support Identify common problem themes: • by service • by units • by problem type

Suggested Reports Clinical Reports Technical/Configuration • Allergies, height and weight • Support builds/loads etc. Suggested Reports Clinical Reports Technical/Configuration • Allergies, height and weight • Support builds/loads etc. entered/reviewed prior order • Queries to check entry configuration: • Time from orders entered until – Find orphan items time acknowledged – List of order sets that contain a specific item • Turn around times: – Order is in catalogue but tests/meds and patient wait not in browser times (ED, OR, …) • Downtime • Order set usage • Incomplete tasks Health Information • Alerts - # of firings, Management acknowledged, action taken, etc • Unsigned orders or documents • Security audits

Acceptance Model Implementation of New Care Delivery System Clinical Population User Acceptance Formative Evaluation Acceptance Model Implementation of New Care Delivery System Clinical Population User Acceptance Formative Evaluation FOCUS Patient Outcomes

Support Evidenced Based Practice Vaccine Protocol Support Evidenced Based Practice Vaccine Protocol

Pneumovax Administration Jan 2004 -Jan 2006* Pneumovax Administration Jan 2004 -Jan 2006*

…

Reduce Harmful Medication Errors No Error A Error, NO Harm B-D Actions to increase Reduce Harmful Medication Errors No Error A Error, NO Harm B-D Actions to increase event reporting Safety interventions CPOE PRE CPOE Error HARM E-H Error DEATH I Modified from Battles and Lilford, 2003 POST CPOE

Error: Ordered wrong drug, first in list Intervention: TALL man lettering Error: Ordered wrong drug, first in list Intervention: TALL man lettering

Error: SA does not mean short-acting Intervention: add definition SA = sustained action Future: Error: SA does not mean short-acting Intervention: add definition SA = sustained action Future: create alert on frequency of > daily

Granisetron Injection Problem: One order entry item with defaulted unit of measure used by Granisetron Injection Problem: One order entry item with defaulted unit of measure used by two different groups. Anesthesia typically prescribes 0. 1 mg and Oncology uses 10 mcg/kg. Inattention to the unit of measure resulted in 0. 1 mcg and 700 mg doses. Over 1 month 36/196 (18. 5%) orders with wrong unit of measure Remedy: • Create two order entry items with the unit of measure defaulted. • Granisetron Inj – MCG Doses • Granisetron Inj. – MG Doses • This alerts clinicians up front that a decision has to be made. The correct unit of measure is then selected. After change: Over 1 month: 5/120 (4%) orders with wrong unit of measure

JCAHO Audit: Transfer to different level of care Transfer from Transfer To Active Meds JCAHO Audit: Transfer to different level of care Transfer from Transfer To Active Meds Modified surrounding time of transfer - Yes or No Med Orders Appropriate for new location at time of transfer Was 'Transfer Complete/Orders Reviewed' order entered Notes 2 BUR 6 W Yes No Yes 2 SIC 8 S Yes Yes 2 HOL 6 S Yes Yes 6 times, correct each time 2 SIC 7 S Yes Yes 2 BUR 6 W Yes Yes No 6 N Nurse had to DC PACU orders, SS orders, and others 4 N 6 N No No

Privacy & Security Reports Privacy & Security Reports

Vendor Support 1. Request advanced report writing classes 2. Request a report library on Vendor Support 1. Request advanced report writing classes 2. Request a report library on vendor customer site 3. Collaborate with other users to identify recommendations for standard reports and report priorities for inclusion in new releases 4. Use reports to uncover issues and submit suggestions for future enhancements

Outline • Data to Wisdom Continuum • Reports – User acceptance – Outcomes – Outline • Data to Wisdom Continuum • Reports – User acceptance – Outcomes – Vendor • Recommendations

Lessons Learned • • • Just because you enter data does not mean you Lessons Learned • • • Just because you enter data does not mean you can retrieve it How you set up the system impacts reports Use standard terminology where available Standard reports are only tip of iceberg Identify what you need to guide implementation Include resources for writing queries and reports Not all reports can be automated Conflict between new enhancements/upgrades and evaluation of current performance Significant workload to keep system up to date: arriving and departing staff, changing roles etc. Users do not always report problems Brainstorm with stakeholders what they would like/need Expect that need for reports will be ongoing

Suggested Reports Indicators Currently Being Collected: • Patient Falls with injury • Pressure Ulcers Suggested Reports Indicators Currently Being Collected: • Patient Falls with injury • Pressure Ulcers - % of patients with documented ulcer (stage I-IV on day of prevalence study. Also have Hospital-acquired ulcer - % of patients with documented ulcer (stage I-IV) on day of prevalence study • Nurse Satisfaction • Nursing Hours Per Patient Day (HPPD) - RN, LPN/LVN, UAP - number of productive hours worked by nursing staff with direct patient care responsibilities • Staff Mix - the total number of productive hours worked by each skill mix category (RN, LPN, UAP)/total staff hours • Type of unit (critical care, step down, medical, surgical and combined) • Number of staffed beds designated by the hospital • Agency staff - total number of productive hours worked by contract staff • Urban vs. Rural category New Indicators Undergoing Pilot Testing: • Pediatric pain • Peripheral Intravenous Infiltration • Restraint Use • Patient Aggression National Database of Nursing Quality Indicators (NDNQI) http: //www. nursingworld. org/quality/database. htm#menu

Future: Expand clinical decision support PROCESS EXAMPLE • Used a clinical alert to • Future: Expand clinical decision support PROCESS EXAMPLE • Used a clinical alert to • Search literature reduce hypoglycemic • Networking episodes by 76% for NPO patients with • Links or membership diabetes. on clinician process improvement groups • Physicians were 2. 6 times more likely to adjust the dose of hypoglycemic agent than before the alert was implemented. Johnson, T. , et al. 2005, New. York-Presbyterian Hospital: Translating Innovation into Practice. Joint Commission Journal on Quality and Patient Safety, 31 (10): 554 -560

Conclusion • Reports provides a way to focus on determinants of clinician acceptance and Conclusion • Reports provides a way to focus on determinants of clinician acceptance and impact on patient outcomes • Analysis of reports provides information that can lead to knowledge and wisdom that guides implementation strategies • Providing resources for data retrieval & analysis is a critical task for implementations