The University of Pennsylvania Health System includes three acute-care hospitals and two large ambulatory networks that serve Philadelphia, the surrounding five-county area and parts of southern New Jersey. Our physicians see more than 2 million outpatient visits in more than 220 practice locations each year.
Our healthcare implementation project for this submission is a comprehensive outpatient electronic medical record. Its features include: clinical documentation, physician ordering, data reporting, outpatient pharmacy, a communications module, myPennMedicine and a referring physicians portal. More than half of our physicians are active users of the ambulatory EMR.
The program started as a pilot in 1998. In 2005 we committed to implementing it in all health system outpatient practices by July 2011. Currently, about 150 of the 200 practices are installed, supporting approximately 4,700 active users. We have spent approximately $36 million to date for this initiative, a figure that includes staff salaries and benefits, consultant fees, software support, hardware and software licenses.
The outpatient EMR initiative is overseen by our EMR Operations Committee, which includes physicians and representatives from our information services, auditing, compliance, quality, safety, laboratory and business administration units. It provides direction on all regulatory, clinical and operations procedures for the EMR.
Our ambulatory EMR staff includes 55 full-time employees and 24 consultants, including:
- Interface developers who develop the software that connects data between systems.
- Development staff who develop the technical system and build databases.
- Application staff who develop or modify software features.
- Implementation staff who work with the practices to go live on the EMR and support them during the transition.
- User support services, such as help-desk agents who answer questions and troubleshoot issues.
- Optimization and sustainment analysts who promote efficiencies and help develop new business processes for better patient care.
- An education team who trains users on all aspects of the EMR.
- The information services communications officer maintains an EMR website and produces monthly newsletters, technology video tutorials and broadcast e-mails.
- The medical director of clinical information systems is a physician-liaison who ensures that the technology features being planned reflect the input of physicians.
UPHS physicians rely heavily on the EMR for all aspects of patient care. It is used to track, monitor and store patient information as well as provide best practices and alert clinicians to potentially problematic findings. In the words of one of our physicians, Susan Day, from PennCare Internal Medicine Associates: “Our ambulatory EMR is at the core of our efforts to improve access, communication, care management and population-based care. Our ability to create and manage patient lists, report cards and work plans for patients, and provide feedback on performance to our providers, has been greatly strengthened because of this system and our information services support team.” We have chosen our EMR/diabetes project to illustrate improvements in patient care generated by the technology. The project has three components:
- The clinical information system, which includes a diabetes database and diabetes- specific health maintenance field.
- Decision support for physicians, which includes a diabetes order set, including best-practices medications and testing; patient action plans and report cards to guide behaviors and track key metrics, which are shared with patients; and active alerts that tell patients when they are due for tests or exams while promoting physician use of report cards; and a practice website, called “PULSE,” to post practice-approved guidelines, policies and resources, such as drug formularies.
- Patient self-management, which includes patient education via online resources incorporated into the ambulatory EMR patient portal; community programs that are identified, which include support groups via a patient portal; and a patient action plan and report cards that are accessible via the patient portal.
We tracked 162 patients and saw improvements in all identified key measures in only nine months, from July 2008 to April 2009.
In fall 2009 we began an assessment of our ambulatory EMR in terms of meaningful-use criteria. Our goals are to link our outpatient and inpatient EMRs in select areas to support patient safety and strengthen our outpatient EMR.
For example: The project has three parts. First, we aim to integrate ambulatory and inpatient medication history and allergy information so it is available in one place. Second, we want to institute bar-coding technology for all inpatient and ambulatory medication administration. This will permit critical five-rights-of-medication administration to be confirmed by the technology. Third, we want to enable physicians and nurses immediate access to comprehensive Web-based drug databases (updated daily) to address prescription or administration concerns without having to exit the ordering system and re-enter the drug name to search via the Web, as is currently the case.
Once 100% outpatient EMR implementation is achieved in July 2011, we will revisit and identify opportunities to optimize clinical decision support.
