Eastern Maine Medical Center is a 349-bed medical center that serves communities throughout central, eastern, and northern Maine. EMMC is a member of Eastern Maine Healthcare Systems, an organization of seven hospitals and other healthcare companies with more than 7,000 staff members. EMHS provides and supports the information technology needs of EMMC. Over the past several years, EMMC has been steadily achieving various stages of EHR implementation.
Eastern Maine Medical Center
In November 2007, EMMC implemented computerized provider order entry (CPOE) for the inpatient care setting. This cardiac catheterization project was initiated as a result of some issues that we experienced with the CPOE implementation. When we transported the cardiologist order sets from the paper world to the CPOE world, we realized that they did not support an efficient, safe workflow for the teams involved in the high-volume catheterization lab procedures. In response to the cardiologists request to redesign the cath lab-ordering process, a rapid design session was held on November 28, 2008 to identify the major issues that needed to be resolved. We were faced with the challenge of developing CPOE for the cath lab-ordering process that spanned the processes from scheduling and preparation of the patient pre-cath, to ordering in the cath lab, to post-cath ordering in both the inpatient and outpatient settings. We could not find any reference site that had automated this ordering process with our clinical information system vendor.
The project plan:
- Set up a very ambitious timeline for completing the project (six months).
- Formed a multidisciplinary team, including provider stakeholders, who demonstrated a high-level of commitment to working through the issues.
- Conducted a rapid design session to identify, clarify and prioritize issues.
- Met weekly for several months for intensive decision-oriented sessions.
- Effectively managed the activities by focusing on establishing common goals/deliverables and assigning appropriate team members to complete the deliverables.
- Enhanced the functionality of CPOE by tailoring the ordering process through the various stages a cath lab patient undergoes, and automating some of the manual hand-offs that previously occurred in the non-CPOE world.
- Trained super users and equipped them with the knowledge to effectively provide support to providers and other nursing staff directly within the departments.
- Vested similar energy and thought into strategizing and planning for implementation including change management.
- The project budget was $165,000 of internal resource hours spent by a 30-member project team over six months. The project took approximately 140 days from inception to implementation.
The solution featured the use of multiphase PowerPlans, which are electronic order sets that contain both pre-selected and optional orders for use by providers from the time that the patient is scheduled for cath lab up to the time the patient leaves the cath procedural area to be admitted to an inpatient unit or discharged to home. The key features of this solution are:
- Use of evidence-based PowerPlans.
- Support of patient care during the scheduling, pre-cath, post-cath and post-PCI (percutaneous coronary intervention) phases by phase-specific orders.
- Patient-tailored orders that could be carried across phases to support the continuity of care.
- Ability to discontinue the previous phases orders prior to moving to the next phase.
- Incorporation of nursing standards in each phase to make the order profile manageable.
- Utilization of provider-driven pharmacy communication orders for the high-risk patients.
- Embedding of tools to support the discharge process with pre-filled prescription information and links to discharge policy and education.
- Decision support and rules at time of order entry.
Using electronic tools and logic, we embedded a hand-off from cath lab to the inpatient unit related to device removal and safe resumption of anti-coagulants.
This program also:
- Implemented standardized orders and order sets that carry-through orders across phases of the cath lab procedure.
- Provided a central view of all orders to help with the management of orders based on the specific phase of the procedure.
- Vastly improved hand-off among care teams through use of embedded nursing and pharmacy communication orders.
- Moved common and repetitive patient-care orders to protocols covered by written policies that eliminated the need for providers to order or communicate to nursing staff these types of orders.
- Innovatively used technology to better capture the workflow, e.g., embedded written policies within the PowerPlan.
Providers, nursing and other project team members came to the table as equals and were open and free to introduce and challenge ideas. This was a dramatic and significant culture shift for the organization to have these varied groups collaborate on achieving the best solution.
Project team members compromised as a result of learning what the changes were and their impact on not just one area, but other areas involved in the process.
This project helps position EMMC for the additional reimbursement provided by the American Recovery and Reinvestment Act of 2009 for meaningful use of a certified electronic health record. EMMC has 93% usage of CPOE in the inpatient setting, and we believe this is a meaningful use of our electronic health records. The use of CPOE in the cardiac cath lab is an important part of CPOE at EMMC.
Chief information officer/vice president
Chief medical information officer
Eastern Maine Medical Center
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