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Hospitals and Health Systems:
Nurses and Physicians in the Implementation of the
EMR at NYC Health & Hospitals Corporation
Marie Ankner, RN, MS, CNAA, HHC
Abha Agrawal, MD, Kings County Hospital/HHC
Louis Capponi, MD, HHC
Glenn Martin, MD, Queens Health Network/HHC
Nadia Sultana, MBA, RN, BC, HHC
HHC Mission Statement
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To extend equally to all New Yorkers, regardless of
their ability to pay, comprehensive health services of
the highest quality in an atmosphere of human care,
dignity and respect;
To promote and protect, as both innovator and
advocate, the health, welfare and safety of the people
of the City of New York;
To join with other health workers and with
communities in a partnership which will enable each of
our institutions to promote and protect health in its
fullest sense -- the total physical, mental and social wellbeing of the people we serve.
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11 Hospitals
5 DTC’s
4 LTC’s
100 Clinics
Home Care
MetroPlus
www.nyc.gov/HHC
HHC
•Revenues totaled approximately $4.3 billion.
•Nearly one million ER visits.
•Five million outpatient visits
including 2 million primary care visits.
•210,000 Hospital Discharges
•The single largest provider of psychiatric
services in New York City
•23,000 births
HHC Organization Chart
Mayor Appoints
Board of Directors
Mayor Appoints
Benjamin Chu, MD, MPH
President
(7) Networks
Facilities
SVP
SVP
SVP
SVP
SVP
HHC EMR Timeline
1991
/
1997
2000
2002
2004
2005
HDS Pilot, Jacobi Medical Center
Labs, CPOE, Documentation
Installation throughout HHC
Lab, Lab Consolidation
CPOE
LTC
OPD Documentation/Coding
Smart Cards
DC Summaries
Disease/Pt. Registries
Medication Admin.
Portals
Vision for HHC Clinical Systems
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Leaders in Clinical Outcomes
Reliably Support the Care Team
Complete Information Availability
Positive Fiscal Impact
Critical Success Factors
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Increase the Speed of Innovation
Complete Projects
 Facilitate System Consistency
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Enhance Clinical Information Access
Registries
 Close the Data Warehouse Loop
 EMPI
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Successful 4.1/4.2 GUI implemented
Critical Success Factors
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Continuous Engagement
SVP IT Steering Committee
 NISA, PISA, DW Users Group
 IT Senior Staff
 Front Line Staff
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Provide Support, Resources & Leadership
Improve Management of our Partners
Using IT to Improve Patient
Safety
Abha Agrawal, MD
Chief Medical Informatics Officer
Associate Medical Director
Kings County Hospital, Brooklyn, NY
HIT Summit, Oct. 2004. Washington, DC
Medication Errors
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One million serious medication
errors every year.
20% are life-threatening.
7000 deaths annually.
$2 billion nationwide in hospital
costs alone.
IT to Reduce Med. Errors
Information Technology is
a critical ingredient to
reduce medication errors.
Medication Process
Physician
Medication Order
CPOE
Pharmacy
Dispensing
Pharmacy
Nurse
Administration
Review
E- Med Admin
CPOE with Decision Support
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Electronic prescribing – eliminates illegibility
issue.
Drug-allergy checking.
Drug-drug interaction checking.
Coming up - Drug-lab checking.
Pharmacy review of meds – matched against an
electronic profile.
CPOE: Incorrect dose warning
CPOE: Drug-drug interaction
warning
Electronic Medication
Administration
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Wireless network and mobile carts on wards
Real-time data entry
Decision support e.g. delayed med admin, too
high dose etc.
Error reporting
No errors during transcription from paper to
MAR sheet
Next steps: Bar-coded matching of patient and
of medication
Med Admin: Info. available to RN
Med Admin: Pharmacy Review
Warning
Med Admin: Incorrect Time
Warning
Challenges in Implementation
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Complexity – interdisciplinary
Clinician buy-in – MD, RN, Pharmacy
Cost of the software, even more – the cost of
the implementation
Putting this in perspective
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5-10% hospitals have adequate CPOE.
<10% hospitals have Electronic Med. Admin.
2003 HIMSS Patient Safety Survey
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Issues that IT can address
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Top issue - Medication errors – 93% respondents.
14th annual HIMSS leadership survey
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Projected IT priorities
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Top issue – Reduce medical errors, promote pt safety –
59% respondents.
It’s All About Results
12-month Evaluation of CPOE at Metropolitan
Hospital
 Overall Med. Error rate down by 40%
Incomplete orders down by 70%
 Incorrect orders down by 45%
 Illegible orders virtually eliminated
 Errors due to drug therapy problems - unchanged
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Igboechi et al. Hospital Pharmacy 2003
Nursing at New York City Health
and Hospitals Corporation
Scope and Informatics
Marie Ankner, RN,MS,CNAA
Assistant Vice President , Nursing
Services
New York City Nursing Services
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Each facility led by a Chief Nurse Executive
6600 RNs located throughout the five boroughs
Nursing teams include ancillary personnel
Interdisciplinary approach to patient care
Unionized environment
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NYSNA, 1199, DC 37
Nursing Presence:
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7 Networks
11 Acute Care
Facilities
4 Long Term
Care Facilities
Diagnostic and
Treatment
Centers
Ambulatory Care
Sites
Home Care
Telemedicine
MetroPlus
Child Health
Clinics
In the beginning …
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RFP was developed and reviewed by an
interdisciplinary team representing all facilities
(90’s)
Pilot developed at Jacobi Medical Center
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Initiative led by nursing and fostered
interdisciplinary screen building
Individualized Network /Facility expansion
Nursing Climate
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National Nursing Shortage
Average age of the RN in NYS is 48 yrs.
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Knowledgeable, aging workforce
Workplace Drivers
Increased patient complexity
 Decreased length of stay
 NYS regulatory requirements
 Focus on access, health promotion and prevention
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HHC Environment
HHC RNs average age 48 yrs
- 60 % direct care providers have > 10 yrs of service
 Nursing and the Electronic Record
- variation in templates and terminology
 Initiation of the NISA committee
 Identification of Nursing Informatics Educational Needs
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Nursing Conference incorporated Nursing Informatics
Pre hire assessment of computer skills
NISA Goals
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Identification and adoption of Best Nursing
Practices
Collaboration of knowledge, expertise
Work smarter not necessarily harder
Safeguard patient care
Assure professional practice
Support Nursing and IT
Maximize IT utilization to support patient care
Driving Force is Patient Care
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Cost effective, quality, safe patient care
Provide IT support for all health care providers,
including nursing
Computerize Nursing Process
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Literature reports that Nursing Documentation
Utilize13-28 % RN time
Achievements
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Online electronic medical records
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Pharmacy, lab and radiology
Medication administration pilots
Patient education
Health Promotion
Immunization screens
Home Care telemedicine program
Paperless NICU at Jacobi Medical Center
Smart Cards
The Nursing and Technology Link
Nadia Sultana
MBA RN,BC
Senior Director, Clinical Information Systems
NYC Health & Hospital’s Corporation
October 23,2004
Historically
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User Groups developed data collection screens separately to
meet their immediate needs:
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Physician Documentation screens
Physician Order Entry
Nursing Assessments and Flow sheets
Data collection screens lack
standardization …impacting
Data Warehouse initiative and
ability to implement timely changes
to CPR
Action Plan
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Formation of …
NISA = Nursing Information System
Advisory Group
…to promote dialogue, share best practices and
foster Nursing Informatic education
NISA Framework
Network Nursing Service Representation
 Regular Monthly meetings
 Co-chaired by Corporate Nursing and IT
 Specific Agenda
 Initiation of an Issues List with Follow-up
 Guest Speakers
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Current Concepts in discussion…
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Development of standardized data collection screens
with data element identification
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Establishment of Change Control Procedures
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Identification of Educational Needs
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Planning next modules incorporating
“best practice”
Standardization
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First attempt - Development of the VISTA Desktop
Nursing Standard
Outcome – some variation continued post
implementation …emphasized the need for
change control process…and need to
continue to Standardize
CONEY
• Medium Issue Redundant icon function
CONEY
• Recommendation –
Remove icon
• High Issue - Block
functions should appear as
tabs. Substantial deviation
from NISA standards.
• Response – Rebuilding
new desktop by April 18th
• Recommendation – Align
desktop with NISA
standards.
•Response – Rebuilding
new desktop for April 18th.
•Status –verify with Misys
analyst if this issue will be
fixed on new desktop
•Next Steps – Re-audit
desktops when desktop
build is complete.
Non-Compliance IP Nursing Issues
• Status - verify with Misys
analyst if this issue will be
fixed on new desktop
• Next Steps - Re-audit
desktops when desktop
build is complete.
WOODHULL
• Medium Issue – Duplicate review queue
functionality
• Recommendation – Remove desktop shortcut
• Status – IT rep will not sign off change control
form or make changes until audit has been
reviewed with NISA rep.
• Next Steps – Review audit results with NISA Rep
and IT.
Non-Compliance IP Nursing Issues
Change Control Procedures
…Experience with VISTA Desktop
Standardization and Phase I Development of
Data Warehouse Reports highlighted need for
Change Control Procedures to Decrease
variation of key data elements and terminology
Change Control Process -CPR /DATA WAREHOUSE
Education efforts
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Development of Survey to assess needs
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Standardized CPR Modules Training and
issue CEUs
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Perform “Gap Analysis” – focus on
Nursing Documentation and CPR usage
to determine “best practice”
Planning next modules incorporating
“best practice”…
 Medication
Administration Expansion
 Interdisciplinary Documentation
 Clinical Pathways
 SMART CARDS
Glenn Martin, MD
Director, Medical Informatics
Queens Health Network
Now that we have an EHR how do
we use the data it generates?
 Shift focus from process to outcomes
 Create clinical data repository and
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management registries
Convert data into useful information
 Use data to segment patient populations according
to condition and acuity
 Draw on clinical repository to measure indicators
and track improvement in patient health outcomes
Report writer sits on QHN Intranet and
provides user-friendly query access:
• Provides flexible parameters for
key indicators
• Output can be saved for
retrospective review
• Can sort data to facilitate patient
segmentation
• Includes patient telephone numbers
and primary care provider name
Diabetes
Diabetes
And information needs to be coordinated and flow seamlessly to
community providers who serve our patients outside the hospital
Community
providers can
forward
consultation
requests and
receive reports
on-line
quickly
confidentially
How do we plan to ensure that patients drive
our services and make decisions about where
to get their care?
Smart cards empower patients and connect providers
across communities and health systems
 Effectively make patients the owner of
their
information
 Provide patients the opportunity to carry their
medical information at all times
 Offers patient a vehicle for communicating
current information to their provider of choice
Health Connection Card
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Functions as Patient ID
Includes 64K chip
Patient summary updated at
each encounter with:
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Patient information
Emergency contact
Problem List and Allergies
Active Medications
Complete, relevant lab
results
6,000 patients own the
Health Connection Card
Patients Name