Y2K compliance speeds design of network, EMR
Y2K compliance speeds design of network, EMR
On-line record phase-in will take five more years
The push for Y2K compliance sped the installation of a new electronic network and electronic medical record (EMR) at Texas Children’s Hospital in Houston. Two years into a seven-year time line, the project team has met the more urgent of two looming challenges: They installed a network to handle the millennial date change. And, to the delight of at least one user segment, some modules of the EMR are in place. But perhaps the greatest challenge lies ahead — to bring all the key players aboard as the EMR phases out paper orders and documentation.
Because many QI/TQM readers might be at a similar juncture, John Espinosa, manager of the project and of application support, counsels, "Get your users involved because they are the owners of the system. And partner with your vendor."
Even in an embryonic state, the EMR is stirring up excitement among users:
Phase 1 (complete)
Anatomic pathology, microbiology, and lab results, as well as text results from diagnostic imaging, are viewable across the Texas Children’s continuum. This includes a 456-bed full-care pediatric hospital and 40 pediatric practices throughout the Houston area. Also on-line are demographic data such as age, weight, and height, as well as encounter histories. (See a sample patient record screen, p. 144.)
Phase 2 (went live August 1999)
Ancillary staff transcribe physicians’ handwritten orders into the EMR. Ancillary staff at Texas Children’s are non-nurses who assist with patient care either directly or indirectly. "Eventually, we will have direct order entry," says Jacqueline Hamilton, senior systems analyst. At the moment, however, physicians are still on the sidelines — by choice, Hamilton is quick to point out. "They want all the functionality of the record to be in place before they have to use it." The project team recognizes the obvious impact of its effort. "In the early months, everybody still relied more on the manual processes, but now everybody is trying to use the system, and they are becoming more dependent on it," Espinosa says.
Phase 3 (year 2000)
Physicians begin entering pharmaceutical and lab orders — "Hopefully!" Hamilton interjects. She explains that while the doctors have accepted the EMR thus far, it hasn’t imposed any appreciable changes on their lives.
Phases 4 and 5 (year 2001 and beyond)
Clinical documentation, ambulatory, and critical care records.
The project team credits the ancillary staff with strong support for the EMR. They helped the project team configure the clinical order screens and suggest error-prevention features. Their guideline: What information do we need from the physicians to accurately and comprehensively enter orders on the record?
For example, they designed reference tabs to click for clarification of unfamiliar terms. If an order specifies a toddler’s meal, the transcriber can go to a nutrition reference tab to find appropriate foods and quantities. However, not all users are expected to be as eager as the ancillary staff.
Processing lab orders could be tricky, notes Linda Mathews, RN, MSN, senior systems analyst. "They’re still on a manual system, so we decided to hold off with them until we have the pharmaceutical orders up and running."
The doctors are not solidly on board either, Hamilton adds. "At the present time, they’re happy. But each time we give them progress reports, they say to us, We will not have to use this yet, will we?’ So, we may have more resistance later when we ask them to do direct order entry."
This project is one where workflow assessment, planning, and user training all happened on the fly. "We had to get the system off the ground in one year. We could have used another two months," Mathews concedes. "It would have been helpful to have management engineering input to analyze the impact of the change on our workflow." Instead, they assess and adjust as they go. A medical-order user group is analyzing the EMR’s impact on work processes and redesigning workflow to align with the changes.
Because there was not enough time to prepare in-house trainers, the hospital hired consultants to conduct intensive workshops for a key group of "superusers," the first ones to transcribe clinical orders. In 20 weeks, the consultants completed over 40 workshops. Training will continue through the next five years of the EMR phase-in.
For information on building electronic networks and EMRs, contact:
o Steve Clark, Vice President and Chief Information Officer, University of Colorado Hospital, Denver, CO. E-mail contacts only: [email protected]. University of Colorado Hospital’s Web site: www.uchsc.edu.
For information on electronic networking hardware and solutions, contact:
o 3Com, 5400 Bayfront Plaza, Santa Clara, CA 95052-8145. Telephone: (408) 326-5000. Fax: (408) 326-5001. Web site: www.3Com.com.
For information on phasing in an EMR, contact:
o Jacqueline Hamilton, Senior Systems Analyst, Texas Children’s Hospital, Houston. E-mail contacts only: jahamilt@TexasChildrens Hospital.org.
For information on computer-based patient record systems, contact:
o Oacis Healthcare Systems, The Oacis Building, 1101 Fifth Ave., San Rafael, CA 94901. Telephone: (415) 482-4400. Fax: (415) 482-4610. Web site: www.oacis.com.
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