Last year, Children’s Hospitals and Clinics of Minnesota became the first pediatric hospital in the US to achieve interoperability between infusion pumps and EHRs. Although the initiative required a great deal of effort, leadership saw it as an opportunity to leverage IT to improve patient safety. Projects like this are precisely the reason Jeff Young made the leap from the pharmacy benefit management world to health IT five years ago, and he hasn’t looked back. In this interview, we talk about Childrens’ efforts to create a clinically integrated system, the special considerations of IT when it comes to pediatric patients, and Young’s unique career path.
- EHR-infusion pump interoperability
- Partnering with Cerner & CareFusion to “create a safety net around high-risk meds.”
- Dosing concerns with pediatric patients — “We’re hyper-diligent about this.”
- Showing concrete metrics
- Being an innovative organization — “There’s a level of excitement.”
- Training staff in CAC & dual-coding
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We felt our current best practices were very solid, but automating them was something that could definitely help provide that next level of a safety net.
Any time you move into a space that’s a little but more innovative and maybe a little less vetted, there’s significant work, and so a lot of that really came down to better understanding resources and what was involved in moving down this path.
I think for the organization, showing that success leads to willingness to do more things down that path again, as we can vet out that case to show where they add value.
Ensuring that we’re documenting at the right level of detail is very important, and that’s something that we can continue regardless as to whether or not we move to ICD-10. It gives us a little bit more runway to work with our clinician groups and ensure that we’re ready to go when the time comes.
Gamble: One of the initiatives I wanted to talk about was the work you did with infusion pumps and EMRs. This is something that makes a lot of sense but I’m sure it took some work on your part. I just wanted to talk about the project — how it started, how it all came about.
Young: Absolutely. For us, this was really all around patient safety. We’ve had clear objectives for years to continue to eliminate harm. For us, the discussions initially started with Cerner as it related to discussions around barcode med administration. We wanted to take our patient safety goals a little bit farther than that, and Cerner had mentioned that they had been in a little bit of discussion with CareFusion related to moving down this path of integrating infusion pumps as well, and we were very interested.
We really probably had some discussion related to how we would move down this path for close to six months. We worked with both CareFusion and Cerner to better understand, first of all, how mature was the capability that we were going to help implement given that from a Children’s perspective, we’re the first really to implement this. There are a number of things that are very different from a pediatric perspective related to infusion management than in the adult world. Once we worked through all of that, we brought this request for something that we thought had a significant value back to our executive team and, ultimately, the board, to request that we move forward with this.
I know there had been a formal announcement related to infusion management, but since that formal announcement of the infusion management barcode program, the system has continued to improve children’s medication management and patient safety. Again, as I had mentioned, children are particularly vulnerable to medication errors. Drug infusion is used on about two-thirds of our pediatric patients, and it represents a special challenge because the dosages and infusion rates vary by a patient’s weight much more so than with adult patients. That’s something that is very different than the adult world, and we’re always hyper-diligent about this. To give you a feel, we administer well over 100,000 infusions a year within our hospitals, and so we did see an opportunity to focus on a major patient safety initiative, with an opportunity to create another level of what you might call a safety net around high-volume and high-risk medications and improve medication administration and data documentation.
Through discussions, we had recognized that it was an innovative approach and more than likely challenging to make a reality. However, it had the ability to dramatically cut the potential for error so we did decide to move forward, obviously. We worked very closely with Cerner and CareFusion to ensure a safe, seamless and efficient rollout that would integrate the new technology with our current best practices. We felt our current best practices were very solid, but automating them was something that could definitely help provide that next level of a safety net. We recognize as well that we were the first pediatric hospital to integrate infusion pump program and automation into infusion smart pumps. However, this partnership was really about ensuring that others have the ability to benefit from this work given the impact to quality and safety, and at some level, efficiency.
So what does this do? The capability allows for the integration between EMR and our infusion pumps so that a physician order placed in Cerner flows into the pump and auto-programs the pump to reduce any risk of manual error. Information obtained from the pump while the infusion is in process then flows back into Cerner, and this allows our nurses to validate this information versus charted. Again, from a quality and safety perspective, it eliminates a number of manual steps.
What was nice about this is that the system provides concrete information related to this that allows us to focus on training and any necessary processes related to improvement toward practice as well. And so, we get real information related to its use post-implementation — where it’s being used and where it’s not with infusions, along with the use of guardrails, etc., and allows us to really work with the nursing community to continue to improve practice also. The improvement builds upon, from our perspective, a 20-year effort to enhance medication management, and thus, patient safety and operational efficiency. By implementing this new capability, we enable our nurses as well to focus more on patient care and less on documentation. Overall, we feel that we’re providing safer care.
Gamble: Was there some level of hesitancy because there wasn’t really a model to work off of, being one of the first pediatric hospitals to do this?
Young: There was a little bit of hesitancy, and part of that came down to the fact that in context of some institutions, we’re not a huge group. Our IT group is around 125 individuals, and we recognize that any time you move into a space that’s a little but more innovative and maybe a little less vetted, there’s significant work, and so a lot of that really came down to better understanding resources and what was really involved in moving down this path. Was it the right thing to do? Everybody in the organization believed that it was the right thing to do, and that we could significantly improve quality and safety, but it was really related to ensuring that we understood what it would take to get there. But we did work through that and moved on, and we think we’re in a better place because of it.
Gamble: Do you anticipate it’s something where other organizations are going to contact you — or maybe they have already — wanting to know more about what you had to do to start this project?
Young: Yes. A number of organizations have already contacted us. A few have made trips out here to discuss the program more in depth and the effort involved in implementing this — not only from an IT perspective, but from a care perspective as well. One of the big questions that many times would come up is, are you providing safer care? A number of them asked that question. It’s a very good question. Just as an FYI, we have something that we call Safety Learning Reports (SLRs), and those reports related to medication administration events have decreased by about 37 percent, which is definitely significant. We’ve had staff nurses report situations where barcode med administration and infusion management have prevented medication errors.
Patient satisfaction data show us a sustained improvement in our parents’ confirmation of patient identification of the six rights of the bedside, which are right patient, right route, right time, right medication, and right dose, before we ever administer a medication. Our data also show an average about a 57 percent increase in smart pump drug safety parameters utilization since the implementation. Those are some of the things that we talk about with them as well because, ultimately, at the end of the day, does the technology help provide safer care? So far, the information we’re tracking shows that it does. And so absolutely a number of organizations have contacted us, and obviously we’ll help in any way that we can.
Gamble: Is this something that you think you might build upon in other areas as far as doing more with interoperability with smart devices and HIT systems?
Young: Absolutely. This is one of a number of things that are potentially possible down the road. The way in which Cerner accomplished this, they have a capability that they call their iBus. What that iBus really allows them to do is more readily and easily plug other capabilities that are not necessarily Cerner into a Cerner environment. Their iBus capability is fairly mature, and from a smart device perspective, there are a number of things that they’re moving forward within that world, and we’re taking a look at it. Part of it, for us, is based on our long term goals, of which quality and safety is always part of it — what are those things that are really going to help propel care to the next level. But yes, absolutely, we’re looking at those things.
Gamble: Now, for you as a CIO, is it important to be part of an organization where you know that there is a willingness to take on a project that few or no other organizations are doing, and to be that leading edge?
Young: For me it’s exciting, and I think for the group it is as well. If you have a conversation with any of the individuals that were involved in this initiative, there’s a level of excitement, and a lot of excitement to really talk about the successes. And so for me, obviously, it’s exciting. I think for the organization, showing that success leads to willingness to do more things down that path again, as we can vet out that case to show where they add value. And so it’s been a very positive thing for us.
Gamble: It’s one of those cases where you really can utilize technology to improve that patient experience and improve the safety. That’s always a big plus.
Young: Absolutely. And again, we’re excited about it. We’ve recognized sustained improvement. However, it wasn’t necessarily an easy effort, and there were definitely a number of lessons learned. But overall, it’s just looking at the raw numbers related to patient safety and understanding that every time there’s a medication error, that is a child. Any time that we can improve that, we’re excited to move down that path.
Gamble: What are some of the other big priorities right now for you and your team?
Young: We have a number of them. As with everybody else, we have been moving down that ICD-10 path. With the recent announcement to delay ICD-10, we’ve been vetting where we want to go and what we want to do in relationship to ICD-10, recognizing that fairly soon we’ll better understand whether the go-live is next year or whether it’s 2016. So ICD-10 has been big for us.
There are a number of things that were already in place or underway. Computer-assisted coding is something that was well underway, and it’s something that within our HIM group will really help our coders become much more efficient, recognizing that the move to ICD-10 could potentially impact our efficiency by 50 percent. This capability, we believe, can help us by giving us added efficiency of 30. So we’re definitely focused on moving down that path.
The other component to that in helping to drive efficiency is that there’s a projected coder shortage of anywhere between 30,000 and 50,000, given that everybody is trying to hire additional coders related to the inefficiency. So we felt we had to do that related to ICD-10. A number of organizations have started provider training.
And again, this isn’t something where in the inpatient world providers necessarily have to assign codes, but ensuring that we’re documenting at the right level of detail is very important, and that’s something that we can continue regardless as to whether or not we move to ICD-10. It gives us a little bit more runway to work with our clinician groups and ensure that we’re ready to go when the time comes, and so we continue to move down that path as well.
We’re also doing what we call dual coding, which is coding in both ICD-9 and ICD-10. We’ve had a collaborative here in the city with some of the adult institutions and with some of our payers to ensure that when that time comes and we have to flip over to ICD-10, that there aren’t any significant impacts to either the providers or the payers. Dual coding allows us to work with our payers to better understand the impact of this change, and so we’re going to continue to move down that path. Some of that reason as well is the fact that a lot of the new graduates coming out of school were trained in ICD-10 and not necessarily ICD-9. And so there are a number of things that we’re continuing to move on, but that’s been a substantial area of focus for us.