For the physicians and nurses at Children's Hospital of Pittsburgh, a member of the 20-hospital University of Pittsburgh Medical Center health system, the logic behind going totally paperless as the clinicians and staff prepared to move into the hospital's new replacement facility in 2009 was inescapable. Already live for several years with its EMR and CPOE, the hospital's move to its brand-new facility was to be accompanied by the elimination of nearly all of its remaining paper-based processes.
And because the hospital's IT staff, led by vice president and CIO Jacqueline Dailey and CMIO James Levin, M.D., Ph.D., had long been collaborating closely with clinician leaders, the organization was well-positioned to reap all the benefits of automation in preparation for the move, which took place in June of 2009.
There was just one big wrinkle, insofar as clinicians in the hospital's three intensive care units (its general ICU, cardiac ICU, and neonatal ICU) were concerned. While the organization's core EMR/CPOE system (based on the Cerner Millennium suite, from the Kansas City, Mo.-based Cerner Corporation) supported a host of innovations to patient care delivery, intensivists working in the ICUs found themselves struggling with one automation element.
In the past, they had worked with what to outsiders might seem like clumsy and indecipherable paper-based patient flowsheets. Yet as unwieldy as those flowsheets might have appeared to anyone else, the intensivists in the ICUs read them with ease. But the first iteration of the automation of those flowsheets had left the intensivists confused by the way in which key patient data was being presented. What's more, a complication with another innovation was creating intensivist pushback. On the one hand, every patient room at Children's had been equipped with a computer workstation. But it often took a full two minutes to log into the system, a frustrating length of time for physicians in the fast-moving practice context of the ICU.
The solution? Dailey, Levin, and the clinical informaticist team went to the vendor and proposed developing a new solution for the ICU, which came to be called iAware (a Cerner spokesperson confirms that iAware had, as of press time, gone live in six other hospitals across the country, and is being customized for a variety of clinical departments).
“I think part of our success in this area came from the fact that we never left this to go onto the next project, until we could make sure our clinicians were comfortable …”
With regard to the two-minute log-in issue, the computers were re-engineered so that a quick jiggle of the mouse would open up the computer screen to show all the key patient data immediately. And more broadly, Dailey, Levin, and their colleagues, in concert with Cerner developers, created with iAware a broad new capability based on the clinical dashboard concept. Now, intensivists and nurses, as they open the iAware dashboard, instantly access the most important patient data for immediate decision-making: hemodynamic data including heart rate, blood pressure, and respiratory rate; lab data including hemoglobin levels, blood gases, lactic acid levels, and creatinine levels, and the patient's current medications.
One early challenge in the development of iAware was the recognition among clinicians and clinical informaticists at Children's that there was a physical limitation to the amount of “real estate” available on the screen. So the hospital's intensivists sat down together to determine which data elements were most important, with the elements mentioned above making the cut. Fortunately, says Constantinos Chrysostomou, M.D., one of the cardiac intensivists, “It didn't take us long to agree on which data elements should be on the dashboard.”
Part of the reason for the success of the alpha-site implementation, says Dailey, was the very rapid cycling of development on the new tool. In fact, it simultaneously both kept clinicians engaged in the process of development (side by side with the hospital's clinical informaticists and with its vendor's developers), and promised a quick return on investment for the time clinicians invested in the development process.
“I think part of our success in this area came from the fact that we never left this to go onto the next project, until we could make sure our clinicians were comfortable with their new e-record,” says Dailey. What's more, she says, “They weren't difficult clients at all. But I think they were as confused as we were at the beginning; so we really had to listen carefully to them and to address their critical care needs.”
At the nub of the development challenge, she says, is that the intensivists at first could not easily articulate what the problems with the new form of data presentation in the system were. So clinical informaticists, including Levin, sat down with intensivists and nurses and painstakingly uncovered and worked through the issues involved.
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