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The 2018 Healthcare Informatics Innovator Awards: Co-Third-Place Winning Team—St. Jude Children’s Research Hospital

February 19, 2018
by Heather Landi
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A multi-disciplinary team implemented EHR-IV pump integration to improve chemotherapy infusion management
L to R: Richard Clark, Barbara Gingras, R.N.; Arta James; Teresa Browning, R.N.; Dana Matheny, R.N.; and Pamela Goodman, R.N.

Operating since 1962, Memphis, Tennessee-based St. Jude Children’s Research Hospital is considered a top pediatric cancer hospital and research center, with nearly 8,000 patients seen yearly.

St. Jude is the only National Cancer Institute Comprehensive Care Center devoted solely to children, having received the NCI’s highest ranking of “exceptional.” The hospital also has been designated as achieving Magnet status by the American Nurses Credentialing Center, which is based on an evaluation of patient care, safety and satisfaction as well as attracting top nursing talent and demonstrating a collaborative culture among nursing staff.

This collaborative culture and commitment to quality and safety has been the driving force behind a recent interoperability initiative by clinical and informatics leaders at the hospital to integrate the electronic health record (EHR) and bedside patient care devices for infusion management and vital sign transmission. These initiatives have helped to eliminate manual pump programming errors, a top patient safety issue. Because of their cutting-edge work, the editors of Healthcare Informatics have chosen the leaders of St. Jude Children’s EHR-device interoperability initiative as the co-third-place-winning team in the Healthcare Informatics Innovator Awards Program, Providers Division.

According to St. Jude executive leaders, with the hospital’s 2016-2021 institutional strategic plan, one of St. Jude’s initiatives is to strengthen its focus on patient quality and safety practices. To move this forward, nursing, pharmacy and IT leaders have been collaborating on two major projects focused on increasing efficiencies with the EHR—infusion pump interoperability and automatic transmission of vital signs to the EHR from outpatient clinics.

Prior to this EHR-IV pump integration project, which started about three years ago, St. Jude nurses manually programmed infusion pumps with patient identifiers and IV medication orders. Once complete, the nurses then had to electronically sign the medication administration and infused volumes in the hospital’s Cerner EHR. This manual intervention and movement between disparate systems created a cumbersome process that reduced nurses’ time for clinical duties and created opportunities for manual errors, according to Keith Perry, senior vice president and CIO at St. Jude.

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“The biggest challenge with infusion management is the human factor,” says Robin Mobley, R.N., inpatient nursing director at St. Jude. “Even though you’ve got a pump that is delivering the medication and it’s delivering it accurately, when you go to that pump and you are entering the rate, the time frame, the volume that is to be infused, every time you do that, every stroke you make on that pump, is an opportunity for error. With interoperability between the EHR and IV infusion pumps, you are taking away that human factor.”

She adds, “The fact that we’re dealing with some really dangerous drugs makes it even more important for us to have that extra security in our workflow processes.”

According to the Agency for Healthcare Research and Quality (AHRQ), adverse drug events are likely the most common source of preventable harm in both hospitalized and ambulatory patients. The greatest potential for harm lies with medication errors related to intravenous (IV) infusion. Hospitals are faced with the challenge of finding ways to reduce these serious and life-threatening errors. The use of smart IV pumps has helped to improve infusion safety, and many healthcare quality and safety experts advocate that closed-loop interoperability between the smart pump and EHR can significantly reduce medication errors. However, EHR-IV interoperability technology is considered a relatively new innovation and it is a challenging IT issue for most hospitals and health systems.

As St. Jude is a pediatric oncology hospital, a major focus on the project centered on complex chemotherapy IV orders that often involve many different medications. About 95 percent of St. Jude inpatients are on infusion pumps and IV medications also are used in the outpatient setting as well.

The initiative was a strategic collaboration between nursing, clinical informatics, pharmacy, biomedical engineering and enterprise informatics teams. “It wasn’t only interoperability between the devices and the EHR, but it was also between departments,” notes Barbara Gingras, R.N., project manager, clinical informatics within St. Jude’s information services department.

While there were many IT-related challenges, some of the largest challenges were identifying and operationalizing the nursing and pharmacy workflows for all IV infusion orders due to the complicated infusion process, such as chemotherapy protocols, as well as workflows for specific drugs and types of infusion.

“Being a pediatric oncology facility, we likely give, on average, 50 percent more medications than a regular pediatric hospital. We have processes that we use to be able to get all those medications in on time,” Mobley says. “So, sitting down with nursing, with pharmacy, and IT and clinical informatics, we had to look at all those processes put together and map those out; that was a crucial step to getting this implemented.”

She continues, “Even during the implementation, there were challenges that we ran into with trying to take technology that is meant for complex infusions but also geared to a more regular workflow. We really had to work closely with Cerner and Alaris [an infusions systems vendor] and with our clinical informatics and pharmacy team to figure out what processes we can use. We didn’t want the technology to determine our process, but for our process to work with the technology.”

As part of this project, pump formularies and associated pharmacy and nursing processes had to be rebuilt and tested. Multiple iterations of testing took place as issues were found and bugs were fixed. “We had to test every drug, because of the rebuild of the Alaris pump system, and to make sure we had the processes right,” Gingras says.

Teresa Browning, R.N., clinical informatics senior reengineering analyst, information services, adds that one of the biggest lessons learned was the critical need for ongoing testing. “You need to have the time and resources to do the testing, it’s essential. We had nursing test it with their workflows. It’s important that you test, test, test.”

The ultimate aim of the project was to create interoperability between the EHR and wireless pumps, which in turn would send patient information and orders via Cerner’s CareAware module to the pump. The pumps then complete the loop by sending IV infused data, via CareFusion technology, to Cerner’s Infusion Management tool and the EHR.

The EHR-IV pump interoperability initiative went live in August 2017, and, as a result, nursing workflow efficiency has increased as 10 out of 15 manual steps have been eliminated, leading to a 50 percent improvement in compliance with Guardrails, a dose-error-reduction system, Browning says.

Electronic infusion orders for complex chemotherapy orders are now sent directly from the clinician’s electronic order to the infusion pump, eliminating manual pump programming errors. Actual infused volumes are automatically populated in the medical record, which eliminates manual entry and associated errors. In addition, nursing and pharmacy now have access to monthly compliance reports for ongoing quality improvements, Gingras says.

“Over the past several years, we have championed a focus on providing a frictionless experience to our patients and their caregivers. In fact, it is our first priority in the Information Services strategic plan,” Perry says. “More times than not, technology teams implement an application or system and walk away believing it has optimized workflow. The challenge that we face in healthcare IT is that work continues to evolve, people and processes change, and technological advances are released at a rapid pace.” And, he adds, “The team that implemented the project was able to recognize this challenge.”

Automatic transmission of vital signs to reduce medication errors

As part of this broader project to increase efficiencies with the EHR, clinical, IT and biomedical engineering leaders at St. Jude also collaborated to implement automatic transmission of vital signs, including patient height and weight, into the EHR from the outpatient clinics. The hospital serves 300 to 400 outpatient visits a day at 10 clinics.

According to Perry, in the clinic setting, nurses previously transcribed the documented vital signs into the EHR. Because of the weight-based dosing and body surface area (BSA) calculation in the majority of medications and complex chemotherapy orders administrated at St. Jude, clinical leaders felt that these inefficient, manual processes needed to be remediated.

“In pediatric organizations, about 10 percent of medication errors that occur are attributed to a discrepancy in weight documentation. We were looking at challenges related to possible data error entry and we were looking at ways to remove that potential risk,” Dana Matheny, R.N., nursing manager for the ambulatory care unit, projects and quality, says.

The original scope of the project was to implement new wireless devices, such as weight scales, stadiometers and vital sign monitors, and Cerner’s CareAware VitalLinks platform in the assessment triage areas of the clinics. Cerner’s platform enables a barcode-driven process on an integrated device for clinicians to chart vitals data directly into the EHR.

The wireless transmission of height and weight in ambulatory care was new for St. Jude, and also new for Cerner and for the hospital’s medical diagnostic equipment partner, Welch Allyn, according to Perry. No other Cerner site had implemented this type of data integration using these specific devices and platforms. The project required extensive collaboration with vendor partners, and there were a number of challenges related to deploying new equipment, changes in nursing workflow and infrastructure issues around wireless connectivity, project leaders say.

St. Jude went live with the implementation in March 2017, and, as a result of this work to link vital signs directly into the EHR, manual entry errors have decreased, Perry says. What’s more, the project has decreased patient turnaround times at the outpatient clinics by enabling nurses to quickly scan patients and devices, then wirelessly submit patient data.

“At face value, this initiative reduced the manual processes in the delivery of complex care to our pediatric patients and challenged the status quo,” Perry says. “Understanding a patient’s weight (body surface area) is extremely important as it is used to calculate the chemotherapy agent dosage, therefore, reducing the likelihood of errors. As a result, the nursing team is now able to focus on the child rather than a process.”

And, Perry adds that this project to enable automatic transmission of vital signs ties into the organization’s strategic focus on providing a “frictionless experience” for patients and caregivers. “The key to focusing on a frictionless experience begins with fostering cross-departmental partnerships, building a culture of improvement that challenges the status quo, and recognizing that how we did something yesterday will not be good enough for tomorrow.”

Matheny says, “We try to align our projects with our organization’s strategic initiatives, and we look at what are the clinical outcomes we’re trying to achieve and where we can make the biggest improvements? We’re fortunate at St. Jude that we have such great teams working together, across all the departments.”

Project leaders emphasize that senior executive leadership support for the interoperability project was a critical key to success. “The direction is coming from the top down and this is a quality initiative and part of enhancing patient care, so we get the support and the resources that we need,” Gingras says.

 


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CommonWell Officials: Carequality Connection Now “Generally Available” for Members

November 16, 2018
by Rajiv Leventhal, Managing Editor
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CommonWell’s executive director said this latest step “breaks down another interoperability barrier”

Connection capabilities to the Carequality framework, by members of the CommonWell Health Alliance, are now “generally available,” according to officials who made an announcement today.

CommonWell, a trade association providing a vendor-neutral platform and interoperability services for its members, announced in August that it had started a limited roll-out of live bidirectional data sharing with an initial set of CommonWell members and providers and other Carequality Interoperability Framework adopters. This marked a key step in a collaborative effort to increase health IT connectivity across the country by enabling CommonWell subscribers to engage in health data exchange through directed queries with Carequality-enabled providers, and vice versa.

In just the first two weeks of a few CommonWell-enabled providers being connected, Jitin Asnaani, CommonWell Health Alliance executive director, said there were more than 4,000 documents bilaterally exchanged with Carequality-enabled providers.

Since then, by leveraging the technological infrastructure built by CommonWell service provider Change Healthcare, members Cerner and Greenway Health successfully completed a focused rollout of the connection with a handful of their provider clients, who have been exchanging data daily with Carequality-enabled providers, officials stated today.

Now, since the connection went live in July, officials noted  that CommonWell-enabled providers have bilaterally exchanged more than 200,000 documents with Carequality-enabled providers locally and nationwide.

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“We are proud to break down yet another barrier to interoperability by making this much-anticipated connection available to our members and their clients,” Asnaani said in a statement today. “This increased connectivity will serve to empower providers with access to patient health data critical to their healthcare decision-making.”

In December 2016, CommonWell and Carequality, an initiative of The Sequoia Project, announced connectivity and collaboration efforts with the aim of providing additional health data sharing options for stakeholders. Officials said that the immediate focus of the work between Carequality and CommonWell would be on extending providers’ ability to request and retrieve medical records electronically from other providers. In the past two years, teams at both organizations have been working to establish that connectivity.

Together, CommonWell members and Carequality participants represent more than 90 percent of the acute EHR market and nearly 60 percent of the ambulatory EHR market. More than 15,000 hospitals, clinics, and other healthcare organizations have been actively deployed under the Carequality framework or CommonWell network.

Carequality is a national-level, consensus-built, common interoperability framework to enable exchange between and among health data sharing networks. It brings together electronic health record (EHR) vendors, record locator service (RLS) providers and other types of existing networks from the private sector and government, to determine technical and policy agreements to enable data to flow between and among networks and platforms.

CommonWell Health Alliance operates a health data sharing network that enables interoperability using a suite of services aiming to simplify cross-vendor nationwide data exchange. Services include patient ID management, advanced record location, and query/retrieve broker services, allowing a single query to retrieve multiple records for a patient from member systems.

Following the August announcement of the limited bi-directional data sharing capabilities, Micky Tripathi, Ph.D., president and CEO of the Massachusetts eHealth Collaborative said, “This is the ‘golden spike’ moment, connecting the two big railroads, like when AT&T and Verizon finally got connected. This is building that bridge.” Tripathi, who also directly observes and participates in conversations with Carequality and CommonWell, added, “It will take a while for all of the production sites and different vendors to get up and running. That will probably take a couple of years. But you have to have the bridge to connect them to begin.”

One key element in this progression is that currently, EHR giant Epic is not a member of CommonWell, despite other major EHR vendors pushing Epic in that direction. “Because sharing among Epic customers is already universal, when CommonWell connects to Carequality, the entire Epic base will become available, creating instant value for most areas of the country,” a recent KLAS report on interoperability stated.

Interestingly, Tripathi noted in August that once there is “general availability” of the data sharing services for all Carequality and CommonWell members, the competition factor will become less important. “It makes both networks more valuable,” Tripathi said at the time.

It appears as if that “general availability” time has now come. “Thanks to the CommonWell-Carequality connection, our patients can have access to their medical records regardless of the EHR a health care facility uses,” said David Callecod, president and CEO of Lafayette General Health, a Cerner client located in Lafayette, La. “When data is made readily available, providers can make diagnostic and treatment decisions more quickly, and patients can recover sooner. Better data means better communication with our patients and providers, better care and better outcomes. This is a very powerful tool!”

Officials also noted that with the connection officially in production, additional CommonWell members, including Brightree, Evident and MEDITECH, are in the process of subscribing to the connection and taking it live with their provider clients.


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Advancements in Healthcare: Interoperability, Data Exchange, and More

Tuesday, December 4, 2018 | 3:00 p.m. ET, 2:00 p.m. CT

Micky Tripathi, President and Chief Executive Officer of the Massachusetts eHealth Collaborative, is one of the most well-informed and well-respected healthcare IT leaders in the U.S. Tripathi has an inside look at the most significant interoperability trends that are happening nationwide and will discuss varying interoperability and data exchange efforts fit together in the bigger picture of U.S. healthcare.

Tripathi will also discuss the future of data exchange, advancements of standards such as FHIR, the reality of information blocking challenges, and more in this latest Healthcare Informatics webinar, which gives a high-level view on the many market forces that impacting nationwide interoperability.

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Epic Lowers App Orchard Program Fees, Introduces New Low-Cost Tier

November 1, 2018
by Heather Landi, Associate Editor
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Verona, Wis.-based Epic plans to lower program fees for health IT developers participating in its App Orchard program, and will launch a new entry-level program tier, called Nursery.

Epic announced the App Orchard updates at its App Orchard conference last week at its Verona headquarters, according to reporting from Politico published Oct. 26.

In an email statement, Brett Gann, App Orchard director, confirmed the company is reducing and simplifying the costs associated with participating in the app developer program. The three tiers of the program will see program fee reductions ranging from 33 to 80 percent as part of the update, Gann said.

Epic launched its App Orchard in 2017 as an online marketplace for third-party developers with 13 applications.

To date, more than 350 companies in the healthcare industry participate in Epic’s app developer program, where they have access to hundreds of application programming interfaces (APIs), documentation, testing tools, individual technical support, training, conferences, and integration with the Epic community, Gann said,

Gann also said the program updates announced last week at the annual App Orchard Conference in Verona will “engage a broader community of developers and increase access to APIs through simplified and reduced costs.”

The updates will help drive healthcare innovation as interested developers have the opportunity to build on top of Epic’s health record platform, using emerging industry standards such as FHIR (Fast Healthcare Interoperability Resources), Gann said.

Epic also announced a new program tier, Nursery, that will enable early-stage startups to enroll in the app developer program to access Epic’s public API documentation, tutorials, and sandboxes. Early-stage startups also will have access to FHIR, SMART on FHIR, and CDS Hooks, Gann said.

Enrolling in the Nursery program tier will cost participants $100 per year, Gann said, and when a company is prepared to go to market with its product, it may graduate to one of the other three tiers.

Nursery members will have access to Epic’s FHIR sandboxes, classroom and online learning opportunities, and the ability to engage with the online community of Epic, health system, and vendor developers and experts.

In addition to the program fee reductions, as part of the update, Epic will offer new program benefits to participants in the other three tiers, such as additional training opportunities, developer events, support services, sandboxes, and program accounts.

Gann also said Epic has simplified the pricing model for API-based integrations, eliminating the minimum fees, and reducing the cap. “It’s our expectation these updates will be a price reduction for nearly all program members,” he said.

Some developers, particularly smaller developers, have complained in the past that the fees to participate in the vendor app store are too steep.

Earlier this year, Politico reported the experiences of Rick Freeman, CEO of Interopion. Freeman told Politico that a family planning questionnaire app he developed for HHS’s Office of Population Health could have cost him up to $750,000 to run on Epic or Cerner for a year.

As reported by Politico in its October 26 report, in response to the program updates, Freeman said he is “very happy with the changes.”

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