FUNDING FOCUS: OHSU RESEARCH 101 - OCTOBER 2012 OHSU Research Funding & Development Services.
Collaborating to Fund and Advance Research- The OHSU Experience Jeffrey A. Gold, M.D. Professor of...
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Transcript of Collaborating to Fund and Advance Research- The OHSU Experience Jeffrey A. Gold, M.D. Professor of...
Collaborating to Fund and Advance Research-The OHSU Experience
Jeffrey A. Gold, M.D.Professor of Medicine December 17th, 2014
Disclosures• Received funding from AHRQ,
AAMC/Donaghue Foundation
Statement of Clinical Problem• Electronic Health Records (EHRs) are at the center
of all data communication, clinical decision making and care implementation in the health care system
• Numerous studies document poor use of EHR can lead to increased patient errors and undermine communication
• The ICU appears to be a highly vulnerable environment to these issues• Massive amounts of data (>1800 data
points/day)
• Most physicians feel that current EHR training is inadequate
SolutionTo use simulation with high fidelity, contextually relevant cases to improve EHR utilization and help focus EHR redesign
What resources are required?• High fidelity (realistic) cases for training.
Need to be created by content experts Cases need to be designed specifically to test EHR
usability and safety (the controlled lie)
• Cases need to be built into the EHR
• Need a cloned version of EHR which looks identical to clinical system but doesn’t have actual patient data• Must maintain user customization
• Problem- I am a basic scientist/fellowship director with background in ICU administration
Step #1-Reach out to Informatics• Chair of Informatics-Bill Hersh
• Introduced me to Fran Biagioli who user EHR simulated cases for Medical Students
• Used resources from ARRA funds to help fund EHR educator (Gretchen Scholl) to help build simulated cases, create separate simulation environment and trouble shoot problems Leveraged support from hospital Human Resources
to allow for shared position Human Resources controls EHR training Engagement of hospital CMO
Barriers to Overcome• Cases need to be created
• Need to test meaningful use of EHR• Recognition of patient safety issues/errors-not
just charting
• Cases need to be imported into EHR• Manually done-no autoimport
• Cases must be temporally contextually correct• They must exist in realtime –cloned forward
• Can’t use actual production EHR environment• Impacts billing, pharmacy, meaningful use etc….• Need to maintain user customization and workflow
Methods
5 day real life ICU stay created in EPIC simulation environment Cases originally created in EXCEL
Every data point created and entered by hand in relative real time (no way to download data into system)-Patient “cloned” forward to day of testing so can be used in real time
Case contains clinical decompensation with 15 built- in patient safety issues• Vitals trends, medication misdosing, lack of best practices
Methods Cont..Trainees given written history, relevant clinical info for last 5 days, Bld Cx results and PE• No radiology in sim and residents told not to look for it
Trainees given 10 min to gather data in EPIC• Done in ICU to recapitulate effect of environment (lights
etc…)
Subjects told to present case as if giving daily plan and signout for weekend
Residents allowed to use own login for customization
Subjects could be tested again, at least 1 week later• Repeat testing with different case-random order
Types of Patient Safety IssuesIssues of Cognition• Recognizing trends in vitals• Recognize high Pplat
Familiarity Issues• Do they even know where things are located
Medical knowledge Issues• Do they even know appropriate VT
Fragmentation issues• How many screens are used
Step #2-See if it works
Re
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rre
nt
Se
ps
isB
P/H
RP
lat
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ve
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an
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rou
gh
Va
nc
o D
os
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os
yn
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se
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se
>2
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r In
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lin
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SS
Da
ily
Aw
ak
en
ing
TV
Flu
id B
ala
nc
e0
10
20
30
40CorrectIncorrect
# S
ub
jec
ts
ClinicalChange
MedicationError
Failure toAdhere to Bestpractice
• Run 40 housestaff through simulations and document that average clinicians miss >50% of safety items within a case
March et al BMJ Open 2013
Step #2-See if it works• Run 40 housestaff through simulations
and document that average clinicians miss >50% of safety items within a case
• Data used to obtain R18 from AHRQ for using simulation to improve patient safety
• Funds from this grant allow for creation of additional cases to document training effect
• Allow to increase N>150
Trainees Fail to Recognize Patient Safety Issues
Stephenson et al BMC Med Ed 2014
Can Simulation Improve Performance?
Pre Post0
20
40
60
80
100
p<0.0001
% C
orr
ect
All Subjects
A.
Case 1 First, then Case 2
0
20
40
60
80
100
p=0.0003
% C
orr
ect
B.
Case 2 First, then 1
0
20
40
60
80
100
% C
orr
ect
p=0.001
C.
Stephenson et al BMC Med Ed 2014
Next Level of Clinical Problem• In the ICU we round as an Interprofessional
team (RN, MD, Pharmacist, RT)
• Effective clinical decision making on rounds is dependent upon Everyone accurately retrieving and reporting
data Everyone effectively using the EHR
Best Practice for ICU Rounds
• Interprofessional Rounds, including RN, pharmacy, and RT
• Multiple studies document improved cost, improved morbidity and patient satisfaction with interprofessional rounds
• Multiple barriers, including information retrieval and EHR Both increase time and decrease
communication
• Little data in controlled settings to determine whether improved error recognition by the group Swiss cheese or Cheese cloth
EHRs Differentially Impact RN and MD Workflow
• RNs like EHRs more often than MDs
• EHR has more dramatic affects on efficiency for MDs (Poissant)
• Only 46% of handoff items overlap in data transmitted during handoff (Collins)
• RNs unaware of abnormal vitals in 43% of ward patients (Fuhrman 2012)
• 25% of goals stated in rounds are not present in EHR (collins 2009)
Solution-ICU Round Simulation• Obtained funding from the AAMC/Donaghue
foundation to allow for entire Interprofessional team to participate in simulation activities.
• Engaged hospital Nursing, Pharmacy and Medical leadership to facilitating testing of all groups.
• Have now tested all of ICU RNs and Pharmacists on same case as MD.
• Beginning full ICU rounds simulation this winter.
• Project is now an Incubator Project for National Center for Inteprofessional Education and Practice Allowed leveraging of resources from OHSU IPE
committee including nursing and pharmacy
Creation of High-Fidelity EHR Simulation for all members of IP Team.• Engaged RN and pharmacy leaders to help in
scenario and case design
• Initial simulation cases modified to ensure contain all relevant information for all professions (almost an extra 400 data pts/day for RNs)
• Needed to frame scenario for workflow
• Pharmacists review chart during mock presentation
• RNs get a mock signout from another RN
Proclivity for Different Professions in Identifying Safety Issues
Recurrent Sepsis
Vanc trough
Vanco Dose
Zosyn Dose
Fever
BP/HR
Glucose
Insulin
D5
maas
Daily Awakening
Plat
TV
Fluid Balance
0
50
100
PharmHousetsaffRN
Differential Patterns in EHR Utilization Amongst Professional Groups
Total of 135 Different Screens Used
Overlap in Screen Utilization
Housetaff
RNPharmaci
st
3
0
13
3
64
What Are Differences in Workflow?
12
3
5
6
9
10
14
17
1920
23
36
82
85
110
111
113
128
135
0
50
100
Pharmacist
Housestaff
RN
Next Steps• Leveraging these data for redesign of
ICU rounds• Focusing on data veracity and patient safety
• OHSU created an ICU Change Management group focused on standardization of EHR utilization and redesign.• Allows dissemination across all ICUs
• RO1 submitted to AHRQ.
Our Team NowDivision of Pulmonary Critical Care• Jeffrey A. Gold, PCCM/CCM Program Director
Department of Medical Informatics• Vishnu Mohan, Bill Hersh
School of Medicine• Gretchen Scholl
School of Nursing• Judith Baggs
School of Pharmacy• Dave Bearden
OHSU Hospital• Jesse Bierman (Pharmacy), Ashley Mulanax (ICU RN), Adrienne
McDougal (ICU RN) • OHSU ICU Change Management Group