Because of the support of the most advanced technology, the clinical team - like nurse Kelly Foltin , RN - can spend more quality time at the patient 's bedside delivering quality care and less time sorting through files tracking , analyzing and comparing notes and data.
Published: Synapse 2012, Vol. 2
WHAT YOU SEE when you're a patient at The Chester County Hospital are nurses, physicians, and other staff frequently attending to you while they add details into the bedside computer. You might assume they are simply updating the electronic health record (EHR) that gives a real-time account of your health status, test results, procedures, and medications to everyone involved in your care. That's true, and vitally important, but it's only part of the story. For more than 25 years, the Hospital has partnered with Siemens Healthcare to design its systems not only to store data, as a traditional medical record does, but to also actively use that information to guide care.
"We haven't simply moved from writing notes by hand to typing them into a computer," explains Karen Pinsky, MD, Chief Medical Information Officer. "We have gone much further than that. We are populating information into a platform that allows us to leverage the data we are entering -- making manual review easier, but also allowing the computer to constantly sift through it and recalibrate your care as needed."
"Think of it as the GPS system in a car," says Ray Hess, Vice President for Information Technology. "You're the driver in control, but the system calculates the turns and alerts you as you are coming up to specific decision points. If for some reason you start going off course, the GPS helps to get you back on course. We are leveraging our systems to give our clinicians this type of directional safety net."
"For any process, we analyze our current workflow, we develop a process for the way we want it to be, and then this becomes the specification for what we need to build," Hess adds. "We figure out what the best process is based on best practices from around the country, and then we build in the system tools to support that."
WHAT YOU GET as a result is a care environment that weds the expertise of its nurses and physicians with systems specifically engineered to support them in giving you the right care at the right time. Whatever your diagnosis, the practitioners will lead you through the most up-to-date process of care, receiving alerts and reminders to guide them along the way. You will receive the right medications and tests. You will get care steps proven to lower the risk of in-hospital complications such as deep vein thrombosis (DVT, or blood clots in the leg) and pneumonia. If you have an intravenous line or a urinary catheter, your nurse will be alerted when it needs to be changed or removed, which drastically lowers infection risk. Your physician or nurse will always know what has happened and what care steps need to be considered next -- or perhaps are overdue.
To achieve this, the Hospital's information technology (IT) staff and clinicians work closely with the Siemens team to build these systems from the ground up. The partnership with Siemens has been critical in this work. "It has been great for Siemens to work with a Health System that is committed to being an early adopter of new technologies," says Tom Giannantonio, Program Manager for Siemens.
"It gives us the opportunity to pilot these systems, receive real-life feedback, and demonstrate how they help improve care at the bedside. The Chester County Hospital continues to be an outstanding showcase for Siemens' technologies, with hospitals from all over the country and abroad coming to see the technologies that have been implemented and are supporting the patient care process here today."
Nichole Coleman, RN, BSN, PCCN, the day shift charge nurse on the Telemetry Unit, witnesses the benefit of this technology daily as she oversees a team of nurses providing care to about 30 patients.
"If there is a new physician order, it pops up right into the nurse's work list. So a nurse can click on the four or five patients in his or her care, see the orders, and acknowledge them right in the system. And then the nurse can take care of them and document the time they were done," Coleman says.
"The computer workflow reports are helpful to charge nurses and nurse managers as well. It gives us a quick overview of the patients who are candidates to receive the pneumococcal or influenza vaccines. These vaccines can then be addressed with the patient in a timely manner."
"We don't have to chase down information, which saves us time, creates less room for error, and most importantly, frees nurses to spend more time at the bedside," she adds.
There is another layer of complexity, though: No two patients are exactly alike, and the technology must be able to recognize your individual needs. If you've told us you are taking certain medications or have a medication allergy, the Hospital's systems are designed to alert the physician or nurse to avoid medications that could be dangerous. If your medical history or test results suggest high risk for cardiovascular disease, diabetes, or some other condition, your physician and a health educator will automatically be notified and start you on the path to better health. If you have any lab test result that suggests a problem in need of correction, your bedside nurse will know about it right away.
"If there is a critically low or high lab value, it shows up in the system as an alert," Coleman says. "Then nurses have to document how they addressed it; otherwise, the alert stays up. This ensures safety for the patient and timely care as well."
"The patient is always at the center, and the technology is there to help us do a better job of individualizing care," Dr. Pinsky adds. "When you shop online or even in the grocery store, you get ads and coupons targeted to your preferences. Well, in a similar way, we want to target the care to your needs. We are trying to leverage this enormous mound of information and present it to the clinician in a very individualized way."
Two examples that illustrate how this works:
Care for the Patient with Diabetes
If you are admitted to The Chester County Hospital and report a history of diabetes, or if you have risk factors for the disease, its system automatically alerts the physician to order a Hemoglobin A1c test, which indicates whether your blood glucose level is under control. If it's not, then your care is tailored to bring the diabetes under control -- during your stay and beyond.
"We know who the patients with diabetes are the day they walk into the Hospital, and that is a great advantage," notes Julie Funk, MS, RD, CDE, LDN, Director of Community Health and Wellness Services. "The same technology automatically creates a census of patients for our diabetes educators, so they know who in the Hospital has diabetes that is not well-controlled. Right away, they can help get them back on track."
The system also guides the physician to tailor insulin treatments to the patient's individual characteristics, including age, weight, blood sugar level, even their meal schedule. The order set is right there in the computer, with the physician able to choose from among different dosing levels to control blood sugar levels within range. Also built in are automatic alerts when blood glucose levels need to be checked or when the level swings out of control, requiring immediate attention. According to Funk, the order set's tailored approach to inpatient diabetes management is fairly new, but the Hospital was among the first dozen or so nationwide to adopt it.
"We want to be sure we are giving people state-of-the-art care as we currently know it. And that they receive it safely," Funk says.
Another example of a key safety check affects patients who are taking the medication metformin (brand name: Glucophage) to control type 2 diabetes. If the physician orders an imaging test that requires intravenous contrast solution, Glucophage has to be stopped for at least 48 hours after the test. Otherwise, kidney complications could result. This process used to be done manually, notes Kathy Zopf-Herling, RN, MSN, Director of Nursing Informatics, but it is much safer and more efficient to rely on technology than people's memories.
"Now as soon as the radiology staff scans the IV contrast to be used for that patient, the Glucophage is automatically discontinued for 48 hours," she says. "After that, the system alerts the physician and gives the option to order a renal panel [kidney function test] or to resume the Glucophage."
Funk and the members of the Diabetes Care Task Force are now working with the IT staff to embed recommendations for self-management skills right in the system, tailored to the severity of patients' diabetes and whether they are receiving this diagnosis for the first time.
Cardiovascular Unit Nurse Tonya Beattie, RN, goes through each element of the detailed discharge plan with her patient. 'My Discharge Plan' has taken away the patient's guess work about what they should do after they leave the Hospital, thus preventing many re-admissions.
A Personalized Discharge Plan
The Chester County Hospital participated in a Boston-based research project called Project RED (Re-Engineered Discharge), which focused on using more intensive education and case management to make sure patients could manage their condition at home once they were discharged -- and possibly avoid readmission for the same ailment. The Hospital targeted its efforts at patients with congestive heart failure and found that more intensive discharge education did indeed reduce readmissions. So it wanted all patients to benefit from an improved discharge process.
"The only way to 'scale this up' for all patients was to use technology," says Dr. Pinsky. Over that past year, the Hospital has been working on a solution that harnesses its current systems to:
- Flag patients who are at higher risk for readmission, whether due to advanced age, multiple conditions, a language or literacy barrier, or some other factor, in order to make sure they get followed more closely.
- Create a new, easy-to-read, comprehensive discharge plan that pulls in all relevant information from the electronic health record about the patient's condition, management strategies, medications, and follow-up appointments.
The result is "My Discharge Plan," an innovative approach to discharge education that rolled out Hospital-wide this summer. Instead of receiving dozens of different papers and forms from different sources at discharge, the patient now receives one booklet targeted to his or her situation.
"You can think of it as a 'symphony' that pulls in various bits of information from the system: physicians' orders, nursing assessments, MAK [medication administration check], and case management," explains Kathy Zopf-Herling.
"Everyone completes his or her piece, and then this all comes together at discharge as a report to the patient. But it uses patient-friendly language, it has large font, and it is visually appealing."
"We know how overwhelming those first days home from the hospital can be," says Nichole Coleman, whose unit was among the first to use My Discharge Plan. "'My Discharge Plan' gives patients a comprehensive overview of what they need to do after discharge. It includes a list of the medications that the patient should be taking after discharge, what the medications are commonly used for, as well as when to follow up with their physicians, plus all the contact information for the follow-up physician. Also, there are special instructions for diet, activity and home needs just for the patient, so they have everything they need to take care of themselves after they leave the Hospital."
For this and all our technology efforts, the aim is to be both more "proactive" and "personalized," notes Dr. Pinsky.
"Can we look at our patients as individuals and do a better job of predicting what their needs are? That is always the ultimate goal."
By Kristine M. Conner
Photos by Rick Davis