The handwriting was on the wall

Like many inpatient behavioral healthcare organizations, Sheppard Pratt Hospital in Towson, Maryland, was inundated with reams of illegible handwritten paperwork, resulting in a functionally unusable chart which, in turn, led to increased potential for medical errors. We also were grappling with how to meet regulations required by external third parties, including The Joint Commission and other agencies. So in 2004 we began to look for a clinical information system that would help us streamline our processes, deliver an electronic patient chart, and improve our ability to meet regulatory guidelines.

A systematic evaluation of both major clinical information technology vendors and behavioral healthcare-specific technology vendors helped us narrow our possible choices. A site visit to see our preferred system actively in use in a similar setting helped the selection committee (comprised of clinical and technology leaders) to confirm our decision, and in June 2005 we selected a product (Eclipsys Corporation's Sunrise Clinical Manager).

We established high-level goals of providing open simultaneous access to the chart across the facility and from physicians’ offices and homes, increasing the amount of time nurses are able to spend on the unit with patients, and reducing medication-related errors. To move forward, we formed a project steering committee that included the vice-president, chief administration officer, chief financial officer, chief information officer, chief nursing officer, and a project manager from the vendor. This committee met monthly throughout the project to check on progress and resolve high-level issues. We established a systematic planning process, beginning 14 months before the first go-live date.

Like many behavioral healthcare organizations, we are heavily reliant upon physician and nursing documentation, and our physicians communicated that these capabilities were mission-critical as we rolled out the system across our organization. Additionally, one of our ongoing challenges was finding adequate resources to dedicate to the clinical-transformation project. To maximize our resources, we focused our efforts on capabilities that held the largest potential for enlisting physician buy-in.

For that reason, initial priorities included activating clinical documentation functionality and implementing medication administration record (MAR) capabilities. Having these tools available at go-live would help ensure we successfully activated the system on time and on budget and provided the best opportunity for wide-scale system adoption and long-term success in achieving our vision of more-connected care.

Physicians and nurses met in parallel workgroups comprised of representatives of each of our clinical specialties. These groups met regularly for eight months to analyze the entire paper chart, documentation forms, and work flow and create structured clinical notes, order forms, systems rules, and work flows. We began with 44 paper work flows, paring them down to 15 electronic documents to activate at go-live (table).

While the workgroups were busy prepping the system for rollout, a communications effort was launched to keep everyone in the organization in the loop. Along the way, we made available on our intranet presentations that described system features and functions, screen shots of the new system, and comparisons of how processes work in the paper world versus the electronic world. Promotional key chains and other trinkets also helped to keep users aware of our progress and promote buy-in. This active effort to convey how the system could help to improve patient care and change the lives of clinicians excited users about the clinical transformation on the horizon.

Maximizing Minimal Training Resources

The resources needed to train more than 1,000 users during six months were hard to come by and hence sorely stretched. To help maximize our training resources, vendor product training, manuals, and presentations were tailored to our unique environment. Additionally, five clinical instructors taught one another how to use the system and in the process determined the best way to instruct users based on their roles. Although it took considerable time to develop, physician-to-physician training for order entry and work-flow configuration was highly effective.

We use a significant number of per diem staff. For this reason, we determined that a “super-user” model didn't suit our environment (Under this model, super-users would be available to help make the transition shift to shift, unit to unit). Instead, we found several clinical specialists particularly adept at using the system and designated them as the “go-to” people on each unit as the system went live.

Success at Go-Live

After testing the new system, it was piloted on a single unit in March 2007. An initial decline in physician productivity was addressed with a temporary compensation bonus, as our physicians are a closed staff paid on a productivity-based percent of collections model. After an initial calibration that included temporarily rolling back seclusion and restraint orders for further evaluation and rework, the system was brought up unit by unit across our inpatient areas and our day hospital in two- to three-week intervals. This gave us ample time for training, support, and debugging before moving on to the next unit.

The system was successfully rolled out throughout the hospital by the end of June 2007. We are proud to say that no unit failed; no physician failed; and no critical events that compromised patient care occurred.

Now that the system is live, we've modified our training effort, and meet every other week to train small groups of 10 to 12 clinicians, usually new hires and rehires, set up in a clinical training area.

The Importance of Structured Clinical Notes

Automating the psychiatric admission note was instrumental to our success. Prior to implementing the system, notes were recorded on paper, and physicians often had to collect information repeatedly. This made the process inefficient and difficult to incorporate notes into the master treatment plan (MTP).

With the new system, it's easy for physicians to create an MTP from the documentation collected as part of the care process. With necessary treatment information already available in the note, nurses can use the copy-forward function to populate the MTP template, and physicians simply enter problems and objectives to create an MTP, which provides direction for the entire multidisciplinary team. Once the physician identifies the problem, information is pulled into the nursing documentation flow sheet, and nurses can easily complete their inpatient progress notes as well. Previously, this documentation was completed manually at night.

With the new system, the entire care community has access to a unified treatment plan and can build, rework, and complete necessary patient documentation within 48 hours of the patient's initial MTP conference. This capability has been valuable to us from a work-flow and efficiency standpoint and aids our ability to meet Joint Commission Core Measure standards for admission notes.

The Result

Patient care is enhanced with the ability for shift supervisors to see a comprehensive view of what's occurring with each patient. For example, the medical director can flag patients who require close monitoring during a shift, and the entire care team is alerted and can quickly provide immediate feedback on patient progress throughout the shift.

Additionally, when a clinician observes any significant event the care team needs to know, he simply enters a note as a headline in the significant event column. Clinicians actively track and monitor new significant events during a shift, and routinely monitor and document progress during rounds each day. This simple yet powerful tool is important for medication management and provides an additional method to help ensure patient safety.

Sheppard Pratt is a teaching site for the combined Sheppard Pratt-University of Maryland psychiatric residency program, and residents appreciate the ability to review and collect all cases into a group, sign off on them, and communicate with one another at shift change. This capability aids our ability to meet Joint Commission guidelines for patient handoff communications.

The copy-forward feature has been quite successful for us by increasing efficiency. When a patient steps down in level of care, information is easily pulled forward into the patient's record and is made available to the care team on the receiving program. This seamless transfer of information has simplified similar processes as well as patients’ movement throughout our organization.

We have patients who return frequently. With anytime, anywhere access to patient information, physicians are able to complete admission orders from home in the evening via our virtual private network (VPN). Instant access to the patient's psychiatric treatment history gives clinicians the opportunity to quickly come up to speed when the patient is re-admitted. This feature will become more valuable over time, as the patient record database grows increasingly robust from a historical perspective.

Today, the hospital is 95% handwriting free, and physicians enter 99% of orders. Medication nurses are able to spend significantly more time educating patients rather than transcribing and checking handwritten orders. While it is too soon to quantitatively evaluate the impact on medication errors, anecdotal evidence suggests that certain kinds of errors, such as those based on transcription and patient misidentification, have been reduced.

The positive momentum gained from meeting our initial goals is propelling us forward. We are in the process of creating order sets and linked order sets (predetermined orders based on certain criteria), which will augment physician and nursing efficiency even further (For instance, a physician might always order the same medications and care orders for a particular diagnosis, so this would be made into a set, becoming a one-click event instead of having to order each individually). This also will enhance our ability to provide standardized orders, something that will provide significant benefit to our residents in terms of education and care consistency. In addition, we are working to activate the system at our Ellicott City inpatient psychiatric center this spring.

For more information about Sheppard Pratt Health System, visit https://www.sheppardpratt.org.