CPOE

There does not appear to be a consistent trend in CPOE adherence across the sites. Advocate will pursue two strategies to improve CPOE rates:
1. Convert Emergency Room triage protocols into "per protocol," removing those orders that were originally entered as phone orders from the denominator. Ron Lawton is leading this effort across the different emergency departments.
2. Test a workflow where nurses propose orders to physicians for signature. Unlike phone orders, these orders will not be activated until the physician signs the orders. This will allow the nurse to "tee up" the order for the physician to review before activation. The workflow requires the physician to review orders in their Message Center in a timely fashion. Jane Denton and Leo Kelly are exploring this option for one floor at Lutheran General. A pilot will probably not go live until late July or August.

Transcription reduction

After a slight increase in April, most sites are seeing a decrease in transcription costs as estimated by projected annual spend. Lutheran General and Children's Hospital-Park Ridge are already below with annual transcription cost target for the year. Assuming there is no dramatic uptake in transcription use, those sites will achieve their 2016 KRA.

In addition to site-specific initiatives (e.g., focus on Obstetrics/Gynecology for Good Samaritan, focus on Psychiatry for Illinois Masonic), we are currently testing a system-wide Nuance Dragon deployment that uses the latest version of the voice recognition technology and is accessible in the cloud. In the pilot testing at Illinois Masonic, most users have been very impressed with the voice recognition, but we have not seen persistently high Dragon use after the initial training period. The Advocate corporate CareConnection and Clinical Informatics teams will complete their assessment of the pilot sometime in mid-July. Based on the pilot results, Advocate will either ask for modifications to a system-wide Nuance contract or accept the contract without additional performance clauses.

Transcription service improvements

Sakhie noted that transcription service continues to improve. In his procedure suite, he's noticed that some transcriptions are available within 15 minutes. If that turnaround time is available for all transcribed documents, the safety argument for voice-to-text or direct data entry would disappear.

Superior speed with data entry using newer technologies

Jim made an argument that entering physician documentation through a CareConnection template or PC Touch is actually faster as it does not require the user to enter all of the information from other parts of the chart that can be summoned with a few keystrokes or embedded within a template.

[] Each medical director should time themselves on data entry via PC Touch, PowerNote template and telephone dictation to see what the range of times might be. With more than one user testing themselves, this information could help encourage skeptical physicians to try newer technologies to complete their documentation.

PC Touch frustration

The directors expressed their frustrations with PC Touch and its frequent unscheduled downtimes. Since the meeting, Anupam has worked with the CareConnection team and Cerner to develop an SBAR . Barring any unforeseen challenges, the SBAR should be presented at the July Health Outcomes Council.

Copy-and-paste

Jim highlighted a copy-and-paste policy created by a neighboring hospital. The policy lists these specific details:
Suggested limitations
1. Copying the "History of present illness" is prohibited.
2. Copying the "Past medical history, Family history, Social history and Surgical history" is acceptable.
3. Copying the "Review of systems" is discouraged.
4. Copying and pasting vital signs from the previous day is prohibited.
5. Copying portions of the "Physical examination" is acceptable.
6. Copying the assessment and plan from a prior note is discouraged.
7. Physicians may copy "Allergies, Procedures and surgeries, Past medical history, Immunizations, Family history, and Social history" from another provider's note.
8. Use of copy-and-paste that leads to internal inconsistencies (e.g., "awaiting surgery" even after the patient has had surgery)

Notification and escalation
Physicians who repeatedly ignore these policy guidelines will be reviewed by the physician's department, legal medical record committee, clinical decision steering committee, professional activities committee and medical executive committee, as appropriate.

First offense - Education
Second offense - Written reprimand with a focused documentation audit to ensure policy compliance
Third offense - Disciplinary action as determined by department leadership

The medical directors agreed that a pilot should be performed before suggesting a policy to any site Medical Executive Committee.

Once-a-stay tests

When the Lab Utilization Committee implemented its decision support rules for once-a-stay testing, they did not include any age cutoffs. For pediatric patients, TSH testing is appropriate more frequently than every 28 days.

The medical directors agreed to implement a age floor for all once-a-stay decision support rules for laboratory testing at 18 years so no physician caring for a pediatric patient will face these alerts.

Tracking covered lives across our care continuum

Anupam and the CareConnection team had been developing several approaches to identify patients who represent covered lives when they arrive in our emergency room. On June 24, Advocate Physician Partners, CareConnection and Advocate's larger Information Technology team agreed to assign a team to investigate this further. The team's executive sponsor is Margi Gavigan. The team's project manager is Mary Roesch.

Issues from prior meetings

[] Advocate signed the Revenue Cycle contract with Cerner on June 20th. The CareConnection team will begin working on a single provider directory as part of this contract. Anupam serves on the committee overseeing the project. The single provider directory will allow physician accounts to be consolidated across sites. We will then be able to reinstate Physician Consults in PC Touch.
[] If the signature + specialty request (with changing the resident's specialty with each rotation) and SmartTemplate work are performed by separate teams, then we will proceed down both paths simultaneously. Otherwise, we will work on the SmartTemplate request first before adding troponin in the daily labs SmartTemplate.
[] Anupam is still waiting to hear back from the Advance Care Planning Council about changing the requirement for a physical signature for LET orders.

The next meeting is scheduled for July 14, 2016.

Minutes from prior meetings