It’s Not About The Box Improving Care at Group Health with People, Process and Technology

December 29, 2006

Update: CIS ERT Response Team : EKG’s and Protime Orders

Filed under: Informatics Team,Safety,Technical Issues — admin @ 4:50 pm

Here is an update on the Emergency Response Team’s work today:

1. EKG’s: I have contacted care teams of surgical offices where EKG orders were placed that were affected. These were principally preoperative EKG’s. Next week, I will contact a small number of family practice and cardiology providers who ordered EKG’s for the future and whose orders were not transmitted to the lab.

We began with this issue well characterized, so worked toward resolution today. The second issue did not start with good characterization. Here’s the update with that:

2. Recently, the epic team encountered a situation where standing orders were incorrectly associated with encounters. The most common example was Protime Order’s added to encounters when in-fact they were not ordered during that encounter. Most of these orders were not cancelled and we have determined that patients had the correct labs drawn and the results routed appropriately. However, if a provider cancelled these tests patients did not get laboratory studies that were due. The programming error that created this problem has been corrected. The problem began on December 21st and was resolved on December 28th.

A report is currently being run to determine the exact number of cancelled orders. We have identified at least 80 cancelled orders and we anticipate the number will rise to several hundred. In addition, many charts will have standing orders incorrectly associated with them and the number of those may be up to 600 in number. Exact numbers will be available on Tuesday, January 2nd.

Next week, we will contact the care teams impacted by the cancelled orders and let them know that we will resubmit the cancelled orders and ask the care team to contact the effected patients to have the laboratory tests. We will be working with coding and compliance to remediate the error in charting accurately reflecting the services provided in the encounter.

We anticipate that the impact on our patients will be low and are making every effort to quickly remediate the problem. Please do not hesitate to contact the Epic team is you have questions or concerns and consult the CIS blog for updates.

Clinical Information System Emergency Response Team Activated

Filed under: Informatics Team,Safety,Technical Issues — admin @ 12:52 pm

The CIS Emergency Response Team was activated on my request, made on behalf of Group Health medical staff, this morning for two issues:

1. An issue I described previously, which was that EKG’s that were ordered in the future, did not have those orders transmitted to our laboratory. The non-transmission was due to a misconfiguration in EpicCare that has since been resolved. After reviewing the charts of patients affected, and going in person to our General Surgery and OB/Gyn Departments at the Capitol Hill campus, I felt that the residual impact needed to be managed as quickly as possible. In some cases, patients who are scheduled to have preoperative or follow-up EKG’s may need to be contacted to have these exams done. We’ll be contacting care teams affected about this.

2. Also related to the misconfiguration above, another misconfiguration was discovered that resulted in certain standing order tests becoming associated with encounters in which they were not ordered. This misconfiguration has also been resolved. In this case, we will review the orders affected to make sure they have been routed and resulted correctly, and will investigate the number of encounters affected. In the meantime, there may be some encounters in the Chart Review section of EpicCare that may erroneously show a lab test ordered as part of a specific visit, but on the correct patient on the correct date and time.

The EpicCare system is fully operational at this time and I do not see any current risk to the work we are doing in our system today. The activation of the Emergency Response Team is a precaution to make sure that we understand both issues thoroughly and all preoperative exams ordered are completed before surgery occurs.

I’d like to thank the staff of both Group Health General Surgery at Capitol Hill Campus (specifically, Tien Bao-Chao, MD), and Obstetrics/Gynecology also at Capitol Hill, for taking the time to assist myself and the team with clinical consultations around their workflow.

December 28, 2006

48 minutes of unplanned downtime since January 2005; timeouts on our systems

Filed under: Informatics Team,Technical Issues — admin @ 5:23 am

This piece of data was provided to the Group Health Permanente Board of Directors last week by Ernie Hood, Group Health’s CIO, and myself. It is a very impressive piece of data. All 48 minutes are related to an issue for which a trap was set, data sent to Epic, analyzed, and patch installed. Our impending upgrade should throttle it permanently.

We were asked to present the issue of system stability to the Board in response to the most recent incident which accounted for several of the 48 minutes. Ernie informed the Board that we now have a fully functioning backup system located outside of Seattle, and to date, we have not experienced an attack by an outside entity.

Ernie explained that the biggest security threat in fact comes from within – our people – who are usually the targets, rather than the system. Most system compromises come from the way people attend to things in their own environment.

Besides the impressiveness of the statistic, there was impressiveness in our CIO attending to the Medical Group’s Board, in my opinion. It made a strong statement about the interest in medical (and all clinical) staff success and the importance of partnership.

Part of this partnership includes work Ernie and I are doing to look at standards around timeouts and passwords. In some areas, it makes sense to change standards because increased flexibility does not mean increased risk. For example, hiding of the UserID when we log into EpicCare is not a norm throughout Group Health (almost every system, including Windows XP shows the UserID visibly when it is being entered). It does not enhance security and may require repeated attempts to gain access if there is a mistype. This is something we can change to save time right away, at the same time we look at timeouts across the systems we use to provide clinical care.

I will post more on this as we determine what’s reasonable based our our experience and expectations of members.

December 27, 2006

Duplicate radiology orders; Some EKG orders not sent to the lab

Filed under: Lab,Radiology,Safety — admin @ 9:00 am

This week, I am reviewing about 150 charts in EpicCare, to assist with the work to correctly schedule patients who had imaging studies ordered in the future which may have been incorrectly cancelled. Our partners in the Radiology Service Line are helping us with those right now. We’ve found all the studies that were cancelled in the immediate period after ordering (assume they were due to duplications) and Radiology is checking to make sure they are scheduled as requested.

We’ve uncovered another error, caused by the first band-aid to this problem, that resulted in EKG’s ordered for future dates not being sent to our laboratory. This is where my review comes in. I see that EKG’s are ordered in the future as part of the perioperative protocol. I also see the benefit of this protocol – it is easy to tell when a patient is scheduled for surgery and what is involved in preparing them. With the fix in place as of 12/10/06, these are now normally flowing to the laboratory.

I also see that EKG’s are sometimes ordered for the future when they do not have to be. I am going to double check with the lab on this, but I believe for an EKG that should be done in the next 6 weeks that a future order is not needed. This should save lots of keystrokes.

In both of these activities, I and others are doing our best to mitigate the impact to patients and care teams. However, involvement may be required when service has not been delivered or the clinical judgment of the care practitioner is required.

My idea at this point is to use this blog to let colleagues know about issues, mostly as a reference tool, and then to contact affected providers individually, rather than sending out broadcast e-mail messages. If people have any other ideas about this or need additional detail, let me know.

MyGroupHealth for Members Interactive Tour now online

Filed under: MyGroupHealth — admin @ 5:02 am

The message below, from Maureena Moran, Executive Director of Web Services says it all. For the times your patients and colleagues inside and outside of Group Health ask how MyGroupHealth works, you can now refer them to a guided tour. You can comment right here on the blog if you’d like. I did review the tour from the medical staff perspective on the team’s request – they wanted to make sure all the case examples reflect the great work that our clinical staff does. I think they’ve succeeded. See what you think.

We have added a new tool to ghc.org to provide a deep tour of the MyGroupHealth for Members services.

Over the past few years, many people, including sales staff, non-member employer representatives, etc., have asked us for log-in ids to the member site so they can see it for themselves. This tour is one answer to that need; it is intended to work in parallel with the demo already available. The Tour provides the user the ability to choose which aspects of the site they want to view and shows page detail in context. It is intentionally long from start to finish; indeed, my expectation is that we will add to the Tour as new services are added to the web site. We did usability testing on the Tour during its development; I anticipate it will support the need identified. I welcome your feedback and that of your staff as they use the tool with customers/potential customers.

For now, we have only updated the Employer home page with the Tour link and description. In the immediate future we will also be adding a link to the Tour from the Online Services page.

Here’s the link:
http://employer.ghc.org/

Please forward this message on to your staff as appropriate.

Big kudos to Ross Heeter [Designer on the MyGroupHealth team] for his thoughtful design and thoroughness in approach.

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