New Clinical Workflow for Sepsis Improves Patient Care Treatment & Outcomes

Sepsis is a potentially life-threatening response to infection that has been known as a leading cause of death nationally. Prompt recognition, timely intervention, and adherence to evidence-based best practices have created well-established associations with improved outcomes and reduced mortality among patients with sepsis. Given its role in modern healthcare delivery, the electronic health record (EHR) provided a unique opportunity to impact clinical care in terms of sepsis response.

A team assembled to assess this need and found that more than 80% of sepsis patients came to Penn Medicine through ED admission, in need of more extensive care. Members from our sepsis alliance helped us design an extensive, multi-faceted sepsis EHR process to promote best practices, quality care through early recognition, and core measure compliance at critically relevant time intervals. A sepsis checklist was implemented to facilitate a new interdisciplinary care coordination process to guide providers and other clinicians through the first 18 hours of management of a patient in sepsis with organ dysfunction or septic shock. The intended goals of the sepsis checklist included:

1. Improving adherence to the 3 and 6-hour sepsis bundle

2. Improving adherence to the use of a problem list

3. Improving interdisciplinary team communication

4. Promoting seamless transitions of care

5. Improving patient outcomes related to sepsis

Upon ED admission, clinicians could see the sepsis treatment status promptly because this sepsis checklist opened automatically as a sidebar report. Due to the new clinical workflow, improved outcomes of septic shock patients quickly resulted from more consistent and timely application of evidence-based care and reduced practice variability. Care coordination from patients presenting with sepsis from the ED and transitioning to the inpatient setting was also a component of success toward promoting continuity of patient care.

Patient Medical Records Gain Electronic Sharing Through 21st Century Cures Act - Phase II

The 21st Century Cures Act required that healthcare providers and systems continually optimize patient’s medical record available to the patient and other healthcare providers electronically. By making data immediately available, the patient could better control their care while being supported with safe and efficient care delivery, especially if they needed to share their information among multiple healthcare sites.

A multi-disciplinary team worked with constituents to develop a deployment strategy that would meet the Act’s requirement while helping assure optimal patient care. The team assessed all the documents in the medical record and the various methodologies that would make them available to patients and clinicians. They evaluated the many complex types of interactions that occur at Penn Medicine, worked to assure patients that data was appropriately handled, and that the relationship between physician and patient remained optimal. The team also developed and delivered comprehensive education so that our clinicians were aware of the rule and its implications.

Patients now have access to most of their medical record and test results through their myPennMedicine portal. They have greater ability to make requests for their complete medical records and can send their health record data to personal health record apps. Other healthcare providers could access a patient’s record when they see that patient to assure safe and efficient continuity of care. In all cases, a patient’s privacy, and ability to control their data sharing has been maintained.

Cancer Registry Case Finder Application Brings More Efficient Reporting

For public health reasons, any healthcare center or office that diagnoses and/or treats oncology patients (including all hospitals, medical centers, MD offices, radiation oncology centers, hematology, and oncology centers, etc.) are required by law to annually report new cancer cases to a central or state cancer registry. Although Penn Medicine uses a commercial third-party vendor tool to collect and store our cancer registry data, we sought to determine how to cohesively identify, manage, and report on all the potential cancer cases from our large academic medical center.

Penn Medicine’s Abramson Cancer Center treats patients from among our six hospitals, many clinical departments and divisions, and has 75,000-100,000 related encounters as well as 30,000 - 35,000 unique patients related to the treatment or diagnosis of cancer each month. Since there was no suitable commercial solution for this problem, our technical experts conceived an in-house application to automate, organize, and manage this process. This has empowered users to identify which patients qualify efficiently and accurately for inclusion in the registry, transforming what was a manual, time-consuming, and resource intensive process. The department sought to use each manager’s time more effectively, instead of manually reviewing and reconciling many different spreadsheets and reading hundreds of e-mails a week related to the reconciliation process.

The Cancer Registry Case Finder (CRCF) was designed as a custom, homegrown, web-based application fully designed and built by the Penn Medicine Application Development - Database and Applications Group (DAG). All software used to build and maintain the CRCF is open-source, can be used with any major database, and uses the BSD-style and MIT licenses. This application is being used in our Cancer Service Line’s Cancer Registry which is an American College of Surgeons (ACOS) Commission on Cancer accredited program. The CRCF application is integrated with our EHR for source data and the cancer registry tool, allowing us to import and export to streamline our full abstraction process.

Case-finding is the first crucial piece in properly identifying reportable cancer cases to collect data on. Now, the application saves time in managing this data. The application provides:

• Real-time data reporting which decreases data delays

• Analytics to assess appropriate staffing

• Data quality improvement

• Data for research

One-Step Specimen Orders Improve Operating Room Specimen Tracking

It has been standard procedure for the operating room (OR) to send numerous specimens to pathology and microbiology for analysis. Tracking of specimens is very important to ensure that all specimens make it to the appropriate lab, minimizing risk of loss and allowing for appropriate evaluation to occur. However, nurses were not well equipped with an electronic mechanism for tracking these specimens with information such as the source, type, and specific tests. Our nurses were documenting intra-specimens using a non-order section of the electronic health record. They wanted the chance to track the specimens electronically from the OR to the pathology lab.

To sunset that workaround, the EHR Application Development team created a one-step specimen order section which interfaces the specimen orders to our lab vendor. The perioperative and pathology departments determined the specific specimen source, type, and tests which facilitated communication between departments. New label printers were ordered for each of the ORs at our hospital entities. By working with our end user services team, we configured these printers within our PennChart EHR to print specimen details onto a label and apply it to the OR specimen collected.

The specimens were tracked through PennChart and an interface message transmitted the specimen collection data to our lab partner. Specimens received in the lab were more efficiently scanned and documented appropriately. This electronic transmission replaced the previous workflow that was done completely on paper.

Now that specimen collection data is documented electronically, tracked, and transmitted through an interface, there has been a decrease in intra specimen errors. The new approach also provides an enterprise standard for how to document the specimen collection data.

New Hospital-wide Dietary System Enhances Patient Safety and Satisfaction

The Hospital of the University of Pennsylvania moved to a new hospital-wide dietary system to enhance service, quality, safety, usability, and system support. The new software included a Point of Sale (POS) system. Improvements included:

• Enhanced patient safety

• Enhanced patient satisfaction

• Full system support, that allows for system changes and settings configuration

Penn Medicine Moves to an Enterprise-wide Patient Flow Solution

In preparation for the opening of Penn Medicine’s newest hospital (the Pavilion), a new enterprise-wide patient flow model was designed, developed, and implemented that provided for the patient progression needs of relevant ambulatory practices and inpatient departments based on practice specific workflows, EHR build, testing, training, and on-site go-live support.

Following an analysis conducted by a core team comprised of nurse managers, IT subject matter experts and IT analysts to understand pre, intra, and postop area, it was determined that recent advancements in the functionality of our EHR’s patient progression module could support the patient progression workflows of ambulatory radiology practices and the inpatient perioperative workflows starting with the Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center. As the staff were already using our EHR module that provides users with a more efficient way to improve operating room utilization, availability, and functionality for both inpatient and outpatient day surgery, the assessment also resulted in adoption of additional functionality within the module documentation and tools along with development of various status boards. The support staff made a full transition to new environmental service and transport modules. Benefits resulted in:

• Saving a significant amount of money each year by sunsetting the previous outdated system

• Increasing patient satisfaction by increasing transparency and eliminating confusion regarding a patient’s specific location within a department

• Reducing patient waiting time, inefficiencies, and reduced exam and clinic time with timestamps for every touchpoint both at the patient level and department level

• One application for surgical documentation and patient progression enhanced workflows

• Standardized processes for shared resources between the Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center

• Ninety new configurable “Status Boards” were implemented to track the timely movement of patients for surgical cases and orchestration of staff and resources

e-Consents Launched for Ambulatory Departments

Transitioning from paper consents to electronic consents was part of the Ambulatory Practices Risk Reduction Initiative to reduce the risk of lost or incomplete consent forms and improve version management with quick and easy access to patient consents in the electronic health record.

The project’s initial phase included reviewing, standardizing, and revising all paper consents into patient-friendly language. The next phase was comprised of the technical consent build in the EHR, followed by the development of education and training materials on the new e-consent workflow by the EHR’s advanced clinical education team. Since go-live on 12/7/2021 over 1,834 consents have been built through fiscal year 2022.

Chester County Hospital Gets a Major Lab Software and Equipment Upgrade

To streamline the specimen labeling process and gain efficiencies with specimen collection workflow, existing lab software got a major upgrade at Chester County Hospital. Also, over three hundred and fifty new specimen label printers were deployed across all inpatient rooms. Printers were installed in the intensive care unit, medical surgery unit, emergency department, PeriOp’s pre/post procedure units, Pediatrics, and all women’s health units.

The installation and testing of all devices were completed without having to close any rooms at the hospital. Extensive lab and nurse training was integral to the success of the project. Initial results showed significant improvement in the turnaround time for specimen processing.

Penn Presbyterian Medical Center Trauma Unit Moves to Cloud-based Patient Monitoring System

Penn Medicine moved to a remote telemedicine intensive care (ICU) module for the Penn-Elert eICU patent monitoring system, used in the trauma unit at Penn Presbyterian Medical Center. The new system supports virtual patient observation for optimal care and staff productivity. The technology consists of wall mounted access point of care systems (APS) which contain high fidelity microphones and speakers, infrared lights for low light and night vision, and a high-definition camera.

The benefits of the system include:

• The availability of telemedicine consults for clinical decision making to aid in the care of the most vulnerable patients

• The activation of an enhanced rapid response system triggers an escalation of care to a higher-level of service in an urgent situation, precipitating a transfer to the critical care team

• Access to on-call specialists should the trauma physician need a patient consult

Radiation Oncology at Penn Medicine Princeton Health Migrates to an Enterprise Solution

In April 2022, the Radiation Oncology department at Penn Medicine Princeton Health migrated to two of Penn Medicine’s enterprise-wide applications:

• An oncology information system that supports medical and radiation oncology, including proton therapy

• A system to optimize a patient’s treatment plan based on a physician’s dose instructions, and information about the size, shape, and tumor location to be treated with radiation

The project included the implementation of all interfaces and archiving of data as determined by the IS team. The migration’s purpose was to improve workflow and efficiency and increase functionality for all shared models throughout the health system. The migration also included safety improvements and added components for radiation oncology business continuity.

Additional effort was needed to integrate a third system used by Radiation Oncology at Princeton health related to third-party professional billing. Charges were rerouted through a new VPN tunnel to bypass charging through the enterprises’ EHR. The benefit of performing this build additionally resulted in significant cost savings.

Penn Medicine’s Gift of Life Organ Donation Program Integrates into the EHR

Penn Medicine’s Gift of Life program has long promoted organ donation and established advancements in the field through innovative clinical programs and novel research at Penn’s Transplant Institute. The move to integrate a patient’s discrete data from their EHR to the Gift of Life’s electronic medical record in real time, was integral in meeting the Transplant Institute’s goal to complete 10x’s the current transplant volume at Penn Medicine by spring 2022.

Penn Medicine was the first healthcare system to develop the ability to integrate patient data over the FHIRAPI model with the Gift of Life system. Thus, Penn Medicine was the beta site which required the core IT team to define the required end points to support the necessary discrete data points so the Gift of Life coordinators could assess a potential donor in real time.

Transitioning from a manual process to an integrated workflow yielded the following project benefits:

• Positive impact on patient care

• Improved workflow

• Reduced inefficiency and associate dis-satisfaction

IS Education Team Breaks Virtual Training Records

Penn Medicine’s education team exponentially increased technology learning throughout the health system in the past two years. The opening of the HUP Pavilion and the pandemic-related turnover in staff were two key factors for the significant increase that occurred in technology education. New staff hiring within Penn Medicine increased, causing a need for new EHR clinical classes.

Five records were broken in FY 2022, including total staff trained, total hours trained, and total classes held. Total learners trained by IS educators was 24,634; 11,696 of these were individual learners, the remaining attended more than one session. This was a 45% increase from the prior fiscal year. Total staff trained in virtual live sessions were 8,863 and total staff trained from e-learnings was 15,771. There were 1,562 classes taught and over 7,800 hours of education provided.

Penn Medicine has depended on our ability to protect the privacy and security of patient data and clinical systems that house it. Regarding privacy, inappropriate access to patient information, both accidental and intentional, can more than ever jeopardize patients’ trust in our institution. Regarding information security, while healthcare organizations have long been a target for hackers, threats have been increasing daily. As a result of these and other threats to our systems and data, we have enhanced our HIPAA education program.

To ensure that new hires completed HIPAA training before gaining EHR access, the education team instituted a new and effective process. The learning management system was reconfigured to match the time management system logic regarding manager oversite, resulting in all NPRs having an assigned manager. Full time employee compliance of completing HIPAA education in a timely manner increased to 94% and non-payrolled resources (NPR) compliance increased to 65%.

Penn Medicine Automates Quality of Care Codes

To eliminate the mandatory, manual, and time-consuming process of submitting quality of care codes to insurance companies for performance improvement data, Penn Medicine implemented a technical system change in our EHR for code submission at the time of billing. The new automated procedure streamlined the metrics collection process to determine baselines and goals with all carriers.

Using quality of care codes at billing has eliminated the need to manually upload the data for the many incentive programs in which Penn Medicine participates. Capturing this data has helped to drive Healthcare Effectiveness Data and Information Set (HEDIS) performance improvements. Gaps in care have been more quickly identified as closed; which drove direct star rating improvements for the health care system. Coding for these services provided access to more accurate medical data which also helped Penn Medicine’s efforts to support our care plan through more targeted case management services.

Using the EHR to Tell a Patient’s Story

Penn Medicine implemented a new user interface tool in the EHR called Storyboard. The new display replaced the patient header and provides a quick overview to more easily access essential information in the patient’s story. Implementing Storyboard made it easier for Penn Medicine users to act on important patient related information in the electronic health record (EHR) using fewer clicks, mouse movements, and screen switches. It changed the way clinicians at Penn Medicine use the EHR. Storyboard took full advantage of modern widescreen monitors in a way that maximized information, presenting on one screen.

Before Penn Medicine implemented Storyboard, the ideas behind it were researched, developed, and tested for over seven years by more than 100 health care organizations. During that time, 1000 usability tests were conducted - involving clinical, revenue cycle, and access users. Storyboard was proven to streamline the user experience, allowing for a more patient centered workflow.

Storyboard provides users with a more tailored experience than in the past. In fact, there have been a variety of storyboards, each designed for a particular role, specialty, or context. At the same time, each storyboard’s content was designed to follow the same format, with basic information about a patient at the top, and specialized information at the bottom. Storyboard was also designed to provide users with options to view all information at once, or “hover to discover” over a section to see more detailed information as needed. To act, they just began to click from within Storyboard.

Benefits gained from this new design:

• Easier visibility of code status, allergies, admission date, and patient precautions

• Easier visibility of care team members, as hovering over Storyboard presented the team list

• Easier visibility of the patient’s primary family contacts

• Enabled ready access to the problem list in a way that was not possible before

• Eliminated need to regularly navigate to other sections of PennChart for essential information

• Gained key information more pronounced on the side of the screen, with added detail, at users’ fingertips.

Dr.

Phoenixville Medical Associates Joins Penn Medicine

Penn Medicine embarked on a journey to incorporate Phoenixville Medical Associates (PMA) into the family of Penn Medicine clinical practices within the tri-county region. The 11 practices situated in Delaware, Montgomery, and Chester counties offer a host of clinical services, such as primary care, internal medicine, rheumatology, and sleep medicine with a total practice make-up of 44 providers, 122 staff, 11 clinical locations, 1 administrative location and 112 exam rooms. The addition of the Phoenixville Medical Practice Group is the largest expansion of Penn Medicine’s primary care network within recent history.

Before coming to Penn Medicine, Phoenixville Medical Associates were part of an accountable care organization (ACO). When integrating the practice group, the health system assumed ownership of the ACO membership, which required capturing specific data elements to maintain the affiliation. Working with our new ACO partner organization and PMMG leadership, Penn Medicine was able to establish four unique interfaces. Incorporating PMA into Penn Medicine opened new opportunities to participate in an ACO for the health system.

The transition of this new practice required the collaboration of many clinical and IT departments in the health system. During the implementation, the project team worked skillfully to migrate PMA, onto a host of Penn Medicine applications, a robust infrastructure and the ACO interfaces. One notable achievement was the conversion from 2 unique legacy electronic medical records onto the Penn Medicine’s electronic health record, within a 6-month period. All teams were presented with time constraints and rose to the challenge of completing the project with great success. Each location was outfitted with Penn Medicine’s Business Continuity Access application for critical access to medical records during any type of outage. The transition also included the activation of four interfaces to maintain the ACO and the electronic conversion from paper faxes, which significantly decreased paper consumption.

With expedited assistance from the networking team, a new network was deployed at each location. Included was new low voltage cabling, new data computing electronics, state of the art wireless networking, and environmental controls for each data closet. Working closely with the internet service provider, expedited delivery of internet services was quickly implemented. Most locations required the construction of a new data closet, which required close coordination with the construction team, low-voltage cabling contractor and the networking team.

Project benefits included:

• Coordination with operations and leadership which resulted in development of a program and toolkits for use on this and future implementations

• Established a regionalized approach for go-live support and deployment, the first of its kind at Penn Medicine to include local support staff

• Redesigned command center approach to accommodate multiple simultaneous activations, which provided improved transitional support for staff during the changeover

• Development of new EHR applications for 19 distinct departments using clinical workflows

• First of its kind rheumatology infusion workflow was developed for specific use in an ambulatory environment

• Deployment of over 5,000 devices, including PC’s, printers, and peripherals devices throughout 112 exam rooms leading to significant improvements in clinical workflows

• On-boarding of 167 employees by providing 2,500 hours of education to support informed and effective users

• Enhancement of on-time deliveries and lower overhead costs by using local warehousing for preequipment orders and deliveries

Penn Medicine Partners Provide Services to the Underserved

Penn Medicine partnered with Public Health Management Corporation (PHMC) and the federal government to implement the PHMC Health Center on Cedar, a Federally Qualified Health Center (FQHC) located on 54th street in West Philadelphia. The PHMC Health Center on Cedar is staffed by clinicians from Penn Medicine’s department of family medicine and community health. This innovative public health campus provides community-informed, integrated care and social services to support individuals and families. The campus’ existing services include an emergency department and onsite inpatient and behavioral health services available through Penn Medicine.

To support this effort, the IT team at Penn Medicine installed state-of-the-art technology, including our networking and electronic heath record systems. Penn Medicine’s Public Health Campus on Cedar has improved the quality of life for the underserved patients of West Philadelphia. The preventative care provided is cost efficient and allows many patients to have access to affordable immunizations, mammograms, pap smears, health education, and other screenings. PHMC meets nationally accepted practice standards for managing chronic illnesses and reducing health disparities.

Services provided include:

• Primary care and preventive health care for adults and children

• Women’s health including regular OB/GYN care, and prenatal and postnatal care

• Behavioral health care

• Substance use disorder treatment

• Chronic disease management

• Social services support

EHR Upgrades Ensure the Latest Features and Functionalities

Each quarter, Epic Systems releases application improvements to their software. This is reflective of the vendor’s commitment to deliver consistent and continuous improvements for both clinical and revenue cycle applications. Information Services has also remained committed to implementing these application enhancements to benefit the health system.

ur organization’s EHR was upgraded in August 2020 and February 2021 to supply the latest functionality and feature enhancements. The upgrades also provided users with annual regulatory updates. The August 2020 upgrade improved employee satisfaction by implementing the first hybrid onsite and virtual approach to command center support and made 3,588 changes to EHR with minimal command center ticket volume.

Notable enhancements in the 2020 upgrade included new documentation options in the provider notes physical exam smart form, clinicians’ shortcuts to activities via patient lists, schedulable orders updated to “appointment requests,” appointment desk and work queues functionality updates, as well as enhancements to the Medicare Secondary Payer Questionnaire (MSPQ) that were instituted to allow for faster documentation. Additionally, clinicians were enabled to add a visit diagnosis from anywhere in an office visit using the taskbar.

Notable enhancements in the 2021 upgrade included the continued implementation of the first hybrid onsite and virtual approach to command center support. The team made 262 changes to the EHR with minimal command center ticket volume. Command center support closed in only 3 days; which resulted in a modified support model that efficiently closed tickets and minimized staffing allocations.

PennChart Hardware Enhancements Support the Performance and Reliability Standards of EHR Upgrades

As part of Penn Medicine’s continuing effort to create the best user experience, the health system upgraded its version of EPIC over a two-year period in 2021 and 2022. In preparation for the upgrades, an evaluation was performed, determining that improvements to specific hardware and database requirements were needed to achieve performance and reliability standards.

The core IT team implemented updated hardware to accommodate additional capacity, licenses, and storage to support the upgrades for the most optimal performance and user experience. This activity required additional hardware to be purchased, provisioned, and installed to proactively mitigate any performance issues. Advance procurement of the hardware allowed for staging of the new hardware with the upgrades which minimized downtime during the EHR enhancements.

The result of the hardware upgrades reduced management and administration costs. Expensive legacy infrastructure was retired, and licensing consolidation efforts were completed to achieve economies of scale. Following the hardware upgrade, Penn Medicine’s electronic health record was successfully upgraded in support of EPIC’s latest functionality and feature enhancements, in addition to making annual regulatory updates.

HIM Data Mapping Improves Patient Care

One essential component of health IT interoperability and the improved care and efficiency it offers, is data mapping. Data mapping involves “matching” between a source and a target that enables software and systems to meaningfully exchange patient information, reimbursement claims, outcomes reporting, and other data.

Penn Medicine’s Health Information Management (HIM) team updated our point of origin table mapping process to ensure the accurate capture of the location of patient intake. Mapping plays a key role in moving data from setting to setting and use to use, from informing patient care to informing national policy decisions.

Early in 2022, our point of origin table mapping process needed updating to reflect the Centers for Medicare and Medicaid (CMS) current values and to accurately capture the location of patient intake for access areas at each hospital in the enterprise. Key changes included the removal of emergency values and defaults, requiring emergency department registrars to select the appropriate admission source/point of origin and the addition of new value added for home or work hospital billing.

• Point of origin accuracy improved metrics across the organization

• Identification of patients coming from a skilled nursing facility impacts other areas such as postacute care/episodes of care models

• Reduced inefficiency; consistency across all entities, including LGH

• Improved workflows for patient access, HIM, and coding

• Improved care quality and patient safety