Redesigning an EHR for Inpatient Use

The widespread use of electronic health records (EHRs) has become one of the federal government’s priorities in healthcare reform, and an increasing number of hospitals and clinics are adopting the technology. Some cancer care providers, like Shirley Sampson, BSN, MA, OCN, NE-BC, and colleagues have been working with developers to optimize EHR systems for use with their patients. Sampson works on an inpatient hematology oncology unit at Stanford University Hospitals & Clinics, Stanford University Clinic. In 2008, Stanford adopted Epic, software that maintains a medical record for each patient seen at the 611-bed teaching hospital. Beacon is a program within Epic for electronic ordering of chemotherapy. It was designed specifically for outpatient use, however, and many of Sampson’s patients receive inpatient treatment. She and her colleagues explored whether the system could be adapted to meet the needs of their inpatient population.

Designing the System

As part of a multidisciplinary team, Sampson and her hospital colleagues—including nurses, physicians, and pharmacists—worked with software developers on modifying Beacon for inpatient use. In September 2008, they began collecting information on all the chemotherapy protocols used by each physician in their facility for each diagnosis. “We wanted to build everything into each protocol—not only the drugs but also the antiemetics, any kind of supportive care, and intravenous fluids,” Sampson said. Once the information was assembled, the team evaluated each regimen to ensure that it was based on the most up-to-date evidence available before submitting it to the developers to be included in the system. “It was probably about a year of building the system together with the interdisciplinary team before we rolled it out on an inpatient unit,” she said.

Before the first phase of the rollout in March 2009, the staff responsible for chemotherapy administration had to be trained in using the new system. Sampson said 63 chemotherapy-certified nurses attended a 4-hour orientation class and 94 physicians attended a 2-hour class during which they simulated order entry. Another 8 nurses were trained as “Super Users.” Sampson became a “Champion User,” and led two retreats to train the Super Users further before the first phase of the rollout.

Beacon Rolled Out in Two Phases

In the first 2 to 4 weeks of the phase I rollout, which encompassed 3 diagnoses and 4 inpatient attending physicians, the Super Users provided dedicated help to the unit nurses on using the Beacon system. They implemented competency checklists and developed informational sheets and bulletin boards. In addition, they assessed the effects of Beacon on workflow and identified problem areas. Sampson said, “We sat one-on-one with the nurses on the unit, and when anything came up…we worked through the glitches with the builders.” The next phase of the rollout was expanded to cover 10 diagnoses and 16 inpatient attending physicians.

“Originally we were on paper; a physician would order chemotherapy on a paper order, and the nurse would review it, then the pharmacy to make sure the orders were correct before giving it,” Sampson said. She compared this to the electronic system. “Now…if a lymphoma patient, for example, comes into be treated, the physician would select the protocol within Epic/Beacon and attach it to the patient record. They can individualize it, changing the doses if needed,” she said. “Then they would sign the protocol, and this includes the antiemetics, the intravenous hydration, the chemotherapy drugs, and any other supportive care. When the patient arrives to be treated, the nurse immediately releases those signed orders into Epic. They pop up on the pharmacy screens and the pharmacy reviews the orders but does not have to enter anything since it’s already on the system.” Sampson said the pharmacy then prepares the chemotherapy and ensures this and all the supportive medications are available to give to the patient.

Improvements Seen

Ongoing monitoring of the system has shown improvement in standardization of protocols, improved clinical documentation, and better access to the plan of care by the practitioner. “It is still a new system, so we’re not quite seeing the through-put time yet because of the learning curve to use the system,” Sampson explained. The system has been a great help when a patient transitions from outpatient to inpatient, noted Sampson. “We can sign their outpatient treatment plan and give it to them inpatient; it’s all in one place, and everybody caring for the patient has access to the same information.” The system is also flexible, with a generic template that Sampson said allows physicians to submit new protocols to the Beacon content oversight board for approval. One of the major goals of adopting this inpatient system, said Sampson, is to reduce medication errors.

She praised the strong collaboration between the Beacon information technology team and the hospital teams and the methods they used for instructing the staff on the new system. “The implementation of new EHR systems can be stressful for inpatient nursing staff,” and the peer support and opportunity to make need-based modifications to the program helped alleviate some of that stress. “It’s scary to go from having control over a paper order…to trust a system,” said Sampson. After a year, Sampson feels the team at Stanford is getting comfortable using the system and the learning curve is leveling out. She expects to see growing interest from other facilities in using a system like Beacon. “I know I’ve encountered a lot of interest from people this year asking how it is going,” Sampson said. She hopes the experience at Stanford can serve as a model for others looking to adopt similar electronic chemotherapy-ordering programs.