Cerner | ED Playbooks

The new Cerner Playbooks, WOW! I have found that the Playbooks deliver uniformity to the ED Physician’s EMR. For me, it streamlines a view that shows what it important. I hate busy screens. No matter what venues or location you will receive a unified view. I found the review, my ordering, and all documenting to be easy. The LaunchPoint holds the clinician-focused view to managing and monitoring all the patients of the ED.

ED LaunchPoint

 

ED Summary MPage

This is a snapshot presenting the patient’s story, relevant to what we as physicians look for.

TOC – Table of Contents

The Table of Contents is presented in an intuitive and easy to read.

 

Quick Orders View

This view is based on our needs as physicians. Flex orders are shown based on encounter types.

Smart Templates

Love these Smart Templates as you never have to leave the documentation window just insert to your note.

It has taken Cerner a long time to eventually hear our needs and actually start working on a clinical interpretation and not just an IT one. Epic is also a great product, BUT it is like eating a bony fish in that I spend more time picking out the bones than enjoying the feast in front of me. Lots of young, smart minds, but not so much clinical input and it shows. Cerner’s greatest downfall is customer service and how they handle consultants at the client sites. I can’t wait to see what Cerner comes up next. I just wish that we could have this great product without all the drama that comes with it. What ObamaCare went through with their web site, is something that is familiar with Healthcare and has been around for years.

Cerner | PowerChart

Legend

In life you hear how it is not so much about the result, but the journey.  When you think of the Life Cycle of most EHRs it is all about the result and the journey can kill you. So how do you make wise choices? Not only do you have to look at EHRs you have to look at the Vendors, then take a deep look at the IT staff that are in place to create, design this product into something that maximizes end user intuition into something relevant. The salesperson is not the one laying on a gurney in the ED or the physician caring for them and 10 others. The salesperson is not the one depending on an EHR to protect patient safety. The salesperson is not the one who faces malpractice situations.  That EHR you select will ultimately drive your workflow, so it needs to be designed that way with an outcome of patient safety. Hold your vendor accountable to design and development specifications. Make sure that you can work with a vendor in the complete life cycle. Make sure you and your organization can survive the politics involved. Hands down Epic has the customer service arena wrapped up, and Cerner has a long ways to go.

Being a practicing clinician as well as EHR consultant, I have used numerous EHRs which have taught me how user interfaces affect the workflow, end user buy in, as well as patient safety.  Another note to consider is that you can take an EHR right out of the box and set in different hospitals across the USA, and it will react different in each of them. EHRs need to go through end user testing by real physicians, clinicians and end users. If you put the effort in the beginning of the Life Cycle, you will see the results of that effort in the Go Live and Implementations. Obama Care results have been common problems with EHRs and short cuts with radical cost cutting measures. Bring in the tools that design, and build tools that improve your work flow. You need designs that work intuitively that are reliable, especially repetitively.  You need a person that just focuses on finding gaps.

Our implementation of Cerner Millennium Power Chart was successful, and we have had a successful implementation with CPOE at both of our facilities, in the last year. We just finished our attestation for meaningful use Stage 1, and now we are well into completing Stage 2 by implementing some additional Cerner tools. At this point Cerner is performing well, and the clinicians seem happy. At this facility, our partnership with Cerner seems to be going well.

Cerner notes are very good, and the dynamic documentation is especially good.  They are working on finalizing the tagging function where we can touch certain things, like labs and then they flow right into the notes. This will allow notes to be formed as we are seeing patients, such a payoff in terms of quality outcomes.

When I worked with Epic, I could create a smart trace and reuse it. In Millennium PowerChart, I am not able to do this function, and I have to type it every time. I can use favorites as a work around, but it isn’t the sleek design that Epic has.  Even with this, Millennium PowerChart is intuitive, easy to use, relatively easy to learn and the EMR GUI one of the very best.

 

Concerning medication reconciliation functionality, I had to give praises to Cerner. Nurses have huge variables in their documentation, and that is usually where EHRs fail. When done correctly it works really well. Cerner is working on upgrading that functionality even more, and I look forward for that to come out. Clinicians viewing patients with long histories in the past were a challenge, but now with the enhanced performances, it is appreciated.

Mobile devices have been an area of challenge for us and Millennium PowerChart. It seems to be a large gap in Cerner being on the front lines of EHRs.

A side comment is that the expectation is that we adapt to Cerner, but I believe that Cerner needs to adapt more to us, our needs and workflows. Cerner is better than Epic in their choices here, as Epic tends to hire technical over clinical.

I’d recommend Cerner Millennium PowerChart to any of my colleagues at a number 4.5 rating.

 

Cerner | FirstNet Experience

FirstNet is the Emergency Management module from Cerner. As part of the EDIS team, interviewing the vendors was a daunting task in itself. When endeavoring on a huge job as this as you know you have to look at the whole picture, then consider that in your decision.  Keep in mind we were going from paper to EHR, virgins of the EHR world. We went with FirstNet for many reasons and I’d like to share some of those reasons with you as well as some of the not so good things we ran into.  Remember that how you move into this will also make a difference like, Big Bang or not and for us we took two years to prepare. Emergency Management was the first bite of the elephant that we tackled. After having that under our belt and information flowing we went full bang for the rest of the facility. It was a nice transition as then the information that the clinicians needed was there for them from the ED. Our experience with Cerner was relatively a good one. Cerner has a tendency to send new associated to handle roles they have not yet been vetted in. We were all for that, but then didn’t see the support. Cerner hires more clinical personal and that clinical experience. Epic doesn’t seem to care about the clinical aspect as they care about using the young and technical. I’ll save some of that for another review experience I had.

Our objectives included: improved usability, improved patient safety, increased efficiency, having happy Providers, reduce the length of stay, identify bottlenecks and the ever concern of increasing revenue. Cerner helped with a true validation of the design in our own environment and provided testing under actual workflow conditions.

ED Summary – ED Timeline

We knew our real-estate was at a premium, so we strove to reduce the information on the screen and made divisions according to the workflow.

We were able to hover to view and locate information, verses clicks and scrolling. An Alert popping up for significant events and having the ability to hover over them to view the comment or note allows, you to keep moving in your workflow.  At this point, you also had the option to view more information or launch to the nursing documentation from the flagged event. The design followed intuitive workflows that providers and nurses would usually do when treating patients. We did notice a difference when the Cerner associates were clinical or not, or had ED experience. It did make the journey more challenging as well as frustrating.

Reducing scrolling and clicks within Triage Documentation

Overall FirstNet was found to be more rigid in adaptability to our dream wish list, and if flexibility was available it came at a cost like, specialty reports. If your facility is report centric, know that up front going into a relationship with Cerner or any of the top EHRs.

Tracking Board

When you hover over the Alert, you will see that the nursing documentation has been flagged.  The Tracking board was an intensive labor of love for the ED. All the way from selecting the icons to what was important enough to see on the Tracking Board was in the decision making of the EDIS team. The Tracking Board gives you a quick bird’s eye view of the ED including where staff are, what rooms are clean, where the Chaplain is at, where the patient in room 6 is, what test results are back or ordered, showing in what phase a patient is towards discharge, what is coming in and LOS (Length of Service) just to mention a few of the activities visible. You can see other views like the Triage area that give you a quick view of how many patients are waiting, patients needing to be roomed in ED, acuity levels of those waiting, any tests ordered, treatments, etc. If an ambulance is coming in, for example, it can help you manage rooms to make available for that patient, equipment needed, possibly call a code team or have a crash cart waiting when the patient arrives. Patients that come in with a similar name or a name that sounds like another name, FirstNet, italicizes the name, so you make a mental note. Name cells can be colored coded by sex, like blue and pink. The Tracking Board is a vital part of ED management and Cerner is one of the few to bring the workflow to design, to reality in a functional way according to ED workflow.

Due to EDs becoming so competitive in marking services we needed to publish wait times to web pages and outside sources. Cerner provided us the tools so that we were able to meet those goals. Overall some of the additional usability improvements that Cerner has managed to design with a high success; is the quick launch of a note from the tracking List, a suggestion of patient education by recognizing age and gender, discharge components, tracking control integration with IView, publish ED wait times (LOS), layout report enhancements, presenting a real time dashboard, multi-facility tracking and documentation management improvements.

Having said all this, the one complaint with Cerner that we heard was the number of clicks it takes to do the simplest tasks. I think that we need to review some of our expectations of completing tasks to our expectations of the availability, extraction of information to have available at out finger tips, a goal that needs attention even in the availability of requested information.

When you begin to look at the top EHRs remember it is not only the software that you need to look at, but the company and how they will help you meet the facility, State and National goals. Cerner has had complaints of wining and dining till the contract is signed and then disappears. In our research, we heard facilities voice that they felt abandoned because they weren’t as big as other facilities or that they weren’t in the major cities, lacking in their customer care and being customer centric. We not only interviewed the showcase sites that Cerner provided, but we did research to find other facilities using Cerner and interviewed them to facilitate our decision. It was a key decision, as we were just beginning to select solutions for the future of our facility. Reminds me of a sign I saw in Alaska, which stated to choose your rut wisely, for you will be in it for the next 7 miles. Choose your EHR wisely!

Cerner | CPOE Significant cultural shifts for review

We needed an EHR system that would drive change as well as organizational redesign. We needed a system that plays a critical role in safety initiatives that were found in CPOE – Cerner. Cerner Millennium architecture provided a comprehensive EMR that was connected bringing up decreased times from medication order to meds cabinet access, significantly. Transformation grew out of that adhesiveness thus driving safety and efficiency with significant improvements. I no longer have to wait for someone else and now have more control. 

The wielding benefit of order entry is found in integrated care where nurses, physicians and pharmacists all see the same information. If you do not have that, that is where the risk comes in and patient safety fails. You see this more in Hybrids than in software like what Cerner offers.

Reliability is another plus I’ve experienced with CPOE – Cerner. When an order is placed for a Chest XR, I can trust that it will be received and completed by radiology. Through transformed workflows and these new tools, we have found improvement. We have seen efficiency in our workflows presently taking on these changes, then how we used to do things. With the staffing, we were able to reduce our HUCs by half and then the remaining HUCs the focus is now more customer-centric.  Nurses used to complete charts at the end of the shift, and now it is mostly being done closer to the actual delivery of care. We found a reduction in elapsed time between dictation and physician signatures as well as a reduction from code to bill time.

Within CPOE, the order sets have improved patient safety. With real time documentation, you cannot help improvements with JCHO standards and advanced directives.  In the ED so many times, the allergies were never documented and now with hard stops, it is always being completed. Patients were getting missed for isolation sometimes for almost a week, and now the required patients are placed in isolation immediately. CPOE presents the right information at the right time for patient care and safety. More times than I’d like to admit CXRs were ordered with no reason. Now we place the orders and document at the same time thus increasing insurance collection with less time in research by support staff or denial. Advance directives compliance has improved with the entering of height, weight and allergy documentation. This just gives everyone the needed information for the most effective decisions and care available.

In the ED, we are totally CPOE, and we were able to replace the old grease board with large plasma monitors that give you an instant integrated view of the ED. If you see Child Life signed in with a suture nurse you know that support is taking place and Child Life will be tied up for the awhile. Lobby management is no longer a guess; you will know what it out there. Triage can see what beds are open. If a patient is in radiology and no longer in their room, we do not spend time looking and asking where the patient is. We can see at a glance if labs are back or how many are still out. We found communication of bed availability saved valuable time, enabling continuity of care from the ED to inpatient. CPOE effectively reduces drug-related injuries and adverse drug events, as well. We saw a reduction in preventable ADEs after the implementation of CPOE.

In summary, we have seen almost a 100% change in compliance driving safety and efficiency with significant improvements all the way around our health system. Cerner CPOE was the best investment.

Cerner | Maternity

Cerner –  Maternity & CPOE for OB Triage/L&D/Postpartum/Newborn

Under the Cerner EHR umbrella, you will find many products. The process of vetting the right EHR can be grueling and cost thousands into millions of dollars. Many providers feel they are actually stepping backwards in functionality when siding with enterprise solutions. The amount of clicks and the effort put into the simplest of tasks to the most critical have been the biggest areas of contention with providers as well as sluggishness.

When looking at EHRs a few questions to consider:

• You need to consider the Company as well as the technology, so look at both

• What will be my implementation experience

• What will be my ongoing support experience be like

• Will the Vendor lead and support us to meet the Meaningful Use deadlines

• Clinical workflow should increase productivity

• Will this EHR help us maintain or improve patient care

• Where to store EHRs? In house or with Cerner in Kansas City

• One house vendor or many – will they play well with each other?

A comprehensive set of capabilities in an integrated database is the sum of the Cerner electronic health record. PowerChart Maternity Ambulatory provides real-time access to gynecologic and maternity information. All labs, fetal tests, hospitalizations and history are displayed for real time viewing from the expectant mother and baby during pregnancy.

This EHR surrounds the entire pregnancy journey. Real-time display, recording, storage and retrieval or data. The clinical information obtained about the mother and baby live in one location and is available at the point of care when you need it.

PowerChart Maternity Basics

• CPOE

• Meds Rec

• PowerNotes

• FetaLink

• Tracking Shell

 

History and Physical of L&D  

 

Tracking 

 

FetaLink+: Mobile Fetal Monitoring for iOS

 

 

 

 

 

 

 

 

 

Critical in the maternal care setting is your ability to manage risk thus giving a high level of care. Cerner FetaLink+ displays the relationship of fetal, and maternal waveforms, allowing clinicians the ability to assess the status of patients. This gives them the ability, to examine changes in waveform patterns over time. Clinicians are able to temporarily, permanently hide or display any waveforms. Waveforms can be analyzed independently or in conjunction with waveforms of choice.

Annotation Summaries on the fetal strip can be quickly viewed by Clinicians providing quick views. The Summary serves as a navigation tool, giving a view of a historical waveform at the correlating time of entry.

This product claims the following benefits for Clinicians and their patients by:

• Critical information regarding a woman’s pregnancy and the health of her baby is accessible

• Patient safety is improved and helping clinicians make informed decisions

• Providing mobile access to fetal and maternal waveform data, key pregnancy related data, EDD, EGA, cervical exam status, and gravida para

• Comparisons of historical pregnancy data can be used to evaluate the health of subsequent pregnancies

• Reducing medical errors

 

Delivery Summary Report                                                                 

 

Overview

PowerChart Maternity is the pregnancy band available for use in the PowerChart solution family. What I liked was that it provided me with a single point of entry in my documentation of an active pregnancy starting from the initial prenatal visit through postpartum follow ups. Additional tools include the EDD/EGA calculator, height/weight and labor graphing, the result copy tool, related records (mother/baby toggle), and the birth log book. PowerChart Maternity also gives users the ability to view all of the documented details of a closed pregnancy from within the OB/GYN tab of the History band.

Three licensed options are available for implementing PowerChart Maternity that I found helpful.

• Ambulatory

• Acute RN

• Acute Provider

Outcomes of PowerChart Maternity that I wanted to note.

• Decreased the number of orders to sign

• Increased visibility of orders

• Improved Provider workflow

• Increased Provider satisfaction

Key Benefits of Cerner Women’s Health Solutions that I found.

• Spans the entire pregnancy process

• Improve patient care, clinicians can focus on the patient’s overall health and not just a visit

• Real-time efficiency, allowing fast and efficient critical decisions

• Increase access to information

• One stop location for all clinical data

• Increases staff efficiency and ability to staff patient care by giving immediate access to the clinical

• Newborn care is improved by looking at current, historical and archived fetal monitoring tracings, by integrating fetal monitoring data into the EHR in one location.
Advanced Nurse Review Notes & Comments (PowerChart Maternity & CPOE) that I have.

Weight based Medications: Weight based medication infusions display the calculation information within the order details both in the Orders view and on the MAR

Titratable Drips: Titratable infusions ordered via CPOE require the physician to enter the titratable medication and then enter the parameters in the order comments section before signing the order. If details are not entered, you will see an incomplete order which requires follow-up with the physician.

Medications with a Tapering Dose: The pharmacy continues to have an active role in entering medications with a Tapering Dose. With tapered dosing, the provider enters an initial order, and then the pharmacy will enter the individual orders required for the taper. With CPOE, the provider’s order will show up automatically in the scheduled medication section of the MAR, but the icon indicating pharmacy verification is required will appear, and there will be no associated task on the MAR. Wait to nurse review the provider’s original order until pharmacy has entered the individual dose orders and all orders appear on the nurse review screen. Use the order comments in the physician’s order to verify correct order entry by the pharmacy.

Total Parenteral Nutrition (TPN): TPN orders appear in the Nurse Review section and on the MAR as usual. All TPN orders are entered online via a PowerForm. To verify the ingredients in your patient’s TPN reflect the entered orders, you should compare the bag to the PowerForm or TPN Therapy Analysis tab. While not new with CPOE the TPN Therapy Analysis band, is a new feature to most, so something to note in your review.

 Pharmacy Verification (Notes that I considered important)

Pharmacy Review: Let’s take a moment to look at the Orders band, the eMAR and review how CPOE will impact Order Review, Pharmacy Verification and Medication Administration. The time it takes for medication orders to be verified by the pharmacy may vary depending on the time of day, patient census, or issues related to a specific order. Unlike medication, orders written on a physician’s order sheet and scanned to pharmacy for order entry, CPOE orders appear on the patient’s eMAR before the pharmacy has verified the medication. The Mortar & Pestle icon indicates the order has not been verified by the pharmacist. Only emergent meds should be given prior to pharmacy verification. Routine medications should not be administered before a pharmacist has verified the order, and Rejected Meds should not be given! You will find the Mortar & Pestle icon (if selected by your facility to represent Pharmacy) viewable on the Orders Band, Nurse Review, and the eMAR.

In urgent or emergent situations, you may need to administer medication before a pharmacist verifies the order. When scanning an unverified medication, the MAR will display a pharmacy verification warning pop up. You may continue to chart. However, be certain it is appropriate to administer the medication per protocols. Be sure to determine whether any follow-up actions are required.

Rejected Medications: Medication orders rejected by the pharmacy appear on the eMAR and the Orders Band with the Pharmacy Mortar & Pestle Rejection icon. A similar Pharmacy Mortar & Pestle Rejection icon appears next to the order on the Medication List tab in the patient’s order profile. Never administer a medication rejected by the pharmacist. The pharmacist will contact the provider to clarify the order. Then the pharmacist will take the appropriate action as an RVVO/RVTO then Pharmacy will discontinue or verify the original order. Based on the discussion between the pharmacist and the provider, a new RVVO/RVTO Pharmacy order may also be entered into Cerner by the Pharmacist. Verbal or telephone orders entered by the Pharmacist appear for the nurse review, as usual.