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HUGO produces huge gains in patient safety

By Jerry Zeidenberg

One year after going live, a project to improve patient safety at 10 hospitals in southwestern Ontario has reduced the number of adverse drug events by 35 percent, an astonishing achievement. “And two of the hospitals have reduced their ADEs by 50 percent,” added Dr. Robin Walker, Integrated Vice President of Medical Affairs and Medical Education at London Health Sciences Centre and St. Joseph’s Health Care London.

Dr. Walker and Glen Kearns, integrated VP of diagnostic services and CIO at the two hospitals, gave a presentation on the HUGO project at the eHealth conference in Toronto last June. HUGO is short for Healthcare Undergoing Optimization, and the project was rolled out to the 10 hospitals and 14 sites in rapid fashion, in just six months. The final go-live was in May 2014.

All of the hospitals are using Cerner’s clinical information system. As Cerner Canada’s president, Jim Shave, put it, “There is one standard electronic health record serving more than 1 million people in the region.”

Other partners in the project include the Listowel Wingham Hospitals Alliance, the Alexandra Hospital in Ingersoll, the Middlesex Hospital Alliance, the St. Thomas Elgin General Hospital, the Woodstock Hospital and Tillsonburg District Memorial Hospital.

Kearns described an incident at one of the hospitals several years ago, before HUGO was implemented, in which a pediatric patient was given the wrong dose of a drug and nearly died. It was the occurrence of such heart-rending accidents that spurred the effort to improve everyday care through the use of computerized tools.

The $32 million project brought advanced systems to each of the participating hospitals, including Computerized Physician Order Entry (CPOE), electronic medication administration record (eMar), closed loop medication administration, including barcoding, and electronic medication reconciliation.

The digital tools replace the traditional hand-written orders of care providers with computerized order entry by the provider (CPOE) eliminating potential transcription errors made by misreading the notorious scribbling of clinicians. Time is also saved, as pharmacists and nurses spend less time tracking down doctors to check their orders.

The whole process of ordering at the 10 hospitals has been made smoother through the use of computers, observed Kearns. “Ordering in the paper-based world involved 24 different steps,” he said. “With automation, that has been reduced to eight steps, all with a double-check built in.”

For example, the system will alert clinicians, at the time of ordering, when patients have allergies or when they already take medications that may produce drug-drug interactions. Prior to CPOE these alerts only occurred once the orders were transcribed by pharmacy, which may have occurred after the patient already received the medication.

Moreover, barcode checks at the bedside ensure the right medication is being given to the right patient at the correct time.

Not only has there been a dramatic improvement in patient safety, but certain processes have also become more effective, particularly through the use of order sets – the ‘best practices’ that are agreed upon by hospitals when it comes to tests and therapies. Before HUGO, said Dr. Walker, “When you were admitting a baby, you could write 30 orders. It could easily give you writer’s cramp. Order sets for complex inpatients can be a real time-saver.”

Order sets also incorporate agreed-upon best practices, which reduce the “variation in medical practice” that results in inconsistent outcomes and varying quality of care. “Consistent care turns out to be higher quality care,” said Dr. Walker. “We’re going to introduce more evidence-based care in the future, as we’ve just scratched the surface.”

HUGO was a large-scale project that involved a core team of 40 information management professionals, as well as 1,000 “super-users” who together trained more than 6,000 clinicians. And in moving from paper-based orders to electronic ordering and checking, it involved a significant shift in the way clinicians were used to working. “It’s the biggest practice change I’ve experienced in my career,” said Dr. Walker.

Doctors can even place orders remotely. “We have an oncologist who likes to stay in close touch with his patients,” said Dr. Walker. “He’s able to place orders even when he’s at his cottage in Huntsville.”

Kearns pointed out that HUGO has already resulted in major improvements for patients, but it has not been without challenges through the implementation process.

For one thing, the team underestimated the recovery time needed by staff members as they launched HUGO at one site and moved on to the next. Fourteen sites were brought to the go-live state in just six months, which left little time for the implementation team to rest up and recover. Kearns and Dr. Walker noted that staff members were exhausted with this schedule, and if they were to do it again in the future, they’d build in more resting time.

At the same time, they cautioned those who are planning similar projects not to train their clinical users too early. Memory-retention of the training provided rapidly diminished if it was not sufficiently close to the go-live date. Indeed, some of the HUGO sites had to re-train their clinical users after launching.

As well, more active engagement of residents and medical students in the core governance and planning of the project may have helped avoid some early challenges with the impact of the project on their workflow.

Kearns added that physicians are sometimes too busy to ask for help, even if they’re floundering with a new system. “You need to be proactive, to identify them and offer additional help,” he said. Identifying individual physicians who might be expected to be early resistors of change and addressing these concerns proactively can mitigate the risk of critical events following go-live.

As an incentive, Dr. Walker said the hospitals will in the future provide better remuneration for physicians who participate in training programs.

Kearns said the region’s hospitals are now at Level Five or higher in the HIMSS Analytics EMRAM scale, and want to continue to progress. He noted that a good deal is still on paper, and that work needs to be done to computerize clinical documentation.

“How will that unfold?” asked Kearns. “We have this work scoped out, and plan to automate all processes not yet digitalized.” For example, data from smart pumps will automatically populate the patient’s electronic record. “For the immediate future, we have identified eight distinct projects which are about to kick-off with a goal to optimize our system in preparation for electronic clinical documentation,” he said.

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