HealthData Management

NURSING IT INNOVATION AWARD

In play are two key EHRs. U-Penn runs an inpatient system, from Allscripts, where all orders originate. In addition, its ambulatory outpatient practices run on Epic. To tackle the vaccination issue, U-Penn charged Terese Kornet, R.N., with convening a disparate group of 35 individuals to map previous vaccine administration workflows. Kornet, the director of nursing systems at the Hospital of the University of Pennsylvania, served as project champion along with Denise Gilanelli, R.N., director of nursing systems at Penn Presbyterian Medical Center, and Mary McCann, R.N., director of informatics at Pennsylvania Hospital.

“We brought in staff from nursing, medi-
cine, pharmacy, quality, data collections and
I.T.,” says Kornet. “The three hospitals had
different workflows, so we had to gain con-
sensus on how the admission order screens
should appear and work.”
The result? The multi-disciplinary group
identified 43 barriers to improvement in
the way the health system handled vac-
cines. “We walked through all the work-
flows,” recalls Christine Vanzandbergen,
clinical decision support officer.

The multitude of barriers uncovered for such a seemingly innocuous task did not surprise Kornet. As soon as she got wind of the new regulations, she began reaching out to colleagues. “I was hearing of the challenges from the nursing staff,” she says. In its old workflow, vaccine orders were part of the overall admitting order entered by physicians. If a physician did not know if the patient needed a vaccination, they would document the fact in the EHR. But the system was configured to turn that into an order—one without a scheduled time. “That led to confusion among the nurses,” says Kornet.

It also led to proliferation of orders, many of which proved to be superfluous—within three months after the new system was rolled out, the number of orders were reduced by about 50 percent. At the same time, there was a 109 percent increase in pneumonia vaccine administration and a 290 percent increase in flu vaccine administration.

Obtaining those numbers required hands-
on design work by a core group of nurses in
the I.T. department. The project team set
about devising changes to the order entry
system and clinician workflows around it.
The admission order entry was modified.
Now, the standard admitting order defaults
to a follow-up order for the nurses to con-
duct a vaccine assessment. Unless the phy-
ment was completed.” There were other cri-
teria built into the nursing assessment task
list to assure that patients who should avoid
getting a vaccine were sidestepped.

sician overrides the default—for a patient he wants to self-assess—the nurse will follow through and conduct the assessment. To support the nursing assessment, the EHR was modified to include administration guidelines and reminders for the vaccines. Via interface with the ambulatory EHR, the Allscripts system will detect outpatient vaccine administration.

If a patient already has had both a flu and pneumonia vaccine, the set-up will automatically update the nursing assessment form, giving the dates of the vaccines. The vaccines will be included in the EHR admission summary and the nurse will receive no assessment task. If only one of the vaccines was previously given, that too will be noted and the task will be presented an assessment form documenting which vaccine needs to be considered. The interface, Kornet says, “was a huge win. If the EHR indicated a patient had a documented vaccine, the assess-

Left to right: Mika Epps, R.N., (left) and Terese Kornet, R.N., discuss screen design with David Stabile, R.N., who served as a clinical analyst on the vaccination protocol project at Penn Medicine.

“We tried to fit the build into the nursing workflow,” says Epps.

If the nurse determines that the patient needs a vaccine, she will first gain patient consent. If the patient says yes, the nurse denotes the need in a medication task list, and the order goes to pharmacy. Pharmacy later schedules a time for administration in Allscripts. The EHR now highlights a message in a red box if the administration is overdue. ”The red box is a fail-safe,” says Kornet.

The vast majority of patients now get a vaccine assessment, and if appropriate, a vaccine. About 13 percent of patients still do not get an assessment, a number U-Penn is trying to reduce.