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
“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.
Photo by Emile Wamsteker