The Philips Xper Information Management System: Looking back after 1 month live at Duke University Medical Center

A behind-the-scenes look with three superusers.

Theresa DeMuro (Holding) and Wanda Cooley (Cath Labs)

Tell us about your previous hemodynamic system and why you changed to the Xper Information Management system. Theresa (Holding): We originally had the Witt Series IV system, which was the previous model. It had been in place for about 4 years, but only in the cath lab. The EP lab installed the same model perhaps two years ago. The holding area was still documenting our patient care and vital signs on paper forms. The Xper Information Management system is the new upgrade to the Witt system. It is a hemodynamic, documentation, inventory and billing system. We decided to place it in all our labs to allow for a continuous flow of patient documentation. The patient’s chart is opened pre procedure in holding, continued information charted throughout the procedure in the labs, and completed post procedure in the holding area. We were also looking for a system that would allow us to run data reports and queries. We implemented the system and went live in early November 2009. Wanda (Cath Labs): At this time, we are only using the charting and hemodynamic monitoring. We plan on implementing the billing and inventory modules in 2010. Our inventory manager has already gone through the Philips training for the system. What changes have you seen in the cath lab since implementing the Xper Information Management system? Wanda (Cath Labs): Within the system itself, menus are mostly the same. Certain features are now located in different places. Another change is that all the medications are now listed under the generic name. This was to comply with a hospital-wide initiative. We had to re-label and re-alphabetize, there was a learning curve for some staff in terms of learning the generic names. An understanding of the system usage and needs for each area has also occurred. There has been a great partnership between the superusers to work as a team and assist with the build. Theresa (Holding): A change we have noticed between the areas with the continuous flow of patient documentation is each separate area (holding, cath, EP labs) can at any time look into the other menus, or charting sections to verify pertinent patient information. All areas share the vital signs capture page, and medication administration menu. There is a more collaborative care approach of the patient. The holding area transition from a paper system to digital documentation must have been a dramatic change. Theresa (Holding): It’s been a little bit of a challenge getting everyone on board, but now that we have been using the system for about a month, I think the nurses in the holding area have really come to like it. Everybody uses the same language and charting forms. The nurses have become familiar with the charting flow and are doing a great job with it. We are all enjoying the convenience of easy access to procedural information and timing of events and medications. We have been able to put all of our custom forms into the system, such as the medication reconciliation, our nursing history, patient and family education forms. Some of these are populated through menu charting with scrapers to alleviate duplicate charting. Everything is right at the bedside in one system. Do you anticipate any time savings with use of the Xper Information Management system? Theresa (Holding): Once we get through the learning curve, there will be a decrease in our prep time in the holding area. Some of our patients are brought in as prescreens up to one week prior to the procedure date. We do all of our labwork, history and documentation. Now, on the day of the procedure, it is a fast and easy process to bring up their information, verify the data, and continue with our pre procedure assessment and prep. The scraping aspect of the Xper Information Management system saves time by allowing you to chart a documentation item once, that we then direct through a “scraper” to populate an entry on a form or report to prevent duplicate documentation. An example would be allergies which must be charted in many parts of the patient record. Wanda (Cath Labs): I don’t think there has been an appreciable change in time for the cath labs thus far. The EP lab will see a time savings due to decreased handwritten forms requiring duplicate charting, as well as product stickers being placed. Once the information is entered into the patient’s chart in the Xper Information Management system, it can autopopulate many of these forms. Can you describe how you became a superuser? Wanda (Cath Labs): I was a superuser for the Series IV. At that time, during the process of creating the menus, they wanted someone familiar with our cath reports. Since I had experience with those, I was asked to help. It evolved into teaching the staff as well. When the Xper Information Management system came around, it was merely an extension of duties I already had. With the Series IV, I went for a one-week training in Melbourne, Florida, and for the Xper Information Management system, three of us went to a two-week training in Florida. The course itself was not that difficult. Philips was very good about explaining things. Theresa (Holding): I decided to volunteer for the project, because it was an extension of a project I had been working on for the outpatient holding area. I am the Green Belt on our Six Sigma Performance Improvement Committee. The current project is focused on our area becoming more efficient. We have seen an increase in patient volume to the area, requiring improved patient throughput. Paperless charting was a step that we thought could help. Streamlining our charting for the procedural patients for both cath and EP, as well as our clinic patients, should improve efficiency. How long did you plan before the system went live? Wanda (Cath Labs): We flew down to Florida for the two-week training in May 2009. When we returned, we started building the menus and creating custom forms. This process continued until the end of August. We were basically doing all of the background work. In October, we started training the staff, employing a step-by-step user guide that we, the superusers, developed for our Duke staff. We spent two weeks trying to familiarize everyone with the system so it would be less of a culture shock. When we did go live, we had 2-4 people here from Philips, as well as Theresa, Carolyn (she was the EP superuser at that time) and I, floating around trying to help people. Holding and cath both had systems going up over several days. We did not have everything go live the same day. EP went live with everything at once. Considering that they were only utilizing two rooms, it seemed to work well for them. Theresa (Holding): We had weekly conference meetings from the time we came back from Florida to the time we actually did the “go live.” A group of about 8 people would conference call to Philips in Florida every Thursday morning. The group was multidisciplinary and included everyone from the finance/business planner, superusers, Dr. Tcheng (our physician advisor), our lab administrators, clinical engineering, IT/DISCC support, performance improvement, and biomed department. The planning was a pretty extensive six- month period. Now that you are so immersed in the system capabilities, are there things you are looking forward to doing with the Xper Information Management system? Theresa (Holding): Yes. There are a great deal of data and reports we can now get from our daily charting. One thing we are looking at is time stamps in patient flow: how long does it takes us to go from point A to point B? If we can trend those types of things, we can see what improvements can be made. As part of our performance improvement and quality control it can definitely give us important information. We can trend patient service types, procedure types and time of cases, procedure and clinic volume, as well as many other things. Wanda (Cath Labs): We are working on a handoff form that will be utilized for a consistent, detailed report to holding and the inpatient units on all of our patients. We will be able to hand a form with all the necessary patient information to the receiving nurse for reference and signatures will be required by both reporting and receiving personnel. What are your thoughts about how the installation has gone? Wanda (Cath Labs): Generally, the installation has gone well. It will definitely get easier as people get used to the system. For holding, it was a totally new area for them. It is an adjustment going from paper to computer charting. Even in terms of the cath lab, the way that we admit patients that come from holding is different from the way we used to admit patients into the Witt system. As time goes on, people will get more and more used to how they are supposed to do things. It’s still a learning curve. Theresa (Holding): In the holding area, with the system being so new, I have been requesting input from the staff. They tell me what works and what doesn’t work. We have made changes since going live a month ago in order to make the system more user-friendly and complete for our needs. Do you make those changes to the system or does Philips? Theresa (Holding): As superusers, we can make changes to the forms and charting menus at any time. We continue to work on those. It will be a work in progress for some time. As we develop more uses for the system, including billing and inventory, and require more queries and reports, we will continue to update the system at Duke. Theresa Demuro can be contacted at theresa.demuro@mc.duke.edu Wanda Cooley can be contacted at wanda.cooley@mc.duke.edu

James E. Tcheng, MD

What advantages do you see with use of the Xper Information Management system? The Xper Information Management system gives us the opportunity to integrate multiple sources of data. We have implemented the system across the continuum of care in our cath lab, including the outpatient and post-procedure holding area. Having access to data across this continuum helps us fulfill our clinical and administrative responsibilities in an efficient fashion, as this gives us access to structured data from all corners of our enterprise. So it isn’t just that we can do things more effectively, but we can actually reuse the data at a later time to evaluate or investigate questions that we might have about patients who come through the system. Are there particular questions you anticipate answering? Yes. Some fall into the rubric of systems and processes. How do you identify points of opportunity for reducing door-to-balloon time in ST-elevation myocardial infarction? How are we doing in terms of preloading patients prior to angioplasty with a thienopyridine? What are the things that we could do to turn over our labs more efficiently? These are examples of the administrative, quality- and process-related issues that we will be able to address. Another level of inquiry has to do with information about individual patients and predictors of outcome. For example, if you have a situation where a series of patients have a particular outcome, for example hematoma formation, bleeding at the access point or infection, we might want to try to correlate that with the laboratory in which the procedure was performed, the physician that performed the procedure, the type of procedure that was done, the technical staff assigned to the case, and/or the medications that were given. Outcomes-based measures are also part of our query system. For example, we can ask the system to tell us outcomes for all the patients who had a 2.5 mm stent implanted or who were calculated to have moderate to severe mitral stenosis. The capture of the data in a structured fashion allows us to ask all those questions in a way that facilitates coming up with answers for clinical, educational, and research purposes. Were you doing data capture on this level with the Series IV? No. There are components in the Xper Information Management system that allow us to ask questions about workflow and work processes from start to finish that we were not able to ask of the Series IV system. We decided to expand the scope of electronic data capture to include the entire cath lab operation and all invasive radiology lab procedures, rather than just the cardiac diagnostic and interventional labs per se. We have extended it to include the pre procedure and post procedure holding area. If we were to ask a question prior to the Xper Information Management system being put in place — for example, how long did an individual patient stay in the holding area before being taken to a procedure room, or what’s the average amount of time that patients are in the holding area before they get brought over to the cath lab for a procedure? — we could only do this on paper via a manual process. Trying to do it for our EP and peripheral vascular patients was nearly impossible because we didn’t have a way to do it in a systematic fashion. Now we’ve converted to an environment where everything is being collected electronically. We can access and query data in a much more straightforward fashion. The potential for error and the effort associated with trying to maintain data on a spreadsheet have been eliminated. How do you access the collected data? There are prebuilt queries that will facilitate a number of the administrative queries, and then there is access to the data itself. The previous Series IV system used a closed, proprietary database structure. Trying to extract information was not straightforward. It typically required an extensive effort to ask even simple questions. You then had to combine the information obtained from the Witt system with other data acquired via a spreadsheet review of individual pieces of paper. Now, all information is collected electronically. Not only is all the data in one place, but we have also been granted access to the data in the database itself. The Xper Information Management system is built on a standard SQL (Structured Query Language) database, so inquiries are much less arduous and problematic compared to the Series IV, where we had no real access to the database structure and we couldn’t run our own queries. Quality is a key part of why we converted from Series IV to the Xper Information Management system. Having access to the data is crucial to understanding our workflows and identifying opportunities to improve our care processes. One final comment — my colleagues, particularly Wanda Cooley and Terry DeMuro, have done a remarkable job. I’ve provided guidance, but they’ve done all the heavy lifting, so they deserve all the credit. It’s been, so far, a better than expected experience. Sometimes new systems are disastrous when you bring them online, but this has been a better than anticipated experience, again, largely because those who were responsible for bringing the system up did a fantastic job. Dr. Tcheng can be contacted at tchen001@mc.duke.edu

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