Transitions of Care

Tuesday, 31 December 2013

We have completed a series of webinars with our Transitions of Care partner, the National Rural Health Resource Center, the video is below:



Understanding HIE Workflows

Wednesday, 13 March 2013

EHR applications have become the center of clinical workflow evaluation and change for many physicians both in the ambulatory physician practice and the inpatient environment. However, the evolving Meaningful Use regulations in Stage 2 and overall competitive pressures have placed a greater priority on the ability to exchange clinical data between disparate systems and independent care providers. The primary vehicle for this exchange of data is through some form of Health Information Exchange (HIE).

HIE solutions are intended to quickly and easily supply healthcare providers with additional information on a patient. Yet, many HIE’s continue to struggle to reach critical adoption levels due to challenges in ease of accessing or utilizing data within the network. HIE solutions with smooth clinical workflows allow users to operate within their existing environments without additional applications or portals requiring a sign-on. Applications that require physicians to break their clinical workflows risk lagging adoption rates.

“The doctors were interested in this to start out, but once they realized that they were going to have to do things in two different places, they lost interest. It is just too cumbersome.” (HIMSS 2012 Presentation, Jason Hess, KLAS)

“Some of our physicians won’t use the HIE if they have to search for the data in a portal. HITECH funding is great but it has ground some of our decisions to a halt.” (HIMSS 2012 Presentation, Jason Hess, KLAS)

How Stage 2 Changes the Challenge of Meaningful Use

Thursday, 03 January 2013

Hielix CEO, Patti Dodgen recently spoke at the 2012 Health Connection Technology Summit, see below for the video.


Post-Op Complications: One HIT Consultant's Nightmare

Wednesday, 17 October 2012

This is a post from Patti Dodgen, Hielix CEO and details her recent experience in October 2012.

It's difficult, but extremely instructive to receive in-patient medical attention if you're someone who analyzes and improves clinical workflows for a living. My husband recently had a hip replacement procedure. It wasn't our first trip to the joint center - he had bilateral knee replacements a few years ago, and there were complications with that procedure - but ultimately, that surgery was a huge success. Even so, this trip we still worked very hard to avoid the complications that almost cost him his life.

We had the same surgeon, a physician universally recognized to be a leader in his field, who also is famous for his bedside manner. Many surgeons are notoriously gruff, but this particular surgeon is a dream to work with. The complications my husband suffered with his first surgery involved the development of a duodenal ulcer that hemorrhaged, causing him to spend five days in the ICU receiving 15 units of whole blood and 8 of fresh frozen plasma. There is a significant risk of this happening if the patient is a long-term user of NSAIDs (non-steroidal anti-inflammatory drugs) like naproxin and ibuprofen, which is the exact profile of someone suffering from advanced osteoarthritis (my husband). Unfortunately, the only way to screen for this complication is endoscopy, which is considered invasive, so they don't do that unless you have specific bleeding symptoms.

So, we consulted with the surgeon and agreed on an alternative anticoagulation therapy for my husband. Every joint replacement patient receives anticoagulants, because blood clots are a potential fatal side-effect of joint surgery. We cut way back on the type and dosage for the hip replacement, so that wasn't a concern. However, almost everything else that could go wrong did.

The surgery went exceptionally well. However, the operating suite was unusually busy that day, so the recovery room was packed. My husband was moved to a recovery bay where his nurse explained that he would begin receiving intravenous dosing of Coumadin, the standard anti-coagulation protocol. And absolutely not what we had agreed with his surgeon that he would receive. We had confirmed the alternative treatment with the surgeon in the pre-op area, and we were all in agreement that no Coumadin would be ordered.

However, our surgeon doesn't write his own orders. He has two PAs that do that for him. My husband became so agitated with the nurse that they brought me back to recovery much earlier than I would ordinarily have been allowed. I confirmed with his nurse that we wouldn't permit the Coumadin to be administered, and she went off to page the surgeon. After the surgeon corrected the post-op instructions, we waited for a room to become available.

I encouraged him to try to sleep as much as possible, but he was situated in the recovery bay next to a hard wall where one of the ward phones was located, and it rang incessantly throughout the afternoon. It turned out that there was some sort of issue with the bed management software (or the number of surgical patients that had been scheduled for that day - we were never able to get a clear explanation) and the beds that were needed were either not being freed, or there were complicated shifts of patients between and among different floors and areas.

Nonetheless, after an being moved to recovery at approximately 1pm, we were still waiting for a room assignment at 7pm that evening. I was told to go back to the family waiting area and we would be going to a room shortly. At 8pm they took me back to recovery to sit with my husband. At this point we realized that he had not had the Plavix that had been prescribed as anticoagulant therapy. My husband takes Plavix regularly because he has a drug-eliding stent in his heart, so the combination of conditions that he needed Plavix for was extremely important.

When the recovery nurse checked with the pharmacy, the pharmacists told her that Plavix is a morning drug and they would not release to be dispensed in the evening. At this point the recovery nurse was a frustrated as we were, and she went physically to the pharmacy to get the Plavix. Finally, at nearly 10 pm we were assigned to a room. After arriving at the hospital earlier that morning at 5:15 am and my husband not being able to sleep at all in the recovery area, we were beyond tired, but of course, we understood and appreciated the need for the staff to check vitals every two hours during the night and administer meds as necessary.

The second day was the easiest of the entire visit. He received physical therapy twice and continued to recover from the effects of surgery. We still hoped he would be released as early as the following day, but certainly by day four. By the evening of the second day my husband hadn't regained his appetite, but was trying to eat a few bites at each meal. Thursday morning (day three) arrived, and we anticipated that he would be evaluated for his readiness to be released. However, he was beginning to experience some heartburn and reflux and his appetite was significantly absent. He took physical therapy only one time that day, and told me he thought he was just as happy to spend one more night in the hospital - he wasn't having pain, but wasn't feeling as well as he would like.

On Friday (day four) morning, we noticed that his abdomen was quite extended, and he was having more heartburn, as well as a bit of nausea. His hospitalist ordered an x-ray to check to see how his digestive system was recovering post-op, and she returned to tell us it appeared that he may have a ileus (a condition where a portion of the large intestine does not recover movement post surgery, which has the effect of stopping all digestive activity). She explained that while they did not see a physical blockage on the films, they needed to insure that the ileus resolved before he could be discharged. At this point his colon was quite distended, and insuring it did not inflate further was an absolute necessity.

She ordered additional drugs to help "move things along". By late afternoon that day he was experiencing significant pain and discomfort from the ileus itself. While trying to eat a small portion of popsicle, he became violently nauseated. The internist on call ordered a gastic-nasal tube be inserted through his nose to his stomach in order to try to release the gas that had accumulated and was now becoming a life-threatening situation. Four nurses converged on his room.

Let me pause for a moment to say that the nurses that cared for my husband during this ordeal certainly saved his life on more than one occasion. They were sympathetic, caring and concerned, and at this point obviously unhappy to have to try to place the tube, but it was becoming more of an emergency every hour. They made three attempts to place the tube, and I can tell you that this is one procedure you never want to have to suffer though. Ultimately, they were unable to get the tube placed. The attending internist then ordered a CT scan STAT to determine whether the tube would be inserted by the emergency department physicians.

I think we all have a pretty good idea of what STAT means. On television, when a doctor yells, "STAT!" it's typically a melodramatic moment, and all hands turn to the task, heroically laboring to save the patient. For those of us who work in and with healthcare, we know it really means that the procedure or process has been prioritized based on a real medical necessity, although we don't all run through the halls like our hair is on fire. In my husband's situation, however, STAT meant absolutely nothing. Because it was a Friday evening and the Radiology Department protocol is to prioritize any and all Emergency Department orders, the Radiology transport finally came for my husband roughly 15 hours later, mid-Saturday morning. Seriously.

Not surprisingly, the CT showed that my husband's situation had become near critical overnight, and a GI consult was ordered. The GI team suggested an emergency colonoscopy to relieve the pressure. The attending internist instead ordered a rectal tube to do supposedly, the same thing. It was clear to me that the GI fellow and attending senior GI did not concur, but the internist prevailed. At this point we were happy to have any kind of forward motion. However, since my husband was admitted to the joint center for a hip replacement, the nurses in that area don't do rectal tubes. So we began on a three hour saga to try to find a bed on a ward where that procedure could be administered. Some four hours later he was moved to an ICU step-down floor. There, once again, he had inspired nursing care. The tube was placed and secured, and he began to finally experience some relief.

Day six (Sunday) dawned with our hope that this nightmare would soon be over and we could start thinking about getting him home. However, another x-ray revealed that the pressure had continued to build! At this point the GI team took over decision making, and an emergency colonoscopy was ordered. However, since it was a Sunday, the endoscopy lab would have to be opened. My husband's GI fellow called ahead to anesthesia to have them meet us at endoscopy. He was told that they would not make a move to join us until he had gotten to endoscopy and been prepped. Once again, the definition of STAT was completely different between departments. However, once anesthesia arrived, the procedure was performed, was a complete success, and my husband was finally released on Tuesday, a full week after he was initially admitted. We can't say enough good things about the nursing staff. They are the first line of care and make all the difference in acute care.

As a consultant providing expert assistance to hospitals in the application of information technology and improvement in clinical and operational processes, what would I tell this hospital? First of all, care coordination needs some serious attention and focus. I understand that the acute care environment is extremely challenging. However, there need to be clear protocols and better communication between the hospitalists, the specialists, and the patient/patient advocate. When a facility has become so large that the questions of access, mobility, and availability are convoluted or excessively complex, the risk of a "never event" goes up tremendously. Acute care is a 24x7x365 proposition. To have a major hospital tell us that diagnostic imaging is triaged to the ED over a weekend is unacceptable. People don't become less critically ill over a weekend. Clinical operations should never take a back seat to time off for staff. Period. Finally, can we take a more collaborative approach to care coordination, and include the RNs in more clinical decision making? I believe outcomes would improve significantly, preventable errors would be greatly reduced, and avoidable readmissions would drop noticeably.