1

Targeting Laboratory Order Entry To Improve EMR Workflow

Tara Sanft, MDNatalie Wallace, MDElizabeth Rosenberg, RNHarold Tara, MD

December 5, 2019

ASCO Quality Training Program

Institutional Overview

2

Smilow Cancer Care Network is the largest cancer system in Connecticut

13 locations43 physicians, 15 APPs300 + staff 7,000 medical oncology visits per month90,000 treatment visits

45% of newly diagnosed patients in Connecticut

Team members

3

Title Name

Team Leader Tara Sanft

Team Members Harold TaraNatalie Wallace

Facilitators Kim SeverinoTom Collins

Participants Neal FischbachJustin PersicoJerry MalefattoDavid WittMichael CohenuramElizabeth Rosenberg

Project Sponsors Anne ChiangKerin Adelson

Coach Holley Stallings

Problem Statement

4

The burnout rate for Oncologists at YNHH is 53%

Excess EMR Documentation is the highest driver of burnout

Time spent in laboratory order entry leads to excess EMR use

MDs in the Trumbull office spend 20 minutes per day putting in orders

MDs across network spend 10 minutes per day

MDs in Trumbull spent twice as long entering orders per day

Outcome Measure

Baseline data summaryItem DescriptionMeasure: Time spent in orders

Patient population:(Exclusions, if any) Dr. Neal Fischbach and Dr. Justin Persico

patients

Calculation methodology:(i.e. numerator & denominator)

Time spent in orders (min/day)/Med Onc Avg# orders entered/patients per clinic# missed orders/patients per clinic

Data source: Clinic lists worksheetEpic Userweb

Data collection frequency: Every 2 weeks

Data limitations:(if applicable)

Relies on multiple people to start and finish data collection 5

Outcome Measure

Baseline data

Red = Trumbull Providers

15

1 1

41

7

1513

4

20

17

14

68 8

11

16

3 4 31

108

0

5

10

15

20

25

30

35

40

45

Tim

e (m

in/d

ay)

Providers

Average time spent on order entry per day

Aim Statement

7

Providers rated excess order entry as a top cause of burnout, our goal is to institute a new order entry work flow with APP support.

We aim to reduce time spent in orders by Trumbull MDs by 10% by November 26, 2019 (20 minutes/day to 18 minutes/day)

Process map

8

The time it takes to enter orders for a clinic is almost 20 minutes dailyEach order requires 16 clicks

28 seconds/order x average 2 orders/patient x 20 patients/day=18.6 minutes/day

Cause and Effect diagram

9

The highest volume of drivers of burnout are issues related to order entryThe red boxes reflect staffing problems

Diagnostic Data

0

1

2

3

4

5

6

7

8

9

10

Insufficient supportstaff/ support staff

services

Need for assistancewith order entry

Excessive numbers ofpatients / appointment

times too short

Software problems EMR problems Insufficient workspace

Reasons for burnout - Smilow Trumbull

Num

ber o

f res

pond

ents

Verbal orders during protected time daily

RN to enter and pend orders

APP to enter and sign orders

Scribes to enter orders

Hire new staff to enter orders

Medical Assistants to enter orders

Educate MDs to enter orders

Email providers to sign orders

Create an order set no one uses

High

Impa

ct

Low

Easy DifficultEase of Implementation

Priority / Pay-off Matrix

Countermeasures

11

Process Measure

Diagnostic Data summary

12

Item Description

Measure: Time spent in orders

Patient population:(Exclusions, if any) Drs. Neal Fischbach and Dr. Justin Persico patients

Calculation methodology:(i.e. numerator & denominator)

Time Spent in Orders (min/day)-----------------------------------Medical Oncology Average (min/day)

Data source: Epic UserWeb Signal Data

Data collection frequency: Every other week

Data limitations:(if applicable)

If volume increases the time in orders will increase (avg pt/day is 23-25)

Process Measure

Diagnostic Data

13

Neal Fischbach (blue) Justin Persico (blue)Avg Med Onc (yellow)

Test of Change

PDSA Plan

14

Date PDSA Description Result

10/15/19 - Phlebotomist generates list 24 hrs- Circle names of those without labs- APP/RN split orders, do in AM during

protected time- After clinic, list kept with notes

about extra orders/extra sticks

List printed with not enough time before clinic

Not enough protected time for RN/APP

11/1/19 - Process continued with more dedicated APP block time and goal to complete 48 hrs ahead of clinic

- Dr. Tara added as 3rd MD- APPs able to be forwarded order

requests to help with team documentation and order entry to better help providers

MDs felt more effect with second PDSA and want to continue with new workflow

Outcome Measure

Change Data

0

1

2

3

4

5

6

Day 1(10/8/2019)

Day 2(11/5/2019)

Day 3(11/6/2019)

Day 4(11/8/2019)

Day 5(11/11/2019)

Day 6(11/12/2019)

Day 7(11/13/2019)

Day 8(11/15/2019)

Day 9(11/19/2019)

Patients without labs entered

Num

ber o

f pat

ient

s

Outcome Measure

Change Data

0

0.2

0.4

0.6

0.8

1

1.2

Day 1(10/8/2019)

Day 2(11/5/2019)

Day 3(11/6/2019)

Day 4(11/8/2019)

Day 5(11/11/2019)

Day 6(11/12/2019)

Day 7(11/13/2019)

Day 8(11/15/2019)

Day 9(11/19/2019)

Patients requiring an additional laboratory draw during visit due to missing labs

Num

ber o

f pat

ient

s

Outcome Measure

Change Data

0

0.5

1

1.5

2

2.5

Day 1(10/8/2019)

Day 2(11/5/2019)

Day 3(11/6/2019)

Day 4(11/8/2019)

Day 5(11/11/2019)

Day 6(11/12/2019)

Day 7(11/13/2019)

Day 8(11/15/2019)

Day 9(11/19/2019)

Duplicate labs entered for patients

Num

ber o

f pat

ient

s

Outcome Measure

Change Data

0

5

10

15

20

25

30

35

Day 1(10/8/2019)

Day 2(11/5/2019)

Day 3(11/6/2019)

Day 4(11/8/2019)

Day 5(11/11/2019)

Day 6(11/12/2019)

Day 7(11/13/2019)

Day 8(11/15/2019)

Day 9(11/19/2019)

Time required each day for order entry by APP

Min

utes

per

day

Outcome Measure

Change Data

Epic User Web Data for November not yet available

Next steps

Sustainability Plan

Next Steps Owner

APPs continue at Trumbull Care Center to perform laboratory order entry prior to the clinic

Hal Tara

Roll out to remaining providers Hal Tara

Consider additional steps to roll out to all care centers Tara SanftAnne Chiang

20

Conclusion

21

- Burnout levels are high among medical oncologists at Smilow- The Trumbull MDs identified laboratory order entry as a driver

of burnout - The Trumbull MDs spend twice the time in orders/day

compared to MDs average across network- Support staff entering lab orders improved perception of work

burden- Awaiting additional UserWeb data to show change in time in

orders/dayLessons Learned: Process took longer due to vacations; buy-in took longer, but eventually team had positive reviews