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March 17, 2016

Electronic Medical Record Implementation Unifies BMC and Community Health Centers

In May, ambulatory clinics at BMC began using eMERGE, our version of the Epic electronic health record (EHR), marking the completion of the eMERGE implementation. BMC now has a single, unified health record for each patient, creating a more efficient and cost-effective system that will lead to better outcomes. Now, Boston HealthNet - a network affiliation of Boston Medical Center, Boston University School of Medicine, and 13 community health centers (CHCs) - is implementing Epic in nine CHCs, further uniting BMC with its community health affiliates and creating a more integrated system for care delivery.

In 2014, Boston HealthNet began evaluating new electronic health records to implement at the CHCs. They found that they could implement an Epic system by the end of 2016 - relatively quickly - and that using Epic would allow for better communication between the CHCs and BMC. They selected a platform called OCHIN, an Epic system with the same core functionality as eMERGE but specifically designed for community health centers.

The new system has a variety of benefits for both BMC and the community health centers. Previously, each CHC had a separate database in the electronic health record. CHCs could not easily share information with each other or with BMC, and the information that could be shared was limited and not well-integrated into patient charts. A shared Epic platform allows for better communication between BMC and the CHCs because it allows the systems to "speak to each other."

"There is a great improvement in the ability to see patient-specific data,” says Daniel Newman, MD, who is directing the OCHIN implementation. “Before, providers couldn't easily reconcile patient data, but now they will be a lot more informed about what's going on with their patients' health. The new system will greatly increase patient safety, as understanding an individual patient's problems and how they interact with treatments is critical. For example, if a patient is allergic to penicillin, but that allergy is only in their primary care provider's chart, a specialist might prescribe penicillin. Now, all providers will be able to see the same information in a patient's chart."

OCHIN will also improve referrals between CHCs and BMC. The referral system is a new module in Epic that allows direct referrals between eMERGE and OCHIN. Referrals from CHCs are sent directly into BMC work queues and look like internal referrals at BMC. BMC and Boston HealthNet are the first in the United States to implement this referral module. Eventually, the system will be able to sync referral statuses directly back to CHCs, so that referring providers can see the status of the referral and when the visit took place.

This higher level of communication between providers at BMC and at CHCs will require that all providers use the Care Everywhere function of Epic, which allows providers to see data for their patients without additional approvals. It will also help streamline the reconciliation of data for patients with multiple providers. Because providers can see what other providers have done, the likelihood of unnecessary or repeated tests or exams will decrease.

All of these features will be beneficial to the development and growth of BMC and the Boston HealthNet system. As part of the 2016 QUEST goals, BMC has been refining referral and discharge processes to help grow volume. With OCHIN and eMERGE, providers at the community health centers know that their patients will be seen at BMC within a reasonable time frame and that they will have timely access to patient data. Similarly, providers at BMC can get data to CHC providers more easily, and there is a much greater probability that their actions and recommendations will be followed up on. Streamlined communication between OCHIN and eMERGE contributes to the success of our QUEST goals by making BMC the best partner for CHC referrals.

The OCHIN implementation began in November 2015 with South Boston Community Health Center and the Greater Roslindale Medical and Dental Center. Implementation has also been completed in Mattapan Community Health Center and Codman Square Health Center. OCHIN will go live at Dot House Health at the end of March, South End Community Health Center in May, Upham's Corner Health Center and Whittier Street Health Center in June, and Boston Healthcare for the Homeless in August. Each implementation requires a 90-day "stabilization" period in which the system is tested to make sure it works properly and meets the users' needs.

Reach Out and Read Promotes Childhood Literacy

On February 29, Lauren Baker, the First Lady of Massachusetts, visited Boston Medical Center to meet with providers, child life specialists, patients and families who are involved in the Reach Out and Reach program. The program, which was founded at BMC and has a site here at the hospital, is now a national nonprofit that promotes literacy by emphasizing reading aloud to children.

Lauren Baker, First Lady of MA, reads to BMC Pediatrics patients 

"Some of our family's fondest memories are from reading aloud each night together," said Massachusetts First Lady Lauren Baker. "I encourage all families to take part as much as they can and applaud Boston Medical Center for their role in founding and expanding this incredible program."

Reach Out and Read was founded in 1989 by Barry Zuckerman, MD, a pediatrician and the former Chief of Pediatrics at BMC, and Robert Needlman, MD, who was a Boston City Hospital Pediatrics resident at the time, along with several early childhood educators at the hospital. As pediatricians and educators, they saw the need for more patients to be exposed to reading early in life. BMC began a pilot program to provide books to pediatric patients at well child visits, and the founders quickly realized that the program could be valuable at other locations as well.

Within five years, Reach Out and Read had expanded to 34 programs in nine states and had given out almost 20,000 books. Today, there are 5,000 programs across the United States - 300 of which are in Massachusetts - and the program gives 6.5 million books to 4 million children annually.

Children who participate in Reach Out and Read receive their first book at their 6 month check-up, and at every well-child-check up to age 5. This year, BMC provided 13,000 books to 12,000 children. Providers select from a range of popular titles based on the family's preferred language and according to the child's developmental level. Books are restocked every six months, come in a variety of languages, and are chosen to be culturally sensitive and include protagonists of color. During the office-visit, parents are taught that reading together not only offers them early opportunities to teach their children such things as counting, colors, letters and words, but also creates bonding time with their children. As children grow, parents are taught how to use books throughout the day to entertain and increase the imaginations of children in ways that have been found to be more effective than TV and video games.

All books are given to children by pediatricians, but BMC is working to train pediatric residents in the Reach Out and Read model as well. The books themselves double as tools to aid pediatricians in making more accurate developmental assessments of their patients. For example, they may look at how the child reacts to the book, if they can grasp or turn the pages, assess object recognition and identify early literacy skills. Often this approach to assessment saves time and provides better information than would result from asking parents and children a long list of questions.

Reading aloud to children is widely recognized as an integral component of promoting language development and can strengthen parent-child relationships during a critical time early childhood. The Reach Out and Read intervention model has been endorsed by the American Academy of Pediatrics as an effective model for improving school-readiness for low-resources children.

"The brain develops more in the first five years than at any other time in life," says Ashley McLellan, a child life specialist and the Reach Out and Read coordinator at BMC. "Exposure to books and language during these critical early years helps to develop the language, cognitive and social-emotional skills needed for a lifetime of success."

In addition to the Reach Out and Read program, BMC partners with the Boston Public Library to have a librarian come to Pediatrics once a month. The librarian reads aloud to children in the waiting room and brings books for families to check out on site. During the librarian's visits, families can also sign up for library cards for their local branch and return any books they check out there.

PIn July 2015, BMC's Ullian Neonatal Intensive Care Unit will become the first NICU in the country to pilot the Reach Out and Read program. The program will provide books for parents and providers and encourage reading to NICU infants during their hospital stays. Preterm infants are more likely to have language delays and are exposed to less language due to a shorter term in utero, making exposure to spoken words even more critical for them. Increased parental talking in the NICU is directly associated to higher seven and 18 month Bayley language and cognitive scores, and research has shown that infants in the NICU who hear more spoken words while in the hospital have better neurodevelopment at 18 months. The NICU Reach Out and Read program aims to help facilitate these long-term benefits.

The program has enrolled approximately 40 infants since it began, and the majority of enrolled parents or providers report reading to their infants at least every other day. Books are provided in English, Spanish, French, and Haitian Creole, with other languages to come. New books are given to parents each week of their infant’s hospital stay, and parents receive check-in phone calls after discharge to encourage them to keep reading to their children.

For more information about Reach Out and Read, visit the program's national website.

 

What do you do, Michael Ieong?

Name: Michael Ieong
Title: Medical Director of the Medical ICUs and Pulmonary Function Lab, Co-Chair of the Ethics Committee and the Critical Care Executive Committee
Time at BMC: 20 years

What brought you to BMC?
BUMC has one of the top programs in the specialty, pulmonary and critical care medicine. I was also interested in working with BMC's patient population. I had worked in safety net hospitals throughout all of my training and wanted to continue to work with underserved populations.

I stayed at BMC for two major reasons. One is that the pulmonary and critical care medicine section is made up of very bright and socially dedicated people - they're all really focused on taking care of patients. Everyone works hard, but is very collegial and supportive. Second, BUMC has a very strong research and academic program in my specialty. I prefer academic medicine because it maintains a high standard of patient care that is evidence-based and current. At the same time it seeks to educate, train and develop new ways of improving healthcare.

What do you do here?
On some days, I'm on service, so I'm an attending physician in the MICU. Those days generally begin with education for the residents, followed by rounding in one or more of the medical ICUs. I'll direct care of the patients, who are among the sickest in the hospital, as the attending of a MICU team. A significant component is communicating with the patient's family or surrogate decision-maker about the critical illness. This is a spectrum that runs from the basic integration of the family into the management plan to support and help in end-of-life decisions.

I also have administrative responsibilities related to the management of the MICU service and Pulmonary Function Test (PFT) lab. For the MICU service, these include working on quality initiatives, addressing specific incident issues, and maintaining effective clinical workflows so that our multidisciplinary MICU staff can focus on delivering high quality ICU care. The same holds for the PFT lab, where I collaborate with Charlie O'Donnell, Director of Respiratory Services. The major difference here being that we provide services to the entire BMC inpatient, ambulatory, and community clinic providers.

Then I have responsibilities related to my positions on the Critical Care Executive Committee that I share with Kellie Smith, Director of Critical Care Nursing, where we work with medical directors, nurse managers, and other staff from the other BMC ICUs to address more global issues regarding standards of care, quality improvements, and other issues. In addition, I have duties for the Ethics Committee, which I co-chair with Cathy Fabrizi, the director of nursing in the Geriatrics section.

What does the Ethics Committee do at BMC?
The committee is all volunteer and multidisciplinary. It includes nurses and doctors from many specialties, as well as from many patient support services, such as interpreter services, patient advocacy, social work, case management, and chaplaincy.

The Ethics Committee has four mandates:

  1. Review, revise, propose, and develop policies related to healthcare ethics such as those for advanced care planning
  2. Develop educational programs addressing common ethical dilemmas encountered at BMC
  3. Provide support to staff members in addressing ethical questions related to patient care through the Clinical Ethics Consult Service
  4. Maintain a database of consults to identify potential systems issues or hotspots for directed attention by senior administration

We provide ethics consults through a committee subgroup called the Clinical Ethics Consult Team. Our primary goal is to serve as a resource to facilitate thinking through a challenging ethical dilemma at the request of providers and teams. Such dilemmas may arise in direct patient care, in disagreements among providers as to the best approach, or in a challenging directive from a patient or surrogate decision-maker. We help the care team get to a place where things make sense and are grounded in basic ethical principles.

A misunderstanding or misconception about the ethics consult service is that we're there to provide a judgment, which is definitely not what we do. One thing we've noticed is that with challenging cases, clinicians or staff may experience what some have termed "moral distress," or in other words, the sense that although a treatment plan may be medically appropriate it may not be the "right" thing to do. As a consult service we're available to help staff members think through, understand, and work to reconcile these concerns.

We're trying to encourage people to call us more often and earlier, when they anticipate that an ethical issue might come up in the course of patient care. If we are called early, we can help avert the prolonging of a difficult situation which, with more time, can develop increasingly more hurdles.

Ongoing education is a running thread through all of our activities. For the BMC staff our most common means of addressing a topic in healthcare ethics is in the format of a grand rounds panel discussion. We'll talk through a case-based ethical dilemma in a seminar fashion and ask the discussants to highlight learning points and principles. Ongoing education is also important for the Ethics Committee members to maintain their skills in analyzing the cases we are presented. To this end the Ethics Consult Team meets between committee meetings to discuss current relevant literature and review the role and approach of the team.

What happens during an ethics consult?
Anyone can either page the Ethics pager (# 4636) or go to our website under the Resources tab of the main intranet page and place the request directly through there. One of our consult team members will call the requesting person to briefly review the case and identify the ethical questions or concerns. Sometimes we find the question to be more of a direct legal or case management issue, in which case we will try to facilitate contact with the right person to proceed. Otherwise, our next step is to convene a meeting of the appropriate people, which usually includes the treatment team, relevant ancillary patient services, and three to four members of the ethics consult team, within 24-48 hours. In some cases we might consider meeting with the patient or the patient's family, but our role is really to facilitate progress towards resolving the ethical dilemma by the involved relevant staff. We review the case and encourage everyone to talk through their concerns, then try to identify the ethical questions and how they might be addressed. We then make recommendations for next steps, taking into account the patient's and the treatment team's values and goals. If necessary we sometimes follow up with a second check-in meeting.

Anyone can consult us. It's not restricted to only physicians. However, it's important to note that the whole treatment team will be involved in a consult, so they should know that it's happening. The idea that anyone can come to us with concerns is highly supported by senior management.

What do you like most about working at BMC?
Everything I've ever done in my career has been focused on providing meaningful service, so working with BMC's patient population is something I really value. We care for a lot of patients who may have limited resources for health care but we treat and manage them with the intent of providing top level care.

The second thing is my colleagues. I've found that the BMC and BUSM communities are stacked with people who are very dedicated to our patients. They are an innovative, creative, bright group of people who are intellectually curious and interested in finding or developing new solutions to the challenges of patient care.

What do you do for fun outside of work?
I have a two-and-a-half-year-old daughter, so I spend most of my time outside work with her and my partner. In a past life I performed a lot of music and always return to it. I also enjoy visiting the many amazing towns and countryside in the New England area as the weather allows. I love to travel and since I'm from Colombia originally, I try to go visit my family there as much as I can.

Do you know a staff member who should be profiled? Send your suggestions to [email protected] .

Hypertension? There's an app for that.

Nowadays, people use their smartphones for everything from getting a ride to watching movies, and taking care of their health is no exception. BMC doctors and researchers have now made it easier for patients trying to lower their blood pressure with an app that provides guidance on using the DASH diet. The app is currently being tested in a pilot study.

The DASH (Dietary Approaches to Stop Hypertension) diet helps people with hypertension control their blood pressure through healthy, yet flexible, eating. It provides daily and weekly nutrition goals for eating specific numbers of servings for different food groups, such as four to five servings of vegetables, six to eight servings of whole grains, and two to three servings of fats and oils per day.

"The DASH diet is a good, evidence-based way to reduce blood pressure, but is not implemented widely," says Devin Mann, MD, Associate Chief Medical Information Officer for Innovation and Population Health at Boston Medical Center, and one of the creators of the app. "It can be hard to promote within the health care system, because we can really only refer patients to nutritionists - which can be too time-intensive for many patients - or to books. The app was created to help overcome resource issues regarding patients not having enough time with trained people and logistical barriers for patients, because it allows them to connect on their own time."

Three years ago, after attending an NIH seminar on mobile technology in health care, Mann saw an opportunity to expand on Boston University's employee-focused "DASH for Health" program with a mobile component geared toward patients. He began working with informatics fellows and Lisa Quintiliani, PhD, a behavioral scientist in General Internal Medicine, to develop an app that would help patients stick to the DASH diet. Now in its second iteration, the app is currently being piloted. The pilot program has currently recruited 11 of the planned 30 patients. Recruiting is ramping up, and they hope to finish the pilot by the end of spring.

The DASH pilot consists of two connected parts: the app and health coaching. Patients are given Bluetooth-enabled devices to measure weight, blood pressure, and steps; these devices sync to the app to allow patients to track their progress more easily. The app also asks patients to input basic information about their diet, such as how many servings of DASH-approved foods they ate on a given day. All patients use their own smartphone for the program.

The coaching aspect of the program is also integrated into the app. Patients talk to their health coach every two weeks, but in-between those phone calls, coaches - who can see all the data patients input into the app - use the app to connect with patients. They can recommend articles to read or videos to watch, post encouraging comments, and reinforce good behaviors. For the biweekly phone calls, coaches have a script outline that utilizes motivational interviewing techniques to guide patients through making lifestyle changes. During the pilot phase there is one coach, Marissa Puputti, a dietitian student and the research project coordinator of the study. After the pilot, additional coaches will be hired if necessary, potentially using a peer counselor or patient navigator model.

"Humans and computers are good at different things, and the goal of having both human coaches and the app is to utilize all of those skills," says Quintiliani. "The coaches are good at listening and responding in real time, as well as promoting self-confidence and providing motivation. Computers are good at gathering and analyzing data, finding resources, and displaying information. These skills are all necessary to help patients align their actions with their personal values, such as becoming a healthier person so that they can play more with their children."

Although the current sample size is small, results of the pilot are positive so far. Patients have reported liking the coaching aspect and feeling that the tracking devices are helpful. Right now, the researchers are considering several next steps for when the pilot is complete. One possibility is to run a larger study to refine the program and prove efficacy. Another is to collaborate with an outside organization to produce a more commercial version of the program. According to Mann, decisions about next steps will be made further along in the pilot process.

For more information about the pilot study, contact Marissa Puputti at [email protected] or 617-414-6656.

 

Awards and Accolades

David Coleman, MD, Elected President-Elect of the Association of Professors in Medicine
David Coleman, MD, Chief of the Department of Medicine at BMC, was named President-Elect of the Association of Professors in Medicine. APM is the organization of departments of internal medicine represented by chairs and appointed leaders at medical schools and affiliated teaching hospitals in the United States and Canada.

This three-year role will begin July 2016, when Coleman will be named president elect of the association. Following a year as president from July 2017-18, he then will serve one year as past president.

Two BMC-Affiliated Programs Receive Honorable Mentions for Gage Award
Two BMC-affiliated programs, the Massachusetts OBAT-B and ICOUGH, were selected as honorable mention recipients for a 2016 Gage Award from America's Essential Hospitals. The Gage Awards recognize the necessary for members to successfully carry out improvement projects, spread best practices and innovative programs to other organizations, and support America’s Essential Hospitals’ research, policy, and advocacy work by sharing stories of member success with a broad audience.

Colleen LaBelle, BSN, RN-BC, CARN, Nurse Manager of the BMC Office-Based Addiction Treatment (OBAT) program, serves as Program Director of Training and Technical Support for the state OBAT program. ICOUGH is a program developed at BMC that reminds patients, families, and staff about important steps to help patients avoid post-operation pulmonary complications.

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