UniversityHealthNetwork(UHN):MOEMORInitiative

ByGroup8
TasnemJahangir
MaryamShahid
PreciousOsuchukwu
FahidShinwar

ExecutiveSummary:

TheUHNnetworkconsistsofthreeoftheoldestandthemostreputablehospitalsin
Canada.InApril1999,TorontoGeneralHospital,TorontoWesternHospitaland
PrincessMargaretHospitalmergedtoformtheUniversityHealthNetwork(UHN).They
cametogetherwithavisiontochangethehealthcareinfrastructuretofocusonolder
demographics,advancesinbiotechnology,andtoeducatepatientsontheirhealthcare
management.WhilemodernizingtheirorganizationUHNwantedtorestructurethe
healthcarefundingpolicyinCanada,andthepermeationofinformationtechnologyin
healthcaresettings.Moreover,theirmaininitiativewastocreateagreaterimpactas
healthnetworkwhiletheuniversityrepresentstheirprimarycommitmenttoresearch
andteaching.

InCanada,mosthospitalsspend2.5percentoftheirannualoperatingbudgeton
informationtechnologycomparedtomorethaneightpercentinindustriessuchasthe
financialservices.AccordingtoUHNmanagers,manyhospitalsandhealth
organizationsdonotpossestheITresourcesthatwouldbefoundedintheprivate
sectorsuchasaseparatemanagementprojectoffice,orchangemanagement
expertise.Moreover,Canadianinformationtechnologywithinhealthcarewasallocated
tosoftware(37percent),hardware(37percent),andservices(26percent).Moreover,
alltheseexpendituresweremostlyforanadministrativesystemwithinahealthcare
organizationwherecoreclinicalprocesseswerepaperbasedanddidnotsignificantly
changeinmorethanahundredyears.

UHNistheeighthlargestacutecareinstitutioninCanada.Thenetworktreatedabout
29,000inpatientsand950,000outpatientseachyear.Theiroperationsbudgetwas$900
million,ofwhich65percentwasprovidedbytheprovincialgovernment.Unlikemost
hospitalsintheCanadiansystemUHNnetworkistheleaderinhealthcareinformation
technology.Since1995theorganizationwascommittedtothedevelopmentof
informationmanagementstrategicplans.Allocatingfourpercentoftheannualbudget
towardsthehealthcareITinitiativeallowedthemtocreatetheSIMSdepartmentthat
supportedallthreehospitalsinthenetwork.ItmanagedtheITinfrastructure
development,applicationdevelopment,performancemanagement,andproject
management.By2004ithadover125peoplewithinthedepartment.In2004SIMS
createda3yearstrategicplanthatincludedtheMOEMARinitiative(Medicationorder
EntryMedicationAdministrationRecord),whichwasaimedtoimprovingthesafetyand
qualityofpatientcarebyeliminatingmedicationorderandtranscriptionerror.Through
thistheyimplementedCPOEinlabsanddiagnosticcenters.Thesystemalsoincluded

onlineclinicalsupportforonlinedecisionmakingandreferencessuchasdrugallergy
andinteractionalerts.

ProblemStatement:

ThedirectorofAcuteCareInformationManagementatUniversityHealthNetwork
(UHN),StephanieSaullMcCaig,wasthinkingtoimplementtheMedicationOrderEntry
andMedicationAdministrationRecord(MOEMAR).Thesystemwouldallowdoctors
andnursestoentermedicationorders,reviewpatientmedicalhistory,anddocument
medicationadministrationonanonlineplatform.Thisprojectinvolvedthreelarge
hospitalswhoallhadtoworktogethertoimplementthissystem.Someoftheproblems
withthisprojectwerethatitwasaverycomplexandchallenginginitiativetakenby
UHN.Apilotprojecthadbeenconductedbutwasnotsuccessfulbecausephysicians
werehavingalotofproblemswiththesystemandthereweretoomanytechnicalflaws.

ITsystemshavealwaysbeenveryexpensivetoimplementwhichiswhymanyhospitals
andphysiciansareagainstadoptingsuchasystem.Thereareseveralotherreasonsfor
alowadoptionoftechnologyinclinicalapplications.Someincludephysicianresistance
tonewtechnologies,thedifficultyofprovingareturnoninvestment,nopressurefrom
regulatorybodiestoimplementsuchasystem,andtheoverallcomplexityofthe
healthcareindustry.AnotherreasonisthatveryfewITsystemshavebeentestedin
hospitalsettingsandimplementerswithinthehealthcaresectorlackthenecessary
projectandchangemanagementskills.

Changeisalwaysdifficultandlearningtouseacomputerbasedsystemcanbe
verycomplicatedforphysicianswhohavealwaysusedpaperbasedsystems.Ittook
themlongertofilloutanelectronicrecordwhile,ontheotherhand,fillingitoutonpaper
tookthemonlyafewsecondstodoandthisledtoalotoffrustration.

UHNsbudgetforthisprojectwas$900million.Theydecidedtolaunchapilot
projectoftheMOEMARmoduletotestthesysteminahospitalsetting.Duringthis
period,physiciansenteredmorethan80%ofmedicationorderstotheMOEsystem.
Thisinformationwastransferreddirectlytopharmacyinformationsystem.Afteramonth
ofthestartoftheproject,residentphysiciansstoppedusingthesystemstatingthatit
performedpoorly.Therewereerrorsandmissingordersandenteringsimple
informationwasverydifficultandtookalotoftime.Thesystemwasnotfunctioningas
advertised.Theyconcludedthatthesystembecameunacceptablebecausephysicians
couldnotrelyonitandthelearningcurveforthissoftwarewasverysteep.They
decidedtostopusingthepilotwhichonlylastedfor32days.Inconclusion,

SaullMcCaigdecidedtofactorinthehesitationofphysicianstolearnsuchacomplex
systemandthefactthatthissystemwouldhavetobeimplementedinthreelarge
hospitalsanddevelopamorestrategicwayofimplementingasuccessfulITsystem.

KeyDecisionCriteria:

TheUniversityHealthNetworkhadtolookatmanydifferentfactorswhen
decidingwhethertoimplementtheMedicationOrderEntryandMedication
AdministrationRecord(MOEMAR).Thisprojectinvolvedalargescale,includingthree
hospitalswithmorethan35inpatientunits.Thisiswhyoneofthekeydecisionfactorsin
implementationwasaccessibility.WiththelargenetworkwithintheUHN,itwas
imperativethattheinformationwasabletogetacrossallhospitalsandfacilitieswithin
theUHN.

Anotherkeydecisionfactorwasaccuracy.WhenUHNinitiatedapilotinearly
2003forthisproject,itfailedmiserablyduetothepoorperformancefromthesystem.
Witherrorsandordersbeingmissed,manyphysicianswithinthetrialstoppedusingthe
system.Thereweretoomanydrawbacksandithadmadeinputtingofsimple
informationdifficult.Theinterfacethattranslatedthedrugbasedlogicfromthehospitals
healthsystemtothePharmacyInformationSystemanddidsocorrectlywassomething
thatthedirectorsoftheMOEMARinitiativewereworriedabout.Thepilotprojectdidnot
assistineasingthatfeelingbecausethesystemdidcreatetheerrorsthatcould
potentiallyendangerpatientswithincorrectdrugs.Theaccuracyofinformationonthe
systemwasaveryimportantdecisionindeterminingwhetherornottoimplementthe
project.

AnotherveryimportantdecisionfactorinimplementingtheMOEMARinitiative
wastimesaving.Animportantreasonthepilotdidntworkisbecauseitprovedtocause
toomanyerrorsandmakesimplephysiciantasksdifficult.Withthat,anewinitiative
wouldprovetobemetwithalotofhesitation.AbigdecisionforSaullMcCaigishowthe
inputofmanyindividualsshouldbetakenintoaccountwhentryingtorolloutthis
project,sosheworkedwithasteeringcommitteetoensurethesuccessoftheproject.
Theevidenttimesavingofaprojectwasanimportantgoalbecauseithadtoshow
somebenefitwiththephysiciansandhowitwasmakinganimpactontheirdailyroutine.
Ifitcouldshaveofftimefromthemhandwritingordersandgettheinformationtothe
pharmaciesmoreefficientlyandaccurately,itwouldbeeasierformanyphysiciansto
wanttoadoptinusingthesystem.


Accessibility,accuracy,andtimesavingarejustacoupleofthemanydifferent
keydecisioncriteriafortheimplementationoftheMOEMARinitiative.SaullMcCaig
knewwhenlookingatthisimplementationitwouldtakealotofworkandmanydifferent
factorswouldplayintoitssuccess.Overallthough,itwascriticalthatthissystemproved
tobeavailabletotheentirenetworkwithease,improvedaccuracy,andprovided
timesavingstotheUHN.

Alternatives:

1)Donothing.

Inthestatusquo16.56%ofdischargedpatientsexperienceadrugrelated
medicalcomplication.MOEMARinitiativewasaimedatimprovingthesafetyand
qualityofpatientcarebyeliminatingmedicationorderandtranscriptionerrorsby
physiciansastheyarelegallyresponsibleforprescribingmedication.Resident
physiciansstoppedusingtheprogramcitingpoorsystemperformancesignificant
issueswithsystemordersandevensimpleinformationentrywasdifficult.Insofaras
implementingtheMOEMARinitiative,increasestheriskofagreaternumberof
physiciansrejectingtheinitiativeanddoingnothingisthealternativethatmostaligns
withtheUHNsgoals(andwastheonetheyendedupchoosing).

2)TheabsenceoftechnicalandbehavioralEHRbarrier.

SuccessfulEHRimplementationdependsgreatlyoncoordinationbetweenthe
technologyandanyonewhowouldutilizeit(physicians,pharmacist,nurses,etc).
AssumingMOEMARaccomplishedeverythingitsetouttoaccomplishitwouldmake
sensetoimplementit.Therewasatechnicalandbehavioralbarrierpresentwithinthe
UHNthatultimatelyledtotherejectionofMOEMAR.Boththephysicianinchiefand
chiefinformationofficerlackedconfidenceinthesystembecauseoftheissues
physicianswerehavingwiththesystem.Theyendedtheprogramandcitedthetrustof
thephysiciansasafacettotheirdecision.Theissueswithinthesystemcouldhave
beenfixedwithmoreinvestmentintothesystem.Withanefficientandreliablesystem,
thedoctorswouldbemoreconfidentinthesystemandmorewillingtoutilizeittothe
fullestextent.

3)ChoosingadifferentsystemsmodelasanalternativetoMOEMAR

TheSIMSteamconsidered3possibleoptions
1UsetheexistingHIS(butaddmedicationinventorymanagementcapability).

2UsetheexistingRxSystem(butaddonlinemedicationorderentrycapability).
3IntegratetheHISandRxSystem.
Theyultimatelyoptedtointegratebothsystems.Addingpharmaceuticalfunctions
totheexistingHISoronlineordercapabilitiestotheexistingprescriptionsystemcould
havemadeforsmootherimplementationbecausethatguaranteesthatpeopleoneither
thefrontendorthebackendwouldbefamiliarwiththesystem.

Conclusion:

Ourrecommendationistodonothing.Wearrivedtothisdecisionbylookingat
numbers.Implementingthesystemwouldrequiremoneyandpotentiallyincreasethe
amountofprescriptionerrorsinthestatethatitisin.Inadditiontothosefigures,the
doctorswouldnotwanttousethesysteminthestatethatitwasin,andtherewasno
speculationastoanincreaseinvestmentortheproblemsbeingresolved.Moreover,the
UHNmanagementwanttobeongoodtermswithmanagementandwantsthemtotrust
theirfuturedecisions.Thisisinadditiontoqualitygoals.ImplementingtheMOEMARis
abaddecisionwithgoodintentions.Maintainingthestatusquoispreferablebecauseit
doesnotexacerbateexistingproblems.

WorkCited

"HealthcareQuarterly."
StrongITEffortUnderpinsMOE/MARSuccess
.N.p.,n.d.Web.
14Nov.2015.<http://www.longwoods.com/content/18502>.