THE STATE OF PENN MEDICINE
INFORMATION SERVICES
2019 • 2020
Kevin B. Mahoney Chief Executive Officer University of Pennsylvania Health System
Purpose of the Report: This report displays the activities of Penn Medicine Information Services in this 2019-2020 report.
J. Larry Jameson, MD, PhD
Executive Vice President University of Pennsylvania Health System & Dean of the Perelman School of Medicine
The initiatives that Penn Medicine Information Services has pursued, and achievements attained throughout fiscal years 2019 and 2020 result from a continuous partnership with operations, clinical stakeholders, and other organizational counterparts to derive benefits and maximum value from our health system’s investment. This ongoing engagement and collaboration is a critical success factor in achieving the benefits associated with gaining value from data, transforming information into knowledge and developing wisdom to drive the value of healthcare.
Michael Restuccia
We strive to contribute to Penn Medicine’s mission as a leading innovator of healthcare technology and by delivering the highest quality service to our users in support of the patient care community. Additionally, our community outreach activities demonstrate our commitment to our fellow neighbors in the region.
John Donohue
Our staff is inspired to “Live their Life’s Work” each day, by leveraging technology to provide service excellence in patient care, education, and research through the design and delivery of innovative, advanced technology and services.
Senior Vice President and Chief Information Officer
Jim Beinlich
Vice President and Chief Data Information Officer
Dan Costantino
Chief Information Security Officer and Associate CIO, Core Infrastructure Services
Vice President, Enterprise Services
Kash Patel
Vice President and Chief Digital Technology Officer
Anna Schoenbaum
Associate Vice President, Operations
Christine Vanzandbergen Vice President, IS Applications
A Penn Medicine Information Services Publication http://www.pennmedicine.org/information-services/ Published on: December 2020
The University of Pennsylvania Health System offers this publication for general informational purposes only. Penn Medicine, Philadelphia, PA 800-789-7366 © 2020 The Trustees of the University of Pennsylvania
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MESSAGE FROM THE
DEAN AND CEO
J. Larry Jameson, MD, PhD Executive Vice President, University of Pennsylvania for the Health System Dean of the Ruth and Raymond Perelman Center for Advanced Medicine at the University of Pennsylvania, Robert G. Dunlop Professor of Medicine
Kevin B. Mahoney Chief Executive Officer, University of Pennsylvania for the Health System
The Information Services team has been instrumental in Penn Medicine’s growth over the last decade and its leadership as an academic medical center. Whether enabling our students to learn online, harnessing the power of data science to support the discovery of new tests and therapeutics, or developing better ways to provide-cutting edge care in our hospitals and clinics, the technology foundations built by Information Services have led to a complete digital transformation that allows us to deliver world-class care to millions of patients in our community and across the globe. Continuously innovating our technology infrastructure and solutions has been critical in our organization’s ability to quickly respond to the COVID-19 pandemic, enabling Penn Medicine to meet the needs of those we serve at an accelerated pace. In this challenging environment, the Information Services team remained as resilient as ever, building on the technological foundations that have placed us at the forefront of the digital era in medicine. The Information Services team is integral in accelerating our ongoing efforts to provide precision diagnostics and therapies. As we look to the future and continue to optimize the PennChart electronic health record and leverage its information, the IS Department keeps us on the cutting edge.
MESSAGE FROM THE
PENN MEDICINE CIO In this current era of healthcare, technology has elevated the impact of patient care delivered, whether in the traditional or virtual medical settings. Technology has evolved in the past several decades to become a close partner in enabling the business while continually innovating to transform healthcare. In stepping back to view the larger picture, the technology foundations were set in the industry by building upon the results of each of the previous three decades. The 1980s were exemplified by challenges in getting hardware and storage to perform at acceptable levels. The 1990s were characterized by the introduction of inconsistent Wifi, mobile and internet connectivity. The 2000 decade focused on implementing electronic health records and gaining clinical adoption. Through these technology stages, application and process platforms have now firmly stabilized in the present decade. All that previous work now leads healthcare technologists to innovate toward achieving digital transformation. This current era embodies leveraging the previous platforms for the betterment of our patient’s care, to enhance clinician capabilities and advance research. The opportunity for this digital transformation holds the promise of delivering dividends in future years to come. Serving as a Chief Information Officer (CIO) in a learning institution, I believe that innovation is not achieved by mere will, it is fostered by cultivating a rich environment within our IS department that thrives on learning, investigating, and trying new concepts to “futureproof” how our health system and medical school function. The projects delivered by our IS team in 2019 and 2020 demonstrate our colleagues’ desire and achievements attained to help patients improve and science and caregiving advance.
Michael Restuccia Senior Vice President & Chief Information Officer, Penn Medicine
Focusing on “team, collaboration and consistently striving to “exceed expectations” are critical elements to achieving overall success. In this complex and ever changing healthcare environment, the need for high performing individuals melding together as a team makes the impossible, possible. And although technology enables many of our efforts, I acknowledge our team as delivering the “services” that makes the “technology” industry what it is and delivers the value behind the data and the platforms. Innovation, team collaboration, and problem solving are critical to working with and meeting the requirements of our operational partners and keeping us in the forefront of digital transformation in the healthcare technology industry.
TABLE OF CONTENTS 6 7 8 10
THE PENN MEDICINE ORGANIZATION
At Penn Medicine, we are dedicated to discoveries that advance science, to outstanding patient care throughout the world, and to the education of physicians and scientists who carry on our legacy of excellence.
CIO DIRECT REPORTS MASTERING DIGITAL TRANSFORMATION AND DRIVING THE VALUE INTO HEALTHCARE
PATIENT CARE
Access to Care, Provision of Health Services, and Population Health Management.
40
EDUCATION AND RESEARCH
50
EMPOWERING TECHNOLOGIES
66
IS DEPARTMENT PROGRAMS
67 68 69
Penn Medicine enhances its status as a world leader in advancing medical science by continually improving the quality and impact of its research.
These technologies and processes address the administrative infrastructure support and physical infrastructure support.
An atmosphere of solidarity is fostered where our employees may attain professional growth, continual learning and personal enrichment while enjoying what they do. Programs such as: Employee Enrichment, We Care for Community Activities, Lunch and Learn are examples of the building blocks that create a supportive atmosphere among our colleagues to network and participate in initiatives which enhance us as individuals and as an IS community.
BY THE NUMBERS AWARDS
Penn Medicine is a leader in pursuing healthcare technology innovation and applying best practices toward delivering service excellence. Our leadership team adopts a progressive approach toward knowledge sharing and collaboration in the local, regional and national healthcare IT community. Healthcare IT committees, collaborative forums, conferences, published articles and speaking engagements are several ways in which we engage with others in the industry. Penn Medicine has also received multiple award recognitions for its accomplishments in implementing new, transformational IT initiatives.
IN THE NEWS
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GLOSSARY
THE
PENN MEDICINE
ORGANIZATION PENN MEDICINE IS COMMITTED TO PUSHING THE BOUNDARIES OF MEDICINE. INNOVATIONS FROM PENN MEDICINE ARE HELPING PEOPLE IN WAYS THE WORLD NEVER THOUGHT POSSIBLE.
MISSON
At Penn Medicine, we are dedicated to discoveries that advance science, to outstanding patient care throughout the world, and to the education of physicians and scientists who carry on our legacy of excellence. We are a world-renowned academic medical center, and strive to improve the health and well-being of people through research, education, clinical care and community service. We are proud of our commitment to service and strive to use discovery and rigorous research to benefit our neighborhoods, our city and our world.
CORE VALUES Penn Medicine’s core values define what we stand for as an organization and how we will continue the work of helping others that began here more than 240 years ago. Excellence We will strive for excellence through creativity and innovation. Integrity We will be truthful, equitable and committed to intellectual honesty. Diversity We will foster intellectual, racial, social and cultural diversity. Professionalism We will achieve the highest standards of professionalism through ethical behavior, collaboration, self-education and respect for all members of Penn Medicine. Individual Opportunity We support equal opportunity and individual creativity and innovation. Teamwork and Collaboration We will support each other and promote collaboration with our colleagues and thoughtful stewardship of University and Penn Medicine resources. Tradition We will learn from our history, take responsibility for the future and promote the unique nature of the Penn environment. 6
HISTORY
Pennsylvania Hospital, part of Penn Medicine, is the nation’s first hospital, and was founded in 1751. The University of Pennsylvania opened its School of Medicine, the nation’s first, in 1765. And, the Hospital of the University of Pennsylvania was established in 1874 as the nation’s first teaching hospital. Over the past 30 years, Penn physicians and scientists have participated in many important discoveries, including: » The first general vaccine against pneumonia » The introduction of total intravenous feeding » The development of magnetic resonance imaging (MRI) and other imaging technologies » The discovery of the Philadelphia chromosome, which revolutionized cancer research by making the connection between genetic abnormalities and cancer Since our founding days, we’ve expanded medical frontiers by creating some of the nation’s earliest programs in areas ranging from dermatology, neurosurgery, ophthalmology and radiology, to the Philadelphia region’s only program to transplantation of five major organs. Our clinicians and researchers continue to make medical advances that help people live longer, healthier lives. We are committed to care for patients with respect and compassion while forging the medical discoveries that will lead our teams through the 21st century.
INFORMATION SERVICES
CIO DIRECT REPORTS
Michael Restuccia
Senior Vice President and Chief Information Officer
Jim Beinlich
Vice President and Chief Data Information Officer
Kash Patel
Vice President and Chief Digital Technology Officer
Dan Costantino
John Donohue
Chief Information Security Officer and Associate CIO, Core Infrastructure Services
Vice President, Enterprise Services
Anna Schoenbaum
Christine Vanzandbergen
Associate Vice President, Operations
Vice President, IS Applications
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MASTERING DIGITAL TRANSFORMATION AND DRIVING THE VALUE INTO HEALTHCARE Building upon the foundations of our information systems, we are transforming healthcare with data, information, knowledge and wisdom. Penn Medicine’s high performing culture upholds our core missions for clinical, research and medical education. Information Services s taff create this reality through innovative planning and execution. Staff are engaged, trained and inspired as “catalysts” of a continuously evolving patient experience.
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FY 2019/2020 CURRENT IS INITIATIVES
PATIENT PATIENT PATIENT CARE CARE CARE Access to Care begins the clinical encounter between the patient, Penn Medicine and its providers. Providing continuous development of best practice processes helps to streamline a patient’s efforts to receive care and ensures that the care received is appropriate in terms of type, intensity and location of care. Providing patients with efficient access to care results in receiving the right care, at the right time, at the right location for the most appropriate cost.
Provision of Health Services expands the scope of care delivery beyond treatment of illness to prevention and wellness promotion in order to achieve optimal health status for individuals and populations. A person-centered and empowering approach to health care combines interrelationships among physical, mental, social, environmental, and spiritual dimensions of health and well-being. Interdisciplinary and inter-professional working relationships among practitioners’ support continuity and coordination in care while minimizing unnecessary variations in care using evidencebased guidelines and system-wide clinical protocols.
Population Health Management is the coordination of health services and the monitoring of health status across a well-defined population to improve clinical outcomes and manage financial outcomes. Population health management programs are the foundation of this process and can include care coordination, case management, disease management and health promotion, all based upon managing patient care and services to an evidence-based standard.
Chester County Hospital Patient Experience Enhanced with Patient Room Digital Whiteboards Chester County Hospital (CCH) expanded their campus footprint in 2019. Approximately 100 new inpatient rooms include an innovative digital patient whiteboard. This digital technology keeps patients and family members informed by displaying relevant patient information. The digital whiteboard is a part of the new 75” footwall, which includes the patient TV display and is integrated with bedside pillow speakers. Patients may toggle to display (or not display) the whiteboard.
Whiteboard display information pulled from our PennChart EHR includes:
» » » » » »
Care Team Members (With Pictures) A Personal Greeting Room Information Current Day and Time Upcoming Events Goals for the Day
» » » » » »
Allergy Status Mobility Order Diet Order Fluid Restriction Status Falls and Isolation Status Consults
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How Penn Medicine’s COVID-19 Chatbot is Helping Our Patients Find Answers During the Global Pandemic As COVID-19 spread globally and people began practicing social distancing to “flatten the curve”, significant patient demand emerged seeking Penn Medicine accurate, upto-date general and specific pandemic related information. To meet that need, a 24/7 rapid response virtual agent was designed to answer the COVID-19 related questions of Penn Medicine patients over chat, voice, and social channels by integration of the agent into PennMedicine.org, myPennMedicine, and our telephony systems. 12
Penn Medicine’s COVID-19 chatbot provides answers to questions like: » How do I get tested for COVID-19? » I will be visiting a patient in the hospital, what do I need to know? » How do I get my COVID-19 test results? » Do you offer telemedicine visits? » How do I schedule an appointment for testing? » I may have been exposed to COVID-19, what should I do? » Am I allowed to travel?
Enabling Radiology Procedure Text Updates for Patient Family Members In our most recent Benefits Realization Report, we featured a project initiative on texting of patient procedure updates from the operating room. Once implemented, thousands of text updates were generated each month from ORs throughout the health system, with about 5-7 texts per patient being sent on average. The initiative was so successful, we continued to expand texting of patient procedure updates to the Radiology department. Although past radiology patient procedure updates were delivered to family members through personal interaction between staff and family who may just sit in the room and wait for updates, we improved our patient experience by implementing EHR functionality to communicate to family members through text messages that are connected to procedure status. As a patient’s status is updated, an automated text is sent to the designated family member to make them aware of where the patient is in the process of the procedure. Clinicians also can send specific messages in the case of a delay.
By March 2020, the texting functionality was live for 4 months in Radiology and reached its peak in usage by sending about 850 text messages. Radiology staff have commented that the functionality has been useful in saving time and creating helpful opportunities to enhance the patient experience.
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Dialysis Patient Tracking Gets a Makeover to Increase Patient Satisfaction To meet the needs of patients receiving treatment in the acute dialysis unit at the Hospital of the University of Pennsylvania, an appointment-based workflow was developed, replacing the previous dialysis transfer workflow. The appointment-based workflow eliminated issues with unit transfers, bed-management, patient transport and meal delivery in order to increase patient satisfaction. With the appointment-based workflow, the perception of available beds changed, and meal trays began delivery to patients at the appropriate times. Also, patient dialysis treatments were added to the daily schedule in our PennChart EHR, making scheduling additional appointments for therapies and radiology much easier. The new workflow effectively alleviated challenges that the unit faced, while maintaining key aspects of the dialysis clinical documentation process: charting, vital signs, clinical orders, results routing, flowsheets, advanced dialysis and transport appointment scheduling and tracking of patient movement.
Benefits Filing Saves Time and Improves Accuracy As part of Penn Medicine’s goal to move toward real time eligibility, the healthcare system implemented new technology for healthcare insurance eligibility verification. As a follow-up to that implementation, Penn Medicine added new benefits filing technology. Prior to benefits filing, users manually transcribed insurance benefit information from insurance verification responses into the PennChart EHR Revenue Cycle. The implementation of benefits filing eliminated that manual effort and increased co-pay collection accuracy upon patient arrival.
Benefits filing technology is used by the scheduling, insurance verification, and patient access departments while providing these users with accurate, timely, and complete patient insurance information. Now, the right collection of copays promotes accurate insurance billing, and streamlines workflows - resulting in time savings. Benefits filing functionality also allows Penn Medicine to enable self-serve patient estimates. Patients can request a price estimate for an elective procedure, and the use of benefits filing provides accurate insurance information to the patient in terms of co-insurance and deductibles prior to scheduling services.
Penn Medicine Provides Patients with Up-front Medical Service Estimates To ensure that patients have access to accurate price estimates for the up-front costs of medical services, Penn Medicine implemented a comprehensive automated price estimator tool. The price estimator tool not only informs patients about the cost of care, it also allows self-pay collections. This functionality administers estimates for both professional and facility fees to current and potential patients. Implementation of the patient services price estimator also meets the requirements for displaying “shoppable� services in a consumer-friendly manner as defined in the Hospital Price Transparency Requirements issued by CMS, effective January 2021. Templates are now used for the most common services requested for estimates. Financial counseling staff create estimates using the newly developed patient estimate templates versus a previous manual process. The development of the initial templates streamlined the process for preparing estimates and constitutes to serve as the foundation to expand estimate functionality. A self-service estimator was also developed so that a patient can access the Penn Medicine web site or use the myPennMedicine patient portal to create their own estimate.
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ENGAGING OUR PATIENTS WITH NEW CONVENIENT FEATURES IN THE PATIENT PORTAL
myPennMedicine Patient Portal Makes Healthcare One way that Penn Medicine sought to increase patient access to care involved reducing barriers to using the patient portal and increasing features and information available. MyPennMedicine mobile applications for iOS and Android were developed and made available for patients to download from respective app stores. Before the custom apps, patients could access myPennMedicine on their mobile devices using Epic’s MyChart application, but this required patients to be familiar with the MyChart name and once installed, find and identify Penn Medicine as their provider. An automated pathway was developed to encourage patients to sign up for myPennMedicine by sending patients an invitation to activate their account when scheduled or checked into an ambulatory office visit. The invitation used the previous instant activation pathway that lets users sign up without having to use the SSN last 4 digits as an identifier if they followed the link within 24 hours of being sent. With the availability of the app in the iOS and Android app stores now under the myPennMedicine name, patients were able to be given simpler and more intuitive instructions when asked to use the mobile app for their telemedicine visits. Patient instructions were updated to direct patients to download the myPennMedicine app instead of the MyChart app, which was the only app available before the custom apps were developed. The mobile app is the patient preferred method to connect to their telemedicine visits due to standard integration of the microphone, speaker, and camera which is often easier than attempting to use a PC or laptop device. Enrollment by month increased slightly on average with instant activation invitations. Before auto-instant activations, enrollment was 1.5% on average per month. With instant activation saw as much as 2.3% increase of enrollment and all were at least .3% higher than the previous year. Currently, approximately 2.5% of appointments are self-scheduled in myPennMedicine.
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Online Bill Pay through myPennMedicine Enhances the Low Touch Patient Experience MyPennMedicine now offers an enterprise-wide electronic bill pay option. With this feature, patients are able to conveniently and securely pay their outstanding balances; for both hospital and professional billing. Patients can also review their payment history, billing statements and send secure messages directly to the customer service department within the web and mobile app. Portal based billing offers several features that help patients manage their accounts and make payments conveniently from within the myPennMedicine patient portal that they are already using to schedule appointments and communicate with their provider. In just the first year of implementation, myPennMedicine bill pay collected over $1.9 million in patient payments with 11.2% of those payments from patients using myPennMedicine.
BENEFITS FOR OUR PATIENTS » Patients have one centralized location within myPennMedicine that provides a convenient, time saving place to make payments and view all account statements. » Patients can message billing staff through myPennMedicine, reducing need for phone calls. » Patients receive quicker notices of new billing information sent via email or text.
BENEFITS TO THE HEALTH SYSTEM » MyPennMedicine payments are processed and posted automatically. » Patients receive quicker notices of new billing information sent via email or text » Removes the need to use an outside vendor for processing payments » Ensures Payment Card Industry Data Security Standards compliance for accepting online credit card payments and handling credit card data
Patients Can Use Pre-Check-In with myPennMedicine
By using the pre-check-in feature through both the web and mobile myPennMedicine (MPM) app, patients can complete the following tasks and streamline intake information before they arrive for their appointment: » Verify or update personal information » Verify or update insurance » Verify or update medications, allergies, and current health issues
» Pay visit copays (for outpatient visits only) » Answer appointment-related questionnaires
myPennMedicine Self-Scheduling Redesign Improves Appointment Scheduling
The dynamic redesign of the myPennMedicine (MPM) Self-Scheduling webpage allows patients to select their provider, location, appointment date and time and make multiple appointments without leaving the page. Approximately 2.5% of appointments are self-scheduled in myPennMedicine.
BENEFITS INCLUDE
» Eliminating user confusion by streamlining the self-scheduling patient experience. » Updating all 21 myPennMedicine patient questionnaires to strengthen patient completion. » Increasing patient satisfaction. 16 » Improving the user experience.
General Statistics Showing the Growth of Our Patient Portals JULY 1, 2018 - JUNE 30, 2020
myPennMedicine Patient Portal
myLGHealth Patient Portal
PATIENTS CURRENTLY ENROLLED IN MYPENNMEDICINE
MYLGHEALTH
13,607,416
10,413
MYPENNMEDICINE
TEST RESULTS RELEASED TO
TELEMEDICINE ENCOUNTERS AND VIRTUAL HEALTH VISITS
18,006
134,022
1,358,109
MYPENNMEDICINE
ENCOUNTERS
TELEMEDICINE
425,423
PATIENTS CURRENTLY ENROLLED IN
SELF-SCHEDULING APPOINTMENTS MADE THROUGH THE PORTAL
407,293
8,160,230
APPOINTMENTS SELF-SCHEDULED IN MYPENNMEDICINE
TEST RESULTS RELEASED TO THE PORTAL
13,884
162,953
NEW TO PENN MEDICINE SELF-SCHEDULED APPOINTMENTS (OPEN SCHEDULING)
APPOINTMENT SCHEDULE REQUESTS PROCESSED
151,728 PRESCRIPTION RENEWAL REQUESTS PROCESSED
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Emergency Department (ED) Shared Provider Note Enhances Documentation Process Historically, provider notes were written individually by each member of the patient’s emergency department (ED) treatment team. Multiple ED provider notes often contained similar, repeated, or inefficient information. Attendings reviewed the other provider’s documentation, switching between that provider’s note and their own. This documentation dilemma ultimately resulted in time lost from delays, which in turn affected patients in being admitted to the hospital in a timely manner. ED providers explored a more concise documentation method that could be completed by all parties without duplicating efforts. This led to a version of the ED provider note that was capable of being shared between providers on the treatment team. The solution was implemented as a pilot in some of our downtown EDs in July 2019. Residents or APPs working with a patient before the attending joined could now record their involvement and clinical findings in a single template, accessed by the attending physician later. Attending doctors were given the ability to review and edit the first provider’s documentation, agree or disagree on certain findings, and record their own findings all in a single note template. After the first couple of months, providers who used the shared note workflow had faster documentation times both in average time spent on provider notes, and the average time to completion of a provider note after the patient was seen. Providers were being more concise and quicker with their note completion rates, thereby avoiding sacrificing time spent working with patients in the emergency department and increasing chart completion for both transitions in care and ability to code charts.
Shared notes functionality has been viewed as a major win for the faculty physicians. The new workflow significantly reduces redundant and time-consuming charting, and timeliness of chart completion has improved. Benjamin “Ben” Sun, MD, MPP Perelman Professor and Chair, Department of Emergency Medicine
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PATIENT CARE OUTCOMES
Genetics Data Plays a New Role in the Electronic Health Record Genomic testing results were historically delivered to Penn Medicine in the form of paper or PDF files that were scanned and uploaded to the EHR. Yet researchers and clinicians alike sought a centralized view of discrete patient genomic information to facilitate clinical decision support and patient care. They wanted a better way to enter genetic tests in our EHR, report the results and any variants associated so that genetic counselors and our clinical community had a central location to view genetic information relevant to the patient. Penn Medicine set a goal to evolve its EHR technology to support genetic data and establish a standard method for managing (receipt, storage, display, and notification) discrete genomic testing results while incorporating the data into both the PennChart EHR and research data warehouse. The project specifically included implementing the Epic Genomics Module for discrete genomic documentation, interfacing with external genomic labs and establishing a single precision medicine tab in our EHR. The team successfully developed a scalable solution for implementing these initiatives. Now, genetic counselors, clinicians and researchers can use the EHR to enter tests, receive results and enter variant data that allows for clinical decision making. The data is kept within the EHR while in its own tab so that the genetic data can be easily accessed. The precision medicine tab allows clinicians to see orders, results and reports specific to genetics more quickly and easily. Also, storage of genetic test results in the Penn DataStore II data lake supports analytics and bioinformatics purposes.
Installation of the module improved patient care as a result of: » The availability of a patient’s genetic information, stored in the EHR and accessible to clinicians » Clinical decision support driven by genomic indicators in the EHR » Patient access of their genetic information through myPennMedicine » Availability of discrete genetic results for research/bioinformatics purposes
The benefit of this project is the continued advancement of our initiatives in precision medicine and genetic research. The advancement also allows us to leverage application technologies to integrate outside genetic clinical and lab data into the EHR while allowing clinicians to more readily detect abnormalities for clinical treatment.
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Nurse Driven Heparin Protocol Implementation Increases Patient Safety A multidisciplinary team (with representatives from nursing, pharmacy, providers, and the medication safety committee) was tasked with developing a nurse driven heparin protocol - requiring development of EHR tools to assist in dose calculations and monitoring. A heparin dose calculator was developed to automate appropriate dosing based on weight, PTT lab results and previous doses. Additional clinical decision tools, such as a nurse driven heparin sidebar monitoring report, nurse driven PTT lab panel, and an alert to enforce a 100 kg dosing weight cap helped promote safe heparin practices. Nurse driven heparin orders increased by 20%. Patients on nurse-driven heparin infusions had adjustments consistent with established protocols much more frequently (93%) than those on provider-driven heparin infusions (52%). The team educated staff through demos, videos, education materials, and in person support to equip staff with the skills and confidence to perform the new workflow successfully. Introduction of a nurse-driven heparin protocol with integration of new clinical decision support tools was a significant practice change for clinicians. However, with enterprise-wide engagement and support from hospital leadership, the response was overwhelmingly positive. Significant increase in clinician satisfaction and patient safety associated with heparin use indicates the value of this initiative in safety and patient care.
Using Electronic Prescriptions to Manage Controlled Substances for Patient Care Pennsylvania Act 96 established requirements and processes for controlled substances medication orders beginning fall 2019. Electronic Prescribing Controlled Substances (EPCS) technology was needed to provide two factor security authentication and electronic order transmission. Initially, in spring 2018, Penn Medicine had set up the ability to support two-factor authentication and electronic transmission of medication orders directly to participating pharmacies. As Act 96 made the use of the technology a requirement, IS worked closely with operational leadership, the office of medical affairs, and legal counsel to review our processes and ensure that any additional identity proofing, technical setup, and support was in place to meet the specific requirements of the new law. A Penn Medicine application was developed to support the required authentication steps. This application significantly automated the process by marrying information from our medical affairs and internal EHR platform, easing the administrative burden while improving documentation and efficiency. As a part of this effort, we modified our EHR to include clinical decision support for clinicians and developed a custom application that assisted operations with the very specific regulatory requirements to automate the recording of internal requests, approvals, and authentications that are required to use EPCS technology. Specialized reports were produced for operations to track ongoing use, compliance, and new enrollments of EPCS for medication ordering leading to the law’s effective date. Upon implementation, a command center provided support for clinicians requiring assistance with education, authentication approvals, the use of two factor authentication technologies and EHR setup. This team was able to resolve 95% of all incoming requests and was able to transition to an ongoing support model after the initial week of support. 20
Improvements in Patient Notification for Diagnostic Imaging Report Results In December 2019, the new Pennsylvania state law, Act 112, was implemented to ensure that diagnostic imagining sites provide direct notification to a patient of significant abnormalities detected on imaging studies. For non-invasive cardiology specific procedures, this included echo, nuclear cardiology, and vascular studies done in the outpatient setting. Our technology team designed an efficient method for identifying patients with a significant abnormality, while limiting the impact to physician’s time in reading these studies. Over 200 data elements were identified across these three specific modalities for non-invasive procedures within their existing structured reporting forms. Upon selecting these pre-determined elements, a report was generated to include relevant patient demographic data that was used as a weekly mailing distribution. The team identified these specific elements with the use of visual indicators within the structured reporting, and additional print groups within the EHR displayed when criteria were selected for PA 112 inclusion. Physicians also had the ability to opt in or out of the PA 112 inclusion criteria based on their interpretation of the study and excluded if results were considered to be a chronic condition. Since implementing the weekly report structure, an average of 1,000 patients present on the distribution list for significant findings. Within that same time period, the time spent by physicians resulting these studies has not seen any significant impact or increase.
Lab Labeling System Increases Stem Cell Product Safety
In compliance with the American Red Cross bar coding system, called ISBT, Penn Medicine implemented Title 21 software, licensed to support ISBT labels for stem cell products at HUP. The new label has embedded patient and product information that meets the requirements of the FDA and CAP laboratory regulatory agencies. This initiative also included the conversion of current manual records and systems within the lab into one electronic record. Benefits: » Ensures data integrity and accuracy » Eliminates human error » Reduces double data entry » Improves patient care through the inclusion of detailed patient information
Intra-procedural Toolbox Redesign Enhances EHR Documentation The EHR team implemented the cardiology module at the end of 2018, while also updating Cath and EP intra-procedural toolboxes. As they were being implemented, the structure and design of the existing toolboxes led to discovering workflow and documentation inefficiencies. Changes included layout format and reordering, consistent language, eliminating redundant documentation, and the addition of detailed documentation capacities. A technology change process was also created for future toolbox updates to maintain consistency and input from all entities. Redesigning these toolboxes enabled multiple benefits: » Accurate structured reporting specific to procedures as they are performed in the labs » Toolboxes function more efficiently within their procedural workflow » Documentation is more accurate with consistent language across entities and procedures » Enables enhanced reporting data elements
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Automating Specimen Requisition in the OR Brings Efficiency to Procedures Clinical teams engaged IS to help develop a workflow to assist with specimen handling in the operating room. The results of the initiative had such a positive impact on patient care that it won two Penn Medicine awards in 2019- the HUP Nursing Exemplary Professional Practice Award and the UPHS Quality & Safety Award HUP honorable mention.
By developing an automated tool for specimen tracking, the following benefits result from a more efficient process: Pathology department can print an electronic specimen report/requisition when the specimen is received/picked up
Specimen dashboard reviews the number of specimens versus the number of specimen requisitions printed
Status board allows the pathology department to view the number of specimens documented for comparison of what is received:
Communication between PeriOp and the lab is improved, specifically turnaround times from specimen collection to lab system entry
Âť The board displays the patient location to identify when the patient has left the OR Âť Can identify what specimens did not reach pathology in a timely manner
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Improvement in turnaround time (excision to accession time) went from 185 minutes to 72 minutes
Penn Integrated Care Program Offers Behavioral Health Support Within Primary Care Setting Statistics indicate that in every American community, whether wealthy or poor, rural or urban, young or old; at least one in five people suffer from mental health disorders. To help address this issue, the primary care service line launched its Penn Integrated Care (PIC) program in January 2018. The program helps facilitate support by embedding a licensed social worker in practices to evaluate and work with patients on their behavioral health needs. An extensive technology build was needed to support these newly added services along with designing a billing model for the services rendered in this setting. The program was piloted in 8 practices and anticipated it would see 500 patients in its first year. Instead, more than 13,000 were referred into the program in the first two years, roughly 10% of whom reported having thoughts of suicide. The overwhelming volume necessitated many changes in the build along with extensive reporting and dashboard support. This integrated care model has improved many key behavioral health concerns expressed by patients. Depression scores for program patients have improved by 47.5% and anxiety scores have also dropped by about the same amount. Data shows that these patients experienced improvement in clinical scores as well, specifically blood pressure readings and HBA1c (diabetes) values. The program has been very successful and continues to expand to additional primary care and specialty care sites.
Investigational Drug Services Migrates to Electronic Documentation Penn Medicine embarked on a project to bring the Investigational Drug Service (IDS) into consistent use of standard tools for electronic documentation of medications and trials. IDS has managed almost 500 active protocols, mostly with the Perelman School of Medicine, but also with the Schools of Nursing, Dental, Veterinary Medicine, and Children’s Hospital of Philadelphia. The initial phase of the project addressed compliance and risk relative to providing IDS with more effective tools to manage a high volume of medication protocols. This was accomplished by an analysis of the protocols of the medications not already built in our EHR (PennChart), followed by the build of all outstanding medications in PennChart, and the implementation of the total EHR medication inventory into the Lab Information Management System software program to align the two systems. By expanding the medication build in PennChart to include investigational drugs, Penn Medicine eliminated the immediate risk to patient safety and to the efficacy of the drug research. These risks were mitigated by eliminating the backlog of investigational medications that could not be ordered or documented on electronically and by the development of procedures and plans to support the maintenance of investigational medications going forward. The next phase of the project expanded IDS’s Laboratory Information Management Systems (LIMS) implementation for stability testing, a process previously managed almost entirely on paper. Stability testing for Investigational New Drug studies, is mandated by the FDA. The Investigational Drug Service had been managing all stability testing via various ad-hoc electronic and paper methods. The LIMS software that was already supported by the LIMS team contained a stability module that was not in use. Implementation of the module automated testing, documentation, and reporting in a single electronic system. The LIMS and IDS teams worked together to define and implement stability study workflows, documentation, and reporting, as well as critical notifications and reminders of upcoming stability samples, greatly reducing the risk of missing a designated time point for testing. Our combined efforts reduced inefficiencies in the stability testing process, saving time for the IDS staff for conducting testing or producing documentation for study monitors. Additionally, we reduced the risk that testing would not be performed at the appropriate time due to reliance on ad hoc calendar reminders or paper methods.
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Lung Module Streamlines Patient Screening Process PennChart’s lung screening module was implemented to readily identify patients who qualify for the lung screening program based on age and smoking history. Execution of the module followed a defined workflow, build and thorough testing process. The use of this application allowed Penn Medicine to remain compliant with industry targets and meet CMS requirements for reimbursement for lung screening procedures. Educational training was also completed to ensure radiologists, providers and coordinators followed the appropriate workflow for accurate submission.
Benefits realized through this improved process: » Development of an approved process to identify eligible patients patients have been In the past year alone, identified and screened for lung cancer. » Implementation of the follow-up monitoring process patients were identified for follow up monitoring in the last year » Direct submission to the ACR Lung Cancer Screening Registry
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Dermatology Shows Positive Results from High-Risk Patient Medications Application Funded by the Penn Innovation Center, HiRPM is a custom software solution that interfaces with our electronic health record EHR (PennChart) to track patients on high-risk medications within Dermatology. The software automatically communicates its findings with physicians, staff, patients, and laboratories regarding the scheduling and status of their required lab tests.
The implementation of this application: Increased patient safety and provider efficiency
Demonstrated a significant uptake in medication monitoring
Automated communication with physicians, staff, patients, and laboratories regarding the schedule and status of their required lab tests
Anticipated decrease in lab result retrieval time from 20 to 2 minutes
Reminder email, texts and calls to patients and labs for upcoming labs that are due
Decreased manual tracking resulting in an estimated savings of $113k annually Expectant use by other departments with patients using high risk medications
Increased documentation into our EHR
Post-Acute Management Program Enhances Patient Care Transitions A new program was developed to provide better transitions in care for patients who are discharged from Penn Medicine hospitals and admitted to skilled nursing facilities. The goal of this patient care initiative was to improve quality of care and reduce readmissions. As part of the initiative, a workgroup was established to develop technology tools required for the program. » An electronic framework was created in our EHR › including documentation tools and rosters for care managers to track their work » Expanded the custom healthcare information sharing portal › helping care managers track patients that were sent to a non-Penn Medicine emergency department or admitted to a non-Penn Medicine hospital
» The program covers approximately 500 patients a month
This new program consists of eight case managers that now have the right technology tools to oversee patients that were discharged to a skilled nursing facility in the preferred provider network; enabling them to track their progress and maximize their care plan. 25
Intraoperative Cardiovascular Monitoring Improves Patient Outcomes The Division of Cardiovascular Surgery at HUP and PPMC acted on advancements in technology to implement a new system that displays data continuously on large OR screens for staff and surgeons to monitor and intervene in care when needed. Stemming from 17 targeted variables identified as vital to adequate perfusion during bypass, the live features of the software also integrate into the PennChart EHR, supply post-hoc data, audit and report for regulatory compliance, quality improvement, and research. Safety checks and real-time best practice alerts for the application were added to alert staff immediately to prevent any unnecessary complications. Since the system was installed in March 2019, the mortality rate decreased to the lowest rate in the last 5 years. The entire operating room team now uses this alerting and monitoring technology in conjunction with a timeout process and team-based communication strategy. At the end of each case, a summary of the bypass compliance/ performance is immediately emailed to the surgeon and perfusionist for review. It provides a graphical metric of how the case performed against some best practice indicators. Cases are also reviewed at a monthly morbidity and mortality conference for trends identification and quality improvement. The Heart and Vascular department along with the data science team is now seeking to develop a platform to statistically correlate OR processes with patient outcomes. They have begun research on questions that have previously been unanswerable due to a lack of data. The cardiovascular surgery and anesthesia faculty and fellows are using the data that the system produces to perform additional research toward this effort. To date, 9 research queries were initiated, with many more on deck. Some of those research questions include correlations with delirium, acute kidney injury, and patient length of stay. In order to be able to take full advantage of the technology’s capabilities, Cardiovascular leadership plans to further integrate the application with the EHR for enhanced perfusion workflow and patient safety.
The entire operating room team now uses this alerting and monitoring technology in conjunction with a timeout process and team-based communication strategy.
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Patient Safety Improved by Drug Diversion Detection Software Drug diversion is the act of transferring controlled substances from their intended recipients. To detect and eliminate the potential threat that drug diversion has on patient and employee safety throughout the healthcare system, Penn Medicine implemented a machine learning advanced analytic software that finds the diversion of controlled substances faster and more thoroughly than a manual process. The software pulls together data from multiple sources, including medication receipts, inventories, administration logs, and waste records together with employee time and attendance information to determine where there is a risk of medication diversion so that the appropriate intervention can be instituted. Prior to implementation of the drug diversion software, IS and clinical teams from the Hospital of the University of Pennsylvania conducted file transfers and validation of historical data from every department. Once the software was implemented, the daily review of high-risk alerts for diversion were performed. These alerts were further investigated for clarification of what happened to the controlled substance medication. The software also calculated a cumulative score for staff behavior risks which is a metric that can be used to determine if further investigation may be needed.
Medicare Cost for Imaging is Reduced To reduce Medicare costs for imaging, Congress passed the Protecting Access to Medicare Act known as PAMA. PAMA directed the Centers of Medicare and Medicaid Services (CMS) to establish a program to promote consultation of appropriate use criteria (AUC) for outpatient ordering and Medicare claims processing for advanced imaging modalities (CT, MRI, PET, or Nuke Med). All changes needed to be live in early 2020, before full mandatory implementation in 2021. PAMA also included potential penalties for non-compliant Radiology and outpatient ordering providers. In cooperation with the Imaging Care Select team from the National Decision Support Company (NDSC) the IS team analyzed image ordering and claims processing workflows and tested necessary system changes. Communications to all internal and external outpatient providers were vetted and distributed. Modified Medicare claims processing began in early January 2020 and Penn Medicine went live on image ordering and claims processing changes for CMS PAMA/ Medicare in late January 2020.
Medication Bar Coding Implemented for Infusion Therapy To increase the safety of patients receiving chemotherapy medications, Penn Medicine implemented barcode medication administration (BCMA) in all outpatient infusion suites across the health system. Further integration of the automated barcode medication administration (BCMA) system into PennChart, Penn Medicine’s electronic medical record system, aides in the elimination of manual documentation errors in drug administration. In order to implement barcode administration for the infusion practices; the PennChart EHR team updated infusion’s BCMA scanning workflow to mimic their current drug administration workflow model. A new online training module was developed for staff. As the new workflow was tested, BCMA scanners were configured and installed for 10 infusion offices that serve approximately 3500 patients a month. Three workstations on wheels and desktop computers were procured, configured and installed for two of the smaller infusion locations. Also, six out of ten offices are configured for blood scanning.
The implementation of barcode medication administration has helped align Outpatient Infusion’s clinical and documentation practices with the rest of the health system and added a robust layer of safety in our medication/blood product administration process. Pamela Cappucci
Manager of Clinical Nursing Information HUP Hematology – Oncology - Chemotherapy 27
MOBILE DIGITAL HEALTH CARE
Telemedicine Patient Data Integrates into EHR, Increases Patient Monitoring The integration of a high-end remote patient monitoring solution provided a scalable solution to send telehealth data into our EHR, PennChart. The software was customized, and an inbound and outbound ADT interface was created along with a new ordering mechanism for the PennChart telemedicine department. Benefits: » Patients can send vitals online from a tablet directly into PennChart » The Center for Connected Care monitors vital inflow and enrolls eligible patients for ongoing monitoring at home.
Expansion of Telemedicine Provides Patients with Increased Access to Care Penn Medicine successfully scaled patient care delivery through telemedicine within our EHR and patient portal. While initially going mainstream in 2016/2017, our business purpose was to further engage our patients in the most appropriate and convenient setting and attain the most effective ROI on various tertiary and quaternary services using telemedicine to connect with patients outside of the traditional brick and mortar setting. Key objectives of our business purpose and adopting this new business technology model: » Increase patient access and adherence » Improve patient and provider satisfaction » Increase provider and clinic efficiency » Improve programmatic integration » Reduce unnecessary technology and health system costs » Ensure regulatory compliance as these services are provided Substantial telemedicine growth occurred with support from 200+ participating caregivers among 35 programs. We consolidated to a single integrated telemedicine EHR platform, educated providers and patients regarding the use of telemedicine, and eliminated substantial costs. The provider “e-consults” service, resulted in seamless EHR workflow and billing for providers to discuss treatment plans. This strategy allowed us to operate telemedicine in a “business as usual” fashion, ahead of the national trend, which was a major Healthcare IT industry milestone. Through our patient portal, patients have been able to easily selfschedule, connect and remotely “be seen by the caregiver” while documentation gets filed in the patient’s EHR and the “e-visit” is fully aligned with in-person practices. Examples these virtual services include certain pre and post-surgery follow up, genetic counseling, an employee telemedicine virtual care program covering 58K lives, among many more applications.
Penn Medicine OnDemand Virtual Urgent Care Visit: https://rb.gy/9t8hbx
When the COVID – 19 pandemic struck, Penn Medicine was poised to immediately meet the demand of providing virtual healthcare to enable patients to get key critical services during a vulnerable time. Virtual visit demand escalated from 40 visits a day to more than 500 a day almost overnight. The connected health team was able to pivot and flex up in providing virtual visits due to the initial investments made in building the foundation of the program. Our telemedicine initiative is paying daily dividends, providing us with multiple new ways to enhance access and convenience for our patients and providers. As a national leader in healthcare, we are continually breaking new boundaries in clinical discoveries creating incredible demand for care. Our telemedicine program allows new ways for patients to seek care with Penn Medicine as a premier national destination to care for the sickest patients and most medically challenging conditions.
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INTEGRATING AND UPDATING CORE SYSTEMS
Installing the Latest and Greatest Anesthesia Machines at Pennsylvania Hospital (PAH) In early 2020, the PAH Clinical Engineering (PAH CE) team partnered with Perioperative Anesthesia Services completing the refresh of all operating and procedure room anesthesia machines. This large project included upgrading the main operating rooms along with SPU, labor and delivery, endoscopy, EP and Cath Lab rooms. The team upgraded about 40 machines with no disruption to day-to-day clinical operations.   In order to maximize project efficiency, a considerable amount of preplanning and staging was undertaken by the team in the weeks leading up to the go-live. The new anesthesia equipment was inventoried, evaluated and outfitted with new hardware mounting solutions. Teams of CE technicians moved physiological monitoring and hardware from existing anesthesia machines to the new devices, outfitting it to each OR connection. Machine connectivity was verified with the data integration team to ensure a seamless transition with the EHR. The standardization of the equipment also increased competency in use of machines as well as better support on maintenance.
PennChart EHR Upgrades Maintain High Standards and Enhanced Functionality To improve and enhance PennChart technology, Penn Medicine’s electronic medical record was successfully upgraded over a two-year period to versions 2018 and 2019. These were full upgrades that included over 1,370 new changes, including visual improvements. The implementations were enterprise-wide at all inpatient and ambulatory sites, impacting over 40,000 active users. The results of both upgrades far surpassed expectations, with positive feedback received from all entities. A command center supported users through the 2018 upgrade. 995 tickets were opened, with a 92% resolution rate at the time the command center closed, just 4 days after launching. The command center for the 2019 upgrade was only active for three days with a drop in help-desk tickets to 112, which represented an 88% decrease in requests for help over the past upgrade. Implementing the upgrades allowed Penn Medicine to maintain system and compliance standards and adhere to the incentive programs while improving and enhancing functionality of the EHR for users. Extensive build and testing efforts were completed by Information Services analysts to ensure new features were working as anticipated. Application specific unit testing followed by two rounds of integrated testing were successfully completed to validate the flow of information between all areas of PennChart. Education was also provided to users to preview the new look and feel of the system. Role-based workshops and knowledge share sessions were developed that targeted the main groups of inpatient and ambulatory physicians and nurses. A new playground environment was stood up to allow users to log into a realistic environment and acclimate to the new features of the system prior to the launch. 29
PennChart Training EHR Provides Penn School of Nursing with a Valuable Teaching Tool The School of Nursing leadership sought to use PennChart as the school’s EHR. The goal was to create a training environment that better mimics the “real world” healthcare environment, while improving clinical skills and teaching critical decision-making skills in the academic setting. The School of Nursing previously used another EHR system to train nursing students on technology used to support patient care. Using the previous system had limitations regarding the clinical workflows and overall use and functionality compared to PennChart. It also didn’t allow for full clinical workflow integration into Penn Medicine’s clinical setting. Penn Medicine is one of a small number of hospitals that has installed the Epic EHR solution in an academic setting, overcoming several complex technology challenges related to integration and curriculum requirements. The new EHR technology mirrors the PennChart environment including patient workflows, medication additions and barcode scanning. The School of Nursing was also able to create and load exams directly into the PennChart environment for testing the nursing students according to their curriculum and academic requirements. The School of Nursing training environment went live with a pilot in August 2018 and live with all courses in January 2019 supporting over 600 nursing students.
» Approximately 25% of Penn nursing students each semester intern or work at a UPHS facility. The hours saved on training nursing students to chart using PennChart at the start of their internships and roles has been significantly reduced, allowing them to start providing patient care sooner. » Penn nursing students experience a near-LIVE clinical environment, making their transition to interns and other nursing roles much easier and quality of nursing education more valuable. » Standardizes and educates nursing students on clinical practices and critical decision making required to practice high quality patient care » Better simulates how to chart a patient encounter, learn to place orders, chart medications, labs and procedures, enter notes for patients » Easier transition to medication administration in clinical practice for the student nurse » Design teaches the WHY and the HOW of clinical workflows and documentation practices
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Behavioral Health at Hall Mercer Moves to PennChart Pennsylvania Hospital’s Hall-Mercer Community Behavioral Health Center provides comprehensive outpatient services to Philadelphia residents in need. As part of Philadelphia’s Behavioral Health System, it is one of 11 community mental health centers, and has one of Philadelphia’s five crisis response centers onsite. Hall Mercer currently supplies behavioral health services for the at-risk populations in the Philadelphia region, as well as traditional clinical care for those of limited means. The practice supports multiple “service lines” of treatments and care teams. To prepare for the migration to PennChart, hardware was procured, assembled, and delivered. Software licensing was purchased, and an implementation was executed that required a coordinated effort by the IT and administrative staff to work between patient visits. The PennChart application used for behavioral health was fully integrated and directly connected to the EHR. All new PC and printer equipment were deployed, and the old legacy PCs were retired. The migration to PennChart met the compliance standards of the Centers for Behavioral Health. PennChart was implemented as a comprehensive patient medical record, that provides clinicians with an integrated and secure repository for a patients behavioral and medical health information. Using existing capacity on the PennChart system, 143 clinicians and support staff were migrated from the legacy system to PennChart. The Hall Mercer staff were trained on workflows and new devices were deployed to support PennChart. This effort also eliminated all costs associated with the previous EHR.
The most significant impact of the transition to PennChart for Hall Mercer Community Mental Health Center has been the increase in the quality of care our clients receive as a result of the integration of behavioral health services with the services provided by the clients’ medical teams. In addition to behavioral health conditions, many of our clients have co-existing chronic medical conditions and are more likely to be taking multiple medications and possess numerous medical risk factors. Timely communication of care between us and the client’s medical provider has improved significantly since the implementation of PennChart. Our clients’ complete health care has benefitted as a result of the ease of collaboration and coordination of services through PennChart. Steve Niederriter Assistant Director of Operations, Outpatient Behavioral Health Services
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Connecting Penn Medicine Partners in Care to PennChart EHR Penn Medicine connected several business partners to EHR capabilities. Penn Medicine Becker ENT & Allergy Practice Migrates to PennChart Penn Medicine Becker ENT & Allergy provides otolaryngology, audiology, facial plastic surgery, allergy and speechlanguage care to clients throughout central and southern New Jersey. This comprehensive practice has 11 clinicians and 3 audiologists at 9 locations, providing approximately 45,000 patient encounters per year. As a member of the Penn Medicine Department of Otorhinolaryngology’s Physician Specialty Network, their EHR was migrated to PennChart, giving them more options for patients in the region and access to the Penn Medicine Princeton Health System. To make the move to PennChart, their patient care workflows were evaluated, followed by a build and test of the PennChart application. This activity re-enforced the existing Otorhinolaryngology EHR workflows and afforded them access to a centralized billing department and streamlined approach for all insurances. PennChart Community Connect App Deployed at Gross Family Medicine Practice In order to provide a more resilient medical record for Gross Family Medicine South Philadelphia patient population, the health system implemented the PennChart Community Connect application. Gaining access to PennChart was fortified by the practice’s close relationship with Pennsylvania Hospital, where most of their patients are treated. Through the collaborative efforts of the PennChart ambulatory, infrastructure and information security team, the following key elements were put into place: » A business-to-business tunnel was established for printing and EHR access » Practice driven clinical workflows were established that maintain PennChart standards » Practice staff received training on all clinical and operational applications » Integrated application testing and device testing was conducted » In person support was provided and a post go-live guide reinforced practice workflows
Penn Medicine’s Behavioral Health Outpatient Services Move to PennChart Penn Presbyterian Medical Center’s outpatient behavioral health practice is a part of Philadelphia’s community behavioral health system. The practice currently operates in the West Philadelphia region and provides vital behavioral health services to the community. To meet the compliance standards of the Centers for Behavioral Health (CBH), PennChart was implemented as a comprehensive patient health record that provides clinicians with an integrated and secure repository for a patient’s behavioral and medical health information. The move from paper documentation to PennChart alleviated the need to scan handwritten documents into a patient’s record, improved accuracy and security and provided behavioral health clinicians with access to a patient’s entire health record which has been proven to enhance continuity of care in the behavioral health setting. This effort has further resulted in: » Standardized and aligned workflows with existing behavior health practices throughout Penn Medicine » Provided practice staff with training on all clinical and operational applications » Established a process for the practice to scan paper records into the patient chart » Integrated billing systems, with a standardized support team » Brought the practice into compliance with CBH standards
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Widescreen Views Developed for 65 Ambulatory Specialties As part of the PennChart EHR 2018 version upgrade, the ambulatory team developed and implemented tailored widescreen visits and views for 65 clinical specialties in the ambulatory setting across Penn Medicine. Specialty widescreen views were developed to enhance user efficiency while documenting in encounters.
To provide widescreen access to over 4000 clinicians and support staff, a multi-team IS effort successfully acted to: » Replace 250 physical monitors with new hardware to replace older equipment » Identify clinical champions for specialties for which widescreens were developed » Set up 10 clinical divisions with standard widescreen view and 55 division specific views » Practice environment enabled clinicians to interact with widescreen and clinical data pre-go live » Complete scripting to default 4,014 users to widescreen view as part of activation event » Developed education materials and videos to demonstrate the new visit taskbar changes » Offered education sessions and rounding activities pre-live and during the live event 33
Voice Dictation System Integrates into PennChart EHR
Penn Medicine identified an opportunity to realize cost savings and operational efficiencies by installing a new PennChart integrated, speech-driven, voice dictation platform across the healthcare system. This all-in-one speech and artificial intelligence-powered solution has enabled clinicians to conversationally create, review, edit and sign clinical notes directly in PennChart. It leverages natural language understanding technology for contextual understanding of the patient’s narrative and helps to improve documentation accuracy. The enterprise strategy directed that the new solution be deployed and transition all existing dictation users to the new solution. As a result of this initiative, the transition led to a cost savings of $3.8 million over 5 years. The system also provides the following benefits: » Fosters enterprise alignment standards via single-platform and centralized cloud hosting » Increases the efficiency and completeness of clinical documentation » Improves coding compliance and billing accuracy » Offers providers more flexibility and distributed access to voice dictation tools » Improves patient safety and elevates quality of care » Results in cost savings and a reduction in multi-vendor contract commitments » Provides best-in-class language recognition with industry standard dictionaries for relevant medical specialties » Provides cloud hosted services and an availability of provider preferences from any Penn Medicine PennChart device » Gives clinicians mobile access to the system through iPhone or Android as a dictation microphone was introduced
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Ophthalmology Image Moves Directly into the EHR To maximize workflow efficiency, an eye care data management solution was integrated into our electronic health record (EHR) and embedded with the single sign-on secure access platform. The new technology combines a full-blown ophthalmic PACS with clinical displays and workplaces for three sub-specialties. The radiology team developed an integrated solution that seamlessly allows the changes made by a provider in PennChart EHR, integrating with the PACS system and data management solution. The integration brought the following benefits: » Increased patient safety » Integrated documentation into the EHR
Increased provider efficiency by: » Eliminating the need for clinicians to input patient data into three separate systems » Providing single tap key badge access that authenticates on the network as well as PennChart, PACS and data management technology
Moving to Zeiss Forum has been tremendously helpful to our practice in several respects. First, the ability to have single sign on that launches both PennChart and Forum at the same time has been a real efficiency for us. Similarly, the ability for Forum to interact with PennChart has reduced transcription errors through direct electronic transmission of patient demographics to the imaging modality. Further increasing safety is the ability for the physician to directly launch the patient’s images from PennChart to Forum which not only limits potential safety issues by assuring we are reviewing the correct patient’s images, but is also an efficiency gain since the images no longer have to be searched for within the PAC system. Lastly, several of our specific service lines like glaucoma have seen a big advantage in how imaging data is captured and reported, allowing for better clinical trend evaluation over time making therapeutic decisions easier. Brian L. VanderBeek, MD, MPH, MSCE Assistant Professor in Ophthalmology, Vice Chair for Clinical Operations Scheie Eye Institute, University of Pennsylvania
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Patient Care Plans Now Accessible via PennChart EHR Access to a patient’s specialized care plan was integrated into PennChart to give providers immediate online availability to make real-time plan updates. Championed by the STEP program team, (a multidisciplinary group that partners with the most frequently admitted patients to improve their health and decrease unnecessary admissions) the move to PennChart was implemented to bring about a more cohesive, user friendly experience through improved functionality that decreased the need for customized third-party interfaces. The cohesive team defined the workflow and related needs as well as integrated between the data management software and PennChart for the requested care plans, while providing enhancements to: » Identify the various care plan types » Provide a mechanism to indicate updates/revisions » Provide seamless access to the documents via PennChart As a result of these changes, providers now easily access, view and manage care plans directly from PennChart, improving their ability to care for their patients.
Integrating Online Scheduling into PennChart While patients were able to schedule appointments online resulting from a partial integration of the scheduling app into PennChart, the appointment was not made directly in PennChart. Manual intervention was needed to create the appointment. To bring about the full incorporation, real-time sync write integration was configured by enabling several Epic APIs allowing information to flow from the online scheduling app to PennChart. Patient registration information, appointments and appointment changes made in the online scheduling app are now communicated to PennChart ensuring correct information. For cancelled appointments on the scheduler, the appointment times were open in real time allowing for new patients to schedule their appointment. Provider profile webpages were updated to add links, allowing patients to schedule directly from their profile. The primary care and orthopedic departments enabled this online scheduling functionality allowing patients another method to schedule their appointment while reducing scheduling errors.
Lancaster General Health (LGH) Joins Enterprise Radiation Oncology System The radiation oncology software system at Lancaster General Health was transitioned to the enterprise system to standardize interoperability, thereby establishing a single enterprise-wide software solution. The downtown campus worked with Lancaster General Health’s clinical, administrative, and project management teams to design the software in Epic and the radiation oncology systems, including Interfaces. The effort resulted in improved safety measures, workflows and efficiencies. It also increased remote dosimetry model functionality, improved standardization, and documentation while assisting LGH to remain on their instance of EPIC.
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Pharmacy Dispensing Cabinet Upgrade at Princeton Health Penn Medicine Princeton Health upgraded their pharmacy automated dispensing cabinet (ADC) system to the most current platform. The IS and pharmacy teams met with the vendor on a weekly basis to layout an initial implementation plan. Our beginning major goals were to devise initial interface specifications and have a test server interfaced with our PennChart testing environments. The testing sessions involved detailed workflows, ranging from a patient taking a leave of absence from Princeton House with a subsequent return, as well as a complex inpatient stay that transferred a patient from the ED to a procedure area and lastly to a critical care area. These testing scenarios were created in collaboration with the clinical informatics team, who ensured the accuracy of the workflows tested. The implementation team took a phased approach to installing the physical cabinets. Five successive rollouts fully converted the Princeton Health Campus to the platform. The first rollout took place in November 2019, with the installation of the anesthesia cabinets. In December 2019, the implementation team converted local dispensing operations at Princeton House to the platform. In late January, all ADCs that served the surgical and procedural areas, including locations at the Medical Arts Pavilion were converted. February brought us two successful installations across all the inpatient units at the main hospital as well as the emergency department, radiology, and the outpatient oncology infusion suite. With each rollout, the implementation team took great effort to strategically coordinate the replacement of legacy cabinets in deliberate groups to the new cabinets in order to minimize disruptions to nursing workflow and overall patient care. By the end of February 2020, all the automated dispensing cabinets at Princeton Health were successfully converted to the new platform. Combined efforts from both Princeton Health operations and Information Services generated numerous benefits. The most evident was enabling nursing staff at Princeton Health to use the most up to date ADC platform with improved functionality and user experience. The platform incorporated Active Directory integration, streamlining user management and alleviating that burden from pharmacy operations. The physical cabinets themselves provided greater customization of capacity to meet the specific needs of individual patient care units. The platform also included enhanced tools and reports designed to optimize inventory, prevent diversion and improve overall medication safety.
Radiology System Upgrade Brings Greater Efficiency to Users at Penn Medicine Princeton Health Penn Medicine Princeton Health upgraded its radiology application system to the current version to be compatible with Windows 10. New features also made creating macros for the radiologists simpler and searching for patient data easier. The new version allows for PDF format to be part of the HL7 message to deliver a user-friendly copy of the report to reside within our PennChart EHR. 37
COVID-19 Surges and Information Services Responds Penn Medicine Information Services established a COVID-19 Response Center to provide enterprise support and address new technology requirements related to business needs for the COVID-19 pandemic. The COVID-19 Response Center remained open from mid-March until the end of May 2020 due to a significant surge in patient volume that emerged during that time. In addition to handling routine technology support ticket management and reporting procedures used to track enterprise technology requests, the IS Surge Response Team was assembled to expedite delivery of urgent technology changes that were needed to adapt our business operations to emerging business requirements throughout the Health System.
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The COVID-19 Response Center and Surge Implementation Team delivered the following benefits between March and May: » Organized a central command center to administer, triage and resolve approximately 8200 IS incident tickets » Expedited COVID-19 census reporting protocols to track and report on surge patient volume and related outcomes » Expedited substantial additional capacity on the enterprise VPN solution to support the business need of a remote workforce » Established new processes to modify PennChart EHR application build, testing and related patient device validations needed to realize entity surge plans » Equipped Emergency Department Overflow Unit flex space to accommodate first level COVID-19 surge response plans in the hospitals » Staged PennChart EHR application build, administered application testing and patient device validations for 34 total patient care units » Converted 11 units to non-ICU overflow in support of entity surge response plans » Converted 13 units to ICU overflow in support of entity surge response plans » 10 staged units remained on hold in anticipation of additional surge – not activated » Reverted temporary ICU space and MedSurg overflow units to prior state at conclusion of response efforts » Configured lab information system and related device technologies to support COVID-19 drive-through testing sites across the enterprise » Provisioned over 200 additional providers for the Penn Medicine On-Demand department and equipped staff with proper technology to conduct telemedicine visits » Rolled out e-consults to all inpatients and to many outpatient areas to allow for provider to provider consultation/communication in order to minimize patient contact which also file to the patient’s chart » Designed a data collection tool and reporting back end to track and report COVID-19 employee exposures and people quarantining across the Health System by Occupational Medicine and Infection Prevention staff » Developed onboarding provisioning workflow to support the urgent reassignment and staff augmentation of licensed providers during the COVID-19 admission surge » Deployed over 470 iPads, and 420 iPad stands/clamps across Penn Medicine in support of the inpatient telemedicine efforts
Service Desk Didn’t Miss a Beat in Pandemic Response
In addition to handling routine technology support ticket management and reporting procedures used to track enterprise technology requests, the IS Surge Response Team was assembled to expedite delivery of urgent technology changes that were needed to adapt our business operations to emerging business requirements throughout the Health System. 39
EDUCATION EDUCATION EDUCATION AND AND AND RESEARCH RESEARCH RESEARCH The Perelman School of Medicine’s education programs develop the next generation of leaders in medicine and biomedical research. To attract the most qualified students and trainees, The School of Medicine and PMMG engage the most outstanding educators and researchers in teaching and training where educational relationships are fostered with the University and Penn Medicine network. We maintain and reward outstanding educators by providing an environment that promotes creativity and rewards teaching excellence. The Perelman School of Medicine, its faculty, and its alumni share a commitment to lifelong learning. Penn Medicine enhances its status as a world leader in advancing medical science by continually improving the quality and impact of its research. The areas that Penn Medicine emphasizes are the fundamental mechanisms of biology and human disease; the translation of discoveries into new approaches for the diagnosis, treatment, and prevention of disease; and the evaluation of medicine’s impact on the health of the public.
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BIG DATA ENABLES RESEARCH AND PATIENT CARE
Opioid Dashboard Facilitates Effective Prescription Monitoring According to the CDC, from 1999-2017 almost 400,000 people died from an overdose involving opioids. This widespread epidemic hit our local region especially hard. Penn Medicine responded by organizing a task force aimed at implementing a system-wide response to this public health emergency, including uniform prescribing and treatment policies as well as provider and patient education. To facilitate these efforts, a tool was needed to promote awareness, education, and outreach, and allow clinicians and practice leaders the ability to easily monitor their prescribing habits and stewardship goals. The Opioid Dashboard was developed directly within our PennChart EHR using Epic’s Radar functionality, so that clinicians can easily access the tool as part of their daily workflow. In order to identify and track chronic patients, we implemented Epic’s Chronic Opioid registry, which works in near real-time to identify patients who have at least 90 net total days covered by an active opioid prescription in the past 180 days (for the purposes of the dashboard, cancer patients are excluded). The data on the dashboard is organized into chronic and acute metrics that reflect standards of care and mandatory requirements. Measures are trended in quarterly, monthly, and weekly intervals, and summarized by provider, practice, department/division, and the overall institution. Directly from the dashboard, clinicians can identify patients at risk and jump right into the patient’s chart to view additional information or take action. Some example chronic metrics include the percentage of patients who have a signed controlled medication agreement, patients who are co-prescribed benzodiazepines (which can be a dangerous combination), and patients at or above accepted dosing thresholds for consideration of tapering or naloxone therapy. The acute side includes metrics such as the average number of days for each acute prescription and the average Morphine Milligram Equivalent (MME) dose per initial prescription. With the implementation of the dashboard, the health system is now able to measure data regarding opioid use, educate providers, perform outreach, and monitor the impact of the task force’s efforts. For example, since FY17 the number of prescribed tablets has decreased by 20% - that’s over 2 million tablets! And in FY20 alone, the percentage of appropriate naloxone therapy improved by 35%.
Predictive Models Transform Approaches to Medicine Leveraging data within our electronic health record helps advance patient care across Penn Medicine by transforming data into knowledge, fostering advanced clinical decision support. Our approach to implementing predictive modeling involves configuring and testing models based on algorithms to detect potential negative patient outcomes before they occur and by improving operational efficiency. As we set new models up, we run them silently in the EHR for several months. Once a baseline of data has been collected, Information Services and Data Science teams work with our EHR vendor to evaluate the model’s performance in the EHR. For models that perform well (by demonstrating the expected outcome and being measurable), the team works with operational and clinical partners to do a feasibility assessment; essentially pilot testing the models in a controlled environment. There are currently six predictive models that have been running silently in our EHR: » Risk of unplanned readmission » Risk of patient appointment no-show » Early detection of sepsis » ICU length of stay » Risk of admission for heart failure » Risk of negative outcomes of type 2 diabetes As these initiatives are launched, the goal of each predictive modeling effort is to deploy the predictive solutions to improve clinical outcomes, operational performance, and enable translational research.
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Users Become Empowered to Draw Data Through Expansion to Penn DataStore II
PENN DATASTORE AND PENN DATASTORE II WERE INSTITUTED TO MEET COMPLEX, RAPIDLY CHANGING DATA NEEDS AND THE DEMAND FOR SELF-SERVICE DATA ANALYTICS FOR A WIDE AND DIVERSE GROUP OF PENN MEDICINE USERS.
Developing a Shared Model
Key metrics are used as an important, fundamental business tool within our health system in order to analyze performance and drive efficiency in the organization. Data analytics reporting delivers the measurable outcomes defined by the metrics. Our Penn Medicine senior leadership relies on tracking data and reports in order to formulate strategic planning, whether proactive or in response to the operations occurring within our enterprise. The data for these key measures and reports was previously pulled from a number of disparate sources where the process to assimilate these reports was entirely manual; requiring a number of people to spend time each month retrieving the data, consolidating it, and then putting it into report form.
In 2019, Penn Medicine implemented a cloudbased enterprise analytics data lake platform, Penn DataStore II. The Penn DataStore II platform integrates clinical, financial, research, and other data and allows users to work in a common Penn Medicine environment to speed discovery, insight, and action through data. Moving to a cloudbased architecture increased operational agility, allowing the flexibility to scale up or down quickly depending on demand but without the on-premise cost of capital, staff, and time. Creation of the data lake allows for rapid ingestion of data from unlimited data sources, both structured and unstructured, and from all Penn Medicine entities. Now, data is available much quicker than retrieval from the traditional data warehouse. In addition to the lake, data is modeled into curated data stores, providing self-service access to data via the method and tool of the user’s choice. With these different access points (source data, data lake, curated data store, data marts, reports and dashboards) we support the needs of our wide audience of data consumers (from caregivers to research data scientists). Another key part of the Penn DataStore II analytics platform is operational governance and ownership, via data domain committees, to develop consistent, system-wide definitions for key metrics and measures. Benefits Include: » Increased discovery and self-access to data in both raw and curated forms » Improved speed to data for quicker decision-making » Validated data are transparent and uniform across the organization » Data from all entities across the enterprise are available for analysis » “Best in class” tools to make it easier to analyze data and provide flexibility in accessing the data » Ability to move data out of the expensive on-premise server storage infrastructure
The Data Analytics Center (DAC) team has created a cloud-based solution that pulls data on a scheduled and automated manner, now unified from all required data sources, removing unnecessary manual involvement. The data was curated, updated, and readily available for both user reports and for direct access from data science or domain analysts. An automated connection to the data servers was created, and the calculated data regularly pulled into the Penn DataStore (PDS II) model. By expanding the options for querying the data, this shared model makes comparative analysis easily attainable, whereas before this was not possible other than drawing data through one-time manually created reports. The DAC team also built a series of interactive reports and custom visuals to represent these data in ways that our leadership could use, ensuring that results were accurate, predictable, reliable, and usable.
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Release II Features
The main initiatives that were built and showcased with the Penn DataStore II model were: Penn Medicine Team Goals (PMTG), Service Line Dashboards (SLD), Penn Diver, and Slicer-Dicer. Penn Medicine Team Goals (PMTG) – This monthly report is used by senior leadership and key staff to monitor progress on key performance indicators across several domains to improve year-over performance based on predetermined thresholds, targets, and goals. Entity-level analysis was enabled - all the way down to the unit, and by date from fiscal year down to the week or day. The underlying data went to the encounter level, which allowed analysts to do detailed investigation into areas of concern and to help guide and predict future performance. Service Line Dashboards (SLD) - Our entities and service line leadership use this report to track progress on key measures, so that changes can be made to improve the patient experience, quality, and patient access to care. Another report for displaying data aggregated by service lines and entities help respective CAOs to track progress across their service line. There is now consistency of results, which was validated, to ensure data is correct on all reports. PennDiver - Operational dashboards displaying enterprise approved metrics for various service areas are no longer manually extracted from a database and manipulated on a monthly basis to provide insights and visualizations to senior leadership. We leverage a third-party vendor platform to extract data, clean it, and build standard dashboards and reports for five key domains: ambulatory, quality, surgery, hospital operations, emergency department. The modules provide operational leaders with turn-key access to data visualizations and drill-down reports into individual service areas. SlicerDicer - is a self-service data exploration tool built into our PennChart EMR. Prior to implementation, all clinical report requests were sent to the Data Analytics Center (DAC) as tickets, needing to be assigned and built. Despite a team of 20 data analysts, the request volume outweighed the ability of the team to match the pace of the demand. To remedy this need, we implemented this self-service reporting tool so that users could create their own reports to quickly reflect what they were searching for from our systems. Users can investigate a hunch and refine their searches on the fly to better understand the data they explore. They can examine trends, drill-down to line level details with the proper security and jump to related records directly in the EHR to follow-up. The first release of SlicerDicer in the EHR includes the “patients� data model with 6.5 million records. With a few clicks, one could find patients who meet criteria such as diagnosis, procedures, demographics, immunizations, chief complaints, allergies, vital signs. New discoveries occurred, finding patients for research studies or screening programs by parsing large quantities of data in minutes.
myPennDataStore
Analytics Storefront is a centralized website accessible to every Penn Medicine employee that houses a catalog of all reports and dashboards, information about data sources, definitions of approved metrics, reporting platforms, or educational content. Users can easily navigate the available content, understand which reports and dashboards are available, and how to get access to data. It contains all relevant information about data across all settings, domains, user roles, and reporting platforms. The storefront allows users to search reports and dashboards and aggregates data by areas of interest for easier discovery. It also outlines monthly releases of critical dashboards. 43
Data Analytics Automates Gastroenterology Adenoma Detection Rate Toward Gold Standard Care The Gastroenterology departments used a third-party tool to track procedures such as endoscopies and colonoscopies. Both the procedure data and the patient data were combined into our EHR. However, the pathology data that resulted from a gastroenterology procedure was not linked directly to the procedure data. Instead a PDF file was attached with the results. This created a data gap. The tracking data has been used to calculate Adenoma Detection Rate (ADR) for each provider, which is the recognized gold-standard for care and prevention of cancer. Given the non-connected procedure and pathology data, the only available way to calculate ADR for providers was through a labor-intensive manual effort. It took considerable time to come up with a one-time snapshot rate, and to get an updated rate. Then the entire process was repeated, which made the effort untenable. In order to maintain this standard in a more effective way, the GI team requested a monthly calculation of Adenoma Detection Rate (ADR) by provider, with various options for filtering and aggregating the data so that they could manage these rates along with outcomes. The DAC team created an automated process which combined procedure data, patient data, and pathology data into an organized and curated database format. The DAC and the GI team used carefully validated and constantly updated and improved logic to combine and calculate data results, now obtained in an automated fashion. An interactive report was created to represent those data in a manner that gave clear results, highlighted areas of concern, and helped identify correlative relationships. All manual interaction was removed. Also, the report updated daily instead of monthly, giving the clinical team near real-time results. Making use of data analytics now available, as designed for this use case, provides the care team and respective leadership with an unprecedented level of access to personalized results, details on factors that impact clinical procedures, as well as a method to effect and monitor change over time. This has resulted in an increase ADR of over 10% resulting in an average ADR that meets/exceeds national ADR benchmark.
Cloud-Based Documentation System Keeps PennVault Data Management Efficient Penn Medicine’s increasing focus on developing novel therapies requires both robust and high-quality manufacturing processes and procedures, including an industry compliant electronic quality documentation system. We implemented a compliant cloud-based quality documentation application to facilitate governance and manufacturing documentation necessary for clinical research. Additionally, we streamlined and centralized documentation while improving documentation management efficiencies for manufacturing cores at Penn Medicine. The new software also provides a foundation for establishing a full electronic quality management system.
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PennDiver Provides Cutting Edge Business Intelligence Data for Ambulatory Operations The implementation of a suite of business intelligence modules known as PennDiver combines multiple data sources and enables access to validated enterprise approved metrics and data via interactive dashboards and reports. To date Penn Medicine has implemented the ambulatory, quality, and surgery advisor modules with two more being developed: ED advisor and hospital ops. The Ambulatory module provides visibility into interactions between providers and patients. This module provides measures that reflect: » Volumes, such as office visits, appointments, and procedures » Revenue and finances, such as charges and accounts receivable » Productivity, such as RVUs (relative value units) and charge lag The quality module provides inpatient measures that are broken out into: » Outcomes/Utilization » Patient Satisfaction » HAI/Complications » Timely/Effective Care The surgery advisor module allows tracking and comparison of varied metrics across perioperative services at each institution and between institutions. This module provides measures that reflect: » Volumes, specific to location and operating room sites » Quality metrics, such as on-time starts, room and block utilization, case length and scheduling PennDiver brings the following benefits: » Validated, enterprise approved metrics and data from multiple source systems are available together in a single user-friendly and customizable set of interactive dashboards and reports. » Data from five of the six entities can be viewed and compared across the health system. » Common metrics, definitions and dimensions are approved by the Data Domain Committees and consistent across the health system. » Increased self-service ability for data analytics to help improve practice operations and outcomes » The PennDiver modules have more data points than previous applications, which provides multiple ways to view and analyze the data.
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EDUCATION AND RESEARCH
Immune Health Report Helps Advance Groundbreaking Science
Cancer immunotherapy is fundamentally changing medicine. Unlike conventional chemotherapy that attacks cancer indirectly by poisoning rapidly dividing cells, cancer immunotherapy stimulates a patient’s own immune cells to destroy tumor cells. Long dismissed as a scientific dream, cancer immunotherapy is now possible – leading to complete responses in some patients – and the potential is difficult to overstate. Along with thousands of clinical trials, dozens of FDA drug approvals, and the 2018 Nobel prize, immunotherapy has brought something truly unprecedented to cancer treatment: a sense of optimism about the future. Cancer immunotherapy more than doubles five-year survival from advanced cancer when given to the right patients yet identifying the right patients has been difficult. This is because a staggering volume of data is required, including highthroughput genomic sequencing and multiplexed immunologic testing, outputs which have been fragmented across separate data silos. These data were poorly accessible through the electronic health record, preventing physicians from accessing information that enables the use of highly effective therapy. In conjunction with the Department of Pathology, the Application Development team developed the Immune Health Report, a software platform that integrates information from across Penn Medicine to enable (1) real time clinical decision support and (2) research discoveries in cancer immunotherapy. The first version of the clinical report was deployed in November 2019, consisting of a secure HTML document, accessible from our electronic health record. The document’s unified landing page integrated the results of immunotherapy diagnostic tests. Prior to the Immune Health report, each piece of relevant data was found in a different location. The Immune Health Report has allowed oncologists to rapidly access critical information in a single location, enabling real-time review and shared decision making with patients during a clinic visit. In parallel, the Department of Pathology used a deidentified companion report to integrate emerging research data from across Penn Medicine and facilitate discovery of relationships between metrics of “immune health” and response to therapy. Future Insights Insights gained from the research platform drives future clinical trials, addressing questions such as why some patients respond dramatically to cancer immunotherapy, while many seemingly similar patients do not receive a clinical benefit. Prospectively validated results will be incorporated back into the clinical version of the Immune Health Report to predict response to cancer immunotherapy, enabling Penn Medicine to rapidly “learn” from research and clinical data and deploy this new knowledge into clinical practice. The next version of the Immune Health report will introduce additional clinical results and updated patient-specific reports triggered by the availability of new and updated clinical information. The cancer immunotherapy market is expected to reach $100 billion by 2020, creating a large opportunity for the Immune Health Report to clarify which patients will most benefit from cancer immunotherapy. Using only existing research assays that undergo clinical validation, the Immune Health Report could more than double the number of patients with cancer who are eligible for cancer immunotherapy. In addition, the Immune Health Report represents an active collaboration between software engineers, basic scientists, pathologists, and oncologists. We are leveraging Penn Medicine’s extraordinary expertise and environment to create a product that is technically sound, scientifically driven, and clinically actionable. Medicine is being transformed by personalized approaches using highly complex data, and the Immune Health Report is uniquely positioned to facilitate discovery and realize the next generation of precision treatments. 46
Live Poll Application Aids in Incoming Medical Student Class Selection Process Faculty and students residing on the Committee on Admissions (COA) have annually reviewed applications for admission to the Ruth and Raymond Perelman School of Medicine. The COA sought a real-time majority voting system based on an applicant’s life experiences, personal attributes and metrics that align with the school’s mission, ensuring consistency in the selection process for admission. Penn Medicine Academic Computing Services (PMACS) worked with the admissions director to build a system where committee members could rank applicants based on a discussion and a review of the applicant’s records. The software was also designed to meet the standards of the Liaison Committee for Medical Education (LCME) by providing the means to take attendance, display live results, and to demonstrate medical student selection with evidence-based outcomes. The Live Poll system allowed for an integrated workflow and improved process within the COA meetings. As a result, the meetings moved at more efficient pace. Committee members could attend the meeting in person, or remotely, accessing Live Poll and all its features from a laptop or any mobile device to ease the burden of performing the tasks necessary for the meeting. Committee members could easily navigate to the applicant’s admission record in another system while also participating in the live poll and receiving immediate feedback on the poll results. The committee was able to provide their vote as to whether they believe a prospective student should be admitted. The participating faculty and student committee members gave positive feedback about the tool and look forward to using it again next year with enhancements to further optimize their process.
Credentials Verification Organization Becomes Streamlined Penn Medicine’s acquired hospitals (CCH, LGH, MCP) were each using separate credentialing processes, systems and policies. Medical Affairs needed to consolidate the various processes onto the central corporate systems. A project team was established to migrate each facility’s data to the existing database. This was performed one entity at time, with all the migrations completed in spring, 2020. One database was now used for credentialing; allowing for one enrollment process to feed our EHR for reimbursement. The integrated system also allowed us to consolidate other processes such as: Chair Review Portal, Late Career Practitioner Testing, Electronic Prescribing Controlled Substances (EPCS), Marketing. 47
IS Support for Cancer Center Clinical Research Unit Collection Kits The Abramson Cancer Center (ACC) Clinical Research Unit (CRU) sought a new, tech-enabled method for tracking sample collection kit inventory and managing the processes for assigning and delivering kits to study participants. The Penn Medicine Laboratory Information Management System (LIMS) team partnered with the CRU to pilot the implementation of Penn Medicine’s enterprise LIMS to streamline the tracking of kit inventory, assignment, and delivery. Since implementing, hundreds of different kit types and over a thousand visits have been tracked. The CRU is pleased with the implementation, finding it helpful in addressing their needs. Since then, the teams worked to expand the implementation across the unit.
Identity Proofing for Electronic Prescribing Controlled Substances (EPCS) Since October 2019, practitioners (excluding those with statutory exceptions) have been required to issue electronic prescriptions for Schedule II-V controlled substances in keeping with Act 96 of 2018. As part of this regulation, healthcare providers have been required to provide proof of identity before being enabled in our EHR for e-Prescribing controlled substances. A workflow was designed where each department would designate certain staff members to attest and report to the Office of Medical Affairs (OMA) that this ID proofing was completed. OMA then needed to provide updates to the EHR team so that they in turn could update each provider’s record. As this applied to all providers including attending and resident MDs, CRNPs, Pas the challenge was to apply this process to thousands of provider records and integrate multiple databases. A web-based application was created to pull records from the credentialing database and identify those who had and those who had not been enabled for EPCS. The application included a user interface for designated ID proofers in all departments to attest that they have verified the identities for their providers. This data was then used to update the database records as well as provide data to the EHR to update and enable for EPCS. Over 7000 providers were enabled for EPCS in time to meet the deadline by creating a single source of data entry which integrated with multiple systems. Learn more about the Act 96: https://www.legis.state.pa.us/cfdocs/legis/li/uconsCheck. cfm?yr=2018&sessInd=0&act=96 48
Investigational Drug Service Stability Support Aids Tracking and Reporting The Investigational Drug Service (IDS) is responsible for carrying out stability studies on the investigational compounds they manufacture. This means that they must sample and test the compound under multiple conditions (e.g., room temperature, refrigerated, elevated temperature) on study-specific schedules that require different tests at different points in time. The Penn Laboratory Information Management System (LIMS) team implemented the stability module to help IDS: keep track of which tests needed to be carried out, record the test results, and generate Certificates of Analysis (COAs). The Investigational Drug Service now has a formal platform to track and manage the stability studies that it carries out, which greatly improves the overall quality control of the process compared to the former approach.
Remote Consent and eSignature Capabilities Support Research Penn Medicine desired to enable a DocuSign eSignature solution for clinical research that met HIPAA and eSignature compliance in order to allow for remote consent of patients on critical COVID-19 and other essential clinical trials. This technology would facilitate important research initiatives alongside the increased need for staff to work remotely. Another need was to limit physical contact with COVID-19 patients who sought to participate in research, notably the PATCH trial investigational treatment for COVID19 positive patients. This implementation was initiated and completed in under two weeks. The process required contracting, including purchasing and BAA processing, Information Security assessment, application build, user provisioning, training, and socialization of the business process. The critical and high-profile trial was activated on time and allowed research staff, providers, and patients to communicate and document in a fully validated electronic solution. This tool minimized physical contact and helped align with COVID-19 guidelines. The activation process was also accelerated by streamlining communication and documentation.
IS Supports Wherry Lab and Allen Institute for Immunology on Research Sample Tracking After being selected as a partner to the Allen Institute for Immunology (founded by Microsoft’s co-founder Paul G. Allen), Penn Medicine was ready to begin its research into baseline immunology. A technology solution was quickly needed to manage samples that would be shared with Children’s Hospital of Philadelphia, the Human Immunology Core (HIC), and Dr. John Wherry’s laboratory. The Lab Information Management Systems (LIMS) team worked with all respective collaborators to bring their study on-board to Penn Medicine’s enterprise LIMS system in time for the arrival of the first sample to provide barcode labeling as well as detailed sample tracking and annotation. As a result, samples collected as part of this study have been tracked by their location and status. The labs have also collected the required annotations on the samples ensuring that the required information to carry out the research is collected in a single, secure, and stable application. 49
EMPOWERINGTECHNOLOGIES TECHNOLOGIES EMPOWERING These technologies and processes address the administrative infrastructure support and physical infrastructure support that includes financial services, operations, human resources, managed care contracting, billing, materials management and other administrative services. This enterprise-wide approach designs and implements product and service processes to achieve performance gains and decrease costs while optimizing resources.
Technology Business Documentation is Optimized with e-Signature Information Services has processed over 1,500 contract related transactions annually; requiring approval at five levels as well as obtaining signatures in the finance and materials management departments. Prior to introducing e-Signature, these approvals were obtained manually, which added processing time and resulted in operational inefficiency. In spring 2020, we piloted an e-Signature solution into our department’s document business process for certain documents such as contracts, order forms, quotes, schedules, SOWs, renewals, supplements, amendments, and contract approval forms (“CAFs”) through Adobe Sign. An evaluation has begun to seek an enterprise e signature strategy based on the pilot experience. By replacing the manual signature process, we now increase operational efficiency in the IS document business process and tracking. Benefits include: » Real-time tracking so IS contract parties can see who has viewed a signature request and whether they have signed or not » Mobile signature of documents via any iOS, Android, or Microsoft device if a desktop or laptop computer is not available to the signer » Signature order allowing the IS contracts team to set the order of signature preferences (e.g., 1st director, 2nd VP, 3rd AVP etc.), routing document flows through individuals in specified order » Encrypted signature verification allows verification that the correct person has signed the document based on specified credentials » Signature delegation so that if a requested signor is not available to sign, they can delegate the signature to another person and the document can be re-routed
Information Services Advisory Center (ISAAC) Goes Mobile In 2018, Information Services transitioned from implementing systems to a more service-based user support orientation. The Information Services Advisory Center (ISAAC) was introduced as a new concierge service for people wanting to know basic questions like “Where can I find? Who do I speak to about? I was thinking but did not know...” that traditionally wasn’t handled by our IS Service Desk. This one-stop contact for all IS related questions regarding advice, resolution, guidance and follow-up has worked both reactively and proactively. ISAAC traditionally offered walk ups on various subjects as well as provided special scheduled “daily topics”. Micro-videos, along with tip sheets, newsletters, webinars, walk-around visits, and optimization sweeps have all been part of their proactive and personal approach. In lieu of the monthly kiosk events at the entity hospitals, ISAAC offers scheduled virtual office hours for users to ask IS related questions in real time. The ISAAC request form also includes an option to schedule an online video meeting through Microsoft Teams to discuss the request. While this service focuses on the most optimal ways to support our caregivers, the Isaac team expanded the ability for users to connect with the team through a mobile website. Isaac now offers a platform for users to ask questions as they come to mind, while they are on the go. » Users can submit questions through a mobile website. https://askisaac.pennmedicine.org » Users do not need to be connected to the Penn Medicine network. » Questions can be submitted from any mobile device or desktop that has internet access. » The form can be added to a mobile device home page for easy access and future use. Since the launch in February 2020 a growing number of mobile requests and positive feedback has been received from users who have used the form. Independent providers have also been pleased because they can now easily connect with our IS department for questions related to the physician referral service and our EHR.
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EXPANDING AND CHANGING THE PENN MEDICINE LANDSCAPE
New Technology Highlights Chester County Hospital Expansion In January 2020, Penn Medicine opened a $300 million expansion at Chester County Hospital with new technology that puts the facility at the forefront of some of the premier hospitals in the nation. The expansion made Chester County Hospital the largest healthcare provider in the County, with 301 licensed beds. The quarter-million square-foot expansion includes 15 modern operating room suites, new areas for non-invasive cardiology, 99 private inpatient rooms with a patient focused digital whiteboard/TV in each room, a 700-car parking garage, an outpatient pharmacy offering over-the counter medications and prescription pick-up and refills, a bistro, and a rooftop helipad. By the end of next year, a 26,000 square-foot expansion and renovation of the hospital’s Emergency Department will be completed, with enhanced security features and specialized exam rooms.
The IS environment includes the installation of 99 digital whiteboards that display patient information on a 75” monitor within the Med/Surge unit. CCH expansion space was also the first location to use the new network segmentation to more efficiently protect sensitive patient data. Over 600 pcs and 100 printers were installed to support more than 18 practices within the facility. Technology additions for this site included new telecommunications systems, updated site wireless systems, and a distributed antenna system to increase cell coverage strength for our guests and staff.
Penn Medicine Expands Services at our New Radnor Medical Arts Building In June 2020, Penn Medicine opened a new multi-discipline outpatient facility located at 145 King of Prussia Rd in Radnor, PA. This innovational facility is in the process of completely replacing the 250 King of Prussia Rd location which has been in operation since 1997. The new location provides comprehensive cancer care, including newly available radiation oncology services and chemotherapy provided by the Abramson Cancer Center, as well as primary care, heart and vascular, orthopedic and neuroscience care. Additional services include four endoscopy suites and coming in March of 2021, same-day surgery with six operating rooms along with full radiology and laboratory services. The IS environment includes over 1200 new computers, 700 printers, state-of-the-art video conferencing technology, as well as standardized up-to-date hardware throughout the entire outpatient medical office building. More than 18 practices will occupy the facility, with specialized cancer service lines of business, including Radiation Oncology treatment and a new 24 patient infusion environment for our guests. Technology additions for this site also include new telecommunications systems, updated site wireless systems, and a distributed antenna system to increase cell coverage strength for our guests and staff. An additional convenience for our guests and staff is a new 1500 parking space garage adjacent to the medical office building including plans for electric charging stations on each parking deck. 52
PENN MEDICINE DIGITAL FOOTPRINT EXPANDING THE LANDSCAPE - A BIRD’S EYE VIEW
131 REAL ESTATE DESIGN AND CONSTRUCTION (REDC) AND FACILITY PROJECTS WERE COMPLETED IN FY19/20
IMPACTS
REDC & FACILITY PROJECTS BY TYPE
IMPROVEMENT IN PATIENT ACCESS EXPANDED PATIENT SERVICES IMPROVEMENT IN PROVIDER EFFICIENCY WITHIN SOME SPECIALTIES IMPROVED PATIENT TIME SAVINGS/CONVENIENCE OVERALL PATIENT SATISFACTION IMPROVEMENT
PPMG* PRACTICES GREW
73 15 HOSPITALS CORPORATE LOCATIONS 43 MULTI-SPECIALTY OUTPATIENT (MSP)
INCREASED PHYSICAL REAL ESTATE
5 PRACTICES to 16 FY18 to FY20 CPUP* PRACTICES GREW
TELEMEDICINE EXPANDED EXPONENTIALLY
IN PROJECTS FROM FY19/20 OVER FY17/18
42 PRACTICES to 71 FY18 to FY20
Encounters exploded from 500 monthly (pre-COVID-19) to 5,000 daily in April 2020
REDC & FACILITY PROJECTS BY PHYSICAL LOCATIONS
PENNSYLVANIA
13 1500 MARKET ST. » 31 HUP » »2 3930 CHESTNUT ST. »1 3624 MARKET ST. »1 CHESTNUT HILL AVE »1 51 N39TH ST. SHEIE
»2 4040 MARKET ST. »3 3737 MARKET ST. »2 3600 CCB »2 EXTON, PA »1 KING OF PRUSSIA »1 3535 MARKET ST.
» PAH » PPMC 11 CCH » 15 » PCAM »1 3701 MARKET ST. »1 800 WALNUT ST. 17
14
NEW JERSEY
»6 CHERRY HILL, NJ »3 VORHEES, NJ
2 SOMERS POINT, NJ » »1 WOODBERRY, NJ
REDC & FACILITY PROJECTS BY PHYSICAL LOCATIONS
54 18 TECHNOLOGY EXPANSIONS REFRESH
21 30 RENOVATIONS MOVES
*PPMG – Penn Physicians Medical Group | *CPUP - Clinical Practices of the University of Pennsylvania
9 CORPORATE SUPPORT
PERELMAN SCHOOL OF MEDICINE PLANNING
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RUNNING THE BUSINESS
Enterprise-wide Staff Badging Streamlines Staff Access Integration of the enterprise-wide staff identification and access card badging system into Penn Medicine’s human resource management system has provided our organization with the ability to accurately track and associate all records to an individual employee.
All previous badging systems were upgraded and consolidated into a singular enterprise solution. As a result, we:
» Eliminated duplicative activities and streamlined transparent access control processes » Ensured that no badge could be generated without a personnel record in the system » Strengthened the health system’s susceptibility to potential hacking » Created a multi-tech access badge for the continuity of current state access, future state expansion and downstream system integration » Increased onboarding process efficiencies » Increased building security » Increased the overall health and stability of the badging system » Allowed staff to work and take on shifts anywhere in the enterprise
Chester County Hospital Migrates to Enterprise System for Employee Badging The badging system for Chester County Hospital employees was upgraded and consolidated into the growing enterprise solution since joining the Penn Medicine family. As a standalone system, CCH doors and badges were not interoperable with the doors and badges throughout the rest of the health system. It was also harder to manage the use of badges on third party systems like time clocks, parking, cafeteria purchases, supply cabinets, etc. Employees required two badges if they needed access to these resources in each setting. The standalone system was also more expensive as it required separate hardware and support processes. From a business perspective, having multiple instances of an application at different entities is inefficient and makes it harder to centralize, manage, and support the business functionality across the entire enterprise. Once the system was upgraded and merged into the main system, employees were rebadged with the enterprise badge format. Now, most Penn Medicine staff have a single badge that can be used across all sites for the associated functions. Security administration is standardized, and data integrity has been improved. Also, support costs have been reduced from consolidating financial and data management - leveraging the combined enterprise for better pricing across all entities. The centralized approach also provides deeper and broader functional and technical support enterprise wide. 54
Enterprise-wide Employee Time & Attendance System Extends to Chester County Hospital Chester County Hospital’s (CCH) implementation of the staff time and attendance system completed the alignment of processes, procedures, and practices across the Penn Medicine network. » Over 65 time clocks were installed throughout CCH and its satellite sites, allowing easy access for employees. » Educator led training and e-learning modules were made available to staff members to familiarize users with the system and new processes. » Full system alignment affords clinical staff with the opportunity to seamlessly transfer their skills to work at any location within the network. » Managers gained more responsibility and oversight of employee schedules. » Payroll proved to be more efficient and time off was captured more precisely.
Chester County Hospital’s Outpatient Pharmacy Management System Migrates to the Enterprise The outpatient pharmacy system at Chester County Hospital was migrated to the enterprise pharmacy management system to standardize interoperability with the downtown pharmacies. In addition, the system was aligned with Penn Medicine’s business management application to reorganize and maintain patient records already in the system. The implementation of this system has improved the employee payroll deduction process by giving the organization the ability to integrate with our Lawson payroll system to improve the automation of employee payroll deductions for Outpatient Pharmacy purchases.
PennforPeople Moves Business Platform to the Cloud PennforPeople is a 5+ year program to move Penn Medicine from our current business application platform to the next generation platform. Our initial phases will focus on Human Capital Management, referred to as PennforPeople. This initiative brings about exciting innovative and robust functionality, that will continue to evolve throughout the years. Leveraging all the benefits that a cloud-based solution offers, we will be able to streamline our processes, maximize the value of our data, and offer significantly improved functionality and capabilities. As we have now migrated our core HR functionality, future Pennfor phases may include: » Continued consolidation of third-party HR systems » Talent Management, comprised of Talent Acquisition, Transition Management, Performance and Goals » Merge of Lancaster General business platform and modules onto Pennfor » Migration of Finance, Supply Chain and Payroll modules » Implementation of future modules for workforce management and learning management Benefits resulting from this transition: » A state-of-the-art human capital management system on a unified platform that allows for robust automation and eliminates many paper-based processes » A single platform for HR, Finance and Supply Chain that leverages a single database for seamless integration of data; eliminates the need for many of our custom interfaces to other systems » Eliminate manual and tedious paper-based processes which saves time, increases efficiencies and reduces errors » A single data repository which includes a robust set of delivered reports and a new advanced analytics tool makes access to critical data easier, reliable, and accurate to manage » Affords access to a broader set of modules that are feature rich and more flexible » This multi-tenant cloud-based solution provides an efficient approach in managing upgrades and gives us a high availability/reliability solution. 55
Enhancements Add Payment Security for Penn Medicine and Those We Serve Software Upgrade Allows EMV Chip Credit Card Transactions, added Security, PCI System Compliance
Penn Medicine’s secure payment processing software was upgraded to allow EMV (chip) credit card transactions at all EHR point of service locations throughout the healthcare system. A phased approached was used to rollout the upgrade across the enterprise over a three-month period. The upgrade involved a two-step process: software updates on the workstation and firmware updates on the device. Onsite tech staff resources were deployed to all impacted locations to provide support and ensure that all in-scope devices were upgraded appropriately. As a result of the upgrade, Penn Medicine validated credit card devices and a secure, PCI compliant payment processing system that protects transactions using multilayered security including point-to-point encryption (P2PE) and tokenization.
The Low Touch Employee Experience is Enhanced at PaH and CCH Food Service Sites
To allow for contactless processing of credit card transactions at food service locations associated with Pennsylvania and Chester County hospitals the point of sale (POS) terminal software and credit card devices were upgraded to meet EMV chip credit card compliance standards. Contactless credit card processing was enabled at Chester County Hospital’s main cafeteria, the Fern Hill Café and The Bistro, in addition to two Pennsylvania Hospital’s sites, the main cafeteria and the Farm Journal Coffee cart. The following benefits resulted from this project:
Leveraged a single virtual server for both entities Upgrades adhered to PCI software and terminal compliance standards Avoided the risks associated with end of life support for the previous POS systems Increased the overall health, security and stability of the new POS systems Provided staff contactless processing at all food service locations within each hospital system 56
Web Application Firewall Performs Proactive Security Monitoring The Penn Medicine community relies on a number of Internet facing websites and services. Included are employee portals, business focused data sharing portals, patient portals, and more. These services are essential for our community as important data resources and help to drive patient care initiatives, but they are also seen as data rich targets by those who have malicious intents. As a proactive measure to protect these Penn Medicine internet resources, Information Security has implemented a Web Application Firewall (WAF) that sits between the general internet and our internet exposed resources. This WAF automatically examines all inbound and outbound traffic for indicators of malicious activity and blocks those attempts. In addition, the WAF also is tied into a global monitoring network that flags who is up to “no good” and prevents them from even trying to connect to our sensitive resources. The results? Our websites and customers are kept secure!
Data Loss Prevention Program Keeps Sensitive Files Safe While Enabling the Business USB or “thumb drive” devices pose a significant risk to healthcare organizations as they carry the ability to contain unencrypted protected health information (PHI). Therefore, they need to be vigilantly managed to prevent the loss of sensitive data. Information Security implemented technology across the health system to filter PHI and other sensitive data in order to reduce the risk associated with lost or stolen USB devices. The goal was to selectively filter and block only sensitive data, thus ensuring a risk reduction related to lost or stolen PHI while enabling the business. Over 20,000 files have been blocked from being stored onto an unencrypted USB drive. Information Security uses the data from the solution to reach out to users who have been blocked as an opportunity to educate and raise awareness to the risks associated with their data management practices.
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Business Continuity Preparedness for EHR Downtime Penn Medicine developed a comprehensive business continuity process (BCA) to keep the electronic health record up and running in the event of an unplanned technology outage. Our application teams perform a full failover test biannually to ensure the integrity of the backup environment and that the system works correctly in the event of needing to use this process. To date, the teams involved in this process ran 7 EHR Disaster Recovery tests. Also, over 200 BCA devices were reviewed, tested, and vetted through our enterprise wide BCA test. In addition, 1,200 clinical departments were reviewed and linked to the correct BCA reports and devices for their locations. Representatives completed an education event with enterprise hospital operations this year to review what BCA is, the options available during outages, and how to use BCA devices correctly. Business Continuity Support is a Continuous Process BCA device monitoring occurs daily. The operations team works directly with application teams on any issues that arise. A quarterly BCA device test also ensures that devices are checked regularly. The backup solution provides the following benefits: » Planned downtime offers users to move to a “read only” version of the EHR. » Unplanned outages are addressed with designated BCA devices containing special software, localized printing, and power capabilities. » BCA devices receive feeds of key clinical, scheduling, and department specific patient information to continue to support care for patients. » “Hot failover” capability exists for extended unplanned downtime at our primary data center. » Housed in a physically separated data center, this redundant EHR platform can be used while enabling fail over of EPIC application services to the alternate site. » Working in the redundant environment is seamless to the user since it replicates our primary EHR environment.
Information Risk Management Serves to Protect Penn Medicine continuously evaluates its security program to incorporate new tools and technologies that assist our experts in assessing and securing the environment against security threats. Our team sets this cadence by using a simple business question to guide their continuous improvement initiatives toward risk management, “What are our top information security risks and how do we approach them?” A new information security program that we have implemented is a governance, risk, and compliance (GRC) solution called Penn Medicine Information Risk Management (Penn IRM). The benefits of implementing this program and process are: » Use of real-time dashboards for assessments, findings, and security exception management » Automated emails that are disseminated according to the stage and status of a security risk assessment » The identification of findings which includes the engagement of a finding owner who is accountable for a remediation plan and subsequent updates » Providing any employee with the ability to request a security risk assessment through our intranet site 58
Advanced Threat Protection Keeps Penn Medicine’s Data Secure Securing our servers and technology endpoints (like PCs) from malware and other malicious threats was paramount due to increasingly complex security threats, such as ransomware. While attempting to prevent a threat as the first line of defense, the ability to have swift identification of malware was essential to timely incident response and eradication. Information Security sought advanced tools to manage against relentless attackers, protect information assets, and to provide detailed historical threat data to assist in remediation and containment in the event of an incident.
An advanced threat protection and endpoint monitoring tool was selected and implemented across the health system, thus aligning the Penn Medicine environment to one centrally managed and monitored solution. Penn Medicine is now operating on a single antivirus solution with the extra layer of advanced threat protection to give deeper insight and awareness around realized threats. This has reduced complexity and increased response time as security operations is able to establish a response playbook that functions for the entire environment.
Strengthening Security with User Education The Information Security team made a concerted effort and allocated budget in strengthening user security awareness by taking a multi-pronged approach. While the team has had a dedicated employee and subject-matter expert tending to security awareness and training, it is not a one-man effort. All members of the team have spent a portion of their time dedicated to security awareness. Through simulated phishing exercises, monthly security newsletters, proprietary just-in-time awareness technologies, and executive support, Information Security at Penn Medicine has been successful at building a culture that is highly interested and willing to protect the business while they carry out their day to day operations. This has been done through a pragmatic approach to training, plus intuitive and convenient ways of reporting suspicion and/or incidents. At Penn Medicine, Information Security truly is everyone’s responsibility.
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Security Operations Center (SOC) Monitoring and Support Penn Medicine recognizes that protecting data is a job to be performed 24x7x365. While many business roles carry “traditional” working hours, security monitoring coverage is needed as an around the clock function, much like hospital care that is always ongoing. Leveraging industry best practices, the Information Security team evaluated providers of managed security services, with a specialty in security operations, to determine if this model could support Penn Medicine for overnight and weekends shifts in the Security Operations Center. Our detailed analysis revealed that establishing a strategic partnership with a managed services provider could provide the required depth of security operations monitoring while also delivering expertise and enhanced threat intelligence to the Security Operations Center team. The Security Operations Center has benefited from the 24x7x365 monitoring and support services which has resulted in the timely identification and remediation of information security incidents.
Early Detection Security Protection Hardware Keeps Malicious Attacks Away Penn Medicine implemented a new system that increases visibility and proactive detection of malicious activity before attempted network intrusion occurs. The technology mimics a production system and serves as an early detection. This hardware aims to lure hackers into real looking targets and trap them before they can breach the network. The software token resembles a URL link and detects when someone clicks on it, shares it, or interacts with it in any other way. Tokens are deployed to key data network shares, adding an additional layer of protection on the internal network to detect unproved access to data. This technology has improved security surveillance through increased visibility and proactive detection of malicious activity before potential harm is targeted at the Penn Medicine environment.
Princeton Storage Upgrade Improves Technology Performance Penn Medicine Princeton Healthcare’s primary data-storage platform was nearing end-of-life. Continuing to operate the platform would have been expensive and risky due to limited availability of components and updates. Without newer, up to date technology, large database backups also took long to complete. Since the adoption of the health system’s EHR, and the subsequent sunset of several legacy applications, the performance and space requirements of the storage array changed. This presented an opportunity to update the environment for optimal performance while improving overall reliability and reducing total cost of ownership. The IS team worked closely with the vendor to review several possible upgrade paths and selected a product that was able to meet the performance requirements of production applications while providing for lower-cost online archive storage for legacy applications. Interoperability with the existing platform was a key requirement in order to seamlessly move the data with minimal downtime. The new storage array was loaded with 96 terabytes of data and most of the applications required no downtime as the migration was done. The upgrade improved applications performance while several end-of-life products were consolidated into a modern platform. Benefits were substantial in transitioning to this more efficient operation with the new platform. Also, the total cost of implementation and was much less compared to costs associated with the older platform. 60
Enhanced Connectedness at Work with Virtual Team Collaboration Platform With a growing remote workforce, the demand for unified collaboration tools gained traction as Information Services took another important step within Penn Medicine’s digital transformation. Our technology team and business partners architected the new platform which was delivered at a time when it was needed most. The global pandemic, which struck in early 2020, emphasized the need for online engagement, as much of our work force shifted to a remote setting for administrative business functions. The technology was fundamental in supporting our ability to communicate and stay connected. Since launching, we realized many benefits from adapting the way we work by providing the technical integration among our colleagues. Many features enhanced existing workflows by streamlining processes and enabled our workforce to further pursue the mission of our hospitals and research community. Core components that employees have been taking advantage of includes: » Online video calling and screen sharing » Creation of groups and teams for meetings and conversations » Chat functionality » Document sharing » Audio conferencing » Application integration
Mobile Device Management Intranet Site With over twenty-six thousand managed mobile devices and forty mobile applications available for download to various Penn Medicine staff through the company’s portal, support demands have increased to aid people in using the technologies. With a 24/7/365 hospital staffing model, a self-service informational resource was needed to supplement our service desk, end-user support, and platform engineering staff. Based on ticket data and usage feedback, the logical solution was to create an intranet site with frequently asked questions and documentation designed to assist the user any time of the day or evening. Our mobile device management team developed an intranet site to provide a single, online resource for users and their support needs. Users have now been additionally helped with available documentation on how to self-resolve common issues with their mobile devices.
Per-App VPN Helps Deliver Care On-The-Go Caregivers have often sought access to mobile applications to view patient data and coordinate patient care while on the go. The problem has been that many applications were only available while users were connected to the internal health system network, generally in the clinical setting. We were able to meet this kind of need for staff working off site (on-call) to connect to necessary mobile applications by delivering access to specific apps using a VPN connection. By using a “per-app” VPN, we have enabled Penn Medicine-managed, trusted devices to access specific internal resources. With such a positive response, we have continued to expand access to identified apps. Penn Medicine providers and staff have been benefitting from greater access to critical applications through their Penn Medicine-managed mobile device to treat patients and serve the Penn Medicine community.
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Tapping a Badge Saves Time Logging into Systems Tap and Go functionality enhances the clinician experience by providing an expedient and automated way to securely log into the Penn Medicine Healthcare network, and PennChart EHR simultaneously without having to key in usernames and passwords. This solution enables providers to use their Penn Medicine employee badge to tap into a small device next to the monitor of a pc in a patient exam room, authenticating the clinician and providing them with fast access to desktops that “follow” the care provider as they move from patient to patient around a facility. The application also maintains the state of a user’s system and applications as they change locations and devices. No matter where they move within a facility, using the badge to tap in and out enables them to pick up where they left off, a feature that offers tremendous time savings. IS staff worked off-hours to reimage all PCs in every ambulatory practice across the healthcare system. All pcs were reimaged with a SCD (Standard Clinical Desktop) image that would essentially secure the PC and introduce new behaviors such as timing out the screen. A test computer was installed at each practice that had Tap n’ Go functionality; allowing the staff the opportunity to train and learn the new procedures. By eliminating the need to repeatedly type usernames and passwords, Tap and Go allows providers to quickly and securely access clinical and administrative applications which streamlines clinical workflows and drives PennChart fluency. It also increases security and makes it easier for staff to maintain patient data confidentiality. Above all, Tap and Go is valuable in time savings and ease of access allow clinics more direct time with patients, hence enhancing the patient experience. The IS team deployed the sign on technology to the devices across 19 departments, more than 22 locations, improving the user experience for 1500 ambulatory practitioners. Also, expansion of the single sign on technology makes the user interface more secure and easy to use. The benefit that we have delivered in streamlining clinical workflows means that providers have more time to spend caring for patients.
Adoption of Cloud Services Enhances Operations and Reduces Expense Penn Medicine has outsourced our data center, server administration and backup services since 2013. With the intersection of maturing Cloud services and increasing annual outsourcing costs, it made more sense to bring infrastructure services back to our organization and leverage the benefits it had to offer. With this shift, the Infrastructure Services team began to design and manage Cloud technology; seizing the opportunity to standardize vendors, provide consolidated contracts for maintenance and support, and also realize significant reductions in operating expense. The infrastructure team performed technology research, candidate selection, system design and feasibility assessments to reduce our physical infrastructure and deliver the ability to scale for growth. Penn Medicine’s Philadelphia Tek Park (PTP) data center was built to house our physical assets. In the fall of 2019; migration, workload insourcing, and new system deployments were under way. On average, 12 servers were migrated, with another 12 new servers built each month. This work resulted in an ongoing operational expense reduction and cost avoidance for outsourced infrastructure expansion. The five-year plan estimated total savings at $3.8MM. 62
Keeping the Enterprise Connected Through Cellular Service Cellular phone services often fail in buildings due to the inability of the carrier signal to reach extensive lengths within a large facility. As cellular devices are a key tool used by both caregivers and patients, it is critical that these mobile devices function within any location at Penn Medicine. Understanding the importance of cellular communications and its value to both clinicians and patients, Penn Medicine adopted the deployment of Private Distributed Antenna Systems (DAS) to allow for the propagation of the carrier signal within the confines of a building structure; ensuring continued cell phone operation. In the past 24 months, DAS platforms have been successfully deployed at our corporate services business center, Chester County Hospital, Radnor, Lancaster General Health and several smaller practice locations. By taking this approach, an additional 2.1 million square feet of carrier coverage has been added. Since the adoption of this strategy, there has been a total of 7.1 million square feet of coverage deployed throughout the health system. This strategy started in 2014 and has greatly improved cellular performance ensuring that the most critical calls are completed while at Penn Medicine.
Network Access Control and Segmentation Enhances Security Measures Network security is a major area of focus across the healthcare industry. Providers recognize that the costs of a security breach can quickly run into the millions of dollars and cause need for fastidious attention to resolve. Penn Medicine is vigilant to protect our patients’ healthcare data. Although previous network designs put in place years ago restricted the outside perimeter while maintaining open inside access, that no longer meets today’s security standards for protective controls. We continue to innovate on our security strategy, maintaining a stride on the foreground of needed measures to keep our patient data secure.
Penn Medicine now runs on a fundamentally redesigned network, using network access control (NAC). Every device connecting to the network is profiled and access is granted that is appropriate to the device and user of that device. Importantly, this is performed automatically as devices move across the network. NAC was piloted in the past year at our corporate services business facility and at Chester County Hospital. This technology is part of all new construction design projects and is now implemented across the entire network. NAC is a major step forward toward improving information security, providing visibility into every device connecting to the network. It presents a more layered approach, where network access is granted and is based on a set of policies which can rapidly evolve depending on needs. As an added benefit, we anticipated and saw that NAC is the most optimal way of supporting the explosion in Internet of Things while maintaining high security standards. 63
Penn Medicine Overhauls Networking to Advance Optimal Connectivity through Wireless LAN (WLAN) The use of wireless networking (WLAN) has grown exponentially - becoming a mission critical service from what was once previously considered to be an added convenience. Six years ago, we began to pursue a multi-year program to overhaul what was previously established for wireless networking (WLAN), in order to optimize connectivity at Penn Medicine. The project team took a clean slate approach; modeling radio coverage across seven million square feet of building space and installing six thousand WLAN access points along with almost five hundred miles of cabling. New management systems were also installed to better analyze performance. As a result, the performance has improved dramatically. Many mission critical services have been moved over to the WLAN system including patient telemetry, asset and temperature tracking, and door locks, to name a few examples. Taking this new approach to network connectivity has resulted in significant cost savings in many cases. Our Guest WLAN performance has also directly improved our patient experience. Lastly, the new system has enabled a wealth of Internet of Things technologies, including such services as language translation tablets and telemedicine services used for COVID-19 response.
Chester County Hospital Gains Voice Over IP (VOIP) Telecommunications System The telecommunications system at Chester County Hospital (CCH) was antiquated and had limited capabilities. Based on the age of the equipment, and the platform lacking redundancy, it was an opportune time to upgrade the system and prevent service impacts to the institution. In December 2019 the existing telecommunications platform was migrated onto the Penn Voice over IP (VoIP) Enterprise. This effort encompassed the installation of a new core telecommunications platform and the placement of approximately 2,000 VoIP telephones at the main hospital and ten ancillary locations in the surrounding region. To minimize disruption, the project was coordinated so that all locations were migrated at the same time with only 5 minutes of enterprise downtime from the old to the new system. Today, the telecommunications platform serving CCH is state of the art in both its feature sets and platform redundancy. As a result of this initiative, business processes surrounding telephony technologies were evaluated and improved upon, enhancing the patient experience. From a business continuity standpoint, the telecommunications platform now in place is geographically redundant, which greatly improves platform resilience and availability. Lastly, through new features available, the campus benefits with a greater range of flexibility in how the telephone can be used in the delivery of excellent patient care. 64
Thermographic Cameras and Employee Temperature Screening
As a result of the COVID-19 pandemic and the need to provide a safe healthcare environment for patients and personnel, daily temperature screening was mandated for all employees prior to admittance at Penn Medicine facilities. Initially, this process was performed by multiple clinicians at entry points using handheld temperature scanners. Several procedural and technological challenges were quickly identified as we adopted the new procedure. Employees were queuing at entrances as temperature screening was performed one employee at a time. Also, the number of clinicians required to perform screening was challenging. Lastly, there was inconsistent accuracy of the handheld temperature devices.
An opportunity was sought to improve upon the screening process. Penn Medicine identified technology which would improve upon all recognized challenges. A pilot was established which focused on thermographic camera solutions. Thermographic cameras allow quick temperature screening of multiple individuals (mass screening) while walking, at normal pace, through the entrance to a facility. With the selected thermographic camera solution in place, the platform was able to detect upwards of sixteen employees simultaneously providing real-time temperature readings. For locations with less employee traffic, such as a practice, a smaller tablet sized solution using the same thermographic technologies was deployed. Several locations received the pilot technology and improvements were quickly realized. With the mass screening technology in place, clinical staffing required to perform employee temperature screening was initially reduced by 60%, which at a second test location recognized an 80% reduction. Employee queuing was no longer an issue. Personnel were able to enter and proceed at a natural pace while the platform actively measured their body temperature and accuracy of the technology provided the consistency sought. Several locations have embedded this technology into their normal operations and continued success has been established, ensuring that we do all we can to provide upon a safe environment for everyone.
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INFORMATION SERVICES
DEPARTMENT PROGRAMS An atmosphere of solidarity is fostered where our employees may attain professional growth, continual learning and personal enrichment while enjoying what they do. Programs such as: Employee Enrichment, We Care for Community Activities, Lunch and Learn are examples of the building blocks that create a supportive atmosphere among our colleagues to network and participate in initiatives which enhance us as individuals and as an IS community.
INFORMATION SERVICES SOCIAL COUNCIL (ISSC)
The Information Services Social Council (ISSC) connects colleagues, friends and family together in a variety of social environments, beyond the workplace. Typical ISSC events include social hours, and friendly in-office or virtual competitions. The committee is an important part of bringing staff together, especially in a time where we are working remotely. Each activity creates memories and strengthens relationships to contribute to our strong culture of collaboration.
ACTIVITIES HAVE INCLUDED: » PUMPKIN CARVING » VIRTUAL SCAVENGER HUNT » PODCAST CLUB » ACTIVE COMMITTEE- RUNNING, BIKING » VIRTUAL HOLIDAY PARTY
WE CARE
» PJS FOR CHOP PATIENTS » ADOPT A FAMILY FOR THE HOLIDAYS » MLK SERVICE DAY » YOUTH DEVELOPMENT
COMMUNITY ACTIVITY REWARDS EVERYONE
We Care was developed to harness the philanthropic spirit of our IS team members to support a variety of the surrounding region’s community needs. Since 2010, the program has grown exponentially. Colleagues from Information Services volunteer to participate in or contribute toward a broad range of charitable initiatives. Employees gather in a teamwork atmosphere, striving to make a difference in our communities. In 2019 - 2020, the We Care program provided a variety of philanthropic donations, school supplies, gifts for families in need during the holiday season and more. While these community activities support the needs of local organizations, we expanded our reach toward a global initiative in 2020. These efforts have brought benefits to those receiving support and heart-warming feelings among those giving and contributing their time.
IN FY2019 / 2020 ACTIVITIES FOR THE WE CARE PROGRAM (TOTAL RAISED $26,421.00):
$9,458
$10,429
$479
$1,600
$4,455
$300+ HATS
PHILABUNDANCE FOOD DRIVE BACK TO SCHOOL PROGRAM HOLIDAY ADOPT-A-FAMILY
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IS PENN MEDICINE HEART WALK CHOP 8 SOUTH HOLIDAY PAJAMAS BABY HAT CAMPAIGN FOR CHESTER COUNTY HOSPITAL
INFORMATION SERVICES FY 2019/2020
BY THE NUMBERS IS DEPARTMENT SUPPORTS
42,014 6,816 250 34,017 24,556 62,938 60 857 15,887,320
THE IS DEPARTMENT HAS OVER
DESKTOP COMPUTERS/LAPTOPS
VoIP TELEPHONES DEPLOYED
PROJECTS ACTIVE AT ANY GIVEN TIME
ACTIVE ACCESS POINTS
MANAGED MOBILE DEVICES
CLINICAL ENGINEERING DEVICES
myPENNMEDICINE REMOTE SESSIONS
THE IS DEPARTMENT ACTIVATES AN AVERAGE OF
PROJECTS MONTHLY
About 40% of IS projects are complex enough to require a dedicated project manager from the Project Management Office.
SERVERS MANAGED
OPERATIONS PERFORMANCE BY THE NUMBERS
1.5 MILLION
1.4 BILLION
29 MILLION
248
5.2 MILLION
46,584
EMAILS INFORMATION SERVICES PROCESSES PER DAY
SECURITY LOGS REVIEWED PER DAY (SOC)
SPAM MESSAGES BLOCKED MONTHLY
EICU BEDS MONITORED
TWO-FACTOR AUTHENTICATIONS THIS YEAR
MYPENNMEDICINE
CALLS TO SERVICE DESK
13,000
DAILY CONCURRENT REMOTE VPN CONNECTIONS (INCREASED DURING PANDEMIC)
RESEARCH
6,316
TOTAL STUDIES
161,381
TOTAL SUBJECTS
CLINICAL TRIAL MANAGEMENT SYSTEM
578
ACTIVE ACCOUNTS
LIMS - NUMBER OF RESEARCH SAMPLES
754,187
SOM CLIENT SERVICES GROUP (CSG)
DATA AND ANALYTICS
3,469
6 MILLION+
1,879
29 MILLION+
PMACS SUPPORTED DESKTOPS
PMACS SUPPORTED LAPTOPS
307
OTHER NON-PRINTER DEVICES
873
PMACS PRINTERS
21,268
TOTAL RESOLVED TICKETS
PENNCHART CARE EVERYWHERE RECORDS EXCHANGED WITH OTHER INSTITUTIONS
ADT TRANSACTIONS SENT TO HSX
(OUR HEALTH SHARE EXCHANGED)
300 MILLION
INTERFACE TRANSACTIONS PROCESSED PER MONTH
3.5 MILLION+
PATIENT RECORDS STORED IN PENN GENOTYPIC & PHENOTYPIC DATABASE (HOUSED ON OUR MICROSOFT AZURE SECURE CLOUD DATA LAKE)
8,000+
REPORTS & DASHBOARDS SUPPORTED BY THE DATA ANALYTICS CENTER (DAC)
300
DAC EPORTS & DASHBOARD REQUESTS PER MONTH *Numbers reported in the last 12-month period ending June 2020 or as of June 2020.
AWARDS
For additional information regarding these awards and more please visit: https://www.pennmedicine.org/information-services/about-us/awards-accolades Awards on this page are not in the order they where recieved by Penn Medicine Information Services.
IN THE
NEWS MEDIA
MIKE RESTUCCIA: HEALTH SYSTEM CIO
“ALL ABOUT TEAM”: CIO MICHAEL RESTUCCIA ON HOW INSOURCING IS HELPED TRANSFORM PENN MEDICINE
https://bit.ly/2Tta9r2
ANNA SCHOENBAUM: HIMSS INFORMATICS
NURSING INFORMATICS KEY ROLE IN DEFINING CLINICAL WORKFLOW, INCREASING EFFICIENCY AND IMPROVING QUALITY
https://bit.ly/3mhfMoO
JIM BEINLICH: THE WALL STREET JOURNAL
HOSPITALS GIVE TECH GIANTS ACCESS TO DETAILED MEDICAL RECORDS
https://on.wsj.com/34uAXxo
JOHN DONOHUE AND LIZ DELEENER: MEDICAL DAILY MEET THE ORACLES OF VIRTUAL CARE
https://bit.ly/35DvGD1
CHRISTINE VANZANDBERGEN: JAMA CARDIOLOGY
EFFECT OF PASSIVE CHOICE AND ACTIVE CHOICE INTERVENTIONS IN THE ELECTRONIC HEALTH RECORD TO CARDIOLOGISTS ON STATIN PRESCRIBING - A CLUSTER RANDOMIZED CLINICAL TRIAL
https://bit.ly/3jq1U9S
DAN COSTANTINO: HEALTHCARE IT NEWS
HOW TO CREATE AND MAINTAIN A PRODUCTIVE, SECURE HOME WORK ENVIRONMENT
https://bit.ly/3kw8JYF
SETH FOGIE: BLACK HAT USA 2020
UNIVERSITIES EXPLORE A PATH FOR A SAFE AND SECURE HEALTHCARE ECOSYSTEM
https://bit.ly/35ERBd4
KASH PATEL: KDD 2020
EMERGING DATA SCIENCE CHALLENGES IN THE ERA OF COVID-19
https://bit.ly/3dVH3Kw
SHARON CIVA: THE PHILADELPHIA INQUIRER
SHE CREATES 100 GET-WELL CARDS A MONTH FOR CANCER PATIENTS SHE DOESN’T EVEN KNOW
https://bit.ly/3ourCOg
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GLOSSARY ACC Abramson Cancer Center
ED Emergency Department
ADC Automated dispensing cabinet
EHR Electronic Health Record
ADR Adenoma Detection Rate
EPCS Electronic prescribing of controlled substances
BCA Business Continuity Access
HIC Human Immunology Core
BCMA Barcode medication administration
HIPAA Health Insurance Portability and Accountability Act of 1996
CAFs Contract approval forms CBH Centers for Behavioral Health CCH Chester County Hospital CE Clinical Engineering CIO Chief Information Officer CMS Centers of Medicare and Medicaid Services COA Committee on Admissions CRU Clinical Research Unit DAC Data Analytics Center DAS Distributed Antenna System
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HiRPM High-Risk Patient Medications HUP Hospital of the University of Pennsylvania ICU Intensive Care Unit IDS Investigational Drug Services ISAAC Information Services Advisory Center IRM Information Risk Management IS Information Services ISBT International Society of Blood Transfusion IT Information Technology LCME Liaison Committee for Medical Education
LGH Lancaster General Hospital
PMO Project Management Office
LIMS Laboratory Information Management Systems
PMPH Penn Medicine Princeton Health
MPM myPennMedicine
POC Point of Care
NAC Network Access Control
POS Point of sale
OR Operating Room
PPMC Penn Presbyterian Medical Center
P2PE Point-to-point encryption
PPMG Penn Physician Medical Group
PACS Picture Archiving and Communication System
PSOM The Perelman School of Medicine
PaH Pennsylvania Hospital
RVUs Relative value units
PAMA Protecting Access to Medicare Act
SOC Security Operations Center
PCAM Perelman Center for Advanced Medicine
SCD Standard Clinical Desktop
PDS Penn Data Store (Clinical Data Warehouse)
Telecom Telecommunications
PHI Protected health information
UPHS University of Pennsylvania Health System, now known as Penn Medicine
PTP Philadelphia Tek Park PIC Penn Integrated Care PMACS Penn Medicine Academic Computing Services
VOIP Voice over IP Enterprise
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