UCSF Takes Giant Leap Toward Improved Patient Safety, Care With Electronic Health Records

UCSF nurse Elizabeth Dunn uses a bar code scanner to chart patient medication using the new APeX system, which creates a single electronic health record for every outpatient and inpatient at UCSF.

UCSF Medical Center has taken a major step forward in advancing patient safety and quality of care by implementing one of the most comprehensive electronic health records systems in the U.S.

The clinical enterprise-wide “go-live” this month marked the completion of an ambitious project, which began with signing a contract in March 2010 with Epic, the company providing the software. The first pilot using the new electronic health records system began in April 2011.

The roll out was essentially complete this month when everything — from inpatient clinical documentation and order entry by clinicians, to the emergency department, the Intensive Care Units, the operating rooms and anesthesia, to hospital registration, admissions, scheduling and professional billing — went live with the new system.

The state-of-the-art electronic system, known as Advancing Patient-Centered Excellence, or APeX, creates a single electronic health record for every outpatient and inpatient at UCSF. It transforms how UCSF providers and staff exchange information across all care settings and gives patients online access to their medical records.

Physician leaders Russ Cucina, left, and Seth Bokser speak to UCSF physicians and allied health staff at a training seminar for the new APeX electronic medical records system that went live this month throughout the medical center.

While other organizations have implemented electronic health records, few have the breadth of functionality that UCSF has deployed, and fewer still that have it on a single platform, which has advantages in usability, support, and reliability.

“This is the single most significant initiative we have ever undertaken at UCSF to improve the quality and safety of medical care we provide to our patients,” said Mark Laret, chief executive officer of UCSF Medical Center and UCSF Benioff Children's Hospital. "This month’s implementation was the culmination of the dedication and hard work of thousands of people at the medical center.”

Under the new system, health providers across all disciplines can access current medical records, electronically prescribe medications and track the continuity of care of ambulatory and hospitalized patients.

“APeX ensures secure access to more accurate patient information, which results in better clinical decisions, improved care, fewer medical errors, and lower costs,” said Michael Blum, MD, chief medical information officer and professor of medicine at UCSF Medical Center, who led the provider aspects of the implementation. “It has been a very large, complex undertaking and is absolutely a major milestone for UCSF.

“The payoff will be enormous for patients, providers, nurses and other allied health care staff, as APeX captures pretty much everything someone experiences when they seek care at UCSF. It is overhauling the way people do their jobs here and catapulting UCSF into the forefront of electronic health records,” Blum said.

UCSF medical students and residents are also benefiting from this investment. “By the time they graduate, UCSF students and residents will be experts in using APEX to deliver safe, effective, patient-centered care. This hands-on experience will allow them to be leaders in redesigning their practice environments to take advantage of all that electronic medical records can offer,” said Catherine Lucey, MD, vice dean for education in the UCSF School of Medicine.

The implementation of the system by June 2012 is part of UCSF Medical Center’s strategy to provide “patients with a world-class experience,” one of numerous goals identified in the University’s 2014-2015 plan.

Tracking Continuity of Care

The new electronic health records system will have a big impact on the way clinicians track patients, said Blum.

UCSF physician leaders, from left, Michael Blum, Andy Auerbach, Ellen Webber, Russ Cucina and Seth Bokser provided the training necessary for health care professionals to use the new electronic medical records system, which is expected will improve patient safety and quality of care.

“You have complete visibility into a patient’s journey through the clinics and the hospital. It’s all there on the chart for the caregivers to find and review. It’s a huge difference from paper charts spread across 165 clinics and throughout the hospital. I can easily see all the medications a patient is getting, all the lab results, all the vital signs, and all the care the nurses are delivering. It’s very easy to access from wherever I am.

“As such, the system allows providers to rapidly gather data, analyze it, and respond more quickly. You immediately have improvements in quality of care and safety,” Blum said. “When a provider enters a medication order, it’s completely legible, and for children the dose has been calculated based on their specific weight. The order instantly zips down to the pharmacy where it is scrutinized for safety and then gets dispensed to the patient much more rapidly. As a final check, the nurses use bar-code scanners when administering the medications to ensure that it is the right dose of the right medication going to the right patient at the right time.”

APeX will help patients manage and engage in their care as well. In fact, more than 25,500 patients have enrolled in the patient portal, UCSF MyChart, which gives patients access to their medical records and enables them to send non-urgent messages to doctors, nurses and office staff.

“The UCSF MyChart online portal was implemented in April 2011 and patients absolutely love it,” Blum said.

Ramesh Shivdasani, 66, a retired mechanical engineer and financial analyst who now tutors young people, started going to UCSF for all his health care needs in 1996.

“It’s definitely the best medical care I’ve ever received,” said the avid squash player. “The physicians are really into prevention. They spend a lot of time explaining a potential health problem and what I should do about it. Nobody rushes me out of there.”

Russ Cucina conducts a training seminar for health professionals as the new APeX electronic health records system rolls out at UCSF Medical Center.

Shivdasani has seen six general practitioners over the years, describing all as “outstanding,” along with two fellows who were being trained. He says MyChart is a “bonus” and he's become a huge fan of the patient portal.

“Now if I go in for blood work, I don’t have to carry any papers around because all the orders are in the system,” he said. “And I can look at my past medical history and email my doctors.”

Creating a New IT Foundation

The latest — and biggest — APeX rollout this month was the culmination of a process that began in December 2009. The implementation process gained speed when Pamela Hudson, executive director of clinical systems at the medical center and program director for APeX, came on board at UCSF in April 2010.

Design work started in earnest in July 2010. A pilot project in four ambulatory clinics was rolled out in April 2011. A robotic pharmacy and barcode medication administration followed, in a move to dramatically reduce medication errors. A video of UCSF's robotic pharmacy is posted online.

“Now we’ve pretty much replaced the foundation of all the technology the organization is using,” Hudson said.

It wasn’t easy. Designing and building the system throughout the clinical and billing areas was extensive due to the complexity of the clinical enterprise.

“We’ve conducted training for thousands of medical center and campus employees in the last 90 days,” Hudson said. “The project team at its height has had about 200 people dedicated to APeX.”

Blum commented that “through the use of sophisticated order sets, APeX allows us to standardize care based on clinical guidelines and the consensus of our clinical experts. Doing so decreased the variability in care delivery and improves quality and safety.”

Hudson, a former bedside nurse, points to another benefit.

“The system provides nurses and physicians with consolidated views of a patient’s vital signs over time for trend analysis. You can see someone’s blood pressure over the course of a day or an hour, and then overlay that with the medications you’re administering. You can see over time if the intervention you performed had the outcome you were looking for,” she said.

The optimization of APeX will continue for some time at UCSF, Blum said, but the biggest and most demanding part has been accomplished.

“This is a very comprehensive implementation,” he said. “Very few places have done as much as we have as quickly as we have. Typically, this extensive an implementation would have taken several more years to complete. Still, we have much more work to do in order to leverage the system and get the maximal benefits out of it. We have made a very large financial investment and put the organization through a huge amount of change. Now we are excited to see it pay off in support of our patient care, research, and teaching missions.”

Photos by Cindy Chew