Running head: QUADRAMED AND EPIC SYSTEMS ANALYSIS

QuadraMed and Epic Systems Analysis

Santa Winkler
Molloy College
NUR 543-01

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Abstract

This paper will analyze Quadradmed which is the information System utilized
at this authors hospital (Acme Medical Center). When QuadraMed was
founded in 1993, the vision was to create a system that would standardize
patients data collection and documentation. The hope was that this system
would increase accuracy while reducing the healthcare providers workload.
The QuardraMed system was implemented at Acme hospital in 2006.
Initially, the system was rejected by healthcare professionals, particularly
nurses. The impression at that time was that QuadraMed was just an
additional burden which added to their workday. Nurses felt that they were
not only expected to care for patients, but they also had to learn and
navigate through a new computer system. This was particularly true with
the workers who were computer novices. As staff worked with Quadramed,
they found that the system was user friendly. Documentation was legible and
standardized, particularly the order entry functions that was created for
Physicians / clinicians. However, nurses were faced with software and
hardware challenges.

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QUADRAMED SYSTEMS ANALYSIS

Acme Medical Center is a hospital located in a busy diverse area in
New York. The hospital offers comprehensive care which includes in-patient
and outpatient services. The mission statement states that it guarantee
equal access to health services for all new York City residents without regard
to an individuals race, color, national origin, religion, gender, age, disability,
alienage, citizen status, marital status or sexual orientation status, The
mission statement also refers to Equal Opportunity, stating Affirmative
Action and Equal Employment Opportunity considerations will be an integral
part of all the Corporations activities performed in the furtherance of our
mission and in meeting our health services. This organization mission
statement reflects the fact that they are in a diverse community and that
they want to ensure that all members of the community are welcome
regardless of their background or ability to pay.

This organization is also

concerned about their hiring practices. They want to ensure that all potential
applicants are given equal opportunity for employment.
Acme Medical Center is part of a large network of hospitals and is
affiliated with a major medical school. According to the hospitals website, in

2013 it had 293 beds, 334,230 outpatient visits, 99,670 Emergency Room
Visits and 14,362 discharges. The strategic vision for Acme hospital is
Continuous improvement of quality of care (www.nychhc.org). The
Administrators of Acme Medical Center hospital wants to accomplish this by
ensuring care provided to patients is safe, timely, efficient, effective and
patient centered. Furthermore, the
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institution wants to support staff and improve provider engagement.
Improvement of the patient experience is the main goal. In order for Acme
Medical Center to achieve their goals and uphold the mission statement, the
corporations visionary executive team introduced an electronic clinical
information system. This system was implemented to help the organization
obtain its goals. The understanding that health care is changing and that
were living in an advance technological era. That is what led the hospitals
executive team to introduce the QuadraMed system. This was a definite way
to improve quality of patient care while keeping patient safety first, and
improve staff / provider engagement.
The implementation of QuadraMed helped to standardize patient data
collection,
documentation, increased accuracy, and reduced healthcare provider
workload. During the initial stages of the QuadraMed implementation, novice
computer users experienced high levels of frustration. However the majority

of QuadraMed users voiced satisfaction and gratitude. The new information

system made patient care easier and safer. Clinicians were able to enter
orders from any computer in the hospital. This allowed nurses to quickly
and efficiently pick up written orders and administer medication in a safe and
timely manner. The Pharmacy staff were able to view and verify the
clinicians order and dispense medication via a computerized machine called
the Pyxis. The automated medication management system or (Pyxis) works
collaboratively with the QuadraMed system to provide additional safety
measures. Although the Pyxis provided alerts and reduced medication
loading errors, it did not eliminate the risk for medication and documentation
errors. Therefore barcode scanning was
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also implemented as an additional safety system feature. The Barcode
medication administration (BCMA) scanner works as an additional safety
feature of the QuadraMed
system. The QuadraMed BCMA process allows the nurse to scan the barcode
on a clients wrist / ID band, which ensures correct verification of patient
identification. The nurse must then scan the barcode on the medication,
which verifies the correct medication. Documentation is the last step of the
QuadraMed BCMA process. Documentation of medication administration is
recorded in the electronic medication administration record or (eMAR). The

multiple functions of the QuadraMed system works well when the systems
are running properly.
Although this system improved workflow and help to standardize
practices in the organization, Nurses still faced Challenges with QuadraMed.
Some of these challenges include information systems downtime, Pyxis
malfunctions during medication dispensing, barcodes missing on medications
and faded barcodes on patient identification bands that are unable to scan.
These are challenges that the intuitions administrators are working to
remedy.

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The QuadraMed system was implemented at Acme Medical Center to
improve documentation
and information sharing. The intended demographic for the Quadramend
system are nurses,
nurses assistant, physicians, physicians assistants, Respiratory therapist
and their assistants,

Occupational therapist, Physical therapist and their assistants, Pharmacist,

and Dieticians.
Nurses use the Quadramed for charting patient progress, reviewing
Physician orders, documenting patient vital signs, documenting medication
administration and medication refusals. Quadramed is also used in
conjunction with medication bar coding. The bar code feature is used to
enhance patient safety. Nurses are extremely busy and their workdays are
unpredictable. Any event can happen at any given minute. A nurses busy
day puts patients at risk for harm. Also, it opens the door for
miscommunication and false documentation. Nursing assistant use the
QuadraMed system for documentation of vital signs, intake and outputs, and
activities of daily living such as eating, bathing, ambulation, and toileting.
Physicians utilize QuadraMed to document orders, review other
providers progress notes, they interpret diagnostic test, and input referrals.
There is a special feature in the QuadraMed system that alerts clinicians of
out of range diagnostic results. Physician assistants (PA) practice medicine
under the supervision of a Physician.

PAs have the same QuadraMed

screens and access the physicians have. However, they are not authorized
to prescribe medication without the supervising physician authorization.
Pharmacists play a vital role in patient care. The QuadraMed system
assist with verifying clinician orders, identifying drug interactions, and
reconciliation of medications.

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QuadraMed and the pyxis interface. The pyxis is a medication or supply
dispensing machine that is conveniently located on each unit.
At Acme Medical Center Social Workers and Case managers do not
have access to Quadramed. When clinical information is needed for
insurance purposes or housing placement. Social Workers and case
managers obtain clinical information from nurses or from the patients
Doctor.
Respiratory, Physical, and Occupational Therapists have limited access
to the Quadramed system. These healthcare professionals work
collaboratively with a patients interdisciplinary team to provide patient
centered care. Therapists can only view referrals for consultation. Dieticians
play a pivotal role in patients recovery. The information system can only be
used to view patients diet orders and nutritional referrals.
Gap analysis
The QuadraMed electronic health systems was implemented to improve
patient care, decrease errors and improve workflow such as, documentation,
communication and user flexibility. At Acme Medical Center QuadraMed is
used in a variety of departments and the electronic system address each
departments specific needs. In psychiatry QuadraMed is partly used. The
electronic system differs from in-patient and the psychiatric emergency

department (ED). This is a major issue for many nurses. Last year there
were two medication errors that occurred as
a result of a nurse not being able to access the ED QuadraMed system. A
nurse was floated to the emergency department and the QuadraMed system
was differed from the system that was
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used on the inpatient unit. Needless to say that the nurse wasnt able to log
on to Quadramed. She had to contact the information technology technician
to assist her with transferring her login information to the ED QuadraMed
system. The entire process took approximately three hours. When the nurse
was finally able to log on to the ED Quadramed system. She noticed that
there were two stat medication orders was ordered two hours prior. Another
gap in the Quadramed system is the downtime feature. DART is the system
that is used at Acme medical Center. This particular system allows the nurse
to view standing orders. However, the nurses cannot document in the DART
system. Also, clinicians have to utilize paper order forms if they want to
prescribe something for a patient during a downtime. This is a challenge for
the nurses and the clinicians as well. The design of the DART software
system allow the nurses to conduct patient care, however, the basic function
of documentation is absent. Another major gap in the psychiatric
Quadramed system is the documentation of progress notes. Because there is
very limited documentation of progress notes in the system, in most cases

the Nurses are documenting the progress notes in the paper chart. This
information is usually only viewed by the Nurses that work on the floor and
those providers that have the time to sit down and read the chart. In most
cases the providers are viewing patient information online and using that
information to order treatments medications discharges admissions or
transfers. If a provider had any questions or concerns about the nurses
documentation he/she would have to call the floor directly and speak directly
to the Nurse. This is a waste of time and resources. If QuadraMed Had a
feature the nurses to write and comprehensive note within the system then
providers would have real time information on the patient that would help
them to make
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clinical decisions. This would be a great improvement in the continuity of
patient care overall as nursing documentation is used by many disciplines
such as social work and case management. Documentation online would
also solve any issues with legibility as all documentation would be clear. To
the nurse documentation is vital in healthcare.
Barcoding is another dilemma that needs to be remedied. Barcoding is an
ideal process when the functioning correctly. Nurses complain that the
scanner doesnt always work, the barcodes on the medication wrapping
cannot be scanned at times, and nurses often have trouble scanning the
barcode on the patients wristband. The barcodes are often faded which is a

barrier to medication administration. QuadraMed has a feature that allows

the nurse to override the system if not able to scan the bar code. This is a
good but time consuming feature. The nurse has to document why he or she
had to override the system.
The nurses of the psychiatry department want solutions to all of these
barriers that complicates their day and inhibit them from performing at their
highest level. As a result of these barriers work productivity decreases as
well as patient satisfaction.
At Acme Medical Center there is a medication committee that meets
monthly. During these sessions all complaints related to QuadraMed and
medication administration / dispensing are reviewed. The nurses on the
committee made some proposals on how to improve all of these issues that
were presented by their peers. The suggestions were as follows, Change the
QuadraMed system, upgrade the system, and purchase printers that are
specifically for printing barcode wristbands. Currently the printers being
used have multiple features such as
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prescription printer, laboratory label printer patient identification band
printer. All of these features causes the printer to be out of ink and
malfunction. The multipurpose printers are also extremely big and takes up

lots of space at the nurses station. Another suggestion was medication

wrappers should be inspected for faded barcodes.
The corporate executives made the decision to change the electronic
health system that is currently being used in the corporation. This year all
of the hospitals within the corporation will change from Quadramed to Epic
electronic health system. It would be reassuring to know that a corporation
executive board members heard the many complaints about Quadramed and
chose to upgrade the system to satisfy their employees, but that isnt the
case. The decision to change the electronic health system was propelled by
an irresistible incentive; money.
According to the Centers for Medicare and Medicaid services (CMS) hospitals
may be qualified for the meaningful use incentive. According to the CMS
website The Medicare and Medicaid Electronic Health Record (HER)
incentive programs provide financial incentives for the meaningful use of
certified EHR technology to improve patient care. To receive an incentive
payment, providers have to show that they are meaningfully using their EHR
by meeting thresholds for various objectives
Hospital have until 2016 to become compliant with meaningful use. This
government incentive is very important because it encourages hospitals to
become more advance and improve the care provided to patients.
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SYSTEMS ANALYSIS
Technologically which will improve patient satisfaction in the long term. The
meaningful use objectives is broken into stage I and stage II. One important
objective in stage I is that hospitals are required to provide patients with an
electronic copy of their medical record. This can include their prescribe
medications, test results and a list of procedures. Currently this is not being
done at Acme Medical Center. Currently patients must put in a request for a
copy of the medical records and there is a very long process in which the
patient must fill out a lengthy forms and wait until someone makes a paper
copy of the chart after their discharge. This process can very easily causes
delays in treatment and effects patient satisfaction. Stage II objectives gives
patient even greater access to their health information such as the ability to
view and download their health information online.
The new EPIC system is one of the best EHR systems on the market
and it will allow the hospital to meet both stage I and stage II objectives.
According to Wikipedia.org this system was founded in1979 by Ms. Judith R.
Faulkner in Madison, Wisconsin. The Epic EHR system is used by many
prestigious organizations such as John Hopkins Hospital and New Yorks
Mount Sinai Hospital. Epic EHR credibility is supported by its millions of
users and the research firm KLAS.
function much more efficiently. The

It will allow the hospitals employees to

QuadraMed system doesnt address all of the issues that were identified in
the gap analysis but Epic does. It will improve communication between
Nurses and Providers, it will allow staff to
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write customized progress notes as well as generic progress notes. This
software system will integrate with the current bar code scanning program
and will allow administration to run
reports which can track organizational efficiency. With the current
Quadramed system the staff in the IT department provides the support
online and through a telephone support line. With the implementation the
new software system the hospitals corporate office recruiters are in the
process of hiring training specialists that will help with not only the
implementation with this system but also as a support system who will
specifically provide support for Epic.
Currently, there is an Epic committee that consist of staff nurses,
nursing educators, information technologist, nurse inforamtisist, and other
members of the interdisciplinary team who serves as subject matter experts.
These individuals are from different departments from multiple hospital
within the organization. Their objective is to communicate the work flow of
their departments. The implementation of Epic is a multimillion dollar
project. The steering team members are motivated and engaged. The

implementation team member are getting certified by Epic to assist with the
fall 2015 Epic implementation.
The Epic electronic medical record system is scheduled to go live in
two sister hospitals. Acme Medical Center and Southside Hospital are the
pilot hospitals. The training process is rigorous. According to HHC
newsletter, at the end of 2014 85% of the programing process was
completed. The journey to Epic is an exciting one.
The Epic system will help to remedy the communication problem that nurses
faced with the QuadraMed electronic health record system. This new
software has a communication system
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that promote interaction among healthcare providers, providers and patients
(Mastrian and McGonigle, 2015). The Epic system has features that will
standardized the language
healthcare providers use to communicate. Nurses have will have the option
to develop care plans that are programed in the system or they can free text
a care. During one of the epic cohorts it was said that the majority of nurses
like the pre-programed care plan, as it reduces documentation time and
increase workflow.
The Epic electronic medical record system also has a core business
system that enhances administrative task within a healthcare organization

(Mastrin and McGonigle, 2015). This system feature allows administrators to

monitor resources, performance improvements, hospital acuity, patient flow
as far as admissions and discharges, and finance of the hospital.
The Epic system has an enhance order entry system that differs from
QuadraMed. With the Epic system the all healthcare providers will have
access to the electronic health records of patients they are caring for.
According to Wikipedia, There was an article in the New York Times that
interviewed providers who were complaining about not being able to share
patient information to non-Epic users. Epic charges a fee to share health
records with non-Epic users.
The Epic software gives patient the ability to access their medical
records, schedule appointments and view any test results. The system is
user friendly and engages the patient which will lead to better health
outcomes.

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The Hospital financial department that handles patient billing, will have
the resolute hospital billing tool on their epic screen. Which will help to
coordinate patient billing. This tool help to reduce payer denials and to
improve patient billing serves.

Overall, the electronic health system that Acme medical Center has is
not helping the employees or patient to improve services. The QuadraMEd
system has many good features that at one time help the organization to
meet its goals. However, currently new innovative technology has been
proven to assist the most prestigious hospitals to not only meet their goals
but exceed them.
Acme Medical Centers mission statement states that it guarantee
equal access to health services for all new York City residents without regard
to an individuals race, color, national origin, religion, gender, age, disability,
alienage, citizen status, marital status or sexual orientation status or ability
to pay. The CMS meaningful use incentive has given the corporation the
opportunity to incorporate a new electronic health record system that will
help healthcare workers of this institution to provide safe, quality care to
patients and their families. While maintaining the patients privacy and
security. Keeping in mind that the patient and the patient experience is what
matters. The patient is a person who is part of a community. Therefore, we
are not just treating one person. We are treating their community. The
implementation of Epic will help this organization meet its goal.

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References
Mastrian, K.G., McGonigle, Dee (2015). Nursing Informatics: And the Foundation of
Knowledge (3rd ed.) Burlington, MA: Jones & Bartlett Learning.
http://www.nyc.hhc.org
http://www.cms.gov/RegulationsandguidanGuidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html
http://www.epic.com/about-index.php
http://en.wikipedia.org/wiki/Epic_Systems

Tech view charting

Meds notes, consults, trac
board
Input vs, completion of ekg FS
Assign patients

In order to remedy the gaps in the Quardramed system the Informatics

Specialist would have to purpose

B. Gap Analysis where we are now and where do want to be. What are the limitations of
quadramed.
1. Current situation (briefly)
2. Desired situation
3. Priorities (list) for change
4. Possible solutions & growth opportunities
C. Physical Requirements (ex. space, environmental conditions, etc.)