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Building Powerchart Maternity from<br />

scratch<br />

<strong>Cayman</strong> <strong>Islands</strong> <strong>Hospital</strong><br />

March 2013


The <strong>Cayman</strong> <strong>Islands</strong>, are located in the western Caribbean about 150<br />

miles south of Cuba, 460 miles south of Miami, Florida, and 167 miles<br />

northwest of Jamaica.<br />

The total population count of the <strong>Cayman</strong> <strong>Islands</strong> was 55,456 in 2010.<br />

From this 50.5% are female and 49.5% are male.


The <strong>Cayman</strong> <strong>Islands</strong> Health Services Authority is the sole<br />

provider of healthcare services in the public system.<br />

It consist of the following facilities and services:<br />

• 104 – bed <strong>Cayman</strong> <strong>Islands</strong> <strong>Hospital</strong> on Grand <strong>Cayman</strong><br />

• 15 – bed Faith <strong>Hospital</strong> in <strong>Cayman</strong> Brac<br />

• 5 District Health Clinics in Grand <strong>Cayman</strong><br />

• 1 District Health Clinic in Little <strong>Cayman</strong><br />

• School Health Clinics


Antenatal Care<br />

Antenatal care is provided through the Women's Health Services. These<br />

clinics consist of combined care between the Obstetrician and Midwives.<br />

Antenatal care is also provided by private OB/GYN.<br />

The Maternity Unit<br />

• The Maternity Unit offers facilities for both low risk and high-risk<br />

mothers and babies. These services are comprised of antenatal care,<br />

labor and delivery, postnatal and neonatal care; including normal births,<br />

twin births, breech, vacuum, forceps and caesarean section deliveries.<br />

• The maternity unit is located on the ground floor of the main hospital<br />

building in the Health Service Complex has thirteen (13) beds for<br />

mothers and their new-born babies, one isolation room for a mother and<br />

baby, and three labor, delivery and recovery rooms.<br />

Delivery per annum<br />

In 2010 total delivery were 708 with average per month 59 and 2011<br />

total delivery 681 with average per month 57.


The <strong>Cayman</strong> <strong>Islands</strong> Health Services implemented Cerner<br />

Millennium in October 2003.<br />

<br />

Fourteen (14) applications were installed including<br />

Enterprise Management (PM), Powerchart, PathNet,<br />

RadNet, and ProFit.


Objective to automate the Maternity process from a paper based<br />

process from the time of Antenatal initial booking through<br />

Labour, Delivery and Postnatal.


Maternity ward using standard paper based document<br />

initiated at Antenatal initial booking<br />

<br />

All Lab and Radiology orders individually ordered for<br />

patient within Powerchart<br />

<br />

At weekends and at night the trolley housing the paper<br />

based documents sent to maternity ward in<br />

preparation for any admissions over night. During the<br />

day theses charts were housed at women’s health<br />

clinics<br />

<br />

Any electronic documentation entered into Powerchart<br />

used standard Cerner adult admission documentationpowerforms<br />

and clinical notes


In <strong>Cayman</strong> <strong>Islands</strong> we have Registered Midwives.<br />

Registered Midwives process differ from L&D (Labour<br />

& Delivery) Nurses.<br />

• Registered Midwives - are practitioners in their own right in<br />

the United Kingdom, and take responsibility for the antenatal,<br />

intrapartum and postnatal care of women, up until 28 days<br />

after the birth. Midwives are the lead Health Care Professional<br />

attending the majority of births, whether at home or in a<br />

hospital.<br />

• L&D RN’S –take care of women and newborns before, during<br />

and after the delivery. The RN creates a personalized care plan<br />

based on the woman's medical history and situation, and<br />

assists the doctor during the delivery of the newborn.


In 2005 Cerner conducted a workflow optimization<br />

assessment of our current system through out the<br />

hospital and found:<br />

• “Fragmented workflows and design/build of clinical solutions are the root<br />

cause of many of the issues discussed and observed. In many instances, the<br />

present functionality of Cerner systems at CIHSA is not fully realized. In other<br />

instances, redundancy of documentation was observed which is time<br />

consuming and adversely affects workflows. In some instances, the further<br />

addition of Cerner solutions may provide the best opportunity to improve<br />

efficiencies and ultimately patient care.”<br />

• “Orders within care sets are not appropriate and order sentence details are not<br />

adequate creating order entry burden on medical staff. The convenience of<br />

bundled orders via Care Sets is not leveraged.”<br />

• “Obstetrics and Post Partum workflow are not supported in Cerner. Duplicate<br />

charting in PowerChart and paper chart result in fragmentation of information<br />

with possible “misses” of critical information.”


Orders<br />

• “Evaluate orders and define “smart defaults” to streamline the<br />

ordering process. Review and agree to most commonly used<br />

ordering details then build order set and develop order sentences to<br />

facilitate efficient ordering process.”<br />

Clinical documentation<br />

• “Develop appropriate PowerForms to support Women’s Health as<br />

functionality allows.”


Nurse Informatics/Analyst<br />

• 1 Nurse Manager transitioned to IT for 2 years to assist with this and<br />

other recommended projects.<br />

HSA Committee<br />

• Transformation & Clinical Advisory combined to a core working group<br />

which was empowered to make decisions<br />

Cerner<br />

• 1 Cerner Clinical Strategist assigned for 2 years to assist with this and<br />

other recommended projects.<br />

Maternity Staff<br />

• 2 Clinical Midwife Super users<br />

• 1 Nurse Manager<br />

IT<br />

• 1 Clinical Business Analyst<br />

• 1 System Analyst


In 2007 meetings commenced for the transformation process of<br />

Powerchart to a version of Powerchart Maternity. To<br />

accommodate this we needed many changes and new build:<br />

• New Clinical positions<br />

• Complete re-design of standard Cerner Maternity Powerforms<br />

• Decision made to use Alpha Billing Powerforms instead of orders where<br />

possible<br />

• Text Rendition and new clinical notes – to enable Physicians to easily<br />

locate and read Powerform information<br />

• Complete re-design of Cerner Antepartum Summary<br />

• Caresets for Ordering<br />

• Advanced Growth Chart, Newborn Powerforms and Immunization<br />

Schedule also built to accommodate the babies documentation<br />

• Decision made against using OBGYN Specialist Flowsheet and to only<br />

use the re-named Antenatal Summary


2 new Clinical positions required<br />

• Midwife<br />

• Physician OBGYN<br />

These 2 new positions would allow for process, workflow and<br />

documentation to be tailored to the relevant Clinical staff in the<br />

Antenatal, Labour, Delivery and Postnatal situations.


Standard Cerner Powerforms where downloaded from start content and<br />

modified for:<br />

• Midwife Process<br />

• Physician’s OBGYN Process<br />

• English spelling and terminology<br />

• Labour - Labor<br />

• Foetal - Fetal<br />

• Antenatal - Antepartum<br />

• Postnatal – Postpartum<br />

• Date formatting 19/Mar/2013 – 03/19/2013<br />

New build for Alpha Billing Powerforms for Clinical Procedures performed by<br />

both Midwives and Physician OBGYN’S to accommodate Billing and<br />

Documentation at the point of care.<br />

New Adhoc charting root folder created called Obstetric forms.<br />

New Clinical Notes created: 5<br />

<br />

Powerforms converted to Text Rendition to allow other Physicians to easily<br />

read and locate Clinical Information.


Obstetric Powerform Root Folder<br />

English Terminology Maternity Powerforms


Alpha Billing Powerform<br />

Text Rendition Clinical Notes<br />

Charge Viewer


Standard Cerner Antepartum Summary was downloaded<br />

from start content and modified for:<br />

• Midwife process<br />

• Active Problem of Pregnant to be documented<br />

• English spelling and terminology<br />

• Labour - Labor<br />

• Foetal - Fetal<br />

• Antenatal - Antepartum<br />

• Postnatal – Postpartum<br />

• Date formatting 19/Mar/2013 – 03/19/2013<br />

• Additional results added as requested by OBGYN<br />

• Re-formatted the layout of Summary


Decision was made to create Caresets to be used both in<br />

the Antenatal setting and during the Labour and Delivery<br />

Process, for mother and baby. The Caresets included Lab<br />

and Radiology orders along with procedures, assessments<br />

and documentation required. All Required information<br />

defaulted in where possible:<br />

• Antenatal – Booking Labs & Radiology<br />

• Admit Maternity – Antenatal<br />

• Admit Maternity – Elective C-Section<br />

• Admit Maternity – Labour<br />

• C-Section – Emergency<br />

• Admit Newborn to Maternity<br />

• Admit NICU


Advanced Growth Chart<br />

Immunization Schedule<br />

Amended the standard CDC chart to<br />

accommodate the Immunization Schedule for the<br />

<strong>Cayman</strong> <strong>Islands</strong><br />

Newborn Powerforms<br />

Newborn and NICU Caresets


The build for the Project took approximately 9 months. The Nurse<br />

Informatics/Analyst build the Powerforms including the alpha<br />

billing. The System Analyst built the Antenatal Summary and the<br />

Clinical Analyst built all other areas of the Project.<br />

Yes it took as long to build this Project as a baby .


The Testing for the Project took approximately 3 months, and was<br />

concurrent with the Build portion of the project.<br />

The Initial testing was done by Nurse Informatics/Analyst and the<br />

Clinical Analyst .<br />

<br />

More detailed testing was done by relevant specialists, they assisted<br />

approximately 1 day a week:<br />

• 2 Clinical Midwife Super users<br />

• 1 Child Health Nurse Super user


The training for the Project was Instructor led and hands on computer<br />

training as this was an entire new workflow and process for the Midwives<br />

and Physician OBGYN’S. Job Aids were given to all staff who attended and<br />

the master training manual was updated for all Locations. The Instructors<br />

were the Super users who had assisted with the testing along with the Nurse<br />

Informatics/Analyst and the Clinical Analyst.<br />

• Midwives = 18<br />

• Physician OBGYN In house = 2<br />

• Physician OBGYN Private = 6<br />

The Physician sessions were one on one, with an instructor.<br />

Title Length Aimed<br />

at:<br />

GC<br />

No:<br />

Brac<br />

No:<br />

# of<br />

classes<br />

Encounter Summary, Immunization Profile, Obstetric<br />

PowerForms, Antenatal Summary, Task List, Shift<br />

Assignment, Advanced Paediatric Growth Chart<br />

1.5, 1.75, 2,<br />

2.5<br />

OB/GYNs,<br />

Women's<br />

Health,<br />

Midwives,<br />

Midwives<br />

covering NICU<br />

32 3 3


Go live for the Project was Monday November 3 rd 2008<br />

On site support was given by Nurse Informatics/Analyst<br />

and the Clinical Analyst during the day. For night the<br />

Clinical Analyst and 1 Super user Midwife who was on<br />

duty.<br />

Go Live day any new patients to clinic and the Maternity<br />

ward were to use the new documentation. Existing patients<br />

during this transition period, some of the documentation<br />

was on paper & some electronic. Notification was made in<br />

the paper or electronic chart to that effect.


Powerforms<br />

• Some additional DTA’S<br />

and nomenclatures<br />

Caresets<br />

• 2 new Caresets for Ward<br />

Bookings<br />

Updated Demographics<br />

Banner<br />

<br />

Still Outstanding<br />

Requests<br />

• Mother to baby<br />

documentation<br />

• Foetal monitoring<br />

interface<br />

• Mpage specific to<br />

Maternal Care<br />

<br />

2 Strep B Rules/Alerts<br />

<br />

NICU Powerforms and<br />

Alpha Billing<br />

<br />

Midwife Medication Order<br />

Entry


Demographics Banner<br />

Midwife Medication Order Entry


<strong>Cayman</strong> <strong>Islands</strong> <strong>Hospital</strong><br />

March 2013

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