Information technology, Transformational change - Stories from the road
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Information technology, Transformational change - Stories from the road. Presented by Robyn Cook, IT Project Manager, University of New South Wales, Australia, at HINZ 2014, 12 November 2014, 1.45pm, Marlborough Room
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Information technology, Transformational change - Stories from the road
- 1. Information Technology, Transformational Change, Stories from the road…….. Wednesday 12th November 2014 Robyn Cook RN MBA CHIA HINZ Conference 2014
- 2. Sidra Medical and Research Center .
- 3. Sidra Medical and Research Center Personally Accessible Record for Life - PEARL Complete electronic medical record with device integration 300 unique devices 4000 devices to be installed Cerner Full Solution Set, plus additional solutions specific areas e.g. patient education, dietary, patient entertainment Philips – PACS and VNA and Cardiology Solution P
- 6. Patient Portal Benefits Lessons Learnt Communication – less telephone “tag” Overall approach to patient engagement Access information: • Care compliance • Patient engagement • Increase health literacy USA versus Local Drivers • Consumer loyalty • Continuity of care – especially complex care Effectiveness and Efficiency • Focused appointments • Streamline follow up and medication refill processes Multilingual user interface and cultural considerations User Education and Support Future monitoring health status Computer, Information & Health Literacy
- 8. Full Electronic Medication Management P Medication Reconciliation Patient e- prescribing with decision support Medication Verification Administration and Recording Dispensing Patient Safety
- 9. Medication Reconciliation and E- Prescribing Medication Reconciliation • Order to complete reconciliation – reminder and tracking • Standardised form and process – standard procedure • Subsequent encounter – streamline and accuracy Medication Orders • Legibility, standard orders sentences • Decision Support • Duplicate Checking • Allergy and Drug- Drug Interactions
- 10. Medication Reconciliation and E-Prescribing Benefits Lessons Learnt Legibility of medication order Integration with MAR Clinical documentation dependency for best practice Compliance medication reconciliation policies Agreement and compliance to medication reconciliation Orders only from formulary Formulary and drug availability, standardised order sentences Decision Support – • Errors of omission • Duplication • Allergies • Dosing support • Alerts Alert fatigue –priority safety alerts
- 11. Medication Verification and Dispensing Robotics and unit dose preparation Medication verification Automated Dispensing Units
- 12. Medication Verification and Dispensing Benefits Lessons Learnt Verify correct drug for patient IV Medications Unit dose Decrease waste and specific to patient 12 Liquids with Paediatrics Reduced errors dispensing Maintenance / sychronisation drug libraries and formulary Improved inventory control Multilingual patient medication labels Consistent administration instructions & compliance Integration effort Increased compliance home medications
- 13. Electronic Medication Administration Electronic Medication Administration Record • Integrated with electronic prescribing, pharmacy verification and review • Standardised Administration Instructions Bar Coded Medication Administration • 5 rights administration Infusion Smart Pump Integration • IV Order to Pump • Infusion Data to EMR
- 14. Electronic Medication Administration Plus Barcoded Medication Administration and Smart Infusion Pump Benefits Lessons Learnt Medication Administration 5 rights checking support • Right Patient • Right Drug • Right Dose • Right Route • Right Time P Paediatric Dosing – Weight based dose Legibility of Medication Record Clinical Documentation Integration Reduced errors infusion dosing Integration Effort and Testing significant Standardised administration instructions
- 15. Decision Support
- 16. Decision Support Evidence Based Practice Provation Order Sets Provation Care Plans • Evidence Content base – UptoDate and Lippincott • Authoring, collaborative review and management tools • Integration with Electronic Medical Record
- 17. Decision Support Benefits Lessons Learnt Consistent evidence based practice P 17 Commitment to evidence based practice Collaboration and agreement across multidisciplinary team Alignment service department offerings (e.g. lab tests) with evidence base Customise to local requirements Full orders management catalogue including formulary Streamlined Governance • On Line authoring • Approvals • Management review cycles Resources for updates and integration with EMR Evidence Based Practice
- 18. Decision Support Hand Over Summary Views of clinical information based on role Supports medical handover and nursing SBAR
- 19. Decision Support Early Warning Systems Modified Early Obstetric Warning System (MEOWS) Paediatric Early Warning System (PEWS) Early Warning System (EWS) Australia “ Between the Flags” Full clinical documentation Algorithm Alerts / Actions lists and routing of calls
- 20. Decision Support Handover, SBAR, Early Warning Systems Benefits Lessons Learnt Consistent and standard approach to handover P Standardisation versus customisation Improved communication Well accepted solution for all clinical groups Alerts and guidance for early intervention Aligned with international evidence for practice Reduced duplication of data capture
- 22. Technologies Mobile access Notification critical results Rapid login – fully integrated Auto log off Range of device for access to electronic medical record Fully redundant, mirrored databases 05/05/2014 22
- 24. Translational Research Environment, the power of information systems Clinical Systems Electronic Medical Record, and Clinican P Tools Data Warehouse Clinical Improvement Clinical Registries Identified Data Research Information Exchange De identified Data Cohort Search and Selection Clinical Portal Patient Portal Researcher Portal Surveys etc Biobank Omics Data Governance Internal, National, International Collaboration
- 26. Transformation with Information Technology Understand clinical, research and operational practices and processes Integrate information system into practice, leverage benefits Monitor adoption with data feedback and continuous improvement Health Information Technology (HIT) Safety Framework – Dean Sittig and Joan Ash Increased health informatics research to demonstrate effectiveness P
- 27. People make the transformation happen Working together to close the gap from bench to practice
- 28. P
Notas do Editor
- Thank you for the opportunity to speak at the conference today. Todays presentation is about the journey of the last 6 years where I was fortunate to be part of developing a truly greenfield fully digital hospital in the middle east and more recently a new journey into the cancer translational research environment. Cover key aspects of information technology and how it can support transformational change and highlight lessons learnt on the journey, with a focus on patient engagement, patient safety with medication management, decision support and the translational research environment
- Sidra Medical and Research Center – this you tube clip will give you an insight into the state of the art, academic medical center in Doha, Qatar – it may be a small country on a pensinsula in the Arabian Gulf, and has an ambitious vision to create one of leading academic medical centers in the world and has the financial capacity to do so with a $7.8Billion endowment. Leading architectural design, steel, glass and ceramics, 3 atriums, representing the dow boats, creates healing gardens, effective use of natural light, visible from all patient rooms and extensive use of beautiful Italian marble in the lobby areas Wireless, filmless and virtually paperless, it is all digital facility with all IT applications for clinical care, research and hospital operations. Integrated with robotics, computer aided surgery and diagnostics and advanced digital imaging. Wayfinding and real time location services are also included in the facility – RTLS – provides the ability to locate patients, equipment and staff at anytime, all equipped with an RTLS sensor. The inpatient care areas were designed with technology in mind , with a large flat screen IP TV available on the wall opposite the end of the patient bed, iPad connectivity and wall mounted all in one devices for use by clinical staff in addition to mobile devices. Clinical Focus is women and childrens services. One of the challenges in implementing the fully digital environment was the greenfield nature of the hospital, no current hospital moving to the site, no operational clinicians, no policies, procedures or processes. Unfortunately even though construction commenced at beginning 2009 the building is still not complete and ready for occupation, so the stories I tell are about what was done to prepare for this fully digital environment but not from an operational perspective – at this stage it is anticipated that the hospital will open in 2016…….. To be able to support clinical transformation a Department of Health Informatics, with 65 staff, is being established along with a separate clinical IT group within the IT department It was still a dream opportunity for a clinical informatician and an exotic location………….
- The patient is at the center of care at Sidra and one of the key aspects of the clinical system is the patient portal. Creates a secure and private on line environment for the patient and family to engage with the health care providers. It includes secure messaging between the patient/ family and the health care providers, on line requests for appointments and confirmations. The ability to review results and summaries of hospital visits, request medication refills, provide access to or push patient education materials, complete on line patient surveys and reminders e.g. immunisations.
- Benefits include streamlined communication between health care provider and patient / family. Provides the patient with access to health care information that can increase compliance with care activities, engages the patient in self care and increases their health literacy. It also supports streamlined patient care processes for appointment and medication refills. In the future it will have the opportunity for patients to enter health data for monitoring e.g. blood sugar levels for the diabetic that can be reviewed by the health care providers and discussed with the patient on the next visit. Lessons learnt What is the overall approach to patient engagement in the organisation, strategic vision and objectives, the patient portal is a tool to support patient engagement and needs to support the organisations vision and meet the health information needs of the patient population. Many of the patient portal solutions are based on the US model of health care – with a focus on gaining customer loyalty and encourage the patient to stay with the organisation. In other health care environments, especially public health systems such as the UK , Australia, New Zealand and Qatar – the focus is on supporting continuity of care, especially chronic and complex care such as diabetes, or obesity ( which is highly prevalent in the middle east) means you need to consider how you manage to bring together patient information from different organisations involved in patient care – this was not addressed at Sidra and yet the country is small , the largest public hospital was a short distance away, no connection with primary health care and all were implementing a Cerner solution. As this is an arabic country, it was important to provide the portal in arabic and in a form that was suitable for an islamic environment. The development and implementation requires extensive community consultation to address the needs of the local qatari community and a mixed arabic and western expat population group. E.g. adolescent access western versus the male dominance in islam. The use of mobile technology in the community is significant, ( many owning 2-3 mobile phones) especially with young people and families, therefore the challenges with accessing the internet were limited. The greatest challenges will be the information and health literacy of the community especially the local community, where bedouin folklore still has a strong influence on behaviour and beliefs.
- In the arena of patient safety I have chosen one area to focus on medication management
- Full Electronic Medication Management system – often in our health systems we do not have the opportunity to fully automate the clinical processes, thus leaving gaps in the processes, which can exacerbate patient safety risks, due to the automation of current practices – for Sidra it was fortunate that technology and information systems were applied for each process within the medical management system - from medication reconcilation, to e-prescribing, medication verification and dispensing to the administration and recording It was when I observed the full automation of the medication management system that I could see the level of transformation that it could bring to clinical practice. Additional benefits from a clinical informatics perspective is the ability to collect data for “near misses” in medication orders and administration to identify opportunities for system improvements
- The solution included An order to complete the medication reconciliation was part of the standard admission / visit order set, transfer of care and as part of the discharge planning processes– this acts as reminder to complete the reconcilation and tracks if it has been completed – outstanding task if not done Medication Reconcilation – completed using standard forms and therefore processes. Once patient medications are in the system it is streamlined and easier to complete the reconciliation and is a good check to remind the ordering physician to review and recommence home medications in preparation for discharge Electronic medication orders – for all medications including IV therapy was included and the provision of decision support with alerts – duplicate checking, allergy and drug/ drug interactions – principle in initial design was to focus on the high risk interactions and gradually increase alerts – monitoring for alert fatigue
- Benefits Legibility Order sets – compliance medication reconciliation, admission, care transfer and discharge Limited to ordering from formulary – important in middle east – access to high quality medications can be difficult and significant controls on opiate based pain relief Decision support Dosing support for paediatrics – once the weight based dosing protocols defined it is easier to manage in an electronic system Lesson Learnt Medications are not ordered or administered without the context of patient information e,g vital signs, other clinical assessments – demonstrated the importance of having full clinical documentation in place in conjunction with electronic medication management systems Drive standards based practice such as medication reconciliation with information systems – through orders, tracking completion, standard documentation and processes Considerable effort to establish formulary for new hospital, where supply can be inconsistent, and agreement to use a standard medication coding system – Rx Norm was chosen as it covers all aspects of medication information. Decision Support – need to have a balance with alerts for patient safety versus alert fatigue – reduces effectiveness of alerts and increases patient safety risks
- Pharmacy automation Clinical Pharmacists to verify all medication orders before dispensing unless in emergency circumstances Use of robotics in both inpatient and outpatient pharmacy dispensing – with inpatient unit dose preparation – fully labelled and barcoded. Outpatient dispensing included arabic and english patient instructions All patient drugs including infusion were distributed to clinical units in automated dispensing units – integrate with order so that administration on the clinical unit – access the ADU with authentication - monitor use and cost directly to the patient
- Clinical Pharmacist increased involvement in patient care and confirming correct drug order for patients Unit dose – specific to patient – less waste Robotics improves inventory control Agreed administration instructions are available with all medications – consistency of information and potential increase compliance for correct administration Home medications – detailed legible instructions – increased compliance – including arabic speakers Lessons learnt Paediatric medications are liquid and therefore less opportunity unit dosing Dug libraries and formularies sychonisation – robots, infusion pumps, Automated dispensing units and the electronic medical record systems Patient labels in arabic – challenge as the characters and format – not just a direct language translation Significant integration effort between EMR, robots, and ADU’s – need to plan sufficient time for interface specifications, development and testing – project impacts – also consideration during procurement of equipment
- Scope in meds administration included bar coded medication administration and infusion pump integration – orders and infusion details
- Benefits – cannot under estimate the benefits to administration of bar coded meds administration – support for the nurse along with the legibility of the medication order IV infusion integration –less errors in infusion dosing – nurse still confirms the order Standardise administration instructions are available at the point of care Lesson learnt Alogorithms with weight based paediatric dosing – especially for neonates as cannot round doses Requirement for clinical documentation to support administration and assessing patient response to medications Integration effort is significant – test test test test test……….
- As the organisation was new, so there was the opportunity to embed evidence based practice from the beginning. Provation was chosen as the source of evidence based content for order sets, orders for specific conditions according to the phase of care for the patient and care plans from a nursing perspective. Content source for the evidence – UpToDate (one of the most common and well used knowledge resource for physicians) and Lippincott for the nursing care plans The Provation solution provides both the content and the tools for authoring, collaborative review and management – prior to review by clinicians – align the orders with the organisational order catalogue and formulary. Establish team for the review which can be done on line and agreement to the final order set. The tools also support set timeframes for review and approval status for each order set Once approved the order set or care plan is then uploaded into the electronic medical record/
- Benefits Consistent evidence based order sets or care plans, with specific customisation to the local requirements– monitor compliance and patient outcomes Tools support collaboration on line across the multidisciplinary team Tools support effective governance Lessons learnt – whilst everyone is claimig evidence based practice – there is still reluctance to adopt external evidence base – despite all references being available within the order set / care plan Lessons learnt Set up for review is extensive initially – order catalogue from each service department – cross check with each order set before the initial review to ensure the orders / formulary are available or mapped to the local order For evidence based updates and the upload into the electronic medical record does require dedicated resources to complete reviews and management of the integration
- One of the advantages of the electronic medical record is the ability to provide information in formats that meet different clincal group needs and practices Hand over summary – structured approach to providing key information for handover of care – less opportunity to miss key information -, flags abnormal results and the reviews of resulst e.g. physician hand off and nursing SBAR – situation, background, assessment, recommendation
- With all aspects of electronic clinical documentation available – able to construct new decision support tools Able to design and implement international standard early warning systems for different clinical settings Construct the algorithm to autocalculate score and then use alerts and actions to support clinical staff actions and can also automate the routing of calls for the response team – still expect the clinical staff to make the judgement
- Standardised handover and improved communication – structured, no reliant on memory Use alerts to guide clinical practice and early intervention Does not require duplication of data capture Minimal adoption issues as tools are designed to meet clinical needs and based on international practices
- Important to provide effective technologies to access the electronic medical record Also logon and log off – using integrate solutions – tap and go Device needs to meet the clnical staff needs and operational environment
- Just to finish off I will describe the value of information to support translational research environment – this has focus on cancer services and improve patient care. Clinical Systems capturing data for patient care – provide data into a data warehouse to support clinical improvement activities, clinical registries with identified data The data can then through a de identification process be transferred to research information exchange – cohort search and selectrion Data can be delivered to different roles including clinicians, patient and researchers Support for internal, national and international collaboration For cancer services - supports specific research databases – omics data, biobank and qualitative data ( surveys etc) Challenges are around effective data governance, including privacy and security as sharing data across organisations
- Overall lessons learnt to transform health Need to understand the operational and clinical processes – opportunities to radically change the process with the integration of technology – change the overall processes and practices Technology and systems have to be integrated into the clinical, research and operational processes Supports increased adoption, need to measure the effectiveness of the transformation and continuous improvement Need to increase the application of HIT safety framework to reduce the impact of unintended consequences of information technology – the work or Dean Sittig and Joan Ash is important in this arena
- And finally transformation will only occur when people are engaged in and leading the change – people are key to transformation in health care