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Not with a Bang: An Incremental Electronic Record Implementation
 

Not with a Bang: An Incremental Electronic Record Implementation

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Presented by Paul Docherty

Presented by Paul Docherty
Business Analyst and Web Developer, Mental Health and Addiction Services, Waikato DHB

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    Not with a Bang: An Incremental Electronic Record Implementation Not with a Bang: An Incremental Electronic Record Implementation Presentation Transcript

    • Not with a Bang An Incremental Electronic Record Implementation Paul Docherty
    • Agenda 1. Housekeeping: Purpose, Definitions Context and Disclaimer 2. Why an Electronic Record? 3. Implementation Approaches - Scanning 4. Incremental Approach 5. Comparison of Approaches 6. Questions
    • 1. Housekeeping Purpose: To present an alternative to the big bang approach normally associated with Electronic Record implementation Disclaimer: The opinions expressed are my own This is not an academic presentation Context: Contrasting the difference between Waikato DHB MH Services, Waikato DHB Medical Outpatients and Auckland DHB. Electronic Record (Electronic Medical Record): For the comprehensive documentation of the care received by one patient delivered by one organisation
    • 2. Why an Electronic Record? Good Reasons: 1. 2. 3. Paper-based notes are not always available at the point of care (particularly in after hours and crisis situations) Notes are up to date (and complete) To improve clinical access to information There is a link between improving Clinical Decision-Makers’ access to information and the quality of their decision making Bad Reasons: 1. 2. Savings on Paper and Administration Processes (filing) Hopes of mining the information for research and clinical audit
    • Whitianga Mental Health Clinic Whitianga Clinic – Waikato DHB • • • A Mental Health Clinical & Community Services base – 2 permanent MH staff + 5 visiting 1 ½ hours from Thames Hospital 3 hours from Waikato Hospital • After hours crisis staff located at Hamilton / can be dispatched from Thames • With an Electronic Record Crisis staff have immediate access to the records for Whitianga patients
    • Auckland DHB – Grafton Road Grafton Hospital / Greenlane Redevelopment (~2003) • • Centralise ED and Theatre to Grafton Road Centralise Outpatients to Greenlane • Without an Electronic Record 2,000+ Clinical Record (file) movements per day (estimate) • Problem: What is the likelihood that Clinical Record would be on the wrong campus (or lost in transit) – particularly since unwell people who attend Outpatients in the first place
    • 3. Record Scanning Scanning • Post event (ED, OP, IP) – all paper associated with the event is scanned, QA’d, and published. Back Scanning • • Decision needs to be made to back scan existing notes Scope of back scan is hopefully associated with a risk assessment Objectives Met? • • • Record is available Not necessarily immediately (delay to scan) Back scan is often cumbersome
    • 3. Record Scanning Issues Visible Issues • • • Expensive setup, Expensive to back scan Can be delay in scanning after event (next day, days later) Maintenance costs equivalent to manual filing Invisibles • • • Disruption caused by big bang implementation Information not easily available for research and clinical audit Existing ‘poor’ processes retained due to paper based recording Outcome • • • • Service disruption at transition Clinical resistance to use Paper use can often increase [bad reason noted above] Result is often ‘e-paper’
    • 3. Scanning Without a location issue a business case for scanning can be very difficult to write and justify. A business case based on ‘saving’ in print cost should be discarded.* *personal view
    • 4. Incremental Approach Forms (Waikato DHB – MH) • • Leveraged National or Required Collections to incrementally introduce an Electronic Record New forms were introduced over time and supporting business processes reworked. Data Migration • • May or may not be required depending upon existing information held electronically There may never be a clear demarcation between paper and electronic Document Substitution Approach • • • Progressive implementation form by form Focus on high clinical value, high compliance value first Left-over paper may never be included (scanning may be used)
    • 4. Waikato DHB – Early Steps Early Timeline: • • • • • Introduced Form Toolkit to collect HoNOS (outcome measures) – required by MoH in 2005. Progressively introduced forms for collection of clinical information required by PRIMHD over time (2006 - 2007) Progressively introduced forms to support clinical process improvement and KPI reporting No effort was made to include historical information Paper based clinical record was maintained in early steps
    • 4. Waikato DHB – 2011 - 2013 Recent Timeline: • • • • First ‘Dictate’ that non collection information must be recorded electronically – Treatment Plans required 2011 Risk Assessment must be recorded electronically - 2012 First electronic only forms (no longer requiring printing) – 2012 Mental Health Electronic Record Strategic Objective approved – 2013 Usability: • • • At all stages clinicians were included in the process and decision making Forms introduction matched existing staff capability (mostly below the pain threshold) Training of staff occurs side by side with introduction of new forms
    • 4. Strategy Early Objectives: • • • To provide a platform for the collection of Outcomes measures for Mental Health To provide a platform for future collection requirements - knowing that additional collections were in the pipeline That this collection platform should integrate with existing systems Current Objectives: • • • To have a single electronic file containing 80% of all documentation and 100% of all high value documentation – within 2 years [for MH] Continue with document substitution strategy These objectives are inline with overall service goals
    • 4. Forms Toolkit Side effect of implementing a generic form toolkit for National Collections was that it enabled the collection and reporting of other types of clinical information. Business case for purchase of the form toolkit was justified solely on the basis of meeting the then current HoNOS requirement.
    • 5. Comparison of Approaches Scanning: • • • • • • Big Bang with Service Disruption Expensive setup / ongoing maintenance Expensive back scanning Notes are available Notes are up to date (delay for scanning) Existing paper-based business processes are maintained Forms / Document Substitution: • • • • • Incremental Implementation with minimal Service Disruption Cheaper implementation (than scanning) Notes are available immediately Business processes are progressively redesigned around with electronic support May take many years to transition from paper to electronic
    • 5. Comparison of Approaches Scanning: • • • • • • Big Bang with Service Disruption Expensive setup / ongoing maintenance Expensive back scanning Notes are available Notes are up to date (delay for scanning) Existing paper-based business processes are maintained Forms / Document Substitution: • • • • • Incremental Implementation with minimal Service Disruption Cheaper implementation (than scanning) Notes are available immediately Business processes are progressively redesigned around with electronic support May take many years to transition from paper to electronic
    • Thank you … questions Paul.Docherty@WaikatoDHB.Health.NZ Phone: 07 838 8899 x 23131
    • 6. Discussion Points Why is a form better? • • • • • Auto population of patient and user demographic information Auto population of previous patient information from previous forms Forms can contain required fields Forms can check ranges to avoid silly data entry errors Forms can contain Business Rules such as date checkers Advanced Form Use Allows: • • • • Living documents Progressive documents Multi author documents (with auditability) Form applications (combinations of forms with reporting)
    • 6. Discussion Points Flying below the radar: • • • Incremental introduction avoids change pain Progressively users do not realise their use is increasing When forms are easier to use than paper there is no stopping uptake Culture of Innovation (How you know you’ve got one) • • • Users ask what’s coming next (Change enthusiasm) Users make unprompted suggestions Users make positive criticism – cross referencing other forms Below the Pain Threshold • • • Incremental change Well communicated change Having leadership support (Staff feel supported)