NI Electronic Care Record - Des O'Loan
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  • Collapse – world today - What is this attempting to convey? Regions are not sharing emr, ehr or domain data?
  • ECR VISION - is achievable
  • Introduction
  • Introduction – may not be needed as follow on from Johnny
  • Collapse - Is this a collage of 2 worlds? Paper and e? Not exactly sure what its conveying
  • Collapse -- What is this attempting to convey? Plethora of e-care solutions?
  • DW - Changed wording
  • The UKPDS showed that: Coronary artery disease is the major cause of mortality in patients with type 2 diabetes mellitus Patients without evidence of disease related to atheroma at diagnosis of type 2 diabetes mellitus had an increased standardised mortality ratio compared with the population of the United Kingdom 11% of patients in the study had a myocardial infarction or developed angina over a median of 8 years' follow up The potentially modifiable risk factors for coronary artery disease were increased concentrations of low density lipoprotein cholesterol, decreased concentrations of high density lipoprotein cholesterol, hypertension, hyperglycaemia, and smoking; these are also risk factors for coronary artery disease in the general population Turner RC, Millns H, Neil HAW, Stratton IM, Manley SE, Matthews DR, Holman RR. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom prospective diabetes study (UKPDS 23). British Medical Journal 1998; 316: 823-828.
  • The UKPDS showed that: Coronary artery disease is the major cause of mortality in patients with type 2 diabetes mellitus Patients without evidence of disease related to atheroma at diagnosis of type 2 diabetes mellitus had an increased standardised mortality ratio compared with the population of the United Kingdom 11% of patients in the study had a myocardial infarction or developed angina over a median of 8 years' follow up The potentially modifiable risk factors for coronary artery disease were increased concentrations of low density lipoprotein cholesterol, decreased concentrations of high density lipoprotein cholesterol, hypertension, hyperglycaemia, and smoking; these are also risk factors for coronary artery disease in the general population Turner RC, Millns H, Neil HAW, Stratton IM, Manley SE, Matthews DR, Holman RR. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom prospective diabetes study (UKPDS 23). British Medical Journal 1998; 316: 823-828.
  • The UKPDS showed that: Coronary artery disease is the major cause of mortality in patients with type 2 diabetes mellitus Patients without evidence of disease related to atheroma at diagnosis of type 2 diabetes mellitus had an increased standardised mortality ratio compared with the population of the United Kingdom 11% of patients in the study had a myocardial infarction or developed angina over a median of 8 years' follow up The potentially modifiable risk factors for coronary artery disease were increased concentrations of low density lipoprotein cholesterol, decreased concentrations of high density lipoprotein cholesterol, hypertension, hyperglycaemia, and smoking; these are also risk factors for coronary artery disease in the general population Turner RC, Millns H, Neil HAW, Stratton IM, Manley SE, Matthews DR, Holman RR. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom prospective diabetes study (UKPDS 23). British Medical Journal 1998; 316: 823-828.
  • The UKPDS showed that: Coronary artery disease is the major cause of mortality in patients with type 2 diabetes mellitus Patients without evidence of disease related to atheroma at diagnosis of type 2 diabetes mellitus had an increased standardised mortality ratio compared with the population of the United Kingdom 11% of patients in the study had a myocardial infarction or developed angina over a median of 8 years' follow up The potentially modifiable risk factors for coronary artery disease were increased concentrations of low density lipoprotein cholesterol, decreased concentrations of high density lipoprotein cholesterol, hypertension, hyperglycaemia, and smoking; these are also risk factors for coronary artery disease in the general population Turner RC, Millns H, Neil HAW, Stratton IM, Manley SE, Matthews DR, Holman RR. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom prospective diabetes study (UKPDS 23). British Medical Journal 1998; 316: 823-828.
  • The UKPDS showed that: Coronary artery disease is the major cause of mortality in patients with type 2 diabetes mellitus Patients without evidence of disease related to atheroma at diagnosis of type 2 diabetes mellitus had an increased standardised mortality ratio compared with the population of the United Kingdom 11% of patients in the study had a myocardial infarction or developed angina over a median of 8 years' follow up The potentially modifiable risk factors for coronary artery disease were increased concentrations of low density lipoprotein cholesterol, decreased concentrations of high density lipoprotein cholesterol, hypertension, hyperglycaemia, and smoking; these are also risk factors for coronary artery disease in the general population Turner RC, Millns H, Neil HAW, Stratton IM, Manley SE, Matthews DR, Holman RR. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom prospective diabetes study (UKPDS 23). British Medical Journal 1998; 316: 823-828.
  • The UKPDS showed that: Coronary artery disease is the major cause of mortality in patients with type 2 diabetes mellitus Patients without evidence of disease related to atheroma at diagnosis of type 2 diabetes mellitus had an increased standardised mortality ratio compared with the population of the United Kingdom 11% of patients in the study had a myocardial infarction or developed angina over a median of 8 years' follow up The potentially modifiable risk factors for coronary artery disease were increased concentrations of low density lipoprotein cholesterol, decreased concentrations of high density lipoprotein cholesterol, hypertension, hyperglycaemia, and smoking; these are also risk factors for coronary artery disease in the general population Turner RC, Millns H, Neil HAW, Stratton IM, Manley SE, Matthews DR, Holman RR. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom prospective diabetes study (UKPDS 23). British Medical Journal 1998; 316: 823-828.
  • The UKPDS showed that: Coronary artery disease is the major cause of mortality in patients with type 2 diabetes mellitus Patients without evidence of disease related to atheroma at diagnosis of type 2 diabetes mellitus had an increased standardised mortality ratio compared with the population of the United Kingdom 11% of patients in the study had a myocardial infarction or developed angina over a median of 8 years' follow up The potentially modifiable risk factors for coronary artery disease were increased concentrations of low density lipoprotein cholesterol, decreased concentrations of high density lipoprotein cholesterol, hypertension, hyperglycaemia, and smoking; these are also risk factors for coronary artery disease in the general population Turner RC, Millns H, Neil HAW, Stratton IM, Manley SE, Matthews DR, Holman RR. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom prospective diabetes study (UKPDS 23). British Medical Journal 1998; 316: 823-828.
  • Show this is a high level plan – is the pilot funded? Outcomes? -Is a Business Case needed for full HSCNI? What does the business case need to have? What incremental Evidence of?
  • I do not have time to do a live demo but hear are a few screenshots of what the pilot ECR looks like. Amazing information. Looks complex but for clinicians easy – takes a few minutes training to get up to speed.
  • All the documents I need at the click of a button
  • Lab results collated from various laboratories
  • X-ray reports and images
  • Up to date medication lists. Some people are on a lot of pills!! No longer have to ring GP surgery and ask them to fax through list of medications!!
  • Collapse – world today - What is this attempting to convey? Regions are not sharing emr, ehr or domain data?
  • ECR VISION - is achievable
  • A match will be made if the data in the message exactly matches that in the MPI on the following items:   HCN or PAS Internal Number or Casenote Number AND Surname and Date of Birth and Gender   NB Blank spaces and punctuation marks have been removed from surnames for matching purposes to allow, for example, O’Connor, O Connor and OConnor to be read the same.
  • The role of ICT Success requires…Leadership and Funding
  • The role of ICT Success requires…Leadership and Funding
  • Introduction
  • Introduction – may not be needed as follow on from Johnny
  • Paperwork overload. Bit of an exaggeration – frontline HSC staff don’t have desks! Spending so much time documenting the care we give that it is seriously eating into the time we have for direct patient bed-side care. Well meaning folks from patient safety side, infection control, medicines management side, governance side are coming up with very valid new processes but what that usually means for staff on the frontline is another page or two of an A4 form to fill out!
  • What this means is that we are free of the dreaded charts. Instead of arriving at my clinic with a trolley load of charts I can at the click of a few computer keys see all the relevant information I need (and some besides) on all my patients. When on call I can be fully appraised of my patients clinical situation in a few seconds rather than wait until all the clinical offices and services start up on Monday morning!
  • What I have discovered is that a lot of the key information we need as clinicians to support patient care is already available in lots of different clinical computer systems spread across the service. Some are good some are not. Some we have access to some we don’t but there is information in there that is really valuable – allergies, medication lists, letters, laboratory results, x-ray reports and images, and lots more. Hard to get at as you can imagine. We need to bring it all together.
  • I do not have time to do a live demo but hear are a few screenshots of what the pilot ECR looks like. Amazing information. Looks complex but for clinicians easy – takes a few minutes training to get up to speed.
  • All the documents I need at the click of a button
  • Lab results collated from various laboratories
  • X-ray reports and images
  • Up to date medication lists. Some people are on a lot of pills!! No longer have to ring GP surgery and ask them to fax through list of medications!!
  • No surprises here – the solution is to move to computerized clinical information systems. Much better.. Have a good IT infrastructure. We have computing power right up to the bed-side now. We just don’t have the clinical information systems as yet but we need to be freed to work on these! We need to move away from the big bulky inflexible systems from large usual suspect suppliers who provide lousy solutions at inflated costs.

NI Electronic Care Record - Des O'Loan NI Electronic Care Record - Des O'Loan Presentation Transcript

  • NI Electronic Care Record (ECR) Dr Roy Harper Consultant Physician and Endocrinologist Desmond O’Loan HSCB e Health & Social Care Team
  • Content
    • Introduction & objective of session
    • Background to HSCNI
    • Challenge to be solved
    • Approach to finding a solution
    • The HSCNI ECR Pilot
    • Findings and business case
    • Communications plan
    • Clinical perspective & Challenges
    • Consent and confidentiality
    • Current position & future plans
  • Objective of session
    • Business
    • Clinical
    • Technical
  • Background to HSCNI
    • HSCNI reorganisation 12 Trusts to 6 Trusts
    • 1.8 million people
    • Revenue constraints
    • Limited capital
    • Efficiency saving
    • Move to community based care
    • Multiple systems unconnected
    • Shortage of skilled ICT hybrid staff
  • HSCNI ECR Background
    • ECR strategic objective since 2005 - officially
    • Deemed too expensive for a single Trust
    • Local initiatives - applications, intranets
    • No significant HSCNI research
    • Summer 2008 site visits
    • Regional ICT Programme Board approved a Proof of Concept in BCH , Ulster & two GP
    • Contract Oct 2009, Live Jan 2010
  • Challenge to be solved
      • Valuable time and resources wasted every day searching and waiting for clinical information needed for effective, fast and safe decision making.
      • Reliance on notes, fax, post, porters, phone calls to obtain relevant clinical information.
      • Significant duplication of effort due to multiple unconnected information systems across the service – limited sharing of information
      • Personal experiences - lack of information increasing clinical risk & reducing efficiency
  • Why we need ECR’s ?
    • “ It’s all there, somewhere”
      • Most information is available electronically - ‘somewhere’ in HSCNI, you just can’t get at it quickly when you need it.
      • ‘ Joining up’ current multiple information systems across HSCNI gives fast access to a patients dispersed clinical information.
      • Access to relevant clinical information improves safety, increases quality and speeds up decision making.
      • ‘ Joined up’ systems reduce reliance on notes, fax, post, porters, phone calls and remove the multiple Logins & Passwords issue.
  • What is an ECR
    • Many different interpretations
      • “ Single ‘portal’ for viewing multiple sources of clinical information via a single logon to a single system”.
      • A. Rip & replace with a new large scale system
      • B. Integrate existing systems - with the option to replace
  • Approach to finding a solution
    • Pilot first
    • Test our capability
  • The challenge
    • How to provide care professionals with a comprehensive summary record, for every patient using HSCNI services, which includes clinically relevant information, assembled from electronic systems located anywhere in the service and presented in real-time via a single, web based, easy to use computer system accessible from anywhere in HSCNI.
  • Specialist Registrar- Medical Assessment Unit
    • “ if I am called to assess a patient in A&E, I will have access to what they have been able to tell the triage nurse, what the patient can tell me, and information from any previous A&E visit to our hospital. That’s it. I will not know any recent blood tests done by their GP, if they have been to any other A&E departments recently, what drugs they’re on, if they’re waiting for an outpatient appointment for a related complaint: all of this information exists, but it is in different systems and maybe in different hospitals and I am unable to get at it when needed in order to best treat the person sitting in front of me”
  • Some of the issues
    • Improve patient safety
    • Improve service productivity
    • Sharing of patient clinical information across multiple HSC organisational boundaries
    • Treat more patients outside of hospitals
    • Reduction of inappropriate admissions
    • How to move services around quickly
    • Maximise the use of the Health Estate
    • How to reduce/contain costs
    • Faster delivery of benefits
  • Clinical User comment
    • ‘ If I had a pound for every time a patient says to me “do you not have my records?” I would now be off to Florida for the winter. This new service has gone some way to let me now say to patients “yes I do have your records!”’
  • Why does the HSC need ECR?
    • Significant potential to improve the quality of care , reduce risk and contain costs .
      • Reduced inappropriate admissions via A&E
      • Improve OP clinic throughput
      • Improved drug reconciliation on admission
      • Reduce duplicate in testing
      • Improve secretarial efficiency
      • Interface more current operational systems
      • Allow the interfacing of future systems
  • Today PAS A&E PACS South Eastern Labs Renal G P Comm H&C Others Belfast Northern Southern Western Western GP’s
  •  
  • Tomorrow Patient Access to Personal Health Records Belfast Western Northern Southern Southeastern Single sign-on, Security, Auditing, Business rules GP’s
  • Technical design
  • Currently 16 interfaced systems External BCH Ulster H&C index Master Patient Index MPI A&E A&E General Practice -ECS Carryduff, Priory Laboratory Master lab Laboratory BSO PAS episodes PAS episodes IUVO Clinical documents Clinical documents Cloverleaf GE RIS Report + Image NIPACS Report + Image SoScare PARIS
  • Technical Implementation
    • 16 core legacy systems integrated into ECR
    • These systems were “silo based” without common interfaces, message types or unique identifiers.
    • Audit of systems outputs led to definition of a minimum data set for the ECR
    • Test strategy and plan using senior clinical users created high levels of confidence and clinical ownership of the system.
    • Network performance was not an issue for clinicians following full rollout of the system.
  • Technical Implementation
    • Clinical confidence in the system increased once a critical mass of data had been “backloaded”
    • Trust level ICT support required was minimal during the development and implementation phases.
    • On site, live testing by senior clinical champions was invaluable as was their assistance during the clinical rollout.
    • 24/7 centralised support is required to ensure smooth operation and high availability
  • Operational Design Overview
  • Technical Design Overview
  • Issues addressed in the PoC
    • Confidentially and Patient consent
      • Communication and consultation
    • Clinical buy-in
        • Clinical tool, No big brother
    • Data quality and Matching
      • Health and Care number
    • Technology
  • Technical experience
    • Technically
      • Lots of challenges
        • Data Quality, Reliable data feeds, Process logic
        • Database and processing speeds, Networking
    • Operationally
        • Huge amounts of testing & training
        • Significant take-up by clinical staff
        • Need more GP practices involved
    • Proved it is achievable
    • Refinement needed
  • Practical challenges
    • Interfaces – push-pull-batch-none
    • Master Patient index – H&C No.
    • Matching transactions to correct patient
    • Error handling replaying messages
    • Messages per day 80 000
    • 4000 Patients viewed per month 200 users
    • Speed to build lists
    • Resist secondary use temptation
    • Zero footprint at users pc
  • Practical challenges
    • Some issues – pdf, activex – images
    • Data centre hosted
    • Bandwidth
    • People
    • ECR team – pilot – for real
    • Help desks, local, regional, supplier
    • Data quality – match rate 90% +
    • Training local, regional, supplier
  • Communications plan
    • How to involve the service
    • Demos – lots
    • Requirements specification
    • Hospital ICT department challenges
    • Clinically lead – clinical system
  • Visualise
    • The reality of a patients experience today
      • and
    • How long would it take to access this level of detailed clinical information without the aid of this technology.
  • Evaluation goals
    • To provide the Project and Programme Board with a written record describing the Pilot, the methods used and approaches adopted in order to share the lessons learned and inform regional decision making.
    • To provide information for the business case, procurement, implementation and support for a regional ECR.
    • To provide any future potential users of an ECR with the NI experience.
  • Evaluation areas
    • System use and benefits March-October 2010
    • Information governance – access and consent models within the pilot
    • Data quality issues arising during the project
    • Technical implementation and performance
    • Overall conclusions
  • Benefits seen
    • 97% of users were very satisfied or satisfied with the ease of use
    • 97% of clinicians surveyed found the PoC system useful and 100% would recommend the system to a colleague
    • 74% of doctors surveyed reported that the ECR use helped them to make the right diagnosis quicker and 84% agreed ECR use had contributed to a better clinical outcome at least once during the evaluation period.
    • 33% of clinicians had found at least one occasion where use of the ECR had prevented an adverse event, such as an allergic reaction.
    • In an outpatient audit the ECR avoided unnecessary review appointments in 6.8% of patients seen.
  • Key findings- System utilisation
    • 7000 +patient records accessed via ECR
    • 100 active clinical users as of end October
    • 97% of users were very satisfied or satisfied with the ease of use
    • System used over 24/7 main use during day
    • On site enrolment and training alongside local “clinical champions” was central to successful implementation
    • Uptake increased dramatically once the critical mass of clinical data was available
    • 97% of clinicians surveyed found the PoC system useful and 100% would recommend the system to a colleague
  • Benefits of an ECR
    • Improving patient safety, quality of care and clinical decision making-
      • “ the ECR site is great as it has everything in one place-patient details, documents, bloods, xrays etc. It saves time going from system to system to check things !”
      • “ Standardises content and quality of medication information” - clinical pharmacist
      • “ ECR was very helpful as I was able to check a patients combined allergies status for a Doctor. Normally we would have to wait to get this info from the old notes or contact the GP surgery”
      • “ ECR lifesaving today. Able to see information (BCH letters) on a patient that brought real clarity to the situation and allowed more appropriate treatment and maybe prevented an HDU/ICU admission”- user feedback Aug 2010
    • 74% of doctors surveyed reported that the ECR use helped them to make the right diagnosis quicker and 84% agreed ECR use had contributed to a better clinical outcome at least once during the evaluation period.
    • 33% of clinicians had found at least one occasion where use of the ECR had prevented an adverse event, such as an allergic reaction.
    • In an outpatient audit the ECR avoided unnecessary review appointments in 6.8% of patients seen.
    • “ system use prevented a repeat ultrasound to investigate abnormal blood tests. The ECR identified longstanding derangement with a recent normal ultrasound in June 2010 “
  • SE Trust Pharmacy audit of ECR
    • Total elapsed time to resolution and medicines reconciliation reduced from 3 hrs 45 mins to 22 mins -ECR is 10 times faster than previous method.
    • Actual work time reduced from 40 minutes to 11 minutes - ECR is 4 times faster.
  • Legacy systems audit SE Trust
    • With legacy systems “logged into”, time taken to access single lab result, x-ray report and a recent clinical document was 56 secs per patient compared to 29 secs per patient using ECR- able to access key info in half the time.
    • With all systems “closed” and requiring “logged into” lookup time with legacy systems was 148 secs compared to 42 secs using ECR
  • Consent and Privacy model
    • Pilot GP practice patients informed via mail drop.
    • Patients asked for explicit consent to view records
    • Role based access based on users status and determines level of information available
    • Privacy overrides for situations where verbal consent is not possible e.g. Medical emergencies, unconscious patients, new clinic referrals.
  • Consent and Privacy model
    • System audits all activity and users from login to logout.
    • Audit trails can be viewed by system administrator
    • If privacy seal is broken system generates an email and audit trail to the privacy officer
    • Pilot used a limited number of clinical roles based on study sites e.g. GP, A&E, acute medicine wards
  • Consent model use in practice
    • 5000 patient records during the pilot to date
    • 78% of accesses were with full patient consent 20% through privacy overrides.
    • 70% users satisfied with the consent model
    • 78% of users would be happy to have their own clinical details in the ECR
    • 120 patients chose to opt out of the ECR-all from the pilot practices. No patient opted out from a clinical setting.
  • Data Quality
    • Initial impression was that data quality on some of the legacy systems was not very good- 60% message matching might be achievable and 80% target was ambitious
    • In- house MPI developed with HCN index as its core
    • Matching logic was refined during the pilot period
  • Data Quality
    • Higher than expected matching rates achieved ranging from 84 - 98% depending on source system
    • No instances of incorrect matching of clinical data to the “wrong” patient identified.
    • The in-house MPI has proven to be very reliable and has shown that proven data quality issues are not insurmountable.
  • Clinical perspective
    • Dr Harper
  • NI Electronic Care Record (ECR) A Physician’s Perspective Dr Roy Harper Consultant Physician & Endocrinologist The Ulster Hospital Visiting Professor, School of Mathematics and Computing The University of Ulster
  • Healthcare Informatics
    • The application of computer and information science in healthcare to facilitate the acquisition, processing, interpretation, optimal use and communication of health related data. The focus is the patient and the process of care and the goal is to enhance the quality and efficiency of care provided.
  • What about?
    • Using ICT to support patients , healthcare delivery and healthcare personnel
    • - making it easier
    • - making it better
    • - making it safer
    • Systematic Review: Impact Of Health Information Technology on Quality, Efficiency, and Costs of Medical Care.
    • Chaudhry et al., Ann Intern Med 2006;144:742-52.
    • Improving Safety with Information Technology
    • Bates and Gawande. N Engl J Med 2003;348:2526-34.
  • Connected Health in NI The road to a regional electronic care record for the population of NI Experience so far Strategy being realised
    • “ Information technology is no longer perceived as just a supporting tool, but has become a strategic necessity for developing an integrated healthcare system that can improve services and reduce medical errors”
    • Source: Le Rouge, Mantzana & Wilson, European Journal of Information systems (2007) 16, 669-671
  • Timeline for Health Computing (Informatics) in Health and Social Care in Northern Ireland (1999 – Present) – A Personal View 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Diamond Diabetes ECR installed HPSS ICT ‘Vision’ HPSS ICT ‘From Vision to Reality’ Emergency Care Record Pilot Goes Live ECCH set up Start of H&C Number roll out Wireless Carts NI BCS Healthset up First COM 723 at UUJ Local PACS Tablet PCs and remote access Regional EHR Research Group Established 2009 PatientCentre [email_address] Appointed as Physician in UCHT RPA Roll out of PCs in all OPD Consulting Rooms Pilot ECR NIPACS 2010
  •  
  •  
  • Nature of the problem
    • To make the best clinical decisions and to deliver safe and effective care clinicians need access to many different pieces of clinical information
    • Northern Ireland is rich in clinical data on individual patients
    • Much of the crucial data is in electronic formats (laboratory, radiology, documents, PAS, CI, EMR)
    • but
  • The problem is in accessing key information
    • Many disparate clinical systems
    • Multiple log-on’s to lots of different password protected systems
    • Only access to a single clinical domain or service
    • Ever increasing amounts of clinical time devoted to locating information
    • Preventing effective and timely decision-making
  •  
  • The problem
      • Valuable time and resources wasted every day searching and waiting for clinical information needed for effective, fast and safe decision making.
      • Reliance on notes, fax, post, porters, phone calls, taxis to obtain relevant clinical information.
      • Significant duplication of effort due to multiple unconnected information systems across the service – limited sharing of information.
      • Personal experiences - lack of information increases clinical risk & reducing efficiency.
  • Patient expectations
    • Timely, accessible and the best care possible
    • Medical decisions based on accurate, current and relevant information
    • Patient care decisions made effectively and efficiently
    • A safe positive experience and outcome
  • The answer – a NI-wide ECR
    • Key information from various disparate legacy clinical information systems brought together effectively and collated within a secure password protected regional electronic health record (EHR)
    Quite feasible
  • The challenge
    • How to provide care professionals with a comprehensive summary record, for every patient using HSCNI services, which includes clinically relevant information, assembled from electronic systems located anywhere in the service and presented in real-time via a single, web based, easy to use computer system accessible from anywhere in HSCNI.
  • HSCNI ECR Background
    • ECR strategic objective since 2005
    • Local and Regional initiatives - applications, intranets, H+C No etc.
    • No significant HSCNI research until Summer 2008 site visits
    • Regional ICT Programme Board approved a Proof of Concept in BCH , Ulster & two GP
    • Contract Oct 2009, Live Jan 2010
  • What is an ECR?
    • A population-based electronic health record (EHR) brings together all types of patient data from lots of different sources and makes them instantly available to designated clinical staff at the point of care in order to aid decision making
  • Washington Hospital Centre (MedStar Health), Washington DC, USA. Largest private academic hospital in Washington DC (926 beds) Leading centre for cardiology, oncology and trauma EHR originated from and designed by ER clinical staff Taken 15 years Originally known as Azyxii – now bought by Microsoft (Amalga TM )
  • Washington Hospital Centre - EHR Integrates data of all sorts from multiple legacy systems Displayed in a highly customisable role-based data dense user interface. ‘ Take it and show it’ philosophy Users define their own information needs and ‘views’
  • Washington Hospital Centre - EHR Listing and searching facilities are extensive Clinical questions easily answered ‘on the fly’ Limited direct data entry in the ER Some text-based information is scanned in Document creation Supporting hospital performance management and finance department
  • Capital Health Edmonton Area, Alberta, Canada (www.capitalhealth.ca) Provides a complete range of health services to 1.7 million people Employs 30,000 staff Pioneered the development of a web-based EHR across its catchment area and beyond Now well developed Cost 10 million Canadian dollars with a deployment time of 9 months
  • Capital Health - EHR Project driven by clinicians with total senior management buy-in Information from 25 data sources brought together using integration software (Concerto TM from Orion Health) Legacy systems stand as before – updated or replaced as needed The ‘netCARE’ portal is up and running and in use (>20,000 accessing per day)
  • Capital Health - EHR ‘ Dashboard’ presented to users is easy to use Training takes 5 minutes Single sign one with pass through to legacy systems as required Largely read only Linked to a pharmacy information network Bolted on chronic disease management modules
  • Capital Health - EHR Information for clinical use only No secondary uses allowed Local population buy-in Some patient data masked Access only to selected clinicians with robust audit of all ‘break the glass’ events
  • Key components of an effective EHR
    • Password protected single sign-on with pass through
    • Fast, easy-to-use, intuitive, training in 5 minutes
    • Quick wins with early release and ‘quarterly pearls’ approach
    • Read only data to start then bolt on direct data entry, chronic disease management, etc
    • Security paramount with user groupings and access levels carefully defined with routine auditing of access
    • Opt out is the only viable consent model
    • Agreed processes to add additional data sources
  • A NI-wide ECR achievable?
    • We have seen - real live, well used ECRs which are indispensable clinical information tools
    • We have seen - ECRs producing untold benefits for patients, for healthcare professionals and for healthcare systems
    • We have proven - that it can be done and fairly quickly with early wins
  • Here’s what is happening
    • HSC decision to support a pilot
    • Scoped out and integration provider procured
    • ECR pilot is up and running
    • Running for >12 months
    • Evaluated and made the case for roll out
  • External BCH Ulster H&C index Master Patient Index MPI A&E A&E General Practice -ECS Carryduff, Priory Laboratory Master lab Laboratory BSO PAS episodes PAS episodes Clinical documents Clinical documents GE RIS Report + Image NIPACS Report + Image SoScare SoScare PARIS PARIS
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  • Today PAS A&E PACS South Eastern Labs Renal G P Comm H&C Others Belfast Northern Southern Western Western GP’s and Community Services
  • Tomorrow Patient Access to Personal Health Records Belfast Western Northern Southern Southeastern Single sign-on, Security, Auditing, Business rules GP’s
    • Safer, Faster, Better Care
        • Swift access to relevant and timely information
        • Less time wasted searching for or requesting information
          • Cross-site information available, including GP drugs
        • Pre clinic preparation
          • Improved face-to-face patient experience
          • More efficient clinics
        • Ward rounds quicker and more effective
        • Better informed decision making
    • Rapidly increasing usage
  • Benefits seen in Proof of concept
    • 97% of users were very satisfied or satisfied with the ease of use
    • 97% of clinicians surveyed found the PoC system useful and 100% would recommend the system to a colleague
    • 74% of doctors surveyed reported that the ECR use helped them to make the right diagnosis quicker and 84% agreed ECR use had contributed to a better clinical outcome at least once during the evaluation period.
    • 33% of clinicians had found at least one occasion where use of the ECR had prevented an adverse event, such as an allergic reaction.
    • In an outpatient audit the ECR avoided unnecessary review appointments in 6.8% of patients seen.
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  • Technically feasible Well accepted and used by clinicians Increased patient safety and reduction of medical errors. Decrease in unnecessary and costly medical tests and procedures. Increased efficiency and a shorter care cycle. Improved patient care. Improved integration between acute and primary care. ECR POC Evaluation
  • Key steps towards an effective EHR
    • See it as an essential core tool for clinicians
    • Acceptance that it is a ‘no brainer’ and must happen
    • Buy in from population, clinicians and management
    • Master Person Index is fundamental for correct ID
    • Clinicians drive the project – IT deliver on specifications
    • IT investment (2.5% of total Capital Health spending)
  • What we need
    • Continued investment in HSC ICT infrastructure
    • Support and long-term investment to create a Regional ECR for the population of Northern Ireland
    • Support healthcare workers with the tools they need
  • Only the start
    • Integrate more clinical systems (cardiology, oncology, TMS, renal, diabetes, community systems, NISAT, RTM, screening services, mental health, etc)
    • Link in with (subsume) ECS project
    • Alerting, chronic disease management support, Audit, Research
  • Timescales
    • Business case approval Pending
    • Procurement start October 2011
    • Contract sign March 2012
    • Roll out start Summer 2012
  • A NI-wide ECR
    • Making the right decision
    • for the right patient
    • at and in the right time
  • NI Electronic Care Record (ECR) A Physician’s Perspective Dr Roy Harper Consultant Physician & Endocrinologist The Ulster Hospital Visiting Professor, School of Mathematics and Computing The University of Ulster
  • Clinical User comment 1
    • “ if I am called to assess a patient in A&E, I will have access to what they have been able to tell the triage nurse, what the patient can tell me, and information from any previous A&E visit to our hospital. That’s it. I will not know any recent blood tests done by their GP, if they have been to any other A&E departments recently, what drugs they’re on, if they’re waiting for an outpatient appointment for a related complaint: all of this information exists, but it is in different systems and maybe in different hospitals and I am unable to get at it when needed in order to best treat the person sitting in front of me”
  • Clinical User comment 2
    • ‘ If I had a pound for every time a patient says to me “do you not have my records?” I would now be off to Florida for the winter. This new service has gone some way to let me now say to patients “yes I do have your records!”’
  • Some of the issues
    • Improve patient safety
    • Improve service productivity
    • Sharing of patient clinical information across multiple HSC organisational boundaries
    • Treat more patients outside of hospitals
    • Reduction of inappropriate admissions
    • How to move services around quickly
    • Maximise the use of the Health Estate
    • How to reduce/contain costs
    • Faster delivery of benefits
  • What is an ECR
    • Many different interpretations
        • “ Single ‘portal’ for viewing multiple sources of clinical information via a single logon to a single computer system”.
    • How is this achieved
      • A. Rip & replace with a new large scale system
      • B. Integrate existing systems - with the option to replace
  • Why we need an ECR
    • “ It’s all there, somewhere”
      • Most information is available electronically - ‘somewhere’ in HSCNI, you just can’t get at it quickly when you need it.
      • ‘ Joining up’ current multiple information systems across HSCNI gives fast access to a patients dispersed clinical information.
      • Access to relevant clinical information improves safety, increases quality and speeds up decision making.
      • ‘ Joined up’ systems reduce reliance on notes, fax, post, porters, phone calls and remove the multiple Logins & Passwords issue build on our previous investments in ICT.
  • Our pilot solution
    • Provided an Electronic Care Record (ECR) system which spans the Belfast City and Ulster hospitals.
    • Single summary view of the patient/client history
      • GP practice details
      • GP drugs and allergies
      • Encounter history – past and future
      • Clinical coding information
      • ED triage information
      • Laboratory results
      • Radiology reports and images
      • Clinical documentation
        • In/Out/Day/Result/.... letters
  • Visualise
    • The reality of a patients experience today
      • and
    • How long would it take to access this level of detailed clinical information without the aid of this technology.
  • Connected Health in NI The road to a regional electronic care record for the population of NI Experience so far Strategy realised
  • Healthcare Informatics
    • The application of computer and information science in healthcare to facilitate the acquisition, processing, interpretation, optimal use and communication of health related data. The focus is the patient and the process of care and the goal is to enhance the quality and efficiency of care provided.
    • “ Information technology is no longer perceived as just a supporting tool, but has become a strategic necessity for developing an integrated healthcare IT infrastructure that can improve services and reduce medical errors”
    • Source: Le Rouge, Mantzana & Wilson, European Journal of Information systems (2007) 16, 669-671
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  • Benefits seen
    • 97% of users were very satisfied or satisfied with the ease of use
    • 97% of clinicians surveyed found the PoC system useful and 100% would recommend the system to a colleague
    • 74% of doctors surveyed reported that the ECR use helped them to make the right diagnosis quicker and 84% agreed ECR use had contributed to a better clinical outcome at least once during the evaluation period.
    • 33% of clinicians had found at least one occasion where use of the ECR had prevented an adverse event, such as an allergic reaction.
    • In an outpatient audit the ECR avoided unnecessary review appointments in 6.8% of patients seen.
  • Where Next
      • Business case approval needed by
        • July 2011
            • 5 year capital investment £10m
            • 5 year revenue investment £7.5m
      • Procurement complete by
        • March 2012
      • Live by
        • September 2012
  • ECR core team
    • Dr Carolyn Harper (SRO) - PHA
    • Dr Roy Harper - Ulster
    • Dr Ken Fullerton - City
    • Dr Jimmy Courtney - GP Hollywood
    • Dr Clive Russell - Clinical adviser
    • Gary Loughran
    • Ella Jameson
    • BSO Technical teams
    • Orion Health
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  • Objectives
    • Install a solution by March 2010
      • Belfast Trust – Belfast City Hospital Site
      • South Eastern Trust – Ulster Hospital site
    • Evaluation, learning and lessons
    • Prove HSCNI can technically build and implement an ECR
    • Virtually zero footprint on desktops
  • Experience to date
      • Technically
        • Lots of challenges
          • Data Quality
          • Reliable data feeds
          • Process logic
          • Database and processing speeds
          • Networking
      • Operationally
        • Hugh amounts of testing
        • Take up slow by Clinical staff
        • Need more GP data
    • Proved it is achievable
  • Summary
    • Introduction & objective of session
    • Background to HSCNI
    • Challenge to be solved
    • Approach to finding a solution
    • The HSCNI ECR Pilot
    • Findings and business case
    • Communications plan
    • Clinical perspective & Challenges
    • Consent and confidentiality
    • Current position &