Surgeons cutting and running safe solutions with ICT. Presented by Stuart Gowland & David Hopkins, The NZ Mobile Surgical Project, at HINZ 2014, 12 November 2014, 12.22pm, Marlborough Room

1. Surgeons ‘Cutting and Running’.
Safe Solutions at Last Available
An ‘in house’ solution
Dr Stu Gowland, Dave Hopkins and Mark Eager
Auckland
November 2014

2.  Information and communications technology (ICT)
makes huge inroads into resolving issues that makes
modern iterant surgery safe. Having specialists prepared
to travel has huge benefits for isolated communities and
they regularly express their support.
 The Mobile Surgical Project has developed a series of
solutions to the inherent dangers with ‘cut and run’
surgery.
 Surgery is now safe ‘closer to home’ in remote locations

3. Who are we?
 A small Government funded organisation
formed in 2002 to provide share mobile
and video services in Health across New
Zealand.
 We employ an office of 12 in Christchurch
and an additional 10 part time staff across
the country
 An advisory board of surgeons,
anaesthetists, nurses and GP’s.

4. The vision overview of ‘Share Mobile’
 If equipment or facilities are not needed
every day then share them mobile so
local healthcare professionals and their
patients can have direct access to these
otherwise unaffordable medical facilities
and equipment.

5. The application of ‘Share Mobile’
 Vision 1
 Mobile low risk elective day surgery
delivering safe surgery into small rural
communities bringing the best
equipment and staffing assisted by
reskilled local nurses in theatre and
recovery.

6. The ‘airbrushed’ bus!

8.  Vision 2 (not being discussed today)
 Open up a new attack on the tyranny of
time and distance for communities using
easily available video communications in
a wide range of collaborations not just
education sessions and remote
consultations

9. Where the bus goes….. 23 rural hospitals across
the country
17,950 patients since 2002

10.  Mary thinks she has a hernia. She checks on
the mobile surgical website and learns what
would be involved if she was to have an
operation

11. Patient research on what is available

12.  The new style ‘patient journey’ for surgery
closer to home for those in our more remote
communities is now available. Mary plans to
see her GP

13.  Meanwhile the surgical bus has a multitude
of tasks nowadays facilitated across the
organisation by everything being web based

14.  Schedules have been put out for 6 months
ahead. Where the bus will be and what specialty
it is planning for.
 From DHB booking clerks to Specialists all have
their schedules on the web as well
 We also need a scheduling system that
automatically reminds people
 David Hopkins

15. Staff access to all current information

16.  Mary sees her GP who confirms the hernia
and gets an appointment for a ‘first specialist
assessment’in 2 months time. In due course,
after her assessment Mary gets put on the
waiting list for her hernia operation. Suggests
her rural locality makes her suitable for the
the mobile surgical unit (the bus)
 Now is the wait………….

17. A ‘booking
clerk, sees a
gap in a general
surgical list (on
the surgical bus
next visiting for
general surgery
in 3 months)
An ‘on line’ web
booking is
made

18. The booking clerk has had an automatically generated email
reminder when the general surgery specialist and bus are 5 weeks
away

19. Mary’s name
is added to
the list ‘on
line’.
Also added is
the referral
letter and
Mary’s pre
operative
anaesthetic
assessment
The date is
now set

20. Mary’s
Referral
Letter is
forwarded to
the web
based
operating list

21. Mary’s Pre Operative
Questionnaire is
currently faxed to the
Mobile Surgical
computers and joins
the web based list

22. Everything is checked. 7 days out, the operating list is
electronically available to the specialists; anaesthetist and
surgeon. The automatic email advises them to check regularly as
lists can change and there should be no surprises. They check
Mary’s referral letter and pre op assessment. All good

23. The specialists
can also check
visits planned for
them over the
next few months
in this case at
Ashburton
hospital visited
by the ‘bus’ since
the theatres
were damaged
by the February
earthquake.

24. The list is
checked. It is
noted some
of the
information
has not yet
been loaded.
A text to the
bookers fixes
this.
David Hopkins

25. While Mary’s operation is in the surgical bus connected to a
conventional hospital some more innovative sites are used.
Warkworth made use of a helicopter pad at the Snell’s Beach
community fire station

26. Mary’s operation goes well. The specialist’s
also do some pre arranged nurse training

27. The on board equipment has some special features: On the (R)
computer monitoring of anasthetic drugs and progress. On the (L)
a real time video link to the nurses in recovery a few hundred
metres away.

28. An IDAS electronic anaesthetic chart. Automatically
checks adverse drug interactions and warns if allergies
noted could be a problem.

29. An IDAS anaesthetist events list with timings

30. An IDAS drugs summary automatically scanned
into Mary’s clinical record. Review of patterns of
practice of different anaesthetists is possible

31. Mary’s Operative
Record typed here
but sometimes
notes are added to
a pre-formatted
template.
The record in some
cases is now
transmitted directly
into Mary’s DHB
hospital record
using the HL7 link
as transport.
Expansion of this
option is planned
David Hopkins

32. The days
completed
check list
with other
tasks still to
do being
prompted
on the top
line
David Hopkins

33. Nurse training and monitoring is essential for ensuring quality and
safety. Targets are set and progress can be reviewed. Specialists
and bus host staff participate in the mentoring at every operating
day and at other specially run sessions

34. Reports are regularly generated and are used for the nurse’s
continuing professional development (PDRP) programmes

35. A global overview of the training programme is
possible to review the nurses and our completions

36. Mary is discharged home with her operation note and GP
letter. A phone check will be made the following day and
data acquisition nurse Michele McCormack will phone
her also in 30 days with a questionaire.

37. 30 days later Michele fills out the Post Operative Review
Form. This will form a significant part of the overall
reports on amount of surgery and complications etc.

38. Michelle has available several tools to help her
keep on top of her follow up calls. Average follow
up success is 90% probably unmatched in our
health system
David Hopkins

39. The dashboard snapshot of how surgery, training and
complications rates are doing at any point in time. Any
date range or hospital is reviewable

40. The Ministry, who fund the rural surgical
programme, require numerous reports. For several
years they have been given access to the
appropriate portion of the website for their reports
which are simply ‘our’ reports.

41.  Nearly 18,000 rural patients have had day surgery
in their communities proven to be safe.
 90 nurses spread across the country look after the
Mary’s during their surgery
 About 100 specialists (surgeons and anaesthetists)
also work on the bus across the country.
 The bus has travelled nearly a million kilometers

42.  The combination of systems and ICT has
been the most significant factor in
making this form of itinerant surgery
safe.

43. Dave Hopkins will now explain how he
manages to sweep up after our streams of
ideas leave the inevitable mess
End of part 1
Thank you

44. Mobile Surgical Services
under the hood

45. Design Requirements
Access from everywhere
Data security + privacy
High availability.
Stable and robust system
Exploit future technologies
iPads, Smart phones etc
Rapid development.
Low maintenance
(write less do more)
Communicate:
Automated eMails, Txt
capability
Multiple database access
Audit trail of data
changes.
Database replication to
and from Surgical Bus
Customisable access rights
and system view
Log on once, Access all
** Simple, easy to use, - all systems similar

46. Who needs access ?
Office staff
Booking Clerks
Nurse Rosterers
Surgeons
Anaesthetists
MSS Nurses
Rural Nurses
Anaes.Techs
ICD Coder
Patient Post Op
Follow up
Auditors and analysis
The Ministry
Suppliers
Maintenance staff

47. Components of the solution
eScripts

48. Mobile Theatre
System
Lithotripsy
System
Vehicle
Maintenance
Stock
Control
Education
System
Other Files
& Systems
Solution HW
WWW
Web Server
Office server
Signed Certificate = HTTPS
Encrypted Interface
Replication via encrypted field
level delta packages

49. Complex
Functions &
Widgets
eScript file
Interpreter
(XML HTML)
Database &
File Access
Routines
eScripts
Engine
HL7,eMails,
Txt, Excel,
Outlook
eScripts Files
High volatility, simple to maintain
XML/HTML
Solution eScipts
eScript files

50. Security
 HTTPS
 Subnet – Web and Data Server
 No patient data on web server
 Encryption between servers
 End user logon – Customised view
 Embedded images within HTML
 Web page access logged
 Time out – hidden fields

51. Safety

52. Safety
 Email to booking clerk (6 w.)
 Email rosterers (5w.)
 Email if any missing Pre. Ops (4 w.)
 Email surgeons (1 w.)
 Email anaesthetists (1 w.)
 Indicate any theatre list changes
 Txt message reminder to patient (2 d.)
 Online real time access. All users viewing the
same data
 Pre op. questionaire and referral letter viewable
 Operative record returned to DHB system.
 Post operative patient follow up.

53. Some MSS Statistics
 No. of days surgery > 2,000
 Total Patients treated ~ 18,000
 Number of Rural Hospitals – 23
 No. of Medical Specialties - 9
 No of Surgeons ~ 150
 No of Anaesthetists ~ 70
 No of Rural Nurses > 200
 Office Staff < 20

54. What are eScripts
Defines a webpages. - GUI,Data and Events
 Text base system
 Extends HTML
 XML complaint
 Rapid development
 Low inter dependency
 Powerful generic widgets
 Simple to write, test and
maintain.

55. eScripts
 Defines: GUI, Data, Events
 All on one page
 Exploits HTML
 Adds Powerful Widgets
 Single Portal to multiple
systems and databases
 Over 500 web pages

57. User Specific Menu - Inhouse

58. User Specific Menu - Surgeon

59. Nurse Login

60. User Specific Menu - Ministry

62. Workflow Driven

63. Workspace

64. Reporting - Dashboard

65. Operative
Record

66. Reporting - Location

67. Reporting - Infection

68. Reporting – Infection (test data)

69. Dental Wizard

70. Report - Map View

71. eScript
example (test data)

72. eScript
example