EHRs - The thin end of the wedge


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Phil Brimacombe
Health Alliance

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EHRs - The thin end of the wedge

  1. 1. Health Informatics New Zealand Electronic Health Records: The Thin End of the Wedge Phil Brimacombe Chief Information Officer 1
  2. 2. Health Informatics New Zealand Agenda Auckland Region DHBs EHR direction CCM: a completed EHR project TestSafe: an EHR project in progress ARMHIT: an EHR project coming up Auckland DHBs EHR direction Driven by the RISSP Improving health outcomes through information exchange Information systems will contribute to the development of new processes for improved clinical effectiveness and efficiency Information systems will support the priority development of Primary Health Care. The emphasis will be on supporting new models of healthcare in preference to automating current processes A number of projects building towards CDR, CWS, HES 2
  3. 3. Health Informatics New Zealand Auckland DHBs EHR direction CDR: Develop and publish a regional Clinical Data Repository architecture that will allow logical integration of patient records and clinical images. Implement in stages to enable delivery of Key Projects such as Chronic Care Management, Mental Health, and Community, Ambulatory and Disability systems. CWS: Extend the scope and use of the Concerto clinical workstation to provide secure and seamless access to clinical information. Ensure access at point of care including mobile and bedside. HES: Implement a regional repository of all clinical Health Event Summaries (including discharge summaries) across Primary, Community, outpatient, and inpatient care. Allow clinicians and patients to access relevant information. Why have a CDR? Data for patient care is in different places inside the enterprise – PiMS, CMS, Éclair, PACS, Specialty databases Some key clinical data unavailable at point of care – Alerts/Allergies, problem lists, current medications Communication between systems not standardised – Expensive to create, support, maintain extend ‘Enterprise’ are separate entities – Counties Manukau, Waitemata & ADHB Many specialist systems collecting data that needs to be generally available (at least in summary) – Lab, Cardiology Some fundamental processes not computerised – Internal Referrals, handover of care External entities needing/supplying data increasing – GP, PHO, NGO, Patient, Labs 3
  4. 4. Health Informatics New Zealand Clinical Data Repository Requirements Standardise the presentation of patient information to clinicians – Right data for the right patient to the right person at the right time – ALL key data available to clinician at point of care, regardless of where it is stored Store the same type of information in the same place – Store common information once only – Store data of the same type in the same repository Facilitate retrieval of stored information by other systems – Need to make it simple to update and communicate data between components Clinical Data Repository 4
  5. 5. Health Informatics New Zealand CCM: a completed EHR project Supports delivery of structured care to patients with chronic illness (Diabetes, CVD, CHF, COPD) High need patients Empowered primary care – Secondary outreach/training – Electronic decision support – Regular reporting on progress GP enrols patients according to clinical criteria 4 free practice visits per annum 6 hours nursing time per annum Structured data is collected at each visit Data sent to DHB Server where it is validated and saved Reporting on aggregated data Secondary care access to the data Empowered Patients – Patient held care plans CCM HES primary -> secondary GP/Nurse creates CCM message (HES) and send to DHB system for analysis/reporting Hospital Clinician (ED) can access report automatically generated from that HES (and others) when patient attends ED HES sent to ED Clinician GP/Nurse sees repository can access patient HES report 5
  6. 6. Health Informatics New Zealand GP selects CCM in Medtech GP completes TIM CVD form Lab Results Auto-populate 6
  7. 7. Health Informatics New Zealand GP completes TIM diabetes form GP receives ECDS advice – click “Actions” 7
  8. 8. Health Informatics New Zealand Actions recommended by Predict Reporting & Feedback to GP Reports generated monthly from DHB data Each GP receives their data compared to a similar cohort of aggregated, anonymised GPs Communication via PHO 8
  9. 9. Health Informatics New Zealand EC Whiteboard: Dr selects patient EC Dynamic Patient View – click icon 9
  10. 10. Health Informatics New Zealand Dr is presented with CCM Summary CCM Benefits Patient gets regular, free visits to the GP Specialist training to GPs & nurses Standardised templates, decision support and other resources empower nurses in care delivery Regular feedback to the GP Data repository for reporting Data available to secondary care clinician at point of care Main benefit is improved patient care 10
  11. 11. Health Informatics New Zealand TestSafe: an EHR project in progress Before TestSafe – ‘Regional Éclair’ All results from Auckland DHB laboratories – Excluding: A+ Mental Health and Sexual Health All results performed by Community Laboratories requested by DHB clinicians – where the requesting GP has indicated ‘copy to’ a DHB – Approximately 15% of all Community based laboratory tests were routed to the Regional Éclair repository Before TestSafe - Issues Move Return to (Change GP) Daily Activities Discharged Present at Present at Return to GP (new) Emergency GP ISSUES ISSUES ISSUES •Repeated , tests, staff time •Access to previous •Acute situation, getting results from records tests repeated Hospital •Phone calls / delays •Delay in care while •Delay in care while tests / repeated tests tests are performed are re-done, or results sent from Hospital 11
  12. 12. Health Informatics New Zealand TestSafe - Vision Move Return to (Change GP) Daily Activities Discharged Present at Present at Return to GP (new) Emergency GP ACCESS RELEVANT RESULTS Project Overview Project: All results funded by Auckland DHBs Auckland DHB Diagnostic Éclair Medlab LIS Hospital Lab Results ++ Community Lab Results Stage 1: Business Case Complete Dec 04 Stage 2: Privacy Assessment DHB based access to community Live June 06 results Stage 3: Primary Care Test Orderer access Work In Progress to hospital results 12
  13. 13. Health Informatics New Zealand TestSafe Stage 2: Privacy Process 1. Developed TestSafe Privacy Framework – Incorporated existing DHB privacy policy – DHB based consultation Expert reference group Primary Care liaison officers – Crown Solicitors Legal / Ethical opinion 2. Wider Sector Consultation,10 months to Apr 06 – Resulting in Privacy Framework updates Stage 2: Privacy Process Sector Consultation – DHB PHO Management Groups – DHB Clinical Boards – DHB Community Boards – Consumer focus group – Meetings with interested organisations e.g. Womens groups Regional Privacy Advisory Group (RPAG) established Aug 05 Medical Protection Society Review (early 06) ProCare Privacy Committee review (early 06) 13
  14. 14. Health Informatics New Zealand Stage 2: Privacy Approach Patient Choice – Core aspect of the privacy solution – More information >> Patient Awareness – Test Orderer assistance required Direct mail used a primary means of communication with Test Orderers Implementation pack provided – Help line, website, communication materials 14
  15. 15. Health Informatics New Zealand Stage 2: Privacy Approach DHB Policy – Employment contracts, training, disciplinary procedure Security Audit – TestSafe Service Coordinator employed – Additional patient record monitoring of access to Community results patient records Role Based security – Additional controls recommended by RPAG for existing DHB based users – Currently being implemented Stage 3: Primary Care Access Current State – Orion Concerto for ‘portal’ services – Each DHB has own Concerto instance Technical Issues – User Authentication – User – Patient relationship authentication 15
  16. 16. Health Informatics New Zealand Stage 3: Primary Care Access Separate Concerto for Primary Care access planned Possible use of PHO-Patient registers to verify patient relationship – ‘Break Glass’ override available ‘Copy To’ feature included id Component View ADHB GP CMDHB GP External Concerto Web Eclair (Test Safe) DHB Application WDHB GP DHB Concerto 16
  17. 17. Health Informatics New Zealand Stage 3: Primary Care Access Sample timeline Nov Dec Jan Feb Mar Apr May June Vendor engagement Detailed design Configuration and Testing Privacy and security approval Access available ☺ ARMHIT: an EHR project coming up Clients, their families and clinicians are provided with a computer system that supports a recovery-based approach to mental health care Phase 1 A single shared Mental Health client record across the three Auckland DHBs Phase 2 NGOs, GPs and clients use the system to participate in shared care 17
  18. 18. Health Informatics New Zealand ARMHIT Specific flow ARMHIT Phase 1 Benefits Improved clinical effectiveness and reduced clinical risk Information on clients who access services regionally Access to crisis team services Population health management capability Capture of national KPI data Consistency of use of clinical guidelines Integrated care between DHB community and inpatient Information to primary care through the HES Capture information on client priority for psychiatric input Monitor that accreditation requirements are being met Performance related reporting Information on Maori clinical and cultural service delivery Information on staffing skill mix 18
  19. 19. Health Informatics New Zealand Conclusion There is no conclusion, building an EHR is a never ending journey – E referrals – Medication record – Community & disability – Diabetes retinal screening Health Event Summaries the key to information exchange 19
  20. 20. Health Informatics New Zealand Patient Choice 1. Call to: “0800 LAB PLUS” – Hours 7:00 am to 7:00 pm, Monday to Friday – Patient specifies a date (range) during which the test was ordered – All access to view the test result is removed from the RRR 2. “Prevent TestSafe Sharing” flag on laboratory order forms – Implemented as a new ‘test’ in GP PMSs << Return 20