The document discusses the development and findings of a pilot Electronic Care Record (ECR) project in Northern Ireland. The key points are: 1) The pilot integrated clinical information from 16 existing health systems and allowed clinicians to access patient data via a single login. 2) Evaluation found the ECR improved clinical outcomes and decision making. 97% of users were satisfied with ease of use and found it useful. 3) The pilot demonstrated that a regional ECR is achievable and could help improve patient safety, quality of care and reduce costs across Northern Ireland.

1. NI Electronic Care Record (ECR) Dr Roy Harper Consultant Physician and Endocrinologist Desmond O’Loan HSCB e Health & Social Care Team

2. 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

3. Objective of session Business Clinical Technical

4. 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

5. 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

6. 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

7. 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.

8. 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

9. Approach to finding a solution Pilot first Test our capability

10. 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.

11. 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”

12. 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

13. 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!”’

14. 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

15. Today PAS A&E PACS South Eastern Labs Renal G P Comm H&C Others Belfast Northern Southern Western Western GP’s

17. Tomorrow Patient Access to Personal Health Records Belfast Western Northern Southern Southeastern Single sign-on, Security, Auditing, Business rules GP’s

18. Technical design

19. 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

20. 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.

21. 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

22. Operational Design Overview

23. Technical Design Overview

24. 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

25. 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

26. 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

27. 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

28. Communications plan How to involve the service Demos – lots Requirements specification Hospital ICT department challenges Clinically lead – clinical system

29. 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.

30. 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.

31. 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

32. 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.

33. 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

34. 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

35. 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 “

36. 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.

37. 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

38. 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.

39. 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

40. 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.

41. 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

42. 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.

43. Clinical perspective Dr Harper

44. 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

45. 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.

46. What about? Using ICT to support patients , healthcare delivery and healthcare personnel - making it easier - making it better - making it safer

47. 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.

48. Connected Health in NI The road to a regional electronic care record for the population of NI Experience so far Strategy being realised

49. “ 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

50. 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

53. 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

54. 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

56. 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.

57. 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

58. 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

59. 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.

60. 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

61. 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

62. 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 )

63. 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’

64. 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

65. 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

66. 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)

67. 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

68. 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

69. 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

70. 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

71. 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

72. 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

81. 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

82. Tomorrow Patient Access to Personal Health Records Belfast Western Northern Southern Southeastern Single sign-on, Security, Auditing, Business rules GP’s

83. 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

84. 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.

86. 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

87. 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)

88. 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

89. 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

90. Timescales Business case approval Pending Procurement start October 2011 Contract sign March 2012 Roll out start Summer 2012

91. A NI-wide ECR Making the right decision for the right patient at and in the right time

92. 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

93. 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”

94. 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!”’

95. 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

96. 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

97. 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.

98. 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

99. 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.

100. Connected Health in NI The road to a regional electronic care record for the population of NI Experience so far Strategy realised

101. 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.

102. “ 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

112. 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.

113. 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

114. 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

116. 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

117. 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

118. 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 &