Paperless Possibilities

October 2012Cheryl McCullagh

Director of Clinical Integration

SCHN-Children First and foremost

current state

• Current frustrations can be overcome when technology makes things easier and repetitious data entry is eliminated.

Is ‘paperless’ a realistic goal?

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Evolving Documentation Strategies

Between the Flags• eform for clinical and rapid

response• Increased vigilance for

complications by coders• Increased coding of arrests and

resuscitation events• Form and call triggered by patient

events

Order Sets (Care Sets)

Medication Reconciliation – Home Meds

Antibiotic Stewardship 4 Kids (ABS 4 Kids)

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What is ABS 4 kids?

Drug Dose Guidelines Antibiotic Guidelines Contact Us Antibiotic Approval

View Approval RequestsWhat is ABS 4 Kids? ABS 4 Kids stands for "antibiotic stewardship" or otherwise known as "antimicrobial stewardship" for Kids at CHW. Antimicrobial stewardship is defined as processes to assist and support clinicians with decisions regarding the optimal selection, dose and duration of antimicrobial agents. The objectives of ABS 4 Kids are: To optimise antibiotic use to improve patient care To minimise antibiotic toxicity to the patient To reduce the selection pressure for the emergence and transmission of multi-drug resistant bacteria One of the core strategies of ABS 4 Kids consists of online pre-approval of restricted antibiotics (see below). A hierarchical "traffic light" system has been developed based on the resistance potential, complexity of use and cost of each antibiotic. The restricted agent groups, and mechanisms for obtaining approval are specified below: "Red Agents" are antimicrobials of very high resistance potential and/or cost. When commenced during office hours, approval in advance must be obtained from the Stewardship Consultant on page 7092. The approval number must be written on the medication chart. When commenced after hours, approval must be sought on the morning of the next working day. "Orange Agents" are antimicrobials of intermediate resistance potential, cost and/or complexity of use. Initial empiric use of agents in this group is allowed and their use must be registered on the request form below by the clinical team at time of prescribing. The request will be reviewed by the Stewardship Consultant, on the basis of the clinical information provided, on the same or the next working day. If approved, an approval number will be supplied for annotation on the patient's medication chart. "Green agents" are those where there are no restrictions on use. If required, antibiotic advice is always available by paging the Infectious Diseases registrar (during working hours) or the Infectious Diseases Physician or Clinical Microbiologist on call. Other useful resources include the Australian Therapeutic Guidelines - Antibiotic (available via CIAP) and the Drug Dose Guidelines. CHW "Traffic Light" Restricted Antibiotic Formulary

Historical Challenges• ‘pockets’ of information• No consistent model of analysis / reporting • Consistency and completion of tasks

• Different source systems

• Access

• Timing

• Quality

• Duplication

Risks• Limited $• ABF • Private Patient Revenue• Costing• Site systems differences• Infrastructure• Sustainability

• Patient Safety

Service Needs

• Integrated approach to multiple needs– Strategy – Planning – Costing – Reporting – Performance management– Service delivery– ‘real-time’ information

Strategic Directions AlignmentNational Health Direction

Creation of Local Health Districts and Specialty Networks Implementation of Activity Based Funding (ABF)State Health Strategy

Patients at the centre of everything we do

access to timely, quality health care

keeping people healthy to avoid unnecessary hospitalisation

The Creation of NSW Kids and Families

State ICT strategy

Clinical Systems integration- EMR and unified patient record

Corporate systems integration

Information for performance and ABF

Sustainable Infrastructure

SCHN strategy

Strategictechnologyinvestment

Development &implementation

of responsive IT systems

Meeting the needs for the performance

framework

Delivering seamless

clinical care

Providing infrastructure for research and

educationSCHN IMTS

Sustainability and accuracy Single patient view Access to information Innovation

Aim- connecting information for outcomes

Single patient view

Sustainability and accuracy

InnovationStandardised information

PatientService

Staff• Work with MOH/ e-health and

tele-health international leaders• Equipment universally interfaces

with the eMR• User satisfaction• Up to date technology• Smart theatres 2012/13• Lanier voice recognition

• eMR basis for clinical information• Full redundancy of critical systems,

regular scheduled downtime• Reliable interfaces - no duplication

of systems or data entry• Minimal unplanned downtime due

to preventable internal mechanisms

• Seamless integration of automated information

• Combined local HIE by Dec 2013• Unified and accessible eMR by

2015 (including remote access)• Enterprise Imaging Repository• Unified Implementation of eMR for

inpatient/outpatient notes• Implementation of eMM

• CHIMP/ CHARLI/ e-policy/ Pathlore/ e-quality

• Single data input• Implementation of eMM• Use of innovative data collection

Strategy eMR Orders/Results Growth Charts PAS/Scheduling Allergies/Alerts Outpatient Billing Between the Flags Allied Health Mental Health EDW Client & WL

2000-2011

Dept Databases

Paper

Medical Records

Department Records

Document Imaging

eMR + HPUX Migrations Patient Registry for IHI Enterprise Image Repository Scheduling Correspondence PathNet Millennium Outpatient Reporting PowerNote & MPages Review SCH eMR Workflows eMR Phase 2

Now

Document Imaging

PCEHR

Dept Databases

Paper

Medical Records

Department Records

eMR +

Transition to aSCHN eMR

eMR Phase 2 ICU Medication Management Discharge Referral FirstNet/SurgiNet Immunisations Problems/Diagnosis Inpatient Consult Clinical Reporting XR Reporting (MRP) Other

2013 - 2015

Document Imaging

PCEHR

Dept Databases

Paper

Department Records

eMR +· all Documentation· Safety interfaces

2016

Document Imaging

Paper

PCEHR

Dept Databases

Clinical Information Strategy to 2016

Inte

gra

tio

n

The connected record

Internet based health Conferencing

Management Information

• Delivery across the network• Departmental performance against target• CMI NWAU targets over time• LOS benchmarks• Revenue per pt load• Performance against strategic goals• Aspirational-clinical outcomes

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CLINICAL NURSE CONSULTANT

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ASSISTANT IN NURRSING

CLINICAL NURSE CONSULTANT

CLINICAL NURSE SPECIALIST 2

OCCUPATIONAL THERAPIST

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NURSE EDUCATOR/CLINICAL NURSE EDUCATOR

REGISTERED NURSE

ENROLLED NURSE

ASSISTANT IN NURRSING

CLINICAL NURSE CONSULTANT

CLINICAL NURSE SPECIALIST 2

OCCUPATIONAL THERAPIST

SOCIAL WORKER

PSYCHOLOGIST

PHYSIOTHERAPIST

CHILD LIFE THERAPIST

VMO

CMO

STAFF SPECIALIST

FELLOW

JMO

DIETICIAN

ADMINISTRATIVE ASSISTANT

SECRETARY

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NURSE EDUCATOR/CLINICAL NURSE EDUCATOR

REGISTERED NURSE

ENROLLED NURSE

ASSISTANT IN NURRSING

CLINICAL NURSE CONSULTANT

CLINICAL NURSE SPECIALIST 2

OCCUPATIONAL THERAPIST

SOCIAL WORKER

PSYCHOLOGIST

PHYSIOTHERAPIST

CHILD LIFE THERAPIST

VMO

CMO

STAFF SPECIALIST

FELLOW

JMO

DIETICIAN

ADMINISTRATIVE ASSISTANT

SECRETARY

WARD CLERK

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NURSE EDUCATOR/CLINICAL NURSE EDUCATOR

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ENROLLED NURSE

ASSISTANT IN NURRSING

CLINICAL NURSE CONSULTANT

CLINICAL NURSE SPECIALIST 2

OCCUPATIONAL THERAPIST

SOCIAL WORKER

PSYCHOLOGIST

PHYSIOTHERAPIST

CHILD LIFE THERAPIST

VMO

CMO

STAFF SPECIALIST

FELLOW

JMO

DIETICIAN

ADMINISTRATIVE ASSISTANT

SECRETARY

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DIAGNOSTIC PROGRAM

Patients and Families

Why paperless• We must improve patient care and access• We must address financial sustainability

• Requires– Governance and Infrastructure– standardisation – Sharing– Advocacy– clinician experts

Service Value• Credibility of information• Feeling safe using the information• Better reflection of complexity• Safer documentation and patient care• Improved accuracy reporting up• Ability to refute inaccurate data and contribute

to understanding of paediatric differences

Future

• Connecting IT with strategy• Solving network gaps• Single patient view• Innovating• Automation • Reliability• Clinician driven

The searchable and shared recordSepsis Early Detection Logic

Streamlining multicentre clinical research

• The solution: Online data collection and multicentre project management for clinical research, in real time

• The benefits: - Minimise paper and streamline database creation– Data entry workload spread across research team– Delay in collation of results faster research outcomes– Potential to integrate with eMRs and other data sources

• PTNA = Paediatric Trials Network Australia– A new network of paediatric researchers committed to improving child

health through clinical research. (Institutional membership model)– Currently purchasing the above solution, which will be trialled by Dec 2012

and made more broadly available to the PTNA membership in Q2, 2013.– For more information, visit www.ptna.com.au

Advocacy

• Working with the

• Development of a set of Paediatric CCs and CCLs for Clinical Review– Step 1- Identifying diagnoses with a demonstrated impact on cost and

length of stay.– Step 2 – Assessment of paediatric vs adult impact of CC diagnoses by ADRG– Step 3 – Refine CC list to exclude CCs with high adult impact– Step 4 - Addition of closely related diagnosis codes to resulting CC list

• Need to recognise paed cost drivers, home and social context