IT and JMOs in NSW

Deniz Durmush (Network 2 – Bankstown), Samuel Hall (Network 4 - Liverpool), Alana Lessi (Network 9 – Prince Of Wales), Vanessa Lusink (Network 12 – John Hunter),

Jessica Reagh (Network 6 - Hornsby), Samuel Roberts (Network 12 – John Hunter), Jaime Santibanez (Network 13 - Coffs Harbour), Michael Smith (Network 14 - Nepean)

Summary• Part A – State of IT in NSW health

– Importance of IT to JMOs– Survey responses and what different networks are using)– 5 most common grievances and successes– Electronic handover practices

» Medical Officers Notice Board» Electronic Whiteboard» Powerchart multipatient task list/medical handover

• Part B - Governance – Hierarchy tier

• Part C - Ways forward– Blackbox– Medcom2012 (Nepean)– Patient Controlled Electronic record– Ways for JMOs to get involved

Part A - State of IT

Importance of IT

• Ordering/reviewing pathology• Ordering/reviewing imaging• Electronic discharge summaries• Operation reports • Accessing medical resources• Patient contact information – LMO/specialists• Rosters• Discharge medications direct to pharmacy

(limited)

Interns spend 22% of their time on documentation and administrative tasks

Double the time spent on direct patient care[Westbrook et al. 2008]

Methods of investigating IT across different networks

• IT working group of the JMO forum was each assigned two area health services to obtain information from in the form of a semi-structured survey.

• This information was then pooled and evaluated in a qualitative nature through a round table discussion.

State of IT

• Various programs being utilised– Powerchart– Electronic whiteboard– Separate Pathology and Radiology programs (eg.

Auslab, Centricity and Intelliviewer)• Migratory workforce

– Registrars rotate through different networks – Poor orientation leads to lack of education and

interest in learning new programs and setting up electronic handover.

5 best attributes of IT

• Structuring medical handover and formalising communication between teams and after hours staff

• Ordering imaging and pathology• Access to imaging and pathology results• Access to patient medical records and details• Electronic medication charts (where utilised)

5 Common barriers

• Insufficient number of computers• No wireless capability or lack of access for JMOs• Different programs utilised for patient records,

pathology/radiology results and handover• Poor orientation and use of programs used across

medical staff• Lack of maintenance and capability of computers

• JMOs reported frequent difficulty in accessing computers in ward and office settings.

• That a majority of computers were needed for both urgent and non-urgent activities created problems in accessing them for the latter purpose.

• JMOs noted that computers frequently had to be shared with other health providers, and competing for access to them was not uncommon.

• A lack of office space, and functioning computer hardware therein, was also identified as significant issue.

• Being unable to locate and access computers is a source of immense frustration for JMOs.

Source: Australian Medical Association Council of Doctors-in-Training (AMACDT). October 2010.

JMO Clinical Handover Project

Compared different handover formats aiming to improve consistency, quality and patient care.

• Metropolitan and rural hospitals• Tested handover formats:

– Face/face, written, electronic– Meetings, rounds– Types of staff, levels of staff

Elements that improve handover from a JMO perspective:

• documentation (not duplication)• ISBAR: a clear framework (rather than rigid

structure)• locally appropriate• time efficient (improves attendance)• educational opportunity (improves quality

and quality of care)• integrated with registrar and consultant

handover (improve patient care)

In Short . . .

eHandover tools:– allow documentation– force structured thinking (ISBAR entry boxes)– have potential to improve efficiency by allowing

overtime staff to view and prioritise all current jobs.

In Practice . . • Not all hospitals have electronic handover systems• Mode of use varies:

– A whiteboard that runs day and night– Documentation for the handover meeting– Documentation for overtime staff from day staff– Current jobs list for overtime staff from nurses on the

ward• Users:

– Mainly teams to RMOs (but often not back to teams)– Nurses to nurses (shift summary)

Powerchart multipatient task list / Ad Hoc list

Case Study: JMO experience in a Network 1 hospital• Official handover requirement: add to Ad Hoc list of

Powerchart; discuss at handover meeting– New admissions– Clinical emergencies– sick patients, patients requiring review after hours

• Ad Hoc list discussed at handover meeting with all overtime staff present

WAND / MEDCOM

Case Study: JMO experience in a Network 14 hospital

• Official handover requirement: WAND (for nurse/nurse) and MedCom (for Dr/Dr)

• MedCom is currently being trialled• Job management assistance as organises

entries ward by ward, can ‘flag’ a sick review or timed ward task

Medical Officers Noticeboard (MON)

• Effective Communication of Non-Urgent Jobs• Increased efficiency of JMOs on overtime

shifts• Replaces traditional paging or whiteboard

system• Rolled out across 4 hospitals across HNEAHS• Also has an avenue for electronic

handover/flagging “sick” patients

Implementation

• After initial mistrust now very well accepted by both medical and nursing staff

• Felt to be more efficient by medical and nursing staff

• Push for greater implementation into other hospitals now comes from JMOs

• Anecdotally…much better!

Part B - Governance

IT systems structure• There is a central administration. Each hospital network has a

CIO (chief information officer). Each hospital has in house desktop support.

• The IT program of NSW doesn't write or develop software. It uses health support services.

1. Information management (project management)2. IT operations 3. Knowledge development (designs and improves interface)4. Client services - this would be the department that would be

consulted regarding creating an new project. Projects need to be registered as part of a strategy plan

5. Business

IT working group

Part C: Where to from here?

iHandover

• Many disparate systems generated from interested parties across different area health services

– All agree on ISBAR

• Will discussions between nursing and doctors become a part of the patient’s health record?

MedCom at Network 14: format

MedCom at Network 14: handover

MedCom at Network 14: jobs

MedCom at Network 14: clinical r/v

Patient results & smart devices

• ‘Black Box’ application at Westmead and Nepean hospitals

– Access Cerner Powerchart Pathology results

– Patient search/ Location/Provider list functions

– For iPad, iPhone and Android users

Black Box Trial

Individual Health Identifier (IHI) &Personally-Controlled eHealth Record

(PCEHR)

PCEHR

• Benefits for JMOs

– Reasonably accurate record of their health in one location

– Potentially reduce chasing of previous medical history

PCEHR

• Cons

– May not be a complete record of health info

– Patients may supress certain important aspects of medical hx (eg drug and mental health issues)

Participation in PCEHR

• May be difficult to encourage participants to create PCEHR

• eHealth in USA

– Meaningful Use program aims to get electronic health programs adopted into the health care system faster.

• Pays providers to create HER (electronic health records)

The paperless hospital

• Macquarie University Hospital: collaboration with School of Advanced medicine– 187 beds, 16 OTs, no paper records

Electronic Medication Charts

• MedChart has been used at St. Vincent’s Hospital since 2004 and Macquarie University Hospital in 2010

• New Zealand plans to fund an electronic medication management system starting at Dunedin Hospital.

• NHS in UK has initiated plans to roll up ePMA (an electronic medication chart).

Research for electronic MedCharts

• Westbrook et al looked at the effects of electronic med charts

– “…significant decreases in medication error when ePrescribing systems were used”

– Serious errors decreased by 44%

Future state - Clinical systems strategy 2012-2016

Source - Information Management & Technology Strategic Plan 2012-2016

Other Projects NSW IT has planned

• eMR 2• CHOC (Community Health and Outpatient Care) • Electronic Medication Management (EMM) (tender) • Intensive Care Information System (tender) • Endoscopy Information System• A new Laboratory Information System. • Policy on using mobile devices

How JMOs can be involved in IT development?

Met with CIO for Northern Sydney Health Area who suggested:– JMOs attend the local IMC (information

management committee) meetings which occur at each major hospital network.

• Monthly reports are created and discussed and it would be a good avenue for JMOs to get involved

References

1. NSW Health media release:12 October 2009 “Caring Together: standard principles for handover to improve patient care”. http://www.health.nsw.gov.au/news/2009/20091012_00.html

2. WHO The Research Priority Setting Working Group, December 2008. “Global Priorities for Research in Patient Safety “http://www.who.int/patientsafety/research/priorities/global_priorities_patient_safety_research.pdf

3. NSW Health “Clinical Handover - Standard Key Principles “, Doc No.: PD2009_060. http://www.health.nsw.gov.au/policies/pd/2009/PD2009_060.html

4. NSW Health Acute Care Taskforce “Improving JMO Clinical Handover at all shift changes, Final Report”. November 2010

5. National e-Health Transition Authority (NeHTA) prepared by the Australian Medical Association Council of Doctors-in-Training (AMACDT) “Implementing electronic discharge summaries: the JMO perspective”. October 2010]

6. NSW Health Northern Sydney Health District. “Information Management and Technology Strategic Plan 2012-2016. May 2012.

7. Westbrook JI, Reckmann M, Li L, Runciman WB, Burke R, et al. (2012) Effects of Two Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-Patients: A Before and After Study. PLoS Med 9(1): e1001164. doi:10.1371/journal.pmed.1001164