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NI Electronic Care Record (ECR)
Dr Roy HarperConsultant Physician and Endocrinologist
Desmond O’LoanHSCB e Health & Social Care Team
Content
Introduction & objective of sessionBackground to HSCNIChallenge to be solvedApproach to finding a solutionThe HSCNI ECR PilotFindings and business caseCommunications planClinical perspective & ChallengesConsent and confidentialityCurrent position & future plans
Objective of session
Business
Clinical
Technical
Background to HSCNI
HSCNI reorganisation 12 Trusts to 6 Trusts
1.8 million peopleRevenue constraintsLimited capitalEfficiency savingMove to community based careMultiple systems unconnectedShortage of skilled ICT hybrid staff
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
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
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.
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
Approach to finding a solution
Pilot first
Test our capability
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.
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”
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
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!”’
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
Technical design
Currently 16 interfaced systemsExternal 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
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.
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
Operational Design Overview
Technical Design Overview
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
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
Practical challenges
Interfaces – push-pull-batch-noneMaster Patient index – H&C No.Matching transactions to correct patientError handling replaying messagesMessages per day 80 0004000 Patients viewed per month 200 usersSpeed to build listsResist secondary use temptationZero footprint at users pc
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
Communications plan
How to involve the service Demos – lots Requirements specification Hospital ICT department challenges Clinically lead – clinical system
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.
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.
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
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.
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
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
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 “
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.
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
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.
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
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.
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
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.
Clinical perspective
Dr Harper
NI Electronic Care Record (ECR)
A Physician’s Perspective
NI Electronic Care Record (ECR)
A Physician’s Perspective
Dr Roy HarperConsultant Physician & Endocrinologist
The Ulster Hospital
Visiting Professor, School of Mathematics and Computing
The University of Ulster
Connected Health in NI
The road to a regional electronic care record for the population of NI
Experience so far
Strategy being realised
Connected Health in NI
The road to a regional electronic care record for the population of NI
Experience so far
Strategy being realised
“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
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
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
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.
Patient expectations Patient expectations
Timely, accessible and the best care possible Timely, accessible and the best care possible
Medical decisions based on accurate, current Medical decisions based on accurate, current and relevant information and relevant information
Patient care decisions made effectively and Patient care decisions made effectively and efficientlyefficiently
A safe positive experience and outcomeA safe positive experience and outcome
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
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.
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
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
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 (AmalgaTM)
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’
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
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)
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
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
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
Here’s what is happening Here’s what is happening
HSC decision to support a pilotHSC decision to support a pilot
Scoped out and integration provider Scoped out and integration provider procuredprocured
ECR pilot is up and runningECR pilot is up and running
Running for >12 monthsRunning for >12 months
Evaluated and made the case for roll outEvaluated and made the case for roll out
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
TodayToday
PAS A&EPACS
South Eastern
Labs Renal G P Comm
Others
H&C
Belfast Northern
Southern WesternWesternWestern
GP’s and CommunityServices
TomorrowTomorrow
Belfast
Western
Northern
Southern
Southeastern
Single sign-on, Security, Auditing, Business rules
Patient Access to Personal Health Records
GP’s
Safer, Faster, Better CareSwift access to relevant and timely informationLess time wasted searching for or requesting information
Cross-site information available, including GP drugs
Pre clinic preparationImproved face-to-face patient experienceMore efficient clinics
Ward rounds quicker and more effectiveBetter informed decision making
Rapidly increasing usage
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.
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
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)
What we need What we need
Continued investment in HSC ICT Continued investment in HSC ICT infrastructureinfrastructure
Support and long-term investment to Support and long-term investment to create a Regional ECR for the create a Regional ECR for the population of Northern Irelandpopulation of Northern Ireland
Support healthcare workers with the Support healthcare workers with the tools they needtools they need
Only the startOnly the start
Integrate more clinical systems (cardiology, Integrate more clinical systems (cardiology, oncology, TMS, renal, diabetes, community oncology, TMS, renal, diabetes, community systems, NISAT, RTM, screening services, systems, NISAT, RTM, screening services, mental health, etc)mental health, etc)
Link in with (subsume) ECS projectLink in with (subsume) ECS project
Alerting, chronic disease management support, Alerting, chronic disease management support, Audit, ResearchAudit, Research
Timescales
Business case approval Pending Procurement start October
2011 Contract sign March 2012 Roll out start Summer
2012
A NI-wide ECR
Making the right decision
for the right patient
at and in the right time
NI Electronic Care Record (ECR)
A Physician’s Perspective
NI Electronic Care Record (ECR)
A Physician’s Perspective
Dr Roy HarperConsultant Physician & Endocrinologist
The Ulster Hospital
Visiting Professor, School of Mathematics and Computing
The University of Ulster
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.
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
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
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
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
Summary
Introduction & objective of sessionBackground to HSCNIChallenge to be solvedApproach to finding a solutionThe HSCNI ECR PilotFindings and business caseCommunications planClinical perspective & ChallengesConsent and confidentialityCurrent position &