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 &