Information Management & Technology Division

SSWAHS Clinical Information Systems Strategy

Content of Presentation

Background to SSW Area Health Service

An overview of our clinical information systems strategy

Phases of the EMR development in the old CSAHS

How we are amalgamating clinical information systems from both old AHS

Current and planned projects

EMR Implementation challenges

Sydney South West AHS - Background

In July 2004, the NSW Minister for Health announced the consolidation area health services from 17 to 8 and on 1st January 2005 the former Central Sydney and South Western Sydney Area Health Services were merged to form Sydney South West Area Health Service (SSWAHS)

The area health service manages thirteen public hospitals and an extensive network of community health centres.

These hospitals and health services are located across sixteen local government areas of the inner and south west suburbs of Sydney, serve a population of over 1.4 million people and employ around 16,000 staff.

Clinical services are managed through a clinical stream structure which allows clinical decision making and planning throughout all levels of the organisation, by grouping and networking clinical services across all facilities.

The introduction of clinical streams in the Eastern Zone of SSWAHS (old Central Sydney AHS) in 1993 highlighted the need to provide clinicians with one point of access to a patient’s clinical information to support patient care decisions for the improvement of patient safety, quality of care and patient outcomes.

As a result, the EZ developed an enterprise wide clinical information systems strategy to deliver a single, integrated, patient-centered clinical information system (electronic medical record).

SSWAHS’ EMR architecture is based on a suite of Cerner applications that are interfaced via HL7 to several departmental information systems.

SSWAHS IM&T Strategy - Overview

The core functionality of the EMR is still being defined but currently includes:

Person Management (PAS) Scheduling Order Management Results Reporting Clinical Documentation (including care plans) Medical Record Tracking Clinical Coding Emergency Department Pathology Theatre Management Rules/Decision Support Medication Management (prescribing and medication admin record)

SSWAHS IM&T Strategy - Overview

Support continuous care improvement, research and resource management

Rationalise IM&T delivery, manage IT risk and maintain a reliable IT infrastructure

Provide secure and timely access to clinical information, from any where and for patients from all health care settings including community health

Reduce medical errors associated with missing, incomplete or illegible information

Increase efficiency in care treatment and reduce waste in the system

Improve patient satisfaction by reducing the duplication of records

Maintain patient privacy & confidentiality

SSWAHS IM&T Strategy SSWAHS IM&T Strategy

- Core objectives- Core objectives

Clinical Information Issues - 1995

Facility based MRNs - no ability to link patients across the AHS

Multiple departmental databases resulting in fragmented patient records and the inability for other departments to access that information

Issues with the timely availability and ease of access to all information about the patient

Multiple IT solutions supporting the same function

Data issues - duplication, inconsistency, fragmentation, illegibility and poor security

Y2K problems with several key information systems

In 1996 the Area started laying the foundation to support the clinical information systems strategy by installing Cerner’s patient-centred clinical results repository. This repository now contains over 100 million result records (medical imaging, cardiology and pathology) and has become an integral part of the patient-care process.

In 1997 as part of its Y2K program the EZ became an alpha-site for the Cerner Person Management module.

During 1998 and 1999 the EZ built on its clinical repository investment by adding the integrated person management, resource scheduling and electronic orders functions

Phase 1 - 1996 to 1999- The foundations

Interface Engine

RPAH

RF.

CRGH PAS

Rozelle

Balmain Radiology

• Add on-line scheduling

• Add on-line orders

CLINICAL REPOSITORY• Replace PAS systems with Cerner

Other Dept.sys

CRGH orders

CRGH sched

Person Mgt

Orders Scheduling

NEWAREA-WIDE (HNAM) CLINICAL REPOSITORY

Cardiology

Pathology

• Replace demographic and encounter interfaces

Phase 1 - 1996 to 1999- The foundations

OLD

Phase 2 - 1999 to 2000Phase 2 - 1999 to 2000Develop EMR Support Develop EMR Support

InfrastructureInfrastructure An EMR Group was established within the Information

Management and Technology Division to:

provide a business and information management perspective to IT solutions

and to manage the EMR application development, implementation, training, support and maintenance activities.

The team members do not have technical backgrounds and consist of mostly HIMs and clinicians with some clerical staff

Its important that the team have experience in and knowledge of the business of health care to ensure we can understand the end users needs in order to develop suitable systems and provide appropriate and effective training and support

Phase 3 – 2000 - 2004Phase 3 – 2000 - 2004Extend the EMRExtend the EMR

PAS - Implemented PAS in Nursing, Mental Health, Drug Health and Aged Care community based services

Results – incorporated more results such as nuclear medicine, trialed on-line endorsing/signing of results, implemented a PACS system

Orders – implemented diagnostic test and service orders at RPAH Medical Record tracking – implemented at Concord Scheduling – implemented at RPAH and extended within Concord Billing – utilised the scheduling module to automate the outpatient

billing process Clinical documentation – developed forms to collect clinical data

on-line for mental health, aged care and drug health (hospital and community based services), discharge referrals, rheumatology, renal and liver outpatient clinics and maternity and neonatal services.

The merge of CSAHS and SWSAHS (Western Zone) into one Area Health Service required the amalgamation of two Cerner databases into one.

Given the complexity of this task and the need to continue the implementation and development of the clinical components of the EMR, the amalgamation had to be done in stages.

Phase 4 – 2005 – 2007Phase 4 – 2005 – 2007Extend the existing EMR to WZ Extend the existing EMR to WZ and continue the development and continue the development

of the EMRof the EMR

Step 1 Step 1 – Interface Western Zone – Interface Western Zone PAS and copy historical WZ PAS and copy historical WZ PMI to the EMRPMI to the EMR

To incorporate WZ patient activity into the EMR and to facilitate the use of the EMR by WZ clinicians, new Western Zone patients and encounters and historical PMI data were published to the Area-wide EMR

SSW EMR PAS Clinical documentation Orders Results Scheduling Coding Medical Record Tracking

WZ PASS PAS Theatre Mgt Diet orders Scheduling Coding Medical Record Tracking

1. HL7 – ADT feed

1. Completed in April 20051. Completed in April 2005

2. Completed in July 20052. Completed in July 2005

2. PMI Conversion

Step 2 Step 2 – – Build PathNet inside the Build PathNet inside the EMR and implement in two Lab EMR and implement in two Lab ServicesServices

Western Zone – Completed 22nd November 2005

Eastern Zone – Completed 18th June 2006

Completed in November 2005

Step 3 Step 3 – – Convert historical results into Convert historical results into EMR and build feeds to Radiology EMR and build feeds to Radiology systems and implement results systems and implement results reporting for WZ cliniciansreporting for WZ clinicians

Step 4 Step 4 – – Implement electronic orders for Western Zone

The diet and diagnostic orders (Pathology, Radiology, Cardiology, etc) implementation commenced in January 2006 and implemented for all medical staff

Nurse orders being done in some departments such as Emergency and ICU (issues around co-sign)

Step 5 Step 5 – – Re-build WZ PASS Re-build WZ PASS requirements in SSW EMRrequirements in SSW EMR

This is a 15 month project to amalgamate WZ PASS and SSW EMR databases so only there is only one Cerner database for all SSW patients and staff.

Standardisation of the design was minimised – most will done post-amalgamation due to time constraints.

The project includes standardising and amalgamating the WZ and EZ Mental Health builds for community and hospital based services.

The first hospital will cut-over to the EMR on 1st November 2006 and the last in May 2007.

SSW EMR PAS Clinical documentation Orders Results Scheduling Coding Medical Record Tracking Theatre Mgt

Step 5 Step 5 – – Re-build WZ PASS Re-build WZ PASS requirements in SSW EMRrequirements in SSW EMR

WZ PASS PAS Theatre Mgt Diet orders Scheduling Coding Medical Record Tracking

Step 6 Step 6 – – Continue the development of the EMR, e.g.

Commenced implementing discharge referrals in the WZ

Implemented clinical documentation to allow electronic collection of GP Casualty data and production of referral letters at Balmain

Implemented orders at Balmain & Canterbury due in Jan 2007.

Implemented clinical documentation to support Community Nursing intake & referral processes & mandatory reporting (EZ)

Implemented clinical documentation to allow electronic collection of all EZ dialysis information (inpatient and outpatient) in the EMR

Replacing the DOH legacy maternity system with the SSW maternity and neonatal EMR in all 5 WZ maternity units on 1st December 2006.

Commenced the replacement of several standalone departmental databases such as Respiratory Medicine and Cancer Services by incorporating their requirements in Cerner

Planning underway to implement the Liver Outpatient EMR in the WZ

Step 6 Step 6 – – Continue the development of the EMR (cont)

Implementation of FirstNet (Cerner’s Emergency module) area wide in 2007

Commence extending the PAS and clinical documentation to the WZ community health services in 2007

Commence implementing full SurgiNet (Cerner’s theatre management module) functionality area-wide in 2007

Implement the Medical Record Publishing module to enable the reproduction of medical records as required e.g. for court

Implement clinical documentation to allow electronic collection of all Medical Oncology information into the EMR in early 2007 (includes electronic care plans)

Continue to automate individual clinical processes such as clinical handover

Implement sending discharge referrals to GPs via encrypted emails

Getting consensus on a standard means of collecting, storing and displaying data – necessary for decision support (rules) and data analysis

How to design the system for efficient data collection, location of relevant data and extraction of data

Development of downtime strategies - need dept procedures and technical solutions –mirrored databases, dual networks, etc

Migration from paper to electronic (impact on medical record business processes, ensuring users have access to all information and have knowledge of location of information)

Old issues, such as locating the paper chart, are replaced by new ones, such as how do you manage the release of information in an area-wide integrated electronic record

Managing the medico legal issues e.g. privacy & security – how to deal with privacy breaches, do we have to continue to print paper results if they are stored electronically

Challenges in developing the EMR

- Information Management -

Manage the change in work practice and overcoming workflow challenges e.g. how to do real-time data entry when you see 30 patients in a 4 hour clinic and how to effectively communicate with the patient while using the computer

Information Management and Technology culture – resistance to the EMR (because it can challenge bad work practices) and the corporate strategy (some depts. think they have good reasons to not be in the EMR)

Getting staff to understand that it is not an IT or information management project but rather a clinical system to assist in transforming the business processes of health care

Significant costs associated with the EMR – hardware, staff, software licenses, etc

Significant training implications – current training sessions are usually one off sessions of 1 – 1.5 hrs – this will need to increase.

Challenges in developing the EMR

- Organisational -

The need for an adequate number of clinical workstations that are appropriately located

Mobile computing needs e.g. for nurses administering medications and community health workers doing home visits

Remote access to information for VMOs and clinicians running clinics off-site e.g. in the country

Optimal performance and stability of the database

Resources required to develop the EMR and replace departmental databases in a timely fashion (to stop departments from investing in standalone departmental systems)

Challenges in developing the EMR

- Infrastructure -

SSW Electronic Medical Record Future State – end 2007

Data Mart Data

Mart DataMart

Clinical Documentation Orders Scheduling PathNet

Decision Support

FirstNet

Area-wide patient-centred data repository

PowerChart and Results

ReportingPAS

Medication Management

Multimedia SurgiNetCoding and

Medical Record Tracking

Research/Outcomes/QI Datamarts

End-user complex statistical queries

End-user ad-hoc reporting

Extracts

Interface Engine

PACS/RIS

Cardiology

Cbord

Firewalls

Internet

NSW Health

HIE

Extracts

Mandatory reporting

SSWAHS Clinicians remote accessUnder development

PKI

GPs

Discharge summaries

SSWAHS Clinicians

Retirement underway

paper

DataMart

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