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Spade or Shovel?...
Our approach to reducing the complexity and variation in the chemotherapy journey.
Helen Delimitros
Jennifer Todio
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HIC 2015
About Us – Epworth HealthCare
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Problems we faced…the why?
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Managing a Complex Process with Paper Records
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Managing Variation
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Managing Disparate Access to Information
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Pre Project Measures
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• Clinical experience and feedback
• Riskman Incidents
• Pharmacy Audits
• Manual Chart Audits
• Literature
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Contrast with Pharmacy Audit -Incident rate of 38 prescribing errors/1000 bed days, compared with 6/1000 reported in Riskman, compared with 0.17/1000 hospital wide!
Higher Incidence Rate for Oncology
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Oncology Medication Riskman Incidents made up 30% of Total Reported Incidents
Clinical Risk
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Prescribing errors with the potential to cause harm frequently go undetected.
Reported incidents do not reflect the profile of medication errors.
Only 1.3% of clinically important prescribing errors with the potential to do patient harm were reported in hospital incident systems.
Paper Chart Audit
• Assessed 100 charts for compliance against key COSA guidelines
o Patient ID Criteria
o Height/weight/BSA
o Diagnosis
o All drugs ordered
o Administration route and mode
o Prescriber name and signature
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Audit Findings
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0
20
40
60
80
100
120
Paper Chart Compliance %
Site 1 %
Site 2 %
Our Vision
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We wanted the Rainbow
Project Long Term Vision
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Receives Treatment Summaries; Nursing Care Plans through Document Interface
Order received through the ARIA Outbound Order’s Interface – Manual input eliminated
Nurse & Pharmacist
Review on line
EMRLegend ARIAPharmacy Ordering System
Changes to Drug Order easily
identified
One source of truth for drug
order
Drug Administration recorded on line and in real
time
Clinician Places Order using
Regimens +/-Other
Clinician has real time access to ARIA Patient
record
Toxicities, Treatment summary recorded
Access to Data for Management
Reports & Outcome Data
Technology Brief
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• Connecting the Radiation and Medical Oncology Records
Technology Brief
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• Chemotherapy Scheduling, Prescribing and Clinical Documentation at the Point of Care
• Interfaces with PAS, Radiology and Pathology
Next Challenge…How were we going to approach it? Was it a Job for a Spade or a Shovel?
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Depends on the job in hand
• Shovels are designed for
- Digging big holes
• Spades are designed for
- Defining edges
- Digging hard ground that
must be moved with
substantial force.
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Anticipated Challenges and Risks
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1. Private Hospital Model –Sponsorship & Uptake
2. Organisational Culture & Staff Adoption
3. Infrastructure & SupportModel
4. System Integration
Our Approach
• Started with the “Spade”o Used to define the edge – lead adopters; build
and refine; allow time for change to sink in;
o Minimised the risk of digging ourselves into a big hole (delicate nature of the private hospital model; immaturity with large scale IT change)
• Continued with the “Shovel”o Targeted remaining Oncologists & high Referrers
o 3-4 month roll out
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Implementation Timeline
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21-Oct-13 30-Sep-15
01-Jan-14 01-Apr-14 01-Jul-14 01-Oct-14 01-Jan-15 01-Apr-15 01-Jul-15
Feb 14
Scheduling Go-Live
Jan 15
5 Oncologists; Pharmacy;
Nursing
Jun-14 - Jul-14
Planning Next Phase
Feb-15 - May-15
Stabilisation/Review phase
Jun - Sep
Remaining Oncologists
Aug-15
19 Oncologists
Results/ Outcomes
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Results: Uptake to Date
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0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
% of Patients with Electronic Chemo Order by Oncologist
Results: Pre and Post
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Disconnected Records.Difficult to find information.
Connected Oncology Record.Fully electronic and indexed.
Pre Post
Regimens prescribed not peer reviewed.
100% of Regimens peer reviewed against standard/s.
100% compliant drug orders.Decision support.
Electronic – 1 Version.19/21 electronic prescribers.
Non compliant drug charts.No decision support.
Paper (11 Versions of chart); 0/21 electronic prescribers.
Handwritten Notes; Illegible; Not easily audited. “Chinese Whispers” …
Electronic Notes; Treatment Summary;100% audited. One source of truth.
Results: Oncology Treatment Summary
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Structured Template – Standardised across sites.Data populates automatically from inputs during
Patient Assessment and Treatment.
Results……Requirement for Ongoing Training, QA and Support
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Reported Incidents to Date…
8 Prescribing errors reported in Riskman for the project sites between Feb – Jun. • 1 was attributed to using the electronic chemotherapy prescribing
system ARIA
• 7 were due to paper prescribing processes
9 Dispensing errors reported in Riskman between Feb – Jun. • 1 attributed to an incorrectly configured Regimen (wrong diluent)
• 3 errors prevented by using evidence based regimens in the electronic ordering system.
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Too early to accurately measure
Comments from the floor
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“ This has got lots of good things. I so like it!
I’m going to save 10,000 hours from not having to collate data manually for
management reports
Who thinks this is going to be fantastic?! I do!!
It’s really good that I can see the Patient’s appointment for
Radiotherapy
I don’t want to ever go back to booking
in the diary now that I know how to
do it in ARIA!
“Love the fact that can see the planned treatment dates!”
“How good is that!”(Reviewing the diagnosis
and results)
“Awesome. That’s great!”(Creating the treatment summary)
Images from the floor
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Images from the floor
30 HD
Conclusion
• While you can manage with only a spade or shovel, we concluded that our project was successful because we used both.
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Team Acknowledgments
Phase 2 – Chemo Prescribing
Dr Stephen Vaughan (Lead Oncologist)
Dr Y Tran, Dr R Jennens, Dr K Khamly,
Dr B Shah, Dr S Kamel (Oncologists)
Chris Wall (ITS PM)
Andrew Fodor – CIS
Linda McGinn, Fran Cotching, RahniBurleigh & Susan Bourke – Lead Nurses
Jennifer Todio – Lead Pharmacist
Jonathan Hollis – Communication & Change
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Phase 1 - Scheduling
Paul Fenton - PM (Clinical)
Lindsay Wills (ITS PM)
Suzanne Pohlner (Training & Project Support)
Jonathan Hollis – Training & Communication
Bettina Lijovic – BA
