EDIS Clinical Documentation Project at SOGH ED

1. EDIS Clinical Documentation Project at SOGH ED Introduction of an Electronic Patient Record in an Emergency Department

2. Project Description • On March 12, 2013, SOGH was the first hospital in Manitoba to adopt electronic clinical documentation in an Emergency Department. • The program was limited by software constraints and design options. • This forced the adaptation of current emergency processes to match the product

3. Project Approach • Project delivered through Manitoba E-health and Organizational Change Management in collaboration with the SOGH and ED Team • Supported by the WRHA ED Leadership Team • Project utilized PRINCE2 structured methodology which entailed the use of both project assurance and quality controls

4. Why We Did It?

5. Project Objectives • Implementation of a fixed product and adapt the processes of an emergency to match • Exploitation of opportunity to further patient contact with the introduction of bedside charting • Address the challenges of technology limitations in the context of current practice

6. Project Objectives • Evolution of an exportable model to other emergency departments • Provides one documentation system that brings together patient information from health care disciplines providing service with the ED • Reduces time spent waiting and looking for information

7. Project Objectives • Reduces duplication of data entry • Reduces errors by improving legibility • Improves coordination of patient care within the ED, between ED’s in the WRHA and Primary Care

8. Project Objective • Integration of our care; communication with Primary Care • Integration with In-Patient documentation product ( this was developed first) • Constraints-little ability to customize/tailor to the needs of an emergency department and emergency department processes ( 130 visits/day, 8-10 admissions)

9. Project Objectives • Supports goal of continuity of care for the patient post discharge • Improves clinician access to patient info • Clinician can access from any networked workstation in the ED

10. Why Seven Oaks Emergency?

11. Reason for Choice of Site • Anti-fragility-A postulated antithesis to fragility where high-impact events or shocks can be beneficial. Anti-fragility is a concept developed by professor, former trader and former hedge fund manager Nassim Nicholas Taleb • Note- SOGH has displayed this quality in the last 5 years as we have developed a culture of continuous change

12. Reason for Choice of Site • 2 Project Leads from SOGH and had an understanding of existing culture • Both WRHA ED Program and Site leadership committed to successful implementation

13. Reasons for Choice of the Site • SOGH ED had been purposefully designed for future electronic documentation • Network drops, plugs and space at bedside to facilitate electronic documentation • SOGH had the least challenges with patient flow in the ED therefore inefficiencies brought up with learning a new process could be tolerated

14. Bedside Charting

15. Bedside Charting • Goal was to increase face-time with the patient • Opportunity to do this while waiting for documents to load • Availability of bedside results will enhance discussion and thus patient experience • Opportunity to integrate Patient Order Sets in developing a plan of care with the patient’s input

16. What We Did • Implemented Electronic Clinical Chart and Bedside charting • Introduced Patient Order Sets • Removed paper based reports, x-rays and labs • Did not go fully paperless, some orders still required transcription to a paper based requisistion • Did not have true order entry, not available at this site ( potential for errors)

17. Why We Did It • Introduced a number of changes all at once • Site readiness for change, high tolerance for change • Some concern about staff, people had changed since choosing SOGH • Challenge ( Did not have a product to try)

18. Why We Did It • Piloting at SOGH ensured lessons learned for other sites ( bleeding edge of technology) • Worked on assumptions that product could change- ie. Discharge summary document • Sold concept of artistic license ( an assumption) that product could be changed based on faith

19. What Went Well!

20. Implementation

21. Implementation • Very smooth implementation on Go-Live • Within hours, completely switched from paper to electronic documentation • 1 month after implementation stopped printing results • All staff now dependant on the new technology

22. Implementation

23. Implementation

24. Challenges • We did not have the opportunity to test the product • Software continued to evolve and develop in the background

25. Challenges • As a result, forced us to change existing processes • Document loading time 1hour downtime during an 8 hour shift • Some technical, some perceived security requirements led to increased wait time for log in/log out • Product could be used with mouse and text entry • A number of elements were developed/imported from the inpatient world realizing we would discard

26. Bedside Charting Challenges

27. Bedside Charting • Incredible challenge • Unique experience, adoption is slow, made worse by the technology • Rather than an ER –based document, a decision was made to modify in-patient documents. This created new challenges • The interface, keyboarding, increases documentation time

28. Bedside Charting • Changes required , to decrease log in times and time outs • Perception of lack of confidence/comfort with the technology when interacting/assessing patients • Vulnerability exposing self with learning a new skill in front of a patient

29. Proposed Solutions • Opportunity to develop a teaching session on how to do this • Option 1: Individual tablets Concerns: security, infection control • Option 2 a: Delay log off time Concerns: resource intensity ( servers) • Option 2 b: Proximity Card Access

30. Ehealth EDIS ClinDoc Training Implementation Reality Where do we go from here?

31. Training • Training was arranged through the Emergency EDIS Clinical Coordinator Subgroups • Medical Prescribers • Nursing • Clerical Staff • Allied Health Staff • Registration Staff

32. Training • Training station was placed before project rolled out in room 36 • Log in access to the program was not easily accessed so not many people had the opportunity to practice outside of the classroom scenarios. • As project was rolling out in the live version is where the project team encountered problems that were not tested in the test environment

33. Go Live • Ehealth provided access and system control at site, • ER program provided rovers from the pool of administration to help users implement program • Site had extra staffing for nursing to help all staff become fluent in using this new tool

34. Go Live • Multiple rovers to help front line staff from ehealth project, • Communications from a question and answer board to keep all information current • Post it notes questions? Answers! • Daily information bulletins to keep all staff informed of progress and solutions to problems encountered.

35. Bumps along the way • Some issues were that not all rovers had the same information with content of program and application at our site • As work flow became an issue particularly in MTA processes in using the document changed

36. Bumps Along the Way • Physicians used xrp as a way to park charts to catch up on discharge summaries later in shift. • Found out that this created problems for anyone who was admitted to our hospital as it erased entire hospital encounters

37. New Documentation • ER is the only place clin doc is live, the rest of the hospital has epr view only for results, demographics, allergies and health issues • All computer data has to be printed when patient is transferred to inpatient wards or out of hospital • Had to show rest of hospital what these new documents looked like and how to find information

38. Constraints of the Product • Every scenario developed, scrolling through a number of screens to find the correct scenario cumbersome • Product development not finalized till very close to the Go-Live • Impacted the ability to develop a teaching/communication plan until very close to implementation • Scripting and consistency were impacted as a result • Team were able to adapt quickly and gain from the adaptation

39. Reality • Clin Doc in place since March 2013 all patients have computerized documentation • Resus patients, code blue and patients coming straight into resus have reverted back to paper documentation. There have been issues related to speed in which document will load and take information • Patients who need treatment back in ER after have been admitted stay on paper

40. Gains • Discharge summary to primary care provider • Bedside charting • No trouble with legibility

41. Losses • Format of chart • Consistency of where information belongs • Consistency as to what information needs to be documented • Speed at which documentation is entered into a chart

42. Impact of New Technology • Dr. Paul Dowhanik- measuring impact of flow in new technology • Hybrid charting- blend of electronic and conventional documentation

43. Primary Care MD Feedback • Very positive feedback • Typed document more user friendly and safer • Mandatory fields in the product forced function. • ERP now documentation more information than ever before

44. What’s next • Ongoing auditing to compile standards on which information belongs in all documentation. • Consistency around all users putting information in the same places in the document. • Upgrades to system increase speed and access of documents

45. What’s Next • Rolling out to St Boniface Hospital ER in Nov 2013.