D igital M edical R ecord Project aka Scanned Medical Record

1. Stream 3c Digital Medical Record Projectaka Scanned Medical Record

2. Introduction

3. Background • In 2003, a working party was formed to evaluate options for management of storage of medical records. • It was predicted that within 2 years, all available space for records on-site would be consumed.

4. Current records storage Downstairs – medium-term storage Upstairs – medical records dept

5. Background • Options for resolution included: • Off-site storage with near-immediate availability of records • Expansion of existing space • Electronic document storage $250,000 per annum and increasing Not an option! Higher cost to implement Lower ongoing cost “Pays for itself” within 5 years Safety and quality improvements to clinical practice

6. Further analysis • The RHH now has four wards located off-site. • Record availability is a Safety and Quality issue. • On average each year, 40 ‘record unavailability’ incidents are reported, of which 14 have an actual outcome to the patient.

7. Why a Scanned Medical Record? • As the “e-health” world is realising, Electronic Health Records are several years away from maturity. • A recent report on European hospitals concluded “the number one priority for IT investment is in document management systems”†. • Necessary incremental waypoint on the path to full electronic health records Full paper Full electronic † E-health Insider, 17th March 2005. “Europe making progress to eHospitals”.

8. Project Governance • Implementation Steering Committee • Implementation Advisory Committee • Clinical Advisory Committee • Focus groups – DEM, WACS, Pathology

9. ImplementationSteering Committee

10. ImplementationAdvisory Committee Plus all members of the Implementation Committee

11. How will it work?

12. How project is structured • The group of clinicians on the Implementation Advisory Committee, plus the other committees and staff involved guide the functionality. • Key aim: Minimise impact on work practices and the provision of care.

13. Medical Records (Inpatient) • Medical records have two components: • The History – comprising all information from previous admissions and attendances. • The Current Record – when a patient is admitted or in attendance, this is where all new information goes. • 95% of the time, when the medical record is used on the ward, it is the current record which is accessed. • Historical information is generally of greater relevance during initial diagnosis, and may only be accessed once or twice during an admission (if at all).

14. Splitting the Medical Record • The Scanned Medical Record system will reinforce this division in utility. • All use of the current record will remain unchanged. • Pen-and-paper, generally the most efficient means of recording information, will not be changed. • From July 2006 onwards, all records from admissions and attendances that are received by PIMS will be scanned.

15. Using the “current record”

16. 2. New, empty current record folder created, with only alerts sheet and patient labels. 3. As care is provided, all documentation goes into the current record. 4. Upon discharge, the completed record is sent to PIMS, Medical Records. 1. Patient arrives at RHH 6. The record is available electronically 7. Once all QA processes have been performed, the paper is shredded 5. The contents of the folder are scanned

17. Using the “previous history”

18. 4. List of records available electronically and on paper 3. Log into SMR system, enter patient UR no. 2. Access to the history is needed 1. Patient arrives at RHH 5a. Use electronic record (admitted post-June ’06) 5b. Request retrieval of original paper record if necessary (pre-July ’06) Will automatically be retrieved for first ~18 months or so

19. Forms re-design

20. Forms re-design • All forms in use at RHH require minor re-design to incorporate a barcode in the top-left corner. • Example…

22. Forms re-design • Stocks of all “official” forms are being reprinted currently and will be phased-in as stocks run out. • Most areas of the RHH also use their own “unofficial forms” – forms which record patient information that comprises part of the medical record, but does not comply with Aust Standards for records forms. • Amnesty process – we will work with you to get a barcode on your form. • Please identify allsuch forms ASAP to Holly Derham:ext. 8687, email holly.derham@dhhs.tas.gov.au

23. Forms web-site • Statewide intranet page with all approved and unapproved forms. • Will replace photocopied/laminated master copies of all forms.

24. Security and backup

25. Security & Backup • More secure – auditable • Apply ‘privileges’ to pages (eg. Where legislation mandates) • Better backup – three different copies kept • Hobart • Launceston • Off-site tape backup

27. Demonstration

33. Display of Records • Records can be displayed full-screen by clicking on them. • Records can be zoomed in by right-clicking.

35. Image Quality • Previously, thermal-printed images like this would last ~ 5 years • Archives Act specifies at least 5 years (can be over 50). • With DMR, image is now permanent.

36. Electronic Information

37. Electronic Information • The RHH, and the Hospitals and Ambulance Service, has never had a defined strategy for integrating electronic clinical information. • There is demand for a “one stop shop” for access to information held electronically – eg. ED, Pathology, Pharmacy, Radiology, ECG etc. • Each new system we have introduced has always brought with it “yet another web page, yet another username and password”. • The InfoMedix software we are using will take an information feed from any of these sources and present it in-line with scanned information. One website, one username and password. • Pathology will be integrated at go-live. • Further down the track, can integrate pathology from any pathology lab, even those external to DHHS.

38. Pathology • Pathology working party has endorsed an interface that includes electronic sign-off • Potential to reduce paperwork dramatically and increase auditability • Eg. all path results accessed via SMR system • Doctors can click a “sign result” button that files the result against their name • Could have a “mark for further attention” button to highlight important results (eg. INR>4) • To be discussed with Clinician Reference Group prior to development.

40. Electronic forms • The InfoMedix software we will be implementing has electronic forms capability. • Following go-live, we will investigate uses for this technology. • Incrementally replace paper forms where benefit exists. • Eg. Emergency theatre bookings. • Eg. Forms for clinical research. • Comprise part of the medical record.

41. Accessing the system

42. Staff Specialist laptops • Each of the 70 staff specialist laptops have a connector for a wireless module. • RHH will equip the laptops with the wireless module to enable wireless access.

43. PCs to Access the System • New wireless devices – at least one per ward. • Staff specialist laptops – we will add wireless capabilities to the 70+ in use by RHH staff. • All clinics now have PCs. • Currently 1050 PCs at RHH – 1 for every FTE • Also rolling out 44 PCs to theatres and surgical areas.

44. Wireless networking • One of the goals of the project is to keep the history as accessible as it currently is – this includes the need for portability. • The wards of A block, B block and some of H block will get wireless networking, with full access to the DHHS network. • A block – Dwyer, Ortho, Paeds, DSU recovery, SSU, GSU • B block – DPM, 1BN, 1BS, 1BOP, 2BN, 2BS • H block – ICU, NSU, HDU • Off-site – GEM, TCU • All new building works (eg. DEM, four-storey infill building) • (The shape of D block makes cost prohibitive at this stage to add wireless to 2D and 3D). • The highest standard of security available will be applied. • Take PCs to the end of the bed and review path results etc. on ward rounds, or discuss history with patient.

45. New devices • PC technology is now sufficiently advanced that we may be able to deploy wireless “tablets”. • Weight ~ 700 to 900 grams. • Screen with stylus – no keyboard. • 4-6 hour battery life. • Our intention is to use these as the additional PCs for the wireless wards. • Pending DHHS approvals etc.

46. Custom solutions Laptops on trolleys New devices

47. Work to date

48. Work to date • Scanned Medical Record Project Steering Committee formed in June 2005. • Site visits conducted to evaluate viability of scanning. • RHH Executive gave approval for the project to be submitted for DHHS approval, funding the project through savings from avoidance of off-site storage. • Project encompasses the system itself, and the infrastructure needed in order to use it. • DHHS approval was given for the project to be conducted as a single, statewide information system. • To be implemented at RHH only initially. • We tendered for a suitable system Aug 05. Tender awarded Oct 05 to InfoMedix Pty Ltd. • InfoMedix CPF (Clinical Patient Folder) has just been implemented in a major Australian health network.

49. Work to date • Hardware acquisition • 2 x servers delivered and being configured • Four scanning workstations acquired • 1 for DEM • 3 for PIMS (high-volume scanners) • Network upgrades in key areas complete, to allow greater speed and reliability

50. Work to date • Software • Installed on test platform and operational • HL7 basic interface to go live this week • Training • Training programmes • Medical records employees commence April • Other employees commence May