Mazankowski Health Information/Records in the Out Patient Area

2. Mazankowski Health Information/Recordsin the Out Patient Area Presented by: Inger Eakin, Project Manager, Thanks to Terry Hogan, Patient Care Manager

3. Disclosure • No affiliation with pharmaceutical companies other than buying their OTC or prescribed products from the pharmacy. • No free gifts or payments accepted …from pharmaceutical companies. I do collect anything free I am given at trade shows and conferences… especially candy, stress balls, markers and pens… mostly pens. • A paid employee of Alberta Health Services, working as a Project Manager. I do not have clinical training.

4. Mission • To provide the highest quality of integrated cardiovascular care to Albertans and Western Canadians, pursue new knowledge through leading-edge cardiovascular research, educate the next generation of health professionals, and advance the frontiers of promoting heart health and preventing heart disease.

5. Unique features • Adult and children’s heart care under one roof • A fully integrated model • Research hospital within an Institute • Institute within a tertiary hospital • Institute within a University • Institute within a regional cardiac program • Institute within a provincial cardiac program • Alberta Cardiac Access Collaborative

6. Institute builds on strengths • 50 years of complex cardiac care • First open heart surgery in Canada (1956) • First heart transplant in Western Canada (1985) • Large programs with strong outcomes • Canada’s largest heart transplant program • All complex pediatric heart surgery for Western Canada with outcomes among the best in North America • Two of the largest training programs in Canada • Full range of heart care services – all in Edmonton

7. Physical Integration • Heart Institute is different from others in its physical integration under the same roof as the University of Alberta Hospital and Stollery Children's Hospital • With access to an acute care centre and children's hospital the Heart Institute accommodates both pediatric, adult heart patients and heart patients with other health problems.

8. Service Integration

9. Service Integration • Consolidation and expansion of cardiac surgery operating theatres and procedure rooms for both adult and pediatric surgery and transplantation. • Expansion and enhancement of interventional services such as cardiac catheterization and electrophysiology for both adult and pediatrics • Dedicated Cardiac MRI for adult and pediatric population (installed January 2011) • Sharing of outpatient resources by Cardiology and Cardiac Surgery

10. Patient Navigation Effectively moving patients move through the system Follow up and return to baseline Patient/Client symptoms Yes No Prevention Strategies ED • Self Serve Self Manage • Personal Portal • Information • Advice (HLA) Treatment Admit Procedure Diagnostic tests Family MD/PCN Consultant D/C Integrated Care Pathway Navigation Availability Monitoring Family MD Wait ED Wait (Room, Referral, admit) Diagnostic Wait (x-ray, Lab, other) Consultant Referral wait Procedure Wait Rehab Homecare Wait LOS F/U MD Wait measure Health Link Wait

11. Patient Centered Care • A goal of integration is to create an environment for patient centered care • A significant factor in the support of patient centered care is to have a fully integrated data management system that provides the clinician with a complete longitudinal picture of the patient's medical history and heart health.

12. Delivery of care • Specialized clinics • Cardiovascular Risk Reduction Clinic • Cardiac EASE Clinic • Heart Function Clinic • PCI Clinic • Chest Pain/Peripheral Chest Pain Clinic • Device clinics • Heart Transplant Clinic - Adult • Heart Transplant Clinic – Pediatric • Adult Congenital Heart Clinic (NAACH) • Digital Stethoscope - Telehealth service largely supports remote and under populated communities

13. Delivery of Care Diagnostic Tests • Electrocardiogram (ECG) • Echo • Transthoracic echocardiogram (TTE) • Transesophageal echocardiogram (TEE) • Stress Echo • Dobutamine Stress Echo (DSE) • Stress Tests • Cardiac catheterization (Cath) • Chest X-Ray • MethoxyisobutylIsonitrile Stress (MIBI) • Positron emission tomography (PET) • And many more.

14. Alberta Health Services (AHS)Information Systems • netCare – the AHS Electronic Health Record, is a collection of an individual's key health information stored electronically and accessed by authorized health providers to support patient care. Enterprise Master Patient Index (EMPI) - enterprise-wide directory created to link personal health information. The system contains demographic information for 1.6 million persons.

15. Developments • EPIC project – single vendor solution was selected for CH ambulatory care services and a choice for private MD practices/Primary Care Networks • Recent Implementation of Regional* - Diagnostic Imaging RIS – PAC’s system • Regional - ECG data management solution • Regional - Heart Rhythm device data management system * Regional – Capital Health–Edmonton

16. Scope of EPIC Project • Enterprise scheduling and registration, with patient registry connectivity (currently in use) • Ambulatory charting – documentation, results, order entry and clinical decision support • Administrative functions – reporting, support of billing and service log (work load measurement)

17. Electronic Medical Record (EMR) Challenges • Discussion of an EMR began in 1999 • Regional RFP process 2005 • Vendor/Product selection 2006 – EPIC • Collaborative validation sessions in spring of 2007 • Heart Institute inclusion in ambulatory EMR - 2008 • Organizational change of Alberta Health Services – resulting in slow down of decisions.

18. Cardiac EMR Decision • The question in 1999 was “Do we wait for the ultimate EMR solution to address our data issues?” • Since 1999 there have been five in house databases developed for sub-specialty out patient clinic services • Anticoagulation Management Services, Chest Pain Clinic, Heart Function Clinic, Cardiac EASE, Pulmonary Hypertension.

19. Cardiac EMR Results • These databases have met the information needs of the services – (utilization, patient history, outcomes). • Data captured in a format that can be eventually migrated • Service areas will be able to articulate data template requirements for EPIC EMR based on their experience • Data fields already identified

20. Diagnostic Imaging RIS – PAC’s Challenges • Ongoing project over a period of many years with recent implementation of a regional RIS – PACs system in May 2007 • Concurrent evaluation of “Heart Lab” solution as a cardiology specific system to integrate images/reports for Cardiac Catheterization Lab, Echocardiography Lab and Cardiac MRI. • Heart Lab solution recently rejected, returning to RFP process

21. Cardiac Imaging Decisions • Cardiac Cath Lab has been using Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease – APPROACH database to store cardiac pictorials and reports • Cardiac MRI - developed in house database for reporting for reading Cardiologists

22. Cardiac Imaging Decisions cont’d • Philip’s Enconcert cardiac ultrasound system implemented in 1998, upgraded to Xcelera in 2006 • Used both by Pediatrics and Adult ECHO lab’s for reporting and image storage • Evaluation of “Heart Lab” for two years held up archiving solution for 12 Terabytes of image data • Echo Reports have been trapped in proprietary system when netCare portal has been available

23. Cardiac Imaging Results • APPROACH database capturing provincial Cardiac Cath, HL7 interface to netCare or future EMR solution • Cardiac MRI will continue to capture reporting data • Archiving of ECHO images to temporary storage until long range plan developed (Terabytes) • Interface Xcelera reporting system with CH netCare portal – completed 2010

24. Regional ECG Data Management Challenges • Discussions began in 2001 for replacement of UAH/Stollery site ECG system (Mortara) • Regional RFP started in 2004 and completed 2005 • Philips TraceMasterVue (TMV) and Pagewriter Touch cart chosen for the region

25. ECG Decisions • Maintain the UAH/Stollery site ECG carts and data management system until introduction of system replacement • Migrate ECG’s to new system • Replace aging Holter monitoring and Exercise Tolerance testing equipment • Use TMV to store “waveforms” and reports for Holter monitoring and Exercise Tolerance Testing

26. ECG Results • Site implementation of carts and TMV October 2007 • Migrated approximately 500,000 ECG’s • ECG reports available on netCare • TMV presently not capable of storing “waveforms” from other test modalities • In the process of looking at a single vendorsolution for Holter and ETT’s

27. Regional Heart Rhythm Device Data Management System Challenges • Discussion began in 1998 among three major Pacemaker Clinics in the region to develop a database to better manage patients with device implants. Motivation was that patients often move between sites therefore necessary to centrally maintain current device information. • 2006 introduced Medtronic PaceArt system at four sites of five sites

28. Heart Rhythm Device Decision • 1999 the UAH site purchased a data management system (Concerto) for use in the clinic • Replaced the system in 2006 with Medtronic PaceArt system • Presently developing remote device monitoring & telehealth program for two of three vendor’s ICD (implantable cardioverter defribillators devices) • Developed – Privacy Impact Assessment completion at Maz site is in progress.

29. Heart Rhythm Device Results • Migrated patient/device data from 1999 system to PaceArt which allowed continuity in clinical information for last 8 years. • Even though all sites are using the same database a common repository of patient and device data has not been accomplished. Some changes to data fields by vendor will allow eventual merging of data. • PaceArt more sophisticated than Concerto, allows direct loading of pacing device data to database eliminating manual entry.

30. Summary of Big Challenges • Regional data management solutions to deal with multiple site needs • Time lines from initial discussion to implementation measured in years • Single vendor solutions not always feasible due to lack of functionality • Goal of integration of patient medical information from multiple data management systems

31. Summary of Tough Decisions • Don’t slip into a state of inaction waiting for the “ultimate solution” • Purchase or build with the intent to capture data in a format that can be migrated to the next system • Capturing patient data in silos and waiting for tools to allow integration (i.e. netCare – CH clinical portal, EPIC – CH EMR)

32. Present and Future Challenges • Tele-Homecare technology and management of data • Use of digital stethoscope in Telehealth follow up clinics – archiving heart sounds • Provincial privacy laws – Alberta – Health Information Act • Development of a web based Heart Institute clinical portal for cardiac patients

34. Medical record flow • The paper medical record flow is complex • Tests, charting, letters et al all included • Involves medical records staff, medical office assistants, RNs, NPs, LPNs, Unit Clerks, Physicians, Residents, Students, Technicians and more… • Power Trak • Medical records are scanned as they travel in and out of the out patient medical records area. In patient medical records has the same system.

35. Medical record flow • All the diagnostic tests, all charting notes and contact records with the patient within the out patient area are kept in the out patient medical record area. • All the originals are filed into the medical record chart. • Once all the tests, charting and letters is completed the chart is filed. • Mazankowski Photos.pptx

36. Questions ? Inger Eakin, BA Project Manager,Mazankowski Alberta Heart Institute 3H2.13, WMC University of Alberta Hospital 8440-112 Street Edmonton, AB T6G 2B7 Email: inger.eakin@albertahealthservices.caWeb: www.albertahealthservices.ca