Spade or Shovel?... Our approach to reducing the complexity and variation in the chemotherapy journey. HIC 2015 Helen Delimitros Jennifer Todio 1
About Us – Epworth HealthCare 2
Problems we faced…the why? 3
Managing a Complex Process with Paper Records 4
Managing Variation 5
Managing Disparate Access to Information 6
Pre Project Measures • Clinical experience and feedback • Riskman Incidents • Pharmacy Audits • Manual Chart Audits • Literature 7
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! 8
Higher Incidence Rate for Oncology Oncology Medication Riskman Incidents made up 30% of Total Reported Incidents 9
Clinical Risk 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. 10
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 11
Audit Findings Paper Chart Compliance % 120 100 Site 1 % 80 Site 2 % 60 40 20 0 12
Our Vision We wanted the Rainbow 13
Project Long Term Vision Legend EMR ARIA Pharmacy Ordering System Receives Treatment Summaries; Nursing Care Plans through Document Interface Clinician Places Clinician has real Changes to Drug One source of Order using time access to Order easily truth for drug Regimens +/- ARIA Patient identified order Other record Access to Data for Nurse & Drug Administration Management Toxicities, Treatment Pharmacist recorded on line and in real Reports & summary recorded Review on line Outcome Data time Order received through the ARIA Outbound Order’s Interface – Manual input eliminated 14
Technology Brief • Connecting the Radiation and Medical Oncology Records 15
Technology Brief • Chemotherapy Scheduling, Prescribing and Clinical Documentation at the Point of Care • Interfaces with PAS, Radiology and Pathology 16
Next Challenge…How were we going to approach it? Was it a Job for a Spade or a Shovel? 17
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. 18
Anticipated Challenges and Risks 1. Private Hospital Model – Sponsorship & Uptake 2. Organisational Culture & Staff Adoption 3. Infrastructure & Support Model 4. System Integration 19
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 20
Implementation Timeline Jan 15 5 Oncologists; Aug-15 Pharmacy; Feb 14 19 Oncologists Nursing Scheduling Go-Live Jun-14 - Jul-14 Feb-15 - May-15 Planning Next Phase Stabilisation/Review phase Jun - Sep Remaining Oncologists 01-Jan-14 01-Apr-14 01-Jul-14 01-Oct-14 01-Jan-15 01-Apr-15 01-Jul-15 21-Oct-13 30-Sep-15 21
Results/ Outcomes 22
Results: Uptake to Date % of Patients with Electronic Chemo Order by Oncologist 100 90 80 70 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 23
Results: Pre and Post Pre Post Disconnected Records. Connected Oncology Record. Difficult to find information. Fully electronic and indexed. Paper (11 Versions of chart); Electronic – 1 Version. 0/21 electronic prescribers. 19/21 electronic prescribers. Non compliant drug charts. 100% compliant drug orders. No decision support. Decision support. Regimens prescribed not peer 100% of Regimens peer reviewed. reviewed against standard/s. Handwritten Notes; Illegible; Electronic Notes; Treatment Not easily audited. Summary;100% audited. “Chinese Whispers” … One source of truth. 24
Results: Oncology Treatment Summary Structured Template – Standardised across sites. Data populates automatically from inputs during Patient Assessment and Treatment. 25
Results……Requirement for Ongoing Training, QA and Support 26
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 Too early to system ARIA • 7 were due to paper prescribing processes accurately 9 Dispensing errors reported in Riskman between measure Feb – Jun. • 1 attributed to an incorrectly configured Regimen (wrong diluent) • 3 errors prevented by using evidence based regimens in the electronic ordering system. 27
Comments from the floor “Love the fact that can see the I’m going to save 10,000 planned treatment dates!” hours from not having to collate data manually for management reports “ This has got lots of I don’t want to ever good things. I so like it! go back to booking It’s really good that I can in the diary now see the Patient’s that I know how to appointment for do it in ARIA! Radiotherapy Who thinks this is going to be fantastic?! I do!! “Awesome. That’s “How good is that!” great!”(Creating the (Reviewing the diagnosis treatment summary) and results) 28
Images from the floor 29
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. 31
Team Acknowledgments Phase 1 - Scheduling Phase 2 – Chemo Prescribing Paul Fenton - PM (Clinical) Dr Stephen Vaughan (Lead Oncologist) Lindsay Wills (ITS PM) Dr Y Tran, Dr R Jennens, Dr K Khamly, Suzanne Pohlner (Training & Dr B Shah, Dr S Kamel (Oncologists) Project Support) Chris Wall (ITS PM) Jonathan Hollis – Training & Andrew Fodor – CIS Communication Linda McGinn, Fran Cotching, Rahni Bettina Lijovic – BA Burleigh & Susan Bourke – Lead Nurses Jennifer Todio – Lead Pharmacist Jonathan Hollis – Communication & Change 32
Questions? Thank you for listening! …further Questions? Email Helen.Delimitros@epworth.org.au Jennifer.Todio@epworth.org.au 33
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