Melbourne’s Royal Children’s Hospital has started the six-month countdown to go-live for its new $48 million electronic medical record, with plans on track to switch on all clinical functionality at the hospital on one day next April and go straight to HIMSS Stage 6, only the second hospital in the country to do so.
In what is the first implementation in Australia of an EMR from giant US vendor Epic, the keenly watched project will see the system go live with all clinical functionality fully implemented, including emergency, OR and anaesthesia, all specialist modules, full medications, orders and results, clinical documentation and scheduling.
The hospital’s current patient administration system and radiology and pathology systems will remain for the time being, but the hospital has purchased the full Epic enterprise suite and those functions will come online down the track.
Epic’s mobility solutions have also been purchased, with nurses able to take vitals and do documentation at the bedside through Epic’s Rover app, doctors provided with mobile access to patient charts, lists, scheduling and ePrescribing through the Android and iOS-enabled Haiku app, and iPad access to almost the full EMR for doctors through the Canto app.
The hospital will also have a portal to allow patients and families to enter information, see results and request appointments, and GPs and paediatricians will also be able to see their patient’s records and communicate with hospital clinicians through a secure web portal.
On April 29 next year, the hospital will go from a Stage 2.3 on the HIMSS electronic medical record adoption model (EMRAM) to a Stage 6, although the hospital has also bought the functionality to go to the highest level, Stage 7.
The implementation is big and bold and currently involves 70 full-time project staff – which will rise to 90 at the end of the month – but as project director Jackie McLeod says, it may take a village to raise a child, but it takes an army to implement an electronic medical record at a children’s hospital.
Ms McLeod told the Health Information Management Association of Australia’s (HIMAA) annual conference in Sydney yesterday that there is a huge organisational focus on the project but it was the first in which she was confident enough to allow a countdown clock to be set.
Having formerly overseen the implementation of iPM at Northern Health and the Cerner Millennium system at Austin Health, Ms McLeod has experience in implementing large IT systems in public hospitals, but the Children’s Hospital EMR project is one of the largest and closely watched the country has seen.
It is now at phase four of the 19 month-long project, with the system built and configured and testing starting last week. It is now getting to the pointy end of the project, but its planning seems to have been meticulous.
“In any of the other projects I’ve been involved in I would never have put up a go-live clock, but I feel absolutely confident with what we are doing and in the system we’ve got from Epic that we will go live and we will hit that date,” she said.
Eyes on the prize
Ms McLeod and her team are well aware that all eyes in the health IT industry in Australia are on them with the roll-out. The Royal Children’s is a landmark building for the city of Melbourne and the announcement of the winning tender for the EMR in April 2014 made a lot of headlines, including ranking as the most-read story on Pulse+IT for the whole year.
Ms McLeod told the conference that when the hospital opened in 2011 it was supposed to be fully digital but that didn’t happen and it still very much runs on a mixture of electronic and paper systems.
However, the move to a full EMR was not a question of if but when, she said. “We work in a beautiful hospital that was built to be a digital hospital and was opened as though it was going to be a digital hospital, but it’s not,” she said.
“We all understand where we need to be and it’s not here. But implementing an EMR is not about taking the paper and digitising it. That’s a scanned medical record and we did that in 2011. An EMR is so much more than that.
“Typically when we implement an EMR in this country we go module by module. We do a bit of something, we move from paper to an electronic system and we implement one module at a time.
“We’ve chosen not to do that because we don’t believe it is the safest way to implement. We also believe that you get much better benefits when you implement everything together, and you test and build everything together.”
The hospital will go live with full medications, results and orders, clinical documentation and scheduling, but unlike a lot of other EMR implementations, the specialist modules will also be switched on at the same time.
“We will be doing specialist cancer modules, specialist OR and anaesthetic modules, and they all sit together on an integrated database – no logging in and out of systems, all connected, all on the one database,” she said.
“That was a very strategic decision by the Children’s Hospital because we were unable to see, in our travels throughout the world, a best of breed hospital deliver the benefits that an integrated solution brings.”
In addition to providing Epic’s suite of mobile apps to its clinicians – the Rover app for nurses allows them to do medication administration, see their patient lists and their tasks and take vitals, and is supplied on a Motorola device – the hospital has also completed its integration of medical devices such as ICU monitors and ventilators with the EMR.
“That is live today, ready and waiting,” Ms McLeod said. “No longer will our intensive care nurses, our PICU and NICU nurses, spend time documenting on big foldouts. All of that information will go directly into the EMR.”
The hospital is also integrating with OnBase by Hyland, an enterprise content management system often used with Epic to provide clinicians with access to patient information stored outside of the EMR and to scanned documents. Ms McLeod said the hospital was converting its 17 million scanned documents into Hyland, which will also contain scanned paper documents such as ambulance charts.
Ms McLeod said the hospital still won’t be paperless but that is not the aim of the project. However, she does believe the the implementation will reduce paper use by at least 80 per cent.
In addition to the full clinical suite and mobile apps, the hospital will also implement Epic’s research and analytics capabilities to allow researchers from the co-located Murdoch Children’s Research Institute (MCRI) with access to the system.
MCRI has funded a researcher’s position on the project implementation team, and in the future, subject recruitment and identification for studies can automatically be done through Epic. The system is also be capable of embedded analytics and data warehousing.
GP and patient portals
The hospital is also very keen on opening up Epic’s capabilities to external providers and to patients themselves through portals. RCH will provide an external link allowing authorised general practitioners and private paediatricians a web-based portal into the Epic system.
This will allow GPs and paediatricians to view the EMR of their patients but also some limited functionality such as sending eReferrals and communicating securely with the treating hospital clinicians. The portal has the capability to allow GPs to order radiology and pathology but this will not be turned on for the go-live.
The hospital is also very excited about implementing what it is calling the My RCH Portal, Ms McLeod said. Based on out-of-the-box functionality called My Chart, the portal will be available to patients through the web, as an app and even through the Apple Watch.
“It’s an application that allows families and the patients to view and update information related to their care at the Children’s Hospital. It is a tool for them to manage their own healthcare and is a new way for us to put patients at the centre of care. We always talk about being family-centric and [how families] really need access to information. We are really excited about this. It is a new way to communicate between our clinicians and our patients and families.”
Ms McLeod said the hospital believed opening up the EMR to patients and their families will make a big difference to the way RCH provides care. While the benefits of sharing information with patients is well known and evidence for good health outcomes is mounting, some clinicians still struggle with the concept.
This is despite things like the US Open Notes project proving immensely popular and beneficial for patients and for their doctors, it will still take a bit of change management for some doctors to accept, she said. She cited a 2013 Accenture study that showed that Australian doctors were among the most conservative in their views on patient access to their medical information.
Only 18 per cent of Australian doctors thought patients should have full access to their medical records and yet 83 per cent said they wanted their patients to be more engaged in their own healthcare. This is despite evidence now showing a direct link between engaging patients in their own healthcare through access to information and better health outcomes.
The hospital has surveyed its clinicians and has developed a policy on who can use the portal and what information they can access, Ms McLeod said. For children under 12, only their parents or carers will have access to the record, but for kids aged between 12 and 16, both can have access.
“Once the child reaches 16, they then can consent for their parent or they can cut their parent off, which is an interesting discussion,” she said.
Patients and carers will be able to add information such as their medications, allergies and clinical problems to their records, and the hospital will run a pilot project to see trial allowing them to request, confirm and cancel appointments.
Patients and carers will be able to read their ambulatory progress notes so when they attend an outpatients clinic, by default their note will be released to them unless the doctor ticks a ‘not to be released’ box. They will also be able to request repeat scripts, view their care plans and participate in surveys and research studies.
The hospital has also decided to allow them to view their tests results, which will be released after eight days. While Ms McLeod says this will probably eventually be reduced to three days, many clinicians are still nervous about allowing patients to see pathology data.
“Patients and carers love the idea, particularly parents as they think it will help them make better decisions about their child, but some doctors had some very strong reactions,” she said. “A few strongly opposed it while others had a positive response. One said, ‘that’s not good, I think that’s inappropriate’. ‘That’s not good, that’s inappropriate.’ They had to say it twice so we really got it.”
The final countdown
For the Royal Children’s Hospital, the Epic project is well named. Ms McLeod said it had been the subject of a massive organisational focus at the hospital and was the biggest thing happening at the present time. And there’s still 185 days to go-live.
The planning for the project has truly been epic, and the implementation team has now grown to 70, with more to come.
“It takes a village to raise a child … but it takes an army to implement an EMR,” she said. “We are building a whole EMR – every specialist system is being built all at the one time. I have 12 doctors, seven pharmacists, five health information managers (HIMs), nine nurses, technical folk … we are a big team but this is what it takes to build and implement an EMR.”
Fifty implementation staff have completed training in the US, including Ms McLeod. This involved her gaining certification in the emergency department module through nine days of face-to-face courses, sitting three exams and completing two assignments, one of which took 45 hours to do. Those certified in the OR and anaesthetic course had to complete an assignment of over 160 hours.
“One of the reasons we chose Epic is because they have a very strong implementation philosophy,” she said. “You might be a great HIM or a great nurse or a great doctor, but that doesn’t mean you are a great EMR implementer. It takes resilience, it takes quick thinking, it takes an ability to respond to pressure, and you’ve got to be able to listen to people and understand what workflows look like. All of that and you have to be able to configure software.”
Now the focus is turning to training the hospital’s 4500 staff. This will involve role-based training with a minimum period of training for any clinicians of about six to nine hours. And training is mandatory – no one will be allowed to provide clinical care if they have not been trained.
“It is not an iPad – you cannot learn it by just picking it up and having a go,” Ms McLeod said. “In fact, you would be unsafe.”
Her team has 30 super trainers but is trialling a new model in which medical staff train other doctors. 58 doctors have put their hands up to be EMR trainers, which Ms McLeod said showed that clinicians were fully engaged in the roll-out.
“They picked this system – we had 24 clinicians involved in the evaluation panel,” she said. “They picked this system and they were involved in configuring this system and now they want to take the lead in educating their colleagues.”
Training will begin in earnest seven weeks ahead of go-live, and more than 200 superusers will be on hand post go-live, as will 24/7 supernumerary support. The team has even set up two “command centres” – one with space for 60 staff and one to look after the superusers. The hospital will also reduce outpatient activity in the first weeks of go-live.
“We will have personalisation labs so clinicians will have their favourites set prior to go-live and our project team is employed right up until six months post go-live,” she said. “The first four to six weeks is stabilisation and everything just gets fixed, and then we’ll move into an optimisation phase after that. Ongoing, we think we will have something like 40 EFT to look after this system.”
Ms McLeod is under no illusion that her task is huge – it is a $48 million project and perhaps the largest IT project in Victoria at the moment – and that many staff are worries about what will face them on the day their pens and paper are taken away.
However, she believes it will be a success. “You have to be honest with your staff but you have to say we will do whatever it takes to help you with this. You have to plan beyond go-live because go-live is just the start.
“It is a sprint to get to the starting block but this EMR will be with us for 20 years – it’s like a child and we have to nurture it and nourish it and make sure we have the right supports in place so we can make the best of it.