Fully integrated v best of breed: St Stephen's Hervey Bay

There have been a couple of others in the running to be named Australia's first fully integrated digital hospital, but it looks like the new St Stephen's Private Hospital at Hervey Bay in Queensland is likely to claim the honours when it opens next week.

It will still need to scan in the paper medical records of patients previously admitted to St Stephen's older facilities – a day hospital at Hervey Bay and a medical and surgical admissions facility at Maryborough – but when new patients begin to be admitted to the new hospital, they will all have a full electronic medical record from day one.

Operated by UnitingCare Health (UCH), the $96 million, 96-bed private hospital has been several years in the planning, with specific funding for its eHealth component coming thanks to a large grant from the Commonwealth Health and Hospital Fund.

That fund allocated $21 million to ICT and eHealth alone, and along with $15.5 million from UCH and the main software vendor, Cerner, represents a huge investment in what is hoped will prove a pilot for further digitisation of UnitingCare's other hospital assets.

Both Macquarie University Hospital (MUH) in Sydney and Fiona Stanley Hospital (FSH) in Perth have boasted of being the first in the country to be completely paperless, but both have had well-publicised problems actually getting there.

MUH opened with an electronic medical record consisting predominantly of iSoft's suite, including iPM (webPAS), iCM and MedChart, along with MetaVision in intensive care, but is currently in the process of changing over to InterSystems' TrakCare.

The four-year-old hospital is predominantly digital, but before the implementation of a scanning solution and electronic discharge summaries, it was both receiving and generating paper documents.

Fiona Stanley too has had its problems and will not be completely digital for the foreseeable future, using a mixture of existing systems rather than implementing the big-bang EMR it had hoped to open with. (WA Health began moving patients from the Shenton Park rehabilitation hospital over to FSH last weekend, and acute admissions will begin next year.)

Also laying some claim to being on the way to full digitisation is Blacktown Hospital in Sydney, which has implemented a well-designed new system it is calling Paper-Lite. This includes a mixture of the Cerner EMR with other applications designed both in-house and by eHealth NSW.

For St Stephen's, the main claim is that it will be fully integrated, achieving HIMSS level 6 on opening due mainly to its fully electronic, closed loop medications management system, probably the only one of its kind in Australia. For UnitingCare's executive director, Richard Royle, a closed-loop EMM system is one of the key elements of a full EMR.

The St Stephen's system involves electronic orders at the bedside, integration with the pharmacy system, and electronic drug cabinets in each ward that is also linked to Cerner. Using overseas experiences, Mr Royle said UCH had worked with pharmaceutical companies to provide single-dose blister packs for each drug.

“The doctors will order their drugs, it goes electronically to the pharmacy, they pack them up in the individual blister packs and when the nurse comes to dispense the drug, the drug cabinet opens and there will be those individual blister packs in the tray,” he said.

“That means there is also barcoded medication administration which is linked with the pharmacy order that is in the EMR, and we have also installed a number of alerts in the electronic medication system.

“If the doctor has prescribed a drug that the patient is allergic to or prescribed the wrong dosage for the size of the patient or over the total maximum, it will trigger an alert in the system. This is a very complex system and we are essentially putting the full PBS in there. I know it has been done before, but we are going one step further by making it closed loop.”

Another key element in the move to full integration is the choice of main software vendor. UCH has used variations on Cerner's clinical information systems since 1999, when it was first implemented at the Wesley Hospital in Brisbane. While it isn't official, Cerner is likely to be rolled out in most of Queensland's public hospitals, probably including Hervey Bay Public Hospital, which is located adjacent to St Stephen's.

Mr Royle is not afraid to admit that UCH has had problems with the Cerner system, but was confident with the choice. Like NSW Health, which has implemented a rectification program to iron out problems with the software, UHC has worked with the US giant to try to overcome them.

“I’m not telling tales out of school if I tell you that we, like everyone else, have had significant problems with our software vendor,” he said. “When we implemented Cerner at Wesley in 1999 we had some significant problems with it, some of which was our fault and some of which was Cerner’s fault.

“But with this sort of expensive exercise, I have to be confident that the back-up that we are going to receive is great, so I personally made sure that I got to know the people at Cerner quite well. What I have done is set up an arrangement whereby I meet with essentially the number two and number three [executives] in Cerner quarterly by video conference.

“Anything that is going awry from my perspective and I can’t get help with in Australia, I essentially get help from Cerner in the US. To give them their due, they have responded very well.”

In addition to the ease with which St Stephen's will be able to communicate with the public system through the same clinical system, Mr Royle said it was the ability of the other clinical systems to easily integrate with Cerner that was one of the main reasons for his decision.

He compares the relatively small number of interfaces to third-party software that will be used at St Stephen's to the decision made at Fiona Stanley, where a best of breed platform was originally devised. It is this incredibly complex integration process with clinical systems, along with the enormous amount of work needed on non-clinical infrastructure, that caused the opening of FSH to be delayed by six months.

“[St Stephen's] will be the first fully integrated, digital architecture hospital in the country,” Mr Royle said. “What I mean by that is that we have 29 Cerner applications being put up. That includes all of the clinical side, and we have another 20 devices that link to it.”

The Cerner applications include inpatient pharmacy, surgery, anaesthetics, PowerOrders and PowerChart, critical care, clinical documentation with Dragon dictation and mPages ICU summary and mobile clinical review, as well as pathology specimen management and the CareAware suite for medical device connectivity, alarm management and care team communication.

Some of the third-party equipment includes a patient entertainment and education system, while Cerner is also providing comprehensive barcode scanning and real-time location systems both for patients and equipment.

For nursing staff, UCH has contracted Ascom to provide its workstation on wheels (WoW) solution, providing a fully integrated, fully mobile nursing station. Ascom will deliver 45 Advantech AMiS-50 WoWs together with integrated MedProx cabinets from Elliott Data as part of the solution.

“Our nurse call system is fully integrated with the EMR so every time a patient calls the nurse it is recorded on the EMR,” Mr Royle said. “The room link allows real-time location system for patients and the equipment. Every one of our clinical systems links into the EMR.

“This is integrated clinical architecture. If I look at some of the challenges and what has been happening at Fiona Stanley, one of the challenges is that ... there are 158 interfaces at Fiona Stanley. 158. They have a best of breed model, but history is showing that the more interfaces you have to build into a system the more challenges you will have.

“So what we have done is the opposite. There are actually only five clinical interfaces into the system, including pathology and radiology. There are a total of 30 interfaces but that also includes things like our finance system.”

While the technical achievements and planning are impressive, Mr Royle makes the point that building a successful integrated hospital is more about change management than the technology. In addition to recruiting a full-time chief medical information officer in Monica Trujillo, who will serve as a bridge between the organisation’s medical and IT departments, during the building phase a lot of time and energy has been spent on working with clinicians to get them up to speed.

“We are calling it clinical transformation,” he said. “We are not simply computerising. That statement in its own right means a whole piece of work. We have seven clinical transformation workgroups. We have engaged over 60 of our staff in these teams including over 28 doctors.

“What we are trying to do is ensure that what we are developing at Hervey Bay is able to be rolled out successfully across the whole group. We have a number of very senior specialist clinicians who are based at our hospitals in Brisbane who are well respected and they have been part of this engagement so the doctors at Hervey Bay can see that the key senior clinicians are also involved in establishing this.

“It has to be clinician driven and what I mean by a clinician is in the full sense of the word – that is doctors, nurses, and allied health professionals.

“[UCH's] director of intensive care is personally going to be up there with the clinicians and intensivists to step through any of the challenges that they have got before the system goes live, and that’s after we have done their one-on-one training,” he said.

“It is a major change piece for them. If you think about a 62-year-old surgeon who has been set in his ways for the last 30 years, you’re going to completely change the way he goes about ordering a drug. These are major change pieces that we are very very aware of.”

The hospital has also been working with local GPs to ensure they are happy with the new system. GPs will be able to network into the clinical system while their patients are in hospital and see orders and results, with referrals and discharges all done electronically. The plan is to link the hospital to the PCEHR in the future, with clinicians able to view the record from within Cerner and to send up discharge summaries.

UCH eventually hopes that St Stephen's will act as a population health pilot for the Wide Bay area, including both public and private hospitals, GPs and aged care facilities, Mr Royle said. “There is the opportunity here, in a confined population of 100,000 people and 56 doctors, to look at developing a true population health pilot.”

While the hospital may also work as a showcase for technology, for Mr Royle, the reason behind going fully digital is four-fold: quality, safety, efficiency and staff and patient satisfaction. “You can be very efficient and you can have great quality but if you don’t have the patient or the doctor or the nurse or your staff satisfied, you aren't ticking the boxes,” he said.

“I got together the top 50 executives across my group and we already have identified 21 KPIs that we are already measuring, which are in the areas of quality, safety, efficiency, and satisfaction. We are measuring them now and will be from measuring them for the first 12 months in significant depth for a research piece.

“There are some of the examples of what has been experienced in similar full EMR developments that have been successful in the States. There are about now just on 1000 of these around the world. I’m not anticipating that I’m going to save huge amounts of money on this but I think I’ll actually break even and that is after the additional costs from depreciation of the implementation.

“Where I believe I’m going to save the money or create benefits is in improved quality outcomes. We have already kicked some goals in that I have a number of people wanting to come and work with us. I’m quietly confident that the way that we put this together will end up continuing to attract and retain people.”

Posted in Australian eHealth

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