mHealth gives specialists what they want
As the executive director of medical services at Cabrini, part of Associate Professor Simon Woods’ job is to keep his 1200-strong list of accredited specialists happy and engaged. So when he noticed many of them turning up with iPads, he and his team decided to give them what they want and put access to their patient information in the palm of their hands, whether they are onsite or not.
Dr Woods has been working in hospitals since 1979, for the majority of the time as an upper gastrointestinal surgeon and now as executive director of medical services for the not-for-profit Cabrini. In that time, he has seen many IT systems come and many of them go – often with their tails between their legs, he says.
So when an anaesthetist bailed him up in the coffee line and told him that the new iPad-based patient information system Cabrini had just introduced was the best IT system he had ever used, Dr Woods knew he was onto something good.
Cabrini covers six campuses in Victoria, taking in two hospitals at Malvern and Brighton, two rehabilitation services in Elsternwick, a palliative care centre at Prahran and an aged care facility at Ashwood. At its 508-bed hospital at Malvern, Cabrini has set an ambitious target of installing a full electronic medical record, an electronic medication management system and an electronic discharge summary.
Three years ago, it installed CSC’s webPAS patient information and administration system, along with a new picture archiving and communication system from Intelerad, which comes with an InteleViewer system to enable clinicians to view images. It also has a separate IT system run by Pro Medicus that provides the reports.
Pathology results are provided by a system called Apollo, used by Melbourne Pathology, which also has a separate search function called Webster that allows clinicians on the wards to remotely access its pathology database over the internet. Cabrini is also planning on rolling out CSC’s MedChart medications management system.
While these new systems have reduced the number of older, uncommunicative systems Cabrini had previously used, it still meant that if doctors wanted to see one patient’s full results, such as x-rays, blood tests and their x-ray report, they effectively had to log in to two systems, Dr Woods says.
“We had also just about completed a WiFi rollout in all of the hospitals and had recently upgraded all of our monitoring software to a Philips system, which conveniently transmits all of its information back to a central server. But up to that point, we hadn’t done anything to take advantage of it.”
Then the iPad came out, and its potential, enthusiastically embraced by the medical community, was obvious, he says.
“About that time we were getting towards a full EMR and EMM and talking about the number of devices we’d need around the hospital. No one could see any particular point to the iPad for about 24 hours, and then suddenly realised what they had in their hand. We could see that our doctors were out there buying hardware, so it dawned on us that maybe we should let them buy the hardware, and we could concentrate on the software and the network.”
Keep the doctors happy
So that is exactly what Cabrini did. It decided to find an iPad-based solution that would initially allow the specialists to check on test results for their patients without having to make a phone call to the ward and interrupt the nurses.
“In a commercial environment like a private hospital, my job is to keep [the doctors] happy and I can't have them voting with their feet,” Prof Woods says. “So we actually asked clinicians what frustrated them – and I knew a little myself – about the day-to-day information you need to accumulate to make a clinical decision.
“Paper results all over the place: sometimes at the end of the bed, sometimes in a folder, sometimes in a fax machine, sometimes waiting to be filed, sometimes someone else has them in the medication room. And when you are away from the ward you have to ring up, and you don't even know if the result is actually back yet so you may have a five-minute unproductive phone call interrupting nursing care only to be told that no they don't have the results yet. This is a day-to-day thing that drives people nuts. It is not only unproductive for the doctors but disrupting to the nursing staff.”
Prof Woods and his team set out to try to make it easier for the medical staff, but rather than go for a big bang roll out of a complete system, to start off with some simple, highly desirable functionality and then build on that by asking the doctors what they wanted next. “The first priority was finding a new way to link to clinical results,” he says.
As Cabrini was already working with CSC – then iSOFT – on the roll-out of webPAS and plans for MedChart, the organisation decided to ask iSOFT to come up with a few ideas. “We set a simple challenge to iSOFT – we said we just want you to give us what we need, anywhere, anytime, whether we are on WiFi, whether we are on 3G, we don't want it to drop out when we go from ward to ward or go outside the hospital. We do not want to have a whole lot of log ins – if we have a secure log in to the iPad, we don't want to know what is going on in the background.”
What iSOFT came up with is now known as its Mobility Suite, which allows doctors secure access to a range of internal IT systems remotely, with one secure log-in. Given that Cabrini already had webPAS, which had a range of demographic data on each patient and where they were located, Prof Woods says his team decided to use that as a starting point for the new iPad system.
“As an unashamed Apple enthusiast, I said why can't you do it like Apple would do it, so you don't need to teach people and it would be obvious. We also needed to make sure it wasn't a one-trick pony and we could build on it, but the ultimate goal was to give them something they are going to want to use voluntarily.
“One thing we said was we don't really want a busy screen. We don't want a whole lot of drop-down boxes. We want one function per screen and we want to make sure that you can't get lost in the system. So if I want to do a ward round, I open the iPad and put in my password, it defaults to showing me my patients and where they are.
“When I touch on one of those patients, then it gives me the opportunity to do a whole lot of things. Routine biochemistry, pull up their CT or their plain films. Down in the emergency department they have a different view of it – they can see the next patient and what is wrong with them. They pull up their observations and fill in all of their case notes on this.
“Away from the hospital, I've got the same functionality – it doesn't matter if I am sitting at a desktop or looking at an iPhone. A lot of doctors rapidly put it on their iPhones, which wasn't our intention but others started using it on Android devices and it seems to work. They are all using it in their own way. For me, it doesn't matter.”
In addition to finding test results and demographic information, new functionality has been built in to include the clinical notes used in the emergency department and in Cabrini's Hospital in the Home service. “We are just about to launch test ordering; we are then looking to recording observations. We already can view realtime monitoring of any patient who is attached to a Phillips monitor. It is quite extraordinary to be able to sit at home and see what the oxygen saturation of an ICU patient is. This system is going to be our interface to MedChart, which we've begun deploying, so it will all be through the same interface.”
Prof Woods emphasises that any new IT system has to be designed with the clinician in mind and how they are going to be using it. “If you have enthusiasts, it is much more powerful than telling people what to do,” he says.
He tells the story of a multi-million dollar pathology system he had encountered in the past that had been designed to show the most recent results at the bottom of the screen, not the top. “You had to scroll down every result and for some of our patients who had 250 tests, that was rather cumbersome. When we pointed out that we'd actually like to see the recent results first, the IT department said that we'd 'get used to it in time'.”
The new Mobility Suite system first went live in May 2011, and by January this year there were 320 individual users. The amount of results viewed continues to increase and more people are using the system, he says.
“The doctors supply their own devices, and interestingly, we haven't had to resource this in terms of support. The only support we've had to give is to some doctors trying to set up their iPad. We don't have a training manual and we've run no training sessions in teaching people how to use it.”
His team has made an estimate on how many hours using the device has saved – adding up the odd 10 minutes clinicians were spending on the phone as well as nurses having to leave the patient – and the numbers are looking good. “If you just save 0.2 per cent of the time by having the result in your hand, you can order the next test or change the patient's treatment just one day earlier, that would translate to 480 bed days, and I think that is quite conservative,” he says.
“I was told by the wife of one of the surgeons that his night-time ritual is to sit on the edge of the bed and go through all of his patients and check their monitoring. It is the ability to check and make those real-time decisions... When I was in practice, I was in Amsterdam at a conference and I was worried about one of my patients who was in intensive care the day I had left. I could actually log in, look at his monitoring, look at his biochemistry and his x-rays, and I could ring his wife from the demographic data that was available to me. I could see a freeze frame of the current traces from ICU as of one minute before.”
Security and confidentiality have been tackled in two ways. There is a secure log-in, and the device closes out of any patient file if it has not been used for five minutes. In terms of confidentiality, Cabrini has relied on the professionalism of its specialists.
“The concern was that we can see other doctor's patient files, but effectively you can do that already, it is just clumsier. Any doctor can walk into any ward and open a patient file, pull up some x-rays or log in and see someone else's result. But a surgeon needs to have their files seen by a radiation oncologist – if you put boundaries around it, within our accredited specialists, it doesn't work.
“So we've relied on professionalism and just a little bit of Big Brother, so I leave my fingerprint on it. It says down the bottom, last used by Simon Woods and the time and date stamp. Some doctors who have been patients at Cabrini found that you could look up your own patient records but the reality is if other people want to look up my colonoscopy result, they can do it already.”
While project began to equip accredited specialists with easy access to test results and demographic data, it has not stopped there. Allied health and nursing staff are beginning to use the system in Cabrini's Hospital in the Home, and nurses in the emergency department use it all of the time.
The next stop is nurses on the wards. “Those nurses don't use it as yet, but as we roll out the EMM, they will.”
Posted in Australian eHealth