Challenges in interoperability with endoscopy information system

In 2013, a state-wide endoscopy information system (EIS) based on ProVation MD software was rolled out across endoscopy units in public hospitals in NSW.

The system is able to interface with the various instances of patient administration systems used in NSW, predominantly Cerner and CSC's iPM, as well as the Cerner and Orion electronic medical records.

Now, endoscopists are able to embed clinical images into patient notes that are pre-populated by patient data from the PAS, and to link the report to the EMR. Clinicians are then able to access a PDF of the procedure note from within the medical record, or to click on a link to the endoscopy information system and view the full report and the associated images.

Doctors can also print out instructions for nurses in the recovery room, and instruction notes for the patient on what happened during the procedure and what they should do when they get home. Copies can also be sent to the federal government with the correct codes as part of the National Bowel Cancer Screening Program.

While this sounds like smooth sailing, for those implementing the system there were some challenges. The lack of a common patient identifier, the use of legacy medical record numbers and the problems raised by the different instances of PAS and EMR systems did not make life easy for the implementation teams.

Andrew Young, program manager for the EIS with NSW Health, told the eHealth Interoperability Conference held in Sydney last year that while there were definite challenges, for a health IT project it had all gone quite well.

Approximately 120,000 endoscopy procedures are carried out in NSW public hospitals every year, with the larger hospitals often providing up to 7000 per annum. The majority of information collected on these procedures was either recorded in paper notes – to which doctors often attached a print-out or photocopy of the images captured – or in siloed information systems that were unable to interact with other systems within the hospital or across the state.

Mr Young told the conference that there were three main drivers for installing a common EIS across endoscopy units in the state: the doctors wanted one – particularly the clinicians who are part of the NSW Agency for Clinical Innovation (ACI) gastroenterology network – and if the health service wanted to collect statistics or look at benchmarking for service improvement, it involved a lot of manual data trawling.

And as part of the National Bowel Cancer Screening Program, streamlined payments for procedures meant an electronic system was required, Mr Young said.

“With the screening program that is run by the Commonwealth government, patients are randomly selected and are sent letters advising them to go and have a colonoscopy to screen for bowel cancer,” he said.

“As a result of that, the doctors that perform the colonoscopies have two options: the patient turns up with their letter, their referral and all of the associated details. But some other patients see their letter and think it’s a good idea and go and do it, but they don’t take their letter or information with them to the doctor.

“The doctor will then receive a couple months later a letter from the Commonwealth government saying you saw this patient here a couple months ago, could you send us the details associated with the outcome, and associated with that is the payment.

“What that means is that the doctor, if they know the patient, they download the forms from the internet and manually complete them, or they have to retrospectively go and find the procedure notes for that patient, fill them in and send them back to the Commonwealth. There’s just a lot of manual data that has to be sent back.”

Mr Young said that prior to the implementation of the EIS, there was a lot of paper being used but seldom were images being attached to the notes. “Where there were images captured on those procedure notes, it was generally a photograph that had been scanned or photocopied and attached to the note. The quality of the image wasn’t very good.

“Where they did have information systems it was by hospital and by endoscopy unit. Some of the data may have been added to the medical record or transported between systems; we heard stories where people captured the data in their electronic system, they would print it out and send it to medical records, which is not too bad.

“Some of them scanned it and uploaded it to medical records, and other doctors said that they saved it to USB and the USB was then at the end of the week sent to medical records for printing or scanning. Other occurrences were where the doctor saved the data to the USB, took it to their rooms and printed it or had their secretary print it, scan it in and then email it back to themselves or email it to the hospital.

“So yes, the data was being moved around but the quality of the data was probably not optimal.”

In addition, as part of the Royal Australasian College of Surgeon's endoscopy accreditation scheme, certified proceduralists must do a manual tally of the amount of procedures performed to send to the college.

Electronic system

To overcome a lot of these inefficiencies, HealthShare NSW, in association with the ACI, rolled out the ProVation MD system in over 30 hospitals throughout the state. The system involves a dedicated workstation attached to the endoscope that captures the clinical images.

ProVation software also captures endoscopy procedure notes using data sets, which allows the user to build sentences from structured text and codified data.

“You can also capture up to about 100 images per procedure, not that you have to use all of those,” Mr Young said. “With some of the doctors, because you can capture images and store them, some of them go a bit nuts, but when they attach them to their reports they only use about five.

“A nice part of the system that we have implemented is that we have anatomical diagrams in there, so you can tag where the image was taken and any comments about that.”

While the image capture must be done through the ProVation workstation, doctors are able to write up their notes from anywhere in the hospital. The system is hosted centrally on NSW Health data centres.

“Once the information is captured, the doctors pretty much can go anywhere they want to write their notes up,” Mr Young said. “If they get called out somewhere else or they don’t complete their notes, they can go and sit on a hospital ward that has Citrix access or use a thin client and dial in, connect to our system, and type in their data. Many of them type up their notes while the room is being cleaned.”

In addition to electronic data capture, the EIS has been interfaced to each hospital's PAS and EMR, as well as internal scheduling systems. It was first implemented in the Hunter New England Local Health District with an interface to the PAS and the scheduling system, but clinicians there also said it would be of great benefit if it was implemented across the hospital and allowed other clinicians to see the results through the EMR.

However, Mr Young said that while the system is interoperable with the PAS, the scheduling system and the electronic medical record, there are multiple instances of each.

“Across NSW Health there are nine instances of a patient administration system,” Mr Young said. “They are largely Cerner and iSoft's (now CSC) iPM. With the scheduling it is again Cerner and iPM, and for the EMR, with the exception of one local health district that uses Orion, they use Cerner.

“So with our implementation of the EIS, there are now nine instances across the state.

“There is also an integration layer – the integration layer used across NSW is eGate but it is slowly moving towards JCAPS – but one of the complexities is who owns and manages each of these components.

“Some LHDs own, manage, operate and support their own PAS, scheduling and EMR, and some let NSW Health do it. Some operate their own PAS but not their own EMR system. And with the integration layer, some of the LHDs operate their own integration layer as well.

“It’s a nice puzzle in NSW Health.”

Patient identifiers

Another challenge is the lack of a single, unique patient identifier used across the state. Although the national Individual Healthcare Identifier (IHI) legislated in 2010 will eventually overcome this problem, most hospitals still use an internal identifier and often a separate medical record number (MRN). From an interoperability perspective, this is a huge challenge.

“NSW Health doesn’t have a single identifier and some of the LHDs operate an old Area Health Service identifier,” Mr Young said. “Some of them used a common identifier and would use that on their medical records, but others would use it as a secondary identifier, which meant that they still use their local medical record numbers.

“One of the problems is that your primary and secondary identifiers and your legacy medical record numbers are all sent in the HL7 stream. If they can’t be received, you get an error message and you start losing patients. That’s not a good place to be.”

Another example is the different codes that are used in hospitals, for instance those used for gender. Some used three and some four – predominately M, F, unknown or indeterminate. However, some hospitals use numerals such as 1, 2, 4 and 9 rather than letters or text.

“There were also differences between the different hospitals with scheduling systems,” he said. “While they were all using a scheduling system, some patients were scheduled in when they arrived while others were scheduled in way in advance. What that means is that you are receiving your data at different times.

“What that means is that you can't pick up one interface from one LHD and put it down into the same instance or a similar instance in another LHD,” he said.

Most LHDs were centrally hosting different components of the Citrix thin client environment, and there were also problems with authentication, as consultants pretty much only use this one system within the hospital and were in the habit of getting their secretaries or their interns to sign them in as they weren't quite sure how to do it themselves.

Accessing consultants and senior doctors for pre-training was also a bit difficult, Mr Young said. “Ringing up a doctor and saying can you give me two hours for training? That is not going to happen. So we set up a sort of drop-in centre, where the trainers would wait while the doctors were performing the procedures.”

They could then ask for 15 minutes to show them one aspect of the system, and they were able to learn it over time. “They won’t give you time beforehand but once they see the system and start using it, we got good buy-in,” Mr Young said.

Doctors have reported that on their first list, it took up to three times longer to complete the notes, but this has reduced somewhat to 1.5 times longer. However, Mr Young said the trade-off was the benefits they could see in having an electronic medical record and coded data.

There were also a lot of benefits being reported that are largely attributable to the interoperability of data and systems, he said.

“What it comes down to anyone who has access to the EMR has access to the procedure notes and the images. There are improvements in time-saving associated with the discharge summaries, patient enquiries, the National Bowel Cancer Screening program forms, and for pathology. The doctors also don’t have to physically walk back to the endoscopy unit.”

Posted in Australian eHealth

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