Cabrini goes mobile with MedChart
Melbourne's Cabrini Health has very much been a pioneer in using mobile devices for clinical use in Australia, having rolled out CSC's Mobility Suite back in 2011. Through their own personal devices, Cabrini's visiting specialists can check their patient lists and locate where their patients are, view a patient’s PACS image and result, and order and view pathology tests and results all via the webPAS patient administration system.
The next stage in the development of what is known as Cabrini Clinicals is what could easily be described as the nirvana of hospital IT for doctors: the ability to prescribe and review medications through an iPad-optimised version of CSC's MedChart medications management system. When radiology comes online, visiting specialists will have what is in effect a full electronic medical record in the palm of their hands.
For a not-for-profit private healthcare group like Cabrini it could have proven overly expensive, but the organisation's project team has taken a prudent approach to the roll-out. It has implemented MedChart first at its rehab and palliative care facilities before a planned go-live at the smaller Brighton facility in mid-August and then the 500-bed Malvern Hospital in November this year.
Judith Day, Cabrini's CFO/CIO, says the roll-out of MedChart will ultimately include integration with the hospitals' iPharmacy system, and will in effect be a closed loop medication process. “There are very few private hospitals that have implemented electronic medication management,” Ms Day says. “Once implemented the doctors will be able to launch MedChart from the clinical EMR system on their iPads and I don't think that is possible anywhere else in the country.”
Cabrini’s director of IT, Eddie Harrison, and EMR project director Paul Lanza have been working closely with CSC on developing mobile functionality for clinicians and Cabrini acts as a reference site for the IT vendor. In partnership with Cabrini's eMM project director Peter Bennett, Cabrini and CSC have developed the mobile version of MedChart for doctors to use on their iPads and are getting ready to give nurses access on Motion F5 tablet PCs.
When it all comes together, Ms Day says it will function as an EMR without having to invest in a system on the scale of Cerner, Epic or Allscripts. Cabrini is also working with Argus to develop a method to extract clinical information from the doctors' own medical records and channel it into webPAS, and when that happens, the hybrid system will contain all of the elements required for the traditional description of an EMR.
That's not to say it is an easy process, Ms Day says. “Medication management is one of those elements of an EMR that people steer away from because it is just so hard to implement, particularly in private [hospitals] where the doctors are not employed. We don't have registrars or interns, so it is the doctor being engaged or it's nothing.”
Cabrini first rolled MedChart out in its palliative care facility at Prahran and its two rehabilitation services in Elsternwick, with Brighton to go live in August and Malvern in November. The structure of the organisation has thrown up a few problems for the roll-out, particularly when it comes to transferring patients between sites, as well as during the transitional phase, but the idea was to iron out any problems before it went live in the acute setting.
Cabrini's medical director for home-based services, Jamie McDonald, says patients are at most risk when they are in transition, especially when they are transferred from one type of care to another such as from hospital to hospital in the home (HITH).
"The introduction of the Cabrini Clinicals and roll out of iPads to HITH staff has significantly reduced this risk and increased patient safety by providing instantly accessible progress notes and clinical results at the bedside,” Dr McDonald says.
“The intuitive nature of the eMM further enhances the functionality of the Cabrini Clinicals and having the iPad at the bedside fulfils our obligation to prescribe and administer the appropriate medication, thus diminishing risk and improving patient safety."
Early roll-outWhen Cabrini began the roll-out at Elsternwick and Prahran, a pharmacist was assigned to shadow the doctors on their ward rounds as they began to use MedChart. Mr Bennett says this allowed the pharmacist to observe what medications were most commonly prescribed by each doctor and she was then able to set up quick lists for those drugs, along with expanded protocols for commonly prescribed PRNs.
Those facilities have also installed a ward overview screen for the nurses, so they can easily see when medications are due without even having to go into MedChart. Mr Bennett – a former director of nursing at the palliative facility – jokes that the nurses have become a bit too attached to the convenience that the ward overview screen brings, but it has had the effect of eliminating any missed medications.
The organisation's pharmacy services will also be redesigned when the integration between iPharmacy and MedChart is delivered so that pharmacists are more involved in reconciling medications on admission and enabling the drug chart to be created before the doctors arrive. They then simply have to launch MedChart from their iPad and prescribe from there. This will also remove the need for doctors to sign batches of paper scripts, now that Medicare is taking action to remove the necessity to send in paper forms for PBS claiming.
“The doctors are very happy that they won't have to sign prescriptions any more,” Ms Day says. “In the private sector, doctors complete the medication chart but then when we dispense the medications we have to print off a script, bundle them up and send them to the doctors' rooms, where they have to sign them again. It drives them crazy but as we are rolling out MedChart now we can stop that. That is one of the benefits of implementing the system.”
For pharmacists, Ms Day says they currently spend a lot of time trying to read the doctor's handwriting on the paper medication chart but they will not have to worry about that any more. “One of the deliverables of the project was not to save money on pharmacists but to have them perform tasks that they are professionally trained to do and are more value added and rewarding.”
Ms Day says the potential of the new system is obvious, but that is not to say it is perfect. “Having said all of the good stuff, I don't want you to go away thinking that the doctors were completely enamoured right from the beginning and we still have our larger acute sites to come,” she says.
“There were frustrations in the team with people cancelling training or not turning up, which is why it's so important to do it on the smaller sites. Initially there was a problem with the way doctors had to find a patient in the system and then find them again in MedChart and that has been a little bit clunky.
“But I think there will be a revolution when they see that they'll be able to do all of their ordering and prescribing, and look at their images and their bloods and everything they need, all through the iPad. They'll now only have to search for the patient once.”
And down the track, when iPharmacy is integrated with MedChart, Cabrini will take another big step and roll out the Australian Medicines Terminology (AMT). While AMT has been used for small projects such as the new allergies and adverse events system being used at the Sydney Adventist Hospital, it is still very much in its early stages of implementation in Australia.
Cabrini will hopefully introduce AMT in the second half of next year, Mr Bennett says. “A common language has been part of the problem. We already order all of our chemotherapy electronically using Charm, but iPharmacy and MedChart all use a different coding system so getting one to talk to the other is very difficult in terms of drug information.
“We have worked very extensively with CSC because it is a big priority for us. It moves us much closer to that closed loop medication management.”
Role-based accessAnother thing to be resolved is access to the system using Cabrini's Active Directory for permanent and casual staff. This functionality will be available in a later version. Agency nurses who are unfamiliar with MedChart could be problematic at Cabrini Brighton and Malvern as there could be several on each shift, but Mr Bennett believes that they may have a solution for this.
As Cabrini gears up to roll MedChart out at the two acute hospitals, the team has organised the usual training programs and identified key users, and is also developing eLearning modules as well. However, Mr Bennett believes the best way to learn how to use a system is on the job, and both say that once doctors realise how easy it will be to use through their iPads, they will take to the new system quickly.
“Those key users will be supported during the very busy times between 7:30am and 9am and in the evening between six and nine, because they are the busiest times for drug rounds and also the busiest time for the doctors to do rounds in our setting,” Mr Bennett says. “They do rounds before and after their clinics and their public commitments.
“Training is important but we found with our previous experience that most of the learning happens at go live. It's when they actually start using it regularly that the questions are more realistic and the actions make sense when we are using real-life examples.”
All doctors will be encouraged to use the iPad version or a desktop PC, Ms Day says. “Our internal philosophy is MedChart or no chart because from a patient safety perspective we are not having a dual system. With this foundational work and the planned iPharmacy and MedChart integration, we can at least let the doctors know that with the introduction of MedChart we don't need paper scripts any more.”
David Hooke, a consultant nephrologist who was an early adopter of the iPad and Cabrini Clinicals, says the system is easy to use in that with just a few clicks, doctors have information at their fingertips.
“The pathology functionality has eliminated the need to phone nurses on the ward for results and eliminated the potential of misinterpretation of results,” Dr Hooke says. “It has provided better accuracy and readability of results. The greatest benefit is the ability to view, review and order pathology results whilst off site.”
Posted in Australian eHealth