Blacktown shows how to go Paper-Lite in under two years

Blacktown Mt Druitt Hospital (BMDH) in Sydney's west has achieved the remarkable feat of converting a 500-bed acute facility with 2000 staff from a paper to a digital environment in less than two years, with no extra resources and with a minimum of fuss.

From first discussions in February 2013 to go-live in all 17 inpatient units in September this year, the hospital now completes 85 per cent of its clinical documentation electronically, including orders, results, consults, observation charts and discharge summaries.

It has introduced BYOD and corporate mobility, remote access, clinical and business support tools and is now about to introduce a scanning solution for paper records. It is also preparing for the statewide roll-out of electronic medications management and an electronic ICU system.

All this has been done with existing staff and existing hardware, with only a two-person IT project team that only came on board part of the way through the implementation. According to Peter Rophail, transition manager for the $324 million Blacktown Mt Druitt Hospital expansion project, it has been “cheap, quick and successful”.

Mr Rophail, a hospital physiotherapist, told an Australian Information Industry Association (AIIA) NSW healthcare special interest group meeting in Sydney today that the key to the success of the project was to not think of it as an IT implementation but as an exercise in clinical redesign.

“It is really about redesign and system improvement,” Mr Rophail said. “We are taking a different approach, where it is really about implementation rather than installation.”

BMDH is currently undergoing NSW's largest hospital capital works program, which will see a new building open at the end of next year at a cost of $322 million. In advance of the move to the new building, which will be completely paperless, BMDH decided to implement an electronic medical record and go as paperless as possible through a project known as Paper-Lite.

“We started to talk about this in February 2013 … about moving to a paperless environment,” Mr Rophail said. “There was really strong executive support for that and they essentially said we want to move paperless for a whole bunch of reasons, we can't give you any resources, but see what you can do.

“It has to be done before we finish the [redevelopment] because we want to move into our new building in a paperless environment. You've got about 30 months to do it.”

So they did. Mr Rophail said the project team looked at other jurisdictions as well as overseas to see how this sort of a transformational IT project could be best achieved, but most of those high-value projects took many years and many millions.

“That model was not going to work for us, so what we decided to do was flip it over from being an IT project to being a clinical redesign project,” he said. “That was really key. For the first six months, all we did was meet with clinicians once a month; we had a select group of clinicians that we had hand-picked to assist us with this. We didn't really talk about IT – we talked about clinical practice.

“At the end of that period we had a really clear set of priorities that were coming through from the clinicians in terms of what was required from our IT systems to improve the business. We did a proof of concept a few months later – we took all of those things, we trialled them, and we turned one ward digital for 24 hours just to see how that would look and socialise the ideas.

“Six months later we did an initial go-live, so we flipped a whole ward digital ... and then a few weeks after that we did the main go-live, where we did our other 16 inpatient units and brought the rest of the hospital on.”

Even though this was an incredibly fast implementation, Mr Rophail said that in retrospect the actual go-live period could have been much faster.

“From the thought bubble from the start to when it was finished was 19 months. The actual part of the implementation from we don't have a digital record to the whole hospital is digital, was about six weeks. In that six weeks, five of those weeks was us just learning the lessons of the first ward to go live, and then we flipped over the rest of the hospital in four days.

“There's lots of things we would have done differently, but we thought we would have one 28-bed unit go live and then we would need six or eight weeks to get the rest up to speed. We really should have done it one ward one week and the rest the next week.

“The program stretched out too long and small change is just as disruptive as big change. We needed the same resources and there was just as much disruption to do one unit as 16. We would have compressed the program. If I could go back now to when we did the proof of concept to when we finished the roll-out, it should have been 12 to 16 weeks as opposed to eight months.”

BMDH now has people from 10 local health districts (LHDs) throughout the state coming to see how it was done. eHealth NSW, which helped to develop some of the internal systems, is also keen to play a role in disseminating the lessons learned, as much of the technology used is part of the NSW statewide build.

The electronic medical record BMDH has used is the existing Cerner EMR, which allows mobile and remote viewing and creation of assessments and progress notes, pathology, imaging and dietary electronic orders, and discharge summaries and consultation notes. The project also involves improvements and new functionality to Cerner.

Clinicians can access the system wirelessly on their own devices or through laptops and COWs. All existing paper medical records and forms that cannot be made electronic are being scanned and incorporated into the system.

It also includes the well-regarded Between the Flags observation chart for nurses, which is integrated into Cerner, as well as an electronic dashboard for all active emergency theatre booking forms or green sheets.

A new patient summary is also included, called mPage, along with new forms for nursing and social work, allied health discharge summaries and clinical documentation for physiotherapy.

“It is essentially 85 per cent of our documentation,” Mr Rophail said. “[We have introduced] mobility, BYOD, which is really important but also corporate devices; remote access, which we've always had but have never really implemented well.

“Records scanning, so that we have a comprehensive digital record, and then introducing things like clinical support tools, using the fact that so much data is in the system to assist clinicians with making decisions, but also things like electronic theatre bookings and so on.

“Essentially, all of that has been implemented at Blacktown this year. In September, Blacktown became the first public hospital, in NSW certainly, arguably in Australia, to implement an electronic medical record for almost all of its inpatient documentation. That's a really big achievement.

“We did ours in a very short time and virtually within existing resources, so cheap, quick and successful.”

Just-in-time training and clinical risks

One of the most intriguing elements of the implementation was the use of just in time (JIT) training. Rather than the long and laborious task of shoehorning busy clinicians into classroom-based educational sessions on how to use the system, BMDH instead decided to teach each clinician what they needed to know when they needed to know it.

“Just in time training worked really well for us,” Mr Rophail said. “We started training our 2000 staff two weeks before go-live. We stripped down a four-hour training session to 10 minutes of key information, so that whenever Professor Whatever comes on the ward, someone can grab him and teach him everything he needs to know in five or 10 minutes rather than trying to do it through classroom-based training and all of the logistics and so on.”

He emphasised that it was very much a clinician-driven, clinician-owned process. “That sounds simple and easy to do, but to get clinicians to own and drive a project like this requires a lot of investment up front.

“That first six months, where all we did was talk to people, was really the key to the success of the whole project. By getting that bit right, the rest of it seemed to be pretty straightforward. We did bottom-up planning – clinical practice, what the gaps were, what the frustrations were in clinical practice, what the risks were – and then rolling them up to plan out solutions that might address those things.

“We started at a point that is confronting for some of our staff, [that] we are going to do this within existing resources. We are going to take what we have and what we can get through partnerships, and that's what we are going to use to implement this massive change. That starts the conversation at a completely different level.

“We took a really mature approach to managing risk and I think this is really important. In the clinical setting, resistance is expressed as risk. If a clinician doesn't want to do anything, they will tell you that it's unsafe and will affect the quality of care. That is really a cover for, 'I don't want to do it'.”

Marketing was used extensively, with a lime-green colour scheme chosen for communication materials, and the choice of the Paper-Lite brand. Mr Rophail said the hospital invested a lot of time in getting the marketing right. “When you are working in an organisation as big as our one – it's 2000 staff, 24 hours, seven days a week – you need a way to communicate messages and this was the vehicle for that,” he said.

And it was all pretty much achieved within existing resources.

“We did end up having to put someone part-time because no one understood the techie part, so we needed someone from IT ... and we also needed someone for a few months to do some building for us, so we did end up with a couple of positions.

“We didn't invest in any hardware – we reused what we already had – but subsequent to go-live we've now been able to get some additional devices procured to support it. Suddenly everyone is very interesting in being involved and having a role.

“The big one for us is that we would achieve our human objectives – we would still continue to deliver safe care efficiently but also that we had compliance. The struggle for us from the start was always about how to get 2000 clinicians to use this record in the way that it was intended. We've done that, so we are very happy.”

Posted in Australian eHealth

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