Medical device integration and the paperless hospital
St Stephen's Hospital in Queensland's Hervey Bay is currently running a benefits realisation study in association with PwC as well as some studies on nursing workflows to accurately measure the effects on safety and quality of care of its integrated electronic medical record and medical devices.
The $96 million, 96-bed St Stephen's, which opened in October last year, has implemented 29 applications in the Cerner Millennium suite including Cerner's CareAware iBus solution for device connectivity, with 20 medical devices now integrated with the EMR and using it as the single source of truth.
Patricia Liebke, eHealth learning and change manager with UnitingCare Health, told the Health Informatics Conference (HIC 2015) in Brisbane recently that while there is a view that a high-tech hospital could mean healthcare becomes less personal, St Stephen's is finding the opposite.
US research has shown that device integration in particular can improve patient outcomes and length of stay, as well as freeing up nurses to provide hands-on care at the bedside, Ms Liebke, herself a nurse, said.
St Stephen's is being used as a showcase of what the digital hospital can look like in Australia. UnitingCare Health successfully bid for $47.1 million in funding for the hospital under the Commonwealth Health and Hospital Fund for regional and rural health services in 2010, with $25.9m going towards the construction cost and $21.2 million specifically for eHealth.
The idea was to build a fully digital hospital featuring an integrated eHealth solution with medical device integration and as few interfaces as possible, and with the ambition of becoming the first hospital in Australia to be awarded HIMSS Level 6. This it achieved six weeks after opening.
In addition to the 29 Cerner Millennium applications, including PowerChart, medications management, Surginet and anaesthesia, St Stephen's is using the CareAware suite for medical device connectivity, alarm management and care team communication.
CareAware has plug-and-play capabilities for connecting any medical device to any EHR system, and places the EHR at the centre of all information about the patient to create a single source of truth.
St Stephen's also has bi-directional interfaces to the hospital's pathology, radiology and pharmacy systems, meaning orders can be sent from the EMR to external providers and the results are sent back to Cerner. St Stephen's works with Sullivan Nicolaides and QML for pathology, and Queensland Medical Imaging for radiology. While radiology reports are pulled into the EMR, QMI stores the image, which is accessed by a hyperlink.
The EMR also has several bi-directional interfaces to manage the closed loop medication management system, Ms Liebke said. Doctors order medications through Cerner, which interfaces with the Omnicell automated dispensing cabinets (ADCs) and the Pharmhos pharmacy system.
Pharmhos itself has interfaces with the pharmaceutical wholesaler's (Symbion) system, the SAP billing system and also to the PBS for paperless claiming. St Stephen's has been given special authorisation to trial paperless claiming by the Department of Health.
In terms of workflow, the doctor enters the order into the electronic medications chart. The medication is then verified by a pharmacist through Cerner, and the order then shows up on the nurse's task list at the time that the medication is due. It then interfaces with the Omnicell and the nurses are only able to take out the medications that are due in that time period, which Ms Liebke said substantially reduces the chance of error.
The medications are all unit packaged, and before the nurse administers the dose both the patient's and the package's barcodes are scanned. Ms Liebke said she expects to see a huge reduction in medication errors as part of the benefits realisation study.
The closed loop system has also helped with pharmacy material supply management and with nursing workflows, she said.
“We actually know exactly how many of each medications we have in the cabinet, when they are due to expire, stock can be rotated, it can be refilled. And from a nursing workflow point of view, if I go to a cabinet and I can't find the medication there, I can quickly find where else it’s being stored in another ADC, without having to call other wards trying to track them down.”
Nurses are also very much enjoying the benefits of the meal management system, she said. Diet orders and allergies are placed in the EMR, which interfaces with the electronic patient meal ordering system. Patients can order their meals using the touchscreen patient entertainment system, but as there is an interface to the EMR, they are only able to order meals based on their prescribed diet.
“The nurses love this,” Ms Liebke said. “No more diabetic patients who are on modified carbs and we're trying to keep their blood sugars down being shown the dessert list, thinking they can order three or four desserts delivered from the kitchen and we explaining why they are not allowed to.
“And the other huge safety feature is the allergy documentation. Prior to the implementation of our electronic meal ordering, if a patient was allergic to something, how would we know if the kitchen was using that item in a meal? If the patient does have an allergy to something it is documented as an allergy, and they can’t order anything that has that in the recipe whatsoever.”
Infusion pumps and vital signs monitors are also integrated into the system. Ms Liebke said a bi-directional interface is possible for the infusion pumps but St Stephen's is only using it in one direction at the moment, from the pump to the EMR for populating the fluid balance chart.
For vital signs, St Stephen's has integrated its Welch Allyn portable machines and GE monitors, which send their data by WiFi to the EMR. “We've found some studies from the United States that shows the amount of time saved because of this,” Ms Liebke said. “For a nurse on an eight-hour shift, they should be saving 25 minutes just from taking vital signs.
“The other benefit that we've being seeing is in the known phenomenon in nursing called rounding, where nurses attempt to round up observations. We saw this a lot with our vital signs. Their temperatures were all coming across hypothermic, and we have rules in the background for alerts and triggers to the clinicians that there is a risk of sepsis.
“We found that the nursing staff weren't using the Welsh Allyn machines and taking the vital signs properly. They had been in the habit of having patients with a temperature of 35.5 or 35.7 and just rounding it up to 36 in the paper world.”
St Stephen's has also integrated its ECGs, allowing clinicians to view them from anywhere in the hospital but remotely as well. If a doctors isn't available, nurses can contact HeartCare Partners in Brisbane to interpret it for them.
Clinical images can also be captured through integrated cameras, which upload the image directly to the patient's record. “Where I previously worked we went through a process of getting cameras to take pictures of pressure injuries and wounds but we found that by the time we got the pictures printed … and they made their way to the paper chart, it could take up to a week and you really couldn't track it.
“At St Stephen's we've got a Ricoh camera, it's barcode scanned – you take a picture of the patient's barcode and the nurse's ID as well – and we have that image in the chart for every one to look at.”
The CareAware iBus also handles the Vocera hands-free communication device and integrated nurse call system. Ms Liebke said the Vocera devices were some of the nurse's favourite gadgets. If an alert from a deteriorating patient is issued, it can go straight to the nurse's badge.
The hospital has real-time tracking through RTLS for both patients and equipment – and the nurses would like to see it attached to medical staff as well, Ms Liebke said – Imprivata's tap-on and tap-off sign-in system and workstations on wheels – or “the nurses' entertainment system, as we like to call it”, she said.
What this all adds up to is an expectation that not only is safety improved through better medications management and reducing rounding, but that nursing time is freed up for more bedside care.
“One of the biggest issues and challenges we have is that people think all of this technology is going to make healthcare more impersonal,” Ms Liebke said. “We are finding the opposite.”
Posted in Australian eHealth