Christchurch after the earthquake
This article first appeared in the October 2012 edition of Pulse+IT Magazine.
Nigel Millar doesn’t go so far as to recommend experiencing an earthquake in order to test the foundations of a healthcare system, but he does recommend pretending to have one. The earthquake that destroyed much of Christchurch in February 2011 has taught the Canterbury District Health Board (CDHB) an awful lot about how healthcare IT systems coped in the emergency, but it also had an unexpected effect of boosting the use of innovative healthcare models and systems to provide better care to the community.
Dr Millar, the chief medical officer of the CDHB and a specialist in geriatric and general medicine, took a leadership role in the response to the disaster. Both before and after the earthquake, part of his role had been to try to transform the health system into a fully integrated and efficient one that is sustainable for the future.
For Dr Millar, one of the most beneficial systems already in place was interRAI, the clinical needs assessment program developed by an international network of aged care specialists that has been rolled out throughout New Zealand for home care and which is now being introduced to residential aged care.
Under the NZ Health IT plan, it is being rebadged as the Comprehensive Clinical Assessment program and will be used throughout the country to assess the needs of all people over 65 who require it, whether they are living in their own homes, a rest home or residential aged care.
Dr Millar, who has been involved in interRAI since 2002 and a fellow since 2008, told the conference that vulnerable people such as the elderly living at home were some of the top priorities in the immediate aftermath of the quake.
Having quick, secure access to their information through the interRAI protocol meant that those who had been assessed could be checked on by primary healthcare providers in a hurry.
“About 600 people were evacuated from rest homes and about 300 from residential care, but we had people at home,” Dr Millar told the conference. “We had old people [isolated] at home.
“I’m part of the interRAI collaborative, which is an aged care assessment protocol for the country. It is standardised, organised and every aged care assessment in the country is done using that protocol. And I was able to send an email to a colleague in Canada, asking for help. He sent an email to someone in Wellington, they worked overnight developing an algorithm, they interrogated the data and they gave us back a list of all of the people we had living at home who had been assessed, in order of risk.
“We had that in under 24 hours after the earthquake, including some people who had been assessed on the morning of the earthquake. That is live and that’s real. So we sent it out to the healthcare providers and said if you’ve got people on this list here are the high-risk ones. It was great information in an emergency.”
Community and collaborative care
The damage done to many of the residential aged care facilities meant residents could not move back in quickly, and with Christchurch Hospital stretched to the maximum, the earthquake also spurred on the introduction of another community-based program for older people.
Called the Community Rehabilitation Enablement and Support Team (CREST), this had been in the planning stages before the earthquake, and was aimed at helping older people to get out of hospital earlier and reduce admissions in the first place by providing coordinated at-home care or through the city’s rehab hospital, the Princess Margaret.
After the earthquake, the introduction of CREST was fast-tracked in order to care for older people in their homes and provide support through the city’s recovery, Dr Millar said.
“Life was complex after the earthquake but in a few hours we had things organised, we got the system back on its feet, but now we had a fragile system where things [were] broken. However, it was the best opportunity. I don’t recommend earthquakes, but I recommend you pretending you have had one.
“We came up with a program called CREST, a simple program, hospital in the home, rehab, get you out of hospital, provide comprehensive care in the community… We started from zero and we had it going in three weeks, because people wanted to do it.”
CREST is the first phase in a wider roll-out of services and technologies under Canterbury’s Collaborative Care workstream. Linking many aspects of this workstream is Project Chain, which involves the introduction of HSAGlobal’s Collaborative Care Management Solution (CCMS), also being used in Auckland’s Shared Care Plan project.
CCMS will be used as the underlying technology to create shared care plans for patients with multiple chronic conditions and will bring together GPs, pharmacists, hospital specialists, hospital services and other community health providers.
Matt Hector-Taylor, managing director of HSAGlobal, describes the CCMS as a purpose-built shared care management product that is web-based, highly configurable, designed to integrate, and built using industry standards. It has been developed using standard Microsoft interfaces to provide rich functionality and a familiar look and feel for users.
“Because of the earthquake the Canterbury region lost a number of acute care beds and residential aged care beds so they have a real shortage of capacity,” Mr Hector-Taylor says. “Project Chain is a group of targeted initiatives, all enabled by CCMS, to help maintain the health of high-needs patients in the community.”
In addition to CREST, Mr Hector-Taylor says the project involves a medications management service for high-needs patients with complex medications requirements, and a variety of other “frequent flier”-type initiatives. “Most importantly, Project Chain is looking to introduce long-term funding models to support integrated care, as well the technology enabler (CCMS) and new service delivery models,” he says.
Shared care view
The earthquake has also spurred the introduction of an electronic shared care record viewer, or eSCRV. Based on Orion Health’s Concerto portal, the eSCRV is aimed at giving healthcare providers access to patient records held in a number of different healthcare facilities.
In the immediate aftermath of the earthquake, the DHB faced a big struggle to get general practice back on track, Dr Millar said. “But we ran into problems because GPs had really great systems but one of the problems was people were leaving Christchurch and Canterbury itself to get healthcare, but there was no information on them. So we came up with a concept about a month after the earthquake called the eSCRV – it is a response to the earthquake but it is more about getting the right healthcare to the right people at the right time.
“It is a shared care record view. It is a set of essential information, at the point of care. For hospital clinicians, GPs, pharmacists and nurses in the first instance, after-hours GPs, community nurses, emergency departments – it is accessible at these points of care with some access controls.”
The eSCRV is an opt-out program – patients who do not want to participate can opt out quite easily – but while some patients might not want to participate, Dr Millar said the main hurdle to overcome was breaking down the barriers between the different healthcare providers.
“We had to develop a control system that we call the Matrix. This is where the fun started. We had a GP say, 'hang on, I’m not having a pharmacist look at a liver function test because they might give them liver tonic'.
“We said, 'So what if you are prescribing a medication that can affect the kidneys, but the pharmacist can’t look at their renal function? What about the hospital pharmacist, [do they] they have full access?' It went through a process and in the end it turned out to be a bit of a row. Everyone said it was about privacy, but what it was really about was changing things that made people feel uncomfortable.”
eSCRV was up and running in July with a modest set of data available. However, based on early feedback and expressions of interest, more than 90 per cent of Canterbury clinicians are expected to take part, Dr Millar said.
In addition to these initiatives, Christchurch Hospital itself had earlier introduced a patient flow and capacity planning program called CapPlan, developed by local company Emendo, which is also used at Royal Adelaide Hospital in South Australia.
Dr Millar likened the system to an airport flight control centre. “We worked with [Emendo] ... to develop a snapshot of the hospital that tells you what is going on everywhere.
"It updates every five minutes, it goes down to the ward level and the patient level. It sits in an operations room on the wall and we are running the hospital like we are running flight control for Air New Zealand.”
Together with the CapPlan system, an internal audit system specifically targeting hospital patients admitted for more than 10 days, and the initiatives introduced after the earthquake, Dr Millar said the DHB had achieved quite remarkable results.
“We’ve probably avoided about 10,000 to 18,000 admissions by having an acute demand program in the community, because we are working as one system,” he said. “We’ve taken out 1.5 million days of patient waiting, simply by reorganising our system. We took 70 to 100 bed days out a year by doing our project. We saved $1.1 million for about 10 hours staff time a week, and we’ve got more productivity.”
Dr Millar said the earthquake had taught the health system and those who work in it an awful lot, some of it tragic, some of it unintentionally amusing. People who insist on sticking to paper records rather than electronic due to perceived safety – electronic records aren’t accessible with no electricity, for example – learned a hard lesson. As did some clinicians who hadn’t allowed software updates on their computers for some time.
“When you have an earthquake everything moves and the medical records are at risk. Some of the people who don’t like electronic records and still have paper records … well, their building got a big red sticker on it and they can’t go back in. The records have to go to the dump with the rest of the building.
“In the hospital, we have some Microsoft products in the ED and they sit on PCs that run 24/7. So when the earthquake hit we lost power about seven times because the generators failed. When the PCs came back on, they said ‘please wait while we update’. Some of them had a year’s worth of updates to do that would take hundreds of hours. It wasn’t funny at the time.”
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