Deploying and Integrating an Ambulatory EMR for Cancer Care in Northwestern Ontario

Transcription

1 Deploying and Integrating an Ambulatory EMR for Cancer Care in Northwestern Ontario Dean Jin, PhD CPHIMS ehealth Projects Lead Regional Cancer Care Northwest Thunder Bay Regional Health Sciences Centre 2013 Infoway Fall Partnership Conference Halifax, Nova Scotia November 27,

2 Northwestern Ontario (NWO) Characteristics Greater than ½ the land mass of Ontario 2

3 NWO Characteristics Area: 550,000 km 2 About the same size as France 3

4 NWO Characteristics Population: 225,000 (France has 65,700,000!) 4

5 Regional Cancer Care Northwest Responsible for coordinating and facilitating cancer care services in all of NWO including: Systemic Therapy (Chemotherapy) Radiation Therapy Psychosocial/Supportive Care Palliative Care 5

6 Regional Cancer Care Northwest Oncologists: 7 (medical & radiation) located at Thunder Bay Regional Health Sciences Centre (TBRHSC) Volumes: About 1,600 new patients per year About 25,000 patient visits to cancer outpatient clinics in Thunder Bay and regional hospitals in NWO 6

7 Regional Cancer Care Northwest TBRHSC: Outpatient Clinic Chemotherapy Radiation Therapy 11 Regional Hospital Sites within NW-LHIN: Chemotherapy Outpatient Clinics* 2 Regional Hospital Sites within NE-LHIN: Chemotherapy Outpatient Clinics* * Telemedicine clinics using Ontario Telehealth Network system to Thunder Bay 7

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9 Paper-Based Charts: The Ugly Truth Distance (in km) travelled by one chart in a day: up to 2 Number of cancer program staff who handle a single chart in one day: 15 Hours spent per day tracking, requesting, transporting, searching for charts: 10 Hours spent per day preparing, printing, filing, maintaining, purging, and organizing charts: 28 Number of charts per cancer patient: 5 9

10 Initial State at TBRHSC Although all charting was paper-based, Multi-Access* was already used: In Radiation Therapy for treatment planning and driving Linear Accelerators For all patient scheduling at the Thunder Bay cancer centre * legacy predecessor to MOSAIQ EMR system 10

11 Initial State at each Regional Hospital All charting was paper-based: Documentation for each patient stored in binders at regional hospital chemo suites All chemotherapy orders faxed from Thunder Bay after approved by oncologist Schedules for patient treatments recorded by hand in notebooks and calendars All communication with Thunder Bay cancer centre by telephone or fax 11

12 Critical Requirements to Motivate Change Strong desire across the cancer care organization to move to an electronic chart Evident from clinical leads to administration to front line staff Secure funding for two major aspects of the project: 1. EMR Deployment Ambulatory EMR Program (CHI) 2. Integration HIS Connect Program (CHI) 12

13 Critical Requirement to Permit Change Dependency on Medical Physics: Multi-Access* operated 2 legacy Siemens Linear Accelerators (LINACs) Upgrade from Multi-Access to MOSAIQ was completely dependent on MOSAIQ being able to operate the legacy LINACs The upgrade was not a simple task It was unknown if the upgrade would even work (!) until it was completed in October 2012 * legacy predecessor to MOSAIQ EMR system 13

14 Pre-Existing Conditions: Leverageable Systems 1. Consistent HIS throughout NWO All 11 regional hospitals (except 1) in NW-LHIN on the same shared version of Meditech Single, central repository for demographic information 2 regional hospitals in NE-LHIN on Meditech (but not same version and not shared with NW-LHIN ) 14

15 Pre-Existing Conditions: Leverageable Systems 2. Electronic Distribution of Health Records Physician Office Integration (POI) Developed by in-hospital IS Department Standard approved by Ontario MoH for distributing reports and discrete valued results to primary care EMRs Clinical notes, lab reports, DI reports distributed electronically where possible 15

16 Pre-Existing Conditions: Leverageable Systems 3. Cancer Care Ontario Systems Interactive Symptom Assessment and Collection (ISAAC) system was integration ready Collects patient reported symptoms using Edmonton Symptom Assessment System (ESAS) questionnaire Other integration initiatives in the works: Data reporting ( Databook ) Electronic Drug Claims (eclaims) for New Drug Funding Program (NDFP) 16

17 System Planning: Integration Wherever Possible Admissions/Discharge/ Transfer (ADT) Provides patient demographic information & updates from Meditech* to MOSAIQ POI interfaces Provide lab results, DI reports, and clinical notes from Meditech to MOSAIQ 2 Interfaces required: Meditech (NW-LHIN) to MOSAIQ Meditech (NE-LHIN) to MOSAIQ *NW-LHIN Meditech only 17

18 System Planning: Integration Wherever Possible Cancer Care Ontario ISAAC System Interface provides ESAS Reports to MOSAIQ Palliative Service Client Registry Interface provides status and treatment information to NWO palliative service providers Viewer Integration with ehealth Ontario Jurisdictional Asset (OLIS or ODB Drug Profiles) 18

19 Databook NDFP eclaims (CCO) NW Palliative Service Client Registry ehealth Ontario Jurisdictional Asset ODB Drug Profiles NW Ontario Regional Sites and Remote Users ISAAC (CCO) Electronic Data Submission Palliative Cancer Patient Information HIAL Common Services Communication Bus ESAS Responses ESAS Report ODB Drug Profile Viewer Caregiver/Nurse MOSAIQ Ambulatory EMR Citrix Farm Website CCO Kiosk Radiation Therapy Clinic Arrival/ Queue Cancer Treatment Information ADT + Information Lab Results DI Reports Dictated Notes Lab Results DI Reports Clinical Notes Regional Cancer Care Northwest Patient ID Self-Arrival KIOSK + ADT = Admissions, Discharge, Transfer (includes demographics) Thunder Bay Regional Health Sciences Centre and 11 NW-LHIN Regional Hospitals May * (Meditech HIS) * Includes Kenora (mid-2014) 2 NE-LHIN Regional Hospitals (Meditech HIS) MOSAIQ Amb EMR Architecture Ambulatory EMR HIS Connect Not CHI Funded

20 Deployment Strategy Big Bang approach chosen Staged approach not favourable due to interdependencies across the entire cancer care organization Interim processes would have been required until all departments were live 20

21 Deployment Strategy Big Bang approach chosen Take advantage of change momentum and clear sense of togetherness: If we are successful, we are all successful together, the same if the opposite happens 21

22 Deployment Strategy Big Bang approach chosen Go Live Date: May 13, 2013 a Monday for very good reason Massive preparation required in advance to achieve Go Live 22

23 Advance Preparation: Care Plan Development CPOE is performed by oncologist placing cancer patient on a Care Plan Essentially a treatment template including medications (scheduled), follow up tests, visits and workflow procedures Care Plans can be very complex About 150 Care Plans were developed from scratch Each approved by RCC-NW oncologists familiar with a particular disease site Based on Cancer Care Ontario standard cancer treatment regimens 23

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25 Advance Preparation: Workflow Analysis Commitment to paperless environment required significant workflow changes Focus on clinic operations at TBRHSC and at each regional hospital: Current State Future State analysis Complex, time consuming process Many interdependencies, handoffs Big Picture very difficult to see Fragmentation: staff are knowledgeable of their own work roles, but not necessarily of others in the organization 25

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27 Advance Preparation: EMR Workflow Automation Make use of workflow automation features of MOSAIQ EMR IQ Scripts Event based automation based on clinical or business logic Can be configured to fire based on an event or condition Often used to generate QCLs Quality Check Lists (QCLs) List of things to be done in a process Routing of each thing to appropriate staff responsible for completion 27

28 Advance Preparation: echart Creation Required for all patients expected to be in treatment on Go Live date For each patient: Evaluation of minimal documentation required for continuation of treatment Required paper documentation scanned and placed in patient echart Massive scanning project performed by RCC-NW Health Records Department Documents from over 250 paper charts were scanned into echarts 28

29 Advance Preparation: Regional Readiness Focus on new-to-mosaiq users at all 13 regional hospital sites Provide access (via Citrix) to MOSAIQ for scheduling March-April 2013 Hardware upgrades Onsite training (travel travel travel ) Provided up to 2 months of experience with MOSAIQ in region before Go Live 29

30 Regional Travel: 2 Trips, Each 3,000km, 30 Hours Driving Time 13 moose sighted in one day! 30

31 Where are we now? Ambulatory EMR MOSAIQ EMR in use for cancer care at TBRHSC and all 13 regional hospitals in NWO CPOE Nursing documentation Medication orders, dispensing and administration documentation Work continues on workflow enhancement and policy development 31

32 Where are we now? Integrations ADT and POI (NW-LHIN) Patient Demographics Meditech Lab Reports, DI Reports, Clinical Notes MOSAIQ ISAAC ESAS reports MOSAIQ Work is continuing on remaining integrations 32

33 Databook NDFP eclaims (CCO) NW Palliative Service Client Registry ehealth Ontario Jurisdictional Asset ODB Drug Profiles NW Ontario Regional Sites and Remote Users ISAAC (CCO) Electronic Data Submission Palliative Cancer Patient Information HIAL Common Services Communication Bus ESAS Responses ESAS Report ODB Drug Profile Viewer Caregiver/Nurse MOSAIQ Ambulatory EMR Citrix Farm Website CCO Kiosk Radiation Therapy Clinic Arrival/ Queue Cancer Treatment Information ADT + Information Lab Results DI Reports Dictated Notes Lab Results DI Reports Clinical Notes Regional Cancer Care Northwest Patient ID Self-Arrival KIOSK + ADT = Admissions, Discharge, Transfer (includes demographics) Thunder Bay Regional Health Sciences Centre and 11 NW-LHIN Regional Hospitals May * (Meditech HIS) * Includes Kenora (mid-2014) 2 NE-LHIN Regional Hospitals (Meditech HIS) MOSAIQ Amb EMR Architecture Ambulatory EMR HIS Connect Not CHI Funded

34 A Few Lessons Learned 1. Time is precious Engagement at all levels is imperative Involve staff early and throughout change process Need to be sure staff time can be backfilled 2. Focus on workflow Take time to develop workflows that are intuitive and efficient Look for EMR features that focus on workflow improvement 34

35 A Few Lessons Learned 3. Physicians want to focus on quality care Use integration wherever possible to keep everything they need in one place Training and support is imperative Address workflow issues with physicians 1 st Problems tend to flow down hill from there 35

36 Future Directions Patient Web Portal Patient access to RCC-NW echart Patient Safety Improvements Patient identification and treatment setup in radiation therapy Closed Loop Medication Administration Barcode chemotherapy drugs Match patient to drugs at point of administration 36

37 Questions? 37