Improving Health Management through Clinical Decision Support Systems

Improving Health Management through Clinical Decision Support Systems Jane D. Moon The University of Melbourne, Australia Mary P. Galea The University of Melbourne, Australia A volume in the Advances in Healthcare Information Systems and Administration (AHISA) Book Series

Managing Director: Managing Editor: Director of Intellectual Property & Contracts: Acquisitions Editor: Production Editor: Development Editor: Cover Design: Lindsay Johnston Keith Greenberg Jan Travers Kayla Wolfe Christina Henning Courtney Tychinski Samantha Barnhart Published in the United States of America by Medical Information Science Reference (an imprint of IGI Global) 701 E. Chocolate Avenue Hershey PA, USA 17033 Tel: 717-533-8845 Fax: 717-533-8661 E-mail: cust@igi-global.com Web site: http://www.igi-global.com Copyright 2016 by IGI Global. All rights reserved. No part of this publication may be reproduced, stored or distributed in any form or by any means, electronic or mechanical, including photocopying, without written permission from the publisher. Product or company names used in this set are for identification purposes only. Inclusion of the names of the products or companies does not indicate a claim of ownership by IGI Global of the trademark or registered trademark. Library of Congress Cataloging-in-Publication Data CIP Data Pending ISBN: 978-1-4666-9432-3 eisbn: 978-1-4666-9433-0 This book is published in the IGI Global book series Advances in Healthcare Information Systems and Administration (AHISA) (ISSN: 2328-1243; eissn: 2328-126X) British Cataloguing in Publication Data A Cataloguing in Publication record for this book is available from the British Library. All work contributed to this book is new, previously-unpublished material. The views expressed in this book are those of the authors, but not necessarily of the publisher. For electronic access to this publication, please contact: eresources@igi-global.com.

128 Chapter 6 St. Stephen s Hospital Hervey Bay: Study of Developing a Digital Hospital Constance A. Harmsen UnitingCare Health, Australia Richard N. Royle UnitingCare Health, Australia ABSTRACT St Stephen s Hospital in Hervey Bay, Queensland, Australia, is a new 96 bed state of the art digital hospital that opened on a greenfield site on 13 October 2014. The ehealth project was responsible for providing a fully integrated electronic medical record. The authors explore the unique challenges presented by the project and the solutions deployed. Key components related to the success of the project are identified. The results of the intense two and half year project timeline culminated in a successful go-live and certification as the first hospital in Australia to achieve Stage 6 HIMSS designation. INTRODUCTION This chapter sets out to provide a case study of how UnitingCare Health (UCH) successfully launched a new fully integrated digital hospital in Australia, becoming the first hospital in the country to achieve Stage 6 certification by the Healthcare Information Management Systems Society (HIMSS) for its advanced Electronic Medical Record (EMR) system. Through an Australian Federal Government Health and Hospitals Fund (HHF) grant, UnitingCare Health received $47 million in funding to develop a modern hospital with digital health care solutions at the forefront of Australian health care. In less than three years the UCH team successfully launched the new digital hospital through extensive planning, clinician engagement and leadership strategies that fostered timely identification of challenges and the creation of effective solutions, allowing the $96 million hospital to open on-time and on-budget on October 13, 2014. DOI: 10.4018/978-1-4666-9432-3.ch006 Copyright 2016, IGI Global. Copying or distributing in print or electronic forms without written permission of IGI Global is prohibited.

St. Stephen s Hospital Hervey Bay The case study will describe the ehealth journey including challenges and solutions related to the need for a new hospital in Hervey Bay, digital design parameters, technology components, management and organizational considerations, work redesign and clinical transformation, change management, golive activities and benefits realization. BACKGROUND UnitingCare Queensland (UCQ) is the health and community service provider of the Uniting Church and supports more than 14,000 people every day of the year. With more than 15,000 staff and 8,500 volunteers in more than 400 geographic locations across Queensland, it is one of Australia s largest not-for-profit health and community service providers, with an annual turnover of approximately $1.4 billion (UnitingCare Queensland, 2014). In June 2000, UnitingCare Health (UCH) was formed to bring together the various hospitals owned and operated by the Uniting Church in Australia (Queensland Synod) into one organization within UCQ. The hospitals included: The Wesley Hospital, 536 beds in Brisbane; St Andrew s War Memorial Hospital, 250 beds in Brisbane; The Sunshine Coast Private Hospital, 190 beds in Buderim; and St Stephen s Hospital, 60 beds in Maryborough, which is part of Queensland s Fraser Coast region. UCH thus became one of the largest not-for-profit private hospital operators in Queensland, employing more than 4,000 staff, annually admitting more than 120,000 patients and undertaking nearly 80,000 surgical procedures (UnitingCare Queensland, 2014). The Fraser Coast region is one of the fastest growing regional areas in Australia. In 2011 the population of the Fraser Coast region was 103,358 and projected by 2031 to reach more than 178,000. The region has a high proportion of older residents. In 2006, 19% of the population were aged 65 years or older, and this figure is estimated to increase to 23.4% in 2031 (Office of Economics Statistical Research, Queensland Treasury and Trade, 2012). Maryborough has been the traditional business, commercial and service center of the Fraser Coast. However, in recent years the major growth area has become Hervey Bay which between 2005 and 2010 experienced an average growth of 4.7% per year, the fastest growth rate in Australia s coastal regions (Australian Bureau of Statistics, 2012). The unprecedented growth and shift in regional population settlement factors has had major impacts and redistribution pressures on the Fraser Coast region across many sectors and services. Health care has been no exception. The pressure on the public hospital in Hervey Bay has been profound with an occupancy rate of 94% in 2010 (Australian Medical Association Queensland, 2014). A major contributing factor has been that the region has been critically underserviced in private hospital beds. In 2008, Australia had a ratio of 4.0 acute hospital beds per 1,000 members of the population, with a split of 2.5 public acute beds and 1.5 private beds (Australian Institute of Health and Welfare, 2011). Using this ratio, in 2008 the Fraser Coast population had access to only 60 private beds in Maryborough while the level required to adequately service the demand was 150 private beds. In addition to inadequate private bed numbers, medical specialists who had traditionally lived in Maryborough began relocating to Hervey Bay since the early 2000s. This movement followed the Queensland government s closure of the intensive care unit at the Maryborough Public Hospital and downgrading of its emergency department. At the same time, intensive care and emergency services were upgraded at the Hervey Bay Public Hospital which shifted the focus of the region s health services from Maryborough to Hervey Bay. 129

St. Stephen s Hospital Hervey Bay In 2003, UCH developed a business case which included analysis of the Fraser Coast demographic factors, market forces, health care utilization and demand, capital requirements and financial returns. It was decided to construct a Day Hospital with the option of expanding to include an inpatient facility in the future. UCH selected a greenfield site directly opposite the Hervey Bay Public Hospital. This was intended to contribute to the development of a future Health Precinct where public and private health care could be provided in a synergistic way. While the Day Hospital opened in 2006, the need for private inpatient beds only increased as the population grew in size and age. The business case was presented annually to the UCQ Board but constraints on the UCH capital program due to other major construction projects at the Brisbane-based hospitals prevented it from being approved. In 2010, the Commonwealth of Australia s Department of Health and Ageing developed the Health and Hospitals Fund (HHF) Program Regional Priority initiative. The objective of the program was to improve access to essential health services to as many Australians as possible living in rural, regional and remote areas through investments in health infrastructure. The broader objectives of the HHF program were to invest in major health infrastructure programs that would make significant progress towards achieving the Commonwealth s health reform targets, and to make strategic investments in the health system that would underpin major improvements in efficiency, access or outcomes of health care. In December 2010, UCH applied for a HHF grant program to construct a new inpatient hospital in Hervey Bay. To improve the likelihood of obtaining funding, UCH added an important qualifier to its grant submission: it would build a new state-of-the-art digital hospital. This action was in line with the national ehealth strategy developed by Deloitte and adopted by the Australian Health Ministers (Australian Health Ministers Conference, 2008). The Deloitte study found that investment in information technology (IT) by the Australian health care sector was substantially lower than in comparable industries such as telecommunications and finance. This placed health care years behind other industries and had potentially serious implications for patient safety, particularly in relation to medication errors and adverse events (Ehsani, Jackson and Duckett, 2006). EHealth was therefore deemed to be a key enabler to assist the Australian health system deal effectively with rising costs and a shortage of skilled workers, and to achieve its health reform goals (Australian Health Ministers Conference, 2008). In May 2011, HHF awarded a $47 million grant to UCH with $26 million to be applied for building construction and $21 million to create the ehealth components. It was the largest grant provided by HHF to a private health care organization. CASE DESCRIPTION Key Considerations According to the 2011 agreement between HHF and UCH, the ehealth initiative for SSHB consisted of the development, procurement, purchase, supply, installation configuration, testing, implementation and commissioning of IT equipment, software and associated workflows in the hospital building. In this manner, a fully digital ehealth hospital was to be established and operated to achieve the program objectives. The ehealth initiative for SSHB was to be coordinated and aligned with the hospital construction project and to carry out the following works: 130

St. Stephen s Hospital Hervey Bay Rollout of an Electronic Medical Record (EMR) system over five years (2012-2017). Licensing and roll-out of new Cerner modules. Purchase and installation of hardware. Building and development of: Patient, community and medical portals; Automatic feeds to the EMR from monitoring systems and diagnostic providers; Alerts for pertinent information such as allergies, abnormal vitals or results; Medications management; Electronic orders to diagnostic providers; EMR availability for multiple users (e.g., multiple clinicians in multiple locations); A system allowing clinicians to document electronically the use of their preferred device from multiple locations including theatre, bedside, mobile, and the nurses station; Integrated patient systems incorporating television, internet, telephone, pre-discharge patient education materials, and menu selection systems; Electronic tracking of medical equipment; An integrated staff and doctor voice recognition communication system; Internal infrastructure; and External infrastructure to allow connectivity from SSHB with the Hervey Bay Health Precinct including, at a minimum: Hervey Bay Public Hospital, other UCH hospitals, universities, Queensland Health Ambulatory Cancer Centre, radiation oncology, relevant diagnostic providers, and relevant general practitioners subject to their capability to connect electronically within the timeframes required by the project including an adequate allowance for testing. The project had to be consistent with the Commonwealth ehealth agenda which is focused on delivering electronic referral, discharges, orders, results and medications management as well as the personally controlled electronic health record (pcehr) to the broader community. UCH also decided it was important for the new hospital to be recognized by the Healthcare Information Management Systems Society (HIMSS) as an advanced EMR system: Stage 6 at hospital opening and ultimately Stage 7, the highest level. To attain HIMSS recognition, the hospital required a system that could provide closed-loop medication administration, and this would be a first for an Australian hospital. In short, SSHB was to be a world class digital hospital providing high-quality and safe services to ensure excellent patient outcomes that would place the Fraser Coast region in an optimal position to meet future challenges in the provision of health care. In order to meet these commitments, UCH required an experienced EMR vendor which: was well-established in Australia; had applications running in an acute care setting; and has a good track record for implementation and financial viability. Cerner had been UCH s vendor for a decade, having successfully implemented several clinical applications at its Brisbane hospitals. After lengthy negotiations with Cerner about cost and proposals, UCH selected Cerner as its EMR partner for the SSHB project and provided an experienced program director from the United States. 131

St. Stephen s Hospital Hervey Bay Technology Components: Infrastructure A digital hospital with a full EMR system and multiple devices places intense demand on its technology infrastructure to provide high availability and reliability, mobile and wireless platforms, systems integration and convergence, enhanced privacy and security measures, and business continuity solutions. The technology infrastructure design for SSHB is composed of the following: Core IT services delivered from Brisbane (e.g., Citrix desktop and core applications). Cerner EMR applications hosted remotely from Brisbane. Two on-site data centers and 10 communication rooms to provide locally hosted services for core network, communications, and site-specific applications. Wide area network provision through two diverse exchange links to Brisbane via Telstra exchange network. Local area network provision through the communication rooms with redundant 10 gigabit fibre optic links. Wireless connection through blanket 2 AP coverage via 160 wireless access points. Provision of adequate devices for end-users including 1,500 wired devices and 500 wireless devices. 13 data points available to every patient room. Identity Services Engine (ISE) for enhanced security. Technology Components: The ehealth Digital Solution The ehealth digital solution design was driven by: the commitments to HHF; desired benefits to increase quality and patient safety, improve efficiency, and patient and clinician satisfaction; and to achieve HIMSS Stage 6 certification upon the hospital opening. In addition, in order to minimize interfacing that can often lead to broken business processes or unsustainable workarounds, it was decided to maximize efforts to use Cerner applications rather than a best of breed approach. Key solution design requirements included: Diagnostic orders would be initiated from within the clinical information system (CIS) and not from any other application. Breaking this model would specifically impact decision support capability. Clinical pathways would be defined and managed in the CIS due to its strong tie to issuing orders, medications, decision support and recording observations and interventions in an integrated system. Medication management functions and data would not be shared across multiple applications due to significant clinical risk in replicating this data and functionality across multiple systems. The CIS would serve as the designated master system for medications management and include 132

St. Stephen s Hospital Hervey Bay discharge medication, medication history, electronic medication administration for inpatients, and inpatient and discharge medication orders. Clinical decision support would be driven from the CIS. Orders, results, medications, alerts and allergy information would be entered into the CIS, and therefore the relevant decision rules and functions would best reside in the CIS to realize the desired benefits. Alerts and allergies would be entered into the CIS as the source of truth; HL7 messaging would be used to broadcast this information from the CIS into any key system (e.g., food management) that would need the information. The use of free text alerts would be kept to a minimum because such information cannot be used for decision support rules. Single sign-on was deemed a key success criterion for end-user acceptance. Considering these design elements, the agreed end-to-end solution for SSHB included 29 Cerner Millennium applications, 20 devices, 5 major clinical interfaces including 2 pathology laboratories, radiology, pharmacy, and a food ordering system, and 13 business interfaces. (See Figures 1 and 2 and Appendices 1 and 2.) Management and Organizational Considerations Leadership. Executive leadership is an integral component for project success (Berg, 2001; Boehnecke, 2013; Creswell & Sheikh, 2013; Westerman, Bennet & McAfee, 2014). A study reported by Boehnecke (2013) found only 2% of all EMR projects over $10 million to be successful, meaning on-time, on-budget and operating with planned functionality. While stakeholder adoption, change management, clear objectives and focus were also considered important factors, the number one reason for success in the EMR projects was found to be engaged senior executive leadership. The Executive Director of UCH visited the United States on two study tours looking at fully digital hospitals, in particular Cerner implementations. During these tours, it became clear to him that another critical success factor was to have an experienced UCH program director with the executive skills and knowledge to implement a digital greenfield site hospital project. An ehealth program director from the US was appointed. Because doctor engagement would also be paramount for success, a chief medical information officer (CMIO), Australia s first, was appointed. Staffing. The first responsibility of the UCH and Cerner program directors was to put in place effective teams composed of project managers, clinical informaticists, and technology solution and change management specialists. Within UCH, there were nine capable clinical and business informaticists who were members of UCH IT and, in September 2012, they were appointed as the ehealth team. Finding experienced project managers (PMs) was much more difficult, but by June 2013 three excellent PMs were in place. Ultimately the UCH ehealth team was composed of 20 individuals, including the medications management staff who continued to report to the UCH Director of Pharmacy. Cerner recruited experienced staff primarily from the United States into solution and integration architect roles. There were approximately 30 people across the two organizations who worked solely on the SSHB project. In a unique arrangement, the staff was co-located in the Cerner office in Brisbane which fostered a climate of collaboration, as well as faster, more creative solutions amongst the team members. Vision. A project vision was needed. In November 2012, UCH staff and doctors were invited to suggest slogans and ultimately, ehealth Unite: Transforming the Health Care Experience, was selected. By working together across the system, the ehealth team s vision was to transform health care at SSHB, 133

St. Stephen s Hospital Hervey Bay Figure 1. St Stephen s Hervey Bay digital components UCH and then ultimately across Australia by successfully designing and implementing a state-of-the-art digital hospital. Timeline. The project timeline would be intense in order to be aligned with the building construction. The objective was to ensure that the hospital build and digital elements would be ready at the same time. There were concerns that if that if this did not occur simultaneously there would be impacts on clinical adoption and higher costs due to needing temporary paper records. Kick-off sessions for the project commenced in February 2013. Key project milestone activities included: work redesign activities in April to October 2013; system design with 10% of Cerner build completed in September 2013; system validation with 80% of Cerner build completed in December 2013; doctors system validation in February 2014; and a rigorous testing program including unit, system, integration, user acceptance testing and two mock go-live events which occurred from January to September 2014. Weekly meetings led by the UCH ehealth program director and PMO office were held every Friday morning with team leaders from ehealth, Information Systems department (ISD), UCQ Information and Communications Technology (ICT), SSHB hospital operations and Cerner to keep the project on schedule. 134

St. Stephen s Hospital Hervey Bay Figure 2. St Stephen s Hervey Bay digital elements Benefits. The project took a benefits-driven approach to the design and development of the digital components of the new hospital. In February 2013, a workshop involving more than 60 leaders from across UCH identified 18 expected benefits for the project. An evidence-based paper was developed that established for each benefit the following elements: definitions, metrics, benchmarks, baseline measurements, targets, owners and key enablers. Baseline measures were developed for SSHB as well as each UCH hospital. Thus, the outcomes achieved at SSHB could be applied to all UCH facilities to provide a system-wide impact analysis. The expected benefits include: Improved Patient Safety Decreased number of avoidable clinical incidents. Improved timeliness to identify and respond to deteriorating patients. Improved timeliness of results verification and action. Improved utilization of care protocols and order sets. Improved Risk and Quality Measures Increased frequency of pain assessments and decreased pain assessments with level of five. 135

St. Stephen s Hospital Hervey Bay Increased Efficiency Average length of stay (ALOS) below national average. Increased actual operating time per theatre. Decreased overtime expense. Decreased paper expense. Improved Medications Management Reduced medication errors and adverse drug events. Improved medication-specific communication between hospital and general practitioners (GPs), specialists, and other community health care providers. Medication reconciliation on admission and discharge. Reduced medication turnaround times. Increased Patient, Family, Community Satisfaction Decreased RiskMan incidents related to complaints. Increased patient satisfaction. Increased nursing time at bedside. Improved Staff and Doctor Satisfaction Increased staff satisfaction. Increased doctor satisfaction. Governance. Another critical element necessary for project success was governance. In early 2012 a combined project control governance (PCG) committee with building construction, ehealth, SSHB hospital operations and Cerner attendees was formed and met on a monthly basis. Additional and more robust governance was deemed critical. A clinical governance committee, the Strategic Advisory Group for ehealth (SAGE), was formed in late 2012. The SAGE committee, which met monthly, was chaired by the CMIO and composed of UCH clinical leadership including the chief medical officer (CMO), ehealth program director, chief information officers (CIO) from ISD and ICT, and Cerner program director. An executive control group (ECG) was formed at the same time to meet every second month and was chaired by the UCH Executive Director. Members included the leaders from construction, ehealth, SSHB hospital operations, UCH Finance and Strategy, and the CIOs for UCH ISD and UCQ ICT. In 2014, ECG meetings were increased in frequency to monthly and then fortnightly as the project go-live date drew closer. These governance groups provided active, timely support and decision-making for the project. The UCQ Board was kept informed about the project through periodic presentations. The first occurred in February 2013 with the executive director, CMIO, ehealth and Cerner program directors presenting to the Board. Major project risks and mitigation strategies were shared which included ICT infrastructure and resources, and clinical adoption. At the request of the UCQ Board, two external audits were carried out. The first audit was completed by Syntura in August 2013, followed by an Ernst and Young (EY) audit in March 2014. Both audits provided insight that helped the project leaders adapt and take necessary actions. Syntura s report pointed out the project tended to be Cerner-centric and helped bring about more collaborative working relationships with ehealth, ISD and ICT. The EY report provided important recommendations such as the creation of a Consolidated Program Report for governance that included all the work streams required to successfully open the new SSHB hospital, and the development of a Minimum Viable Solution (MVS) to assist with the final decision regarding readiness for the go-live date. Clinical Transformation. An EMR project presents the opportunity for clinical transformation and indeed, transformational change. Unfortunately, many organizations do not allocate adequate time to do 136

St. Stephen s Hospital Hervey Bay Figure 3. Clinical transformation and work redesign teams this properly within their projects, and instead simply automate current practice, policies and procedures within the established EMR vendor system parameters (Agarwal, Gao, DesRoches & Jha, 2010). The SSHB project, however, seized this opportunity and created eight work redesign teams comprised of 90 clinicians, staff and doctors from across UCH (See Figure 3). The teams worked over a seven-month period to identify current practice, review workflows and documentation with stakeholders and to achieve agreement regarding best practice that would then be built into the Cerner EMR system. In addition to identifying best practice, work redesign teams were a highly effective tool for fostering clinical adoption. When clinicians are involved in the design of the EMR system they are much more inclined to feel ownership of, and use, the system (Berg, 2001; Kruse & Goetz, 2015). Guiding principles were established for the work redesign teams and included the following: We will do what is best for the patient. Patient safety is our primary objective. Design principles will be based on what is best for UCH as a whole, following the 80/20 rule: 80% can be used at any UCH hospital, and up to 20% can be facility-specific. Design will be clinician-driven and support standardization of clinical best practices and medical decision-making. All design work will incorporate Australian National Standards, International Organization for Standardization (ISO) standards, hospital licensing, UCH policies, procedures, guidelines, and best practice. Proactively identify, manage and resolve issues to maintain the project timeline, effectively utilize resources, and ensure design decisions are aligned with the guiding principles. 137

St. Stephen s Hospital Hervey Bay The design must be benefit-driven and focused on improving performance of the organization for the long-term future. Medications Management. Arguably the most challenging of all the work redesign teams and applications was medications management. The full Cerner medications management system integrated with Carenet, its clinical documentation system, and computerized provider order entry (CPOE) had never been implemented before in Australia. More problematically, a closed-loop medication administration process with barcoding was necessary to achieve HIMSS Stage 6 certification. Furthermore, there were regulatory challenges including the Queensland Health Act (1937) requirement that all doctor prescriptions must be signed in ink. Not to be daunted by these challenges, the UCH Pharmacy Director embraced the opportunity wholeheartedly. She believed that medication errors would be lowered dramatically and patient care improved if electronic medication management systems were put in place in hospitals. The closed-loop medication administration process (see Figure 4) designed for SSHB was comprised of the following elements: Medication reconciliation on admission and discharge. CPOE with medication order sentences build and clinical decision support. Electronic dispensing in unit dose packaging. Pharmacist verification and product assignment. Electronic medication administration record (emar) and product location. Automated dispensing cabinets (ADC) and patient profiling. Barcode scanning at point of care. Discharge preparation including patient discharge medication list in line with Australian standards. Omnicell was selected as the ADC system for medications. From a workflow perspective, nurses were to use workstations on wheels (WOWs) to transport the medication from the ADC in a secure manner into the patient s room. To implement unit dose packaging, several types of equipment including JV-DEN84, VIZEN, De-Blistering Machine, Autoprint, and PABS were necessary. In Australia, medications are normally packaged within blister packs rather than in a single or unit dose package as in the United States. Blister packs cannot be barcoded and scanned, whereas unit dose packages can be. Barcode scanning is necessary to ensure compliance with all the steps in the closed-loop medication administration process has occurred, from procurement in the pharmacy department to validating the seven rights of medication administration. In order to lawfully implement the newly developed closed-loop medication administration process, exemptions from both Commonwealth and Queensland Health regulations were required. The National Health Act (1953) governs operations of the Pharmaceutical Benefits Scheme (PBS). Health funds contractual agreements with private sector operators assume maximum utilization of PBS. UCH requested to pilot a trial of paperless PBS claiming which was ultimately granted. While the Queensland Health Act (1937) required the doctor s signature in ink on all prescriptions, an exemption from this requirement was granted to SSHB for two years. Both the Federal and State governments have manufacturing licensing rules that UCH was required to meet in order to prepare unit dose packaging on-site at SSHB. Clinical Innovations. In addition to the closed-loop medication administration, other clinical innovations were developed through the work redesign teams using the Cerner EMR, many of which were firsts in Australia. Sixty power plans were built that integrated best practice doctor order sets. Examples 138

St. Stephen s Hospital Hervey Bay Figure 4. Closed-loop medication administration of clinical innovation include warfarin management, blood product administration, insulin management, deteriorating patient alerts through the Queensland Adult Deterioration Detection System (QADDS), venous thromboembolism (VTE) risk screen and management, pain management, epidural infusion management, hourly rounding and shared handover. Device integration into the Cerner system and practice workflows also required significant work. Twenty devices were put in place at SSHB, which was notably the largest number of devices installed by Cerner in any project implementation. All areas and personnel within the hospital were impacted by device integration including admissions, catering, supply stores, wards, theatre, nurses, doctors, cleaners and transporters. Many end-users who were not previously familiar with such devices are now using barcode scanners, ipods, Vocera hands-free communication badges, single sign-on and WOWs effectively as demonstrated through the 90% adoption rate achieved from opening week on. Clinical Decision Support Systems (CDSS). A benefit of the EMR in relation to patient safety is the clinical alert system in which an alert is fired to the clinician to notify them of potential interactions or pertinent information regarding the patient. Examples of this include free text allergy alerts, potential allergy interactions, drug interactions, relevant laboratory results or tests, VTE risk level and appropriate actions, risk for pressure injuries or falls including interventions, QADD s score with clinical advice, sepsis risk, and presence of Advance Health Directive and end-of-life planning. The SSHB EMR solution also utilized the Cerner solution Millenium Lighthouse, a comprehensive, adaptive and repeatable systematic approach to improving patient safety. The four areas of clinical monitoring and evidence-based interventions are: prevention and management of pressure injuries, prevention and management of falls, sepsis and systemic inflammatory response syndrome (SIRS) screening, and surgical care improvement. The Lighthouse program also provides a clinical data repository which can be evaluated and measured by its outcomes. The data can be as broad as the organization level or mined to an individual user level. 139

St. Stephen s Hospital Hervey Bay Clinical Adoption. Clinical adoption was critical for project success. Doctor engagement strategies were developed and implemented by the CMIO. The primary pre-implementation strategy was early clinical input via the work redesign teams. In January 2013, the CMIO and CMO sent letters to more than 2,000 UCH doctors informing them about the SSHB project and inviting them to participate in the work redesign teams. Ultimately 27 doctors, most of whom were visiting medical practitioners (VMPs), became members of the surgical, physician or anesthetic work redesign teams. Chairpersons, who became clinical champions, were selected by each team s members, with the CMIO facilitating each doctor meeting. The doctor work redesign sessions had multiple focus points: to learn about the EMR system from Cerner staff, to provide input on its desired design elements, and to establish best practice order sets. The high volume and high risk DRGs were identified for SSHB and evidence-based medicine literature, including the British Medical Journal (http://www.bestpractice.bmj.com), therapeutic guidelines (http:// www.tg.org.au), UpToDate (http://www.uptodate.com), medical colleges and societies (eg., http://www. csanz.edu.au), was reviewed. Robust discussion occurred at the work redesign team meetings. In total, 43 best practice order sets were agreed upon by the doctors and built into the Cerner EMR system (See Appendix 3). For doctor training, a targeted learning approach was used. Five doctor superusers were selected to assist the CMIO with the VMP training. These doctors participated in the user acceptance testing and mock go-live drills, and attended the 2013 Cerner annual conference with hospital site visits in the United States. There were 54 SSHB doctors to be trained and each signed a learning agreement specific to their needs with a six-hour training plan at its basis. Individual and small group training was offered, with most doctors choosing to receive individual training. The CMIO personally trained many of the doctors, specifically focusing on the doctors who admitted patients most frequently. At the go-live date and during the first four weeks post go-live, one-on-one support to doctors was provided initially and then at the doctor s request. Rounding by a doctor superuser continued for an additional four weeks, resulting in a total of eight weeks on-the-ground support from doctor superusers post go-live. SSHB staff engagement activities were launched at the early stage of the project. Day-long visioning sessions for staff nurses were conducted in September 2012 and July 2014 by the ehealth and Cerner teams. The nurses were involved in the evaluation of the inpatient room computer terminals in April 2013 and the workstations on wheels (WOWs) in January 2014, resulting in the selection of the Advantech (now Ascom) model. Twenty SSHB staff were members of the work redesign teams. There were 23 superusers trained who participated in User Acceptance testing, a critical three-week test phase. All clinical staff received 16 hours of EMR and device training, plus four hours of general orientation to the new hospital. The training occurred two-to-six weeks prior to the hospital go-live date. Superusers received an additional 16 hours of training. A self-assessment was completed by SSHB staff after completion of their training; uniformly staff rated themselves as somewhat comfortable and ready for go-live. Business Continuity Plan. A critical element for any digital hospital is to have an effective business continuity management system (BCMS) in place. Downtime will occur for multiple reasons including network issues and acts of nature. The Cerner 24/7 application was an important part of the BCMS plan; it provides view access to patients EMRs during downtime. Staff training for the BCMS was completed as part of the general orientation to the hospital. Go-live. The four weeks prior to go-live were pressure-packed. Two-day long mock go-live exercises were held in late September 2014 to assist with go-live preparation. The first exercise was technically focused on the EMR, devices, interfaces, infrastructure and network connectivity. The second exercise 140

St. Stephen s Hospital Hervey Bay involved enactment of five patient journeys from admission through to discharge, utilizing volunteers as model patients. Doctors, SSHB staff and vendors participated in the exercises. Command and Support Centres were also established and rehearsed. The mock go-lives were helpful in preparing for the actual go-live which occurred on Monday 13 October, 2014. The Minimum Viable Solution (MVS) was an essential tool when the remaining work tasks that Cerner and ehealth needed to complete were reviewed and prioritized according to what was required for the hospital opening and what could be deferred. A few stubborn issues regarding medications management required escalation and assistance from the United States in the last week before go-live. The go-live decision meeting was held on October 10, 2014, and was chaired by the UCH executive director and attended by the UCQ Chief Executive Officer; UCH CMIO and CMO; CIOs from ICT and ISD; the SSHB General Manager; and the two program directors from ehealth and Cerner. All ehealth-related and technical issues had been resolved and hospital regulatory certifications granted. This resulted in an affirmative decision by the committee for go-live to occur on the scheduled date of October 13, 2014. The last surgery at St Stephen s Hospital in Maryborough was performed on October 10, 2014. On the weekend of October 11 and 12, necessary items were moved to the new hospital in Hervey Bay. At 9.30 am on October 13, the first patient was received at the new St Stephen s Hervey Bay (SSHB) and 11 patients were transferred that day. On October 14 doctors at the new hospital performed the first surgery. An organized ramp-up beginning with the use of one theatre and increasing to all five theatres over a three-week period had been planned. However, due to volume and surgeon demand, all five theatres were ready and operating on October 20, 2014. A similar ramp-up was to occur with the two hospital wards over three weeks, but both were operational on October 20, two weeks earlier than planned. Support from the ehealth, pharmacy and Cerner teams, or the red shirts as they were commonly called because all wore red shirts to be easily identifiable, was provided on-site around the clock for the first two weeks. Each surgeon and anesthetist received one-on-one support from the doctor superusers and Cerner adoption coaches during their first procedure in the theatre, and thereafter until they were comfortable on their own. At week three, on-site support was provided 18 hours per day, and by week four this was reduced to 12 hours per day. It was identified that more hospital superusers were needed and eight more were trained in week three of post go-live (PGL). This additional training resulted in a total of 31 hospital staff being identified as superusers, equating to one fifth of staff. HIMSS Certification. The next major milestone was to achieve HIMSS certification as a Stage 6 hospital. The first step in the certification process was to complete an online survey report. On paper, the organization must receive a score of 6.0 in order to qualify for the next step of an on-site survey. This was accomplished in week four of PGL and an on-site survey was set for November 28, 2014. A doctor surveyor spent the day at SSHB hearing presentations, reviewing doctor and nursing documentation and work processes on the wards and in theatre, observing the entire medication management process from procurement to administration to patient, and assuring the hospital had a filmless environment. The final step in the process was a conference call in which examples of clinical alerts firing and helping with patient care delivery were provided. On December 1, 2014, SSHB became the first hospital in Australia to achieve Stage 6 HIMSS certification. A successful go-live had been achieved and the official grand opening of SSHB was held on December 8, 2014 which notably the Federal Health Minister and local dignitaries attended. 141

St. Stephen s Hospital Hervey Bay Technology Concerns ICT Infrastructure. Implementing adequate ICT infrastructure for the project was a challenge. The ICT infrastructure within UCH was not robust and the hospital was in a regional location four hours from Brisbane. While the Cerner software would be remotely hosted, and was put in place in November 2013, there were concerns regarding the infrastructure foundation for not only SSHB but all of UCQ. In 2012, UCQ decided to centralize the core IT infrastructure departments for its three companies including the UCH hospitals. A new CIO was hired and the departments were amalgamated into Group ICT in October 2012. A separate decision was then made to outsource most of the infrastructure resources through Dimension Data, which occurred in January 2013. However, for purposes of the SSHB digital hospital project, the centralized support model was immature in its life cycle. The building s physical architecture had been developed prior to the decision to make it a digital hospital. As a result, the power and design of the two on-site data centers and 10 communication rooms were undersized and had to be redesigned which required further funding, raising the total hospital program cost to $96M. CIOs. Another key challenge for UCH during the project was the difficulty it faced in hiring and maintaining CIOs who had health care and successful digital hospital implementation experience. Within a three-year period, there were six different CIOs. Because of difficulties in recruiting personnel with the appropriate experience within Australia, experienced staff ultimately needed to be recruited from the United States, with the current CIO arriving one month prior to go live. Current Challenges Facing the Organization From an ehealth perspective, current challenges include prioritising and completing the required fixes and design enhancements that end-users desire as they gain experience and comfort using the EMR system. In December 2014, 154 issues remained on the active working list, which was started during the testing phases, with 14% identified as high priority, 47% medium, 21% low, and 18% cosmetic. To effectively complete this work, a balance must be achieved between maximizing the use of expert Cerner resources before they depart back to the United States or onto other projects, and internally developing UCH staff to enable the project to be sustainable in the future. Furthermore, it is essential that the change management process is handled effectively. Bringing about the necessary changes in a live production environment that is used for other UCQ facilities can have unintended effects on a fully digital hospital. Simple, even routine updates can force staff to close sessions and log back on, which can be an irritant in the middle of patient care or a surgical procedure. Therefore changes must be considered and timed in order to minimize negative impact either to SSHB or other UCQ facilities. However, end-users grow impatient as they want their issues and changes fixed as soon as possible. A wealth of data is available within the clinical data repository. Early key performance indicators, including a 90% adoption rate, 84% doctor order entry rate and 74% bar coding rate are very promising from a performance perspective. There is no longer uncertainty about whether or not medical errors reported are a result of the quality of the reporting culture; the actual results are clearly evident. An important challenge is to focus on a few key indicators, and integrate those results into existing continuous improvement teams and structure, in order to make significant quality improvements. 142

St. Stephen s Hospital Hervey Bay Annual operating costs for SSHB for the ehealth components are $1 million; it is difficult for a 96- bed hospital to be profitable over time if it must consistently and solely carry that overhead expense. However, once the EMR system is expanded across all UCH hospitals it will become manageable as the operating costs can be spread across 1,000 beds. There has been much national attention on SSHB in the past two years. Some doubted the project could be completed successfully; notably, one of the HHF agreement conditions was that if UCH did not meet its commitments to build a digital hospital, it would have to pay the money back to the government. The fact that the hospital opened on-time, on-budget, and with a complete EMR system and effective clinical adoption has resulted in many people requesting presentations and to tour the hospital. UCH is challenged with the time commitment associated with demonstrating its EMR system to interested parties, and the loss of staff through recruitment by other organizations. Despite the critical nature of the aforementioned issues, the greatest organizational challenge for SSHB is workforce recruitment. Two months before the new hospital opened, a new General Manager was appointed. It became clear at that time that additional clinical workforce staff were needed without delay. Patient volumes were expected to increase when the new hospital opened, in particular in theatre, and this has occurred. Though the Hervey Bay region is rapidly growing, it does not have an adequate supply of experienced nurses and it can be difficult to find job opportunities for partners. To supplement recruiting efforts across Australia, international efforts have been put in place. These workforce challenges have put special pressure on the SSHB superusers as it has been difficult to remove them from patient care responsibilities to allow them time to help staff with EMR questions. The original plan was that ehealth and Cerner staff would provide on-site support for four weeks following go-live, and then provide on-call support from Brisbane, with the SSHB superusers providing on-site support. SOLUTIONS AND RECOMMENDATIONS A new governance structure entitled Cablite was implemented by the ISD CIO immediately following go-live. Cablite met daily and on an emergency basis to review and approve all intended IT fixes for SSHB. Meetings are now held twice a week and will continue in this manner until a new UCH Change Management Board is developed. The UCH CIO was added to the UCQ Change Management Board in order to provide visibility of SSHB regarding any system IT changes. Required digital fixes and design changes must also consider workflow changes within the new hospital. An EMR system often illuminates weak practices that have long existed but have not been acted upon. It would be wise to integrate the required IT fixes and changes into existing quality improvement structures for discussion and action. This work has begun with the doctors and staff at SSHB. Post-implementation strategies for the doctors include actively obtaining their feedback regarding issues and desired changes, utilizing craft groups, and developing a new governance committee for perioperative theatre management. Truly one of the great success stories for SSHB has been the high degree of doctor support and clinical adoption obtained, which is largely due to the intense efforts and leadership of the CMIO. A UCH consulting group for digital health is currently being planned for implementation in 2015 which will allow experienced ehealth UCH staff to take short-term leave from their current positions and work as consultants. The consulting group will serve as a vehicle to allow UCH to assist other health care organizations in Australia along their digital journeys, to retain innovative expert ehealth staff within UCH, and afford staff exposure to other organizations and their practices. White papers 143