Process Change or a New Information System?

Meeting 18 Week Pathway Targets with Our eRecord

Introduction

The Trust has an ongoing challenge in managing waiting lists to meet eighteen week targets.

The management of waiting lists is a complex process that can be easily derailed if information is incorrectly recorded, reported, or managed.

Our new patient administration system will offer many opportunities to improve the quality of the registration, booking, scheduling, admission, discharge, and transfer information that we gather. The system will make it relatively simple to merge double registrations when these are found; and it will enable staff to define useful fields for searching, hence reducing the creation of duplicate records.

However the new system is less helpful than the current one if incorrect information is entered into it to update 18 week pathways. This means that we, as an organisation must make a special effort to ensure that the information that is to be entered is correct before it is entered.

What will happen if we don’t meet our 18 week targets?

Put simply, if the Trust fails to meet 18 week pathway management targets then it does not get paid for the service it has provided. The obvious flow on from this is that there is less money for Directorates in following years and less money for the Trust to invest in improved infrastructure and resourcing.

Why would we not hit our targets?

Our Trust is a top-performer. If we record accurately the details of the services we provide we are unlikely to miss our targets with regard to 18 week waiting lists. If, however, our data collection is inaccurate it is quite likely that we will miss targets.

How can we all help to achieve targets?

We know that sometimes the information that is available to be entered into the computer system following assignment of a patient category by our doctors and others is incorrect. As a result managers need to identify how anyone who is responsible for assigning categories on the pathway might be helped to improve the accuracy of that assignment.

Some ideas that are being explored are presented here:

1)    Engagement of clerical and nursing staff to ensure that all outpatient 18 weeks forms are properly processed (existing status correctly identified and non-relevant patient categories scored through), returned, and entered into the computer system in a timely (same day) manner.

2)    Increased focus on training and support of staff to check patient categories for accuracy and validity before they are entered into computer systems. Further development of support tools for people entering patient categories into computer systems.

3)    Standardising our 18 week pathway data collection processes across all departments with well understood Key Performance Indicators to measure enable ongoing monitoring and review by a dedicated 18 week pathway coordinator.

4)    Completion of the 24 hour admission, discharge and transfer project and incorporation of real time 18 week data entry into this process.

5)    It is possible to eliminate non input of non-sequential patient categories (excluding typographic mistakes and wilful errors) by printing individualised 18 weeks sheets according to simple rules that offer the doctor only the logical choices.

By doing this, with no extraneous information the appearance of the sheets will improve, there will be more space to explain better what the fewer choices mean, the sheets would be more acceptable to the doctors with the possibility of fewer sequential but incorrect inputs. There should be no non-sequential inputs except through typographic mistakes.

Note: Ensuring the sequentiality of the data recorded is critical to the process of managing the 18 week pathway and to achieving compliance with waiting list targets.

6)    Development of a short on-line tutorial for doctors regarding how to effectively code outpatient appointments. Making this available to doctors via the Intranet so that they can review it in their own time and revise at any time.

7)    Identification and development of reports that will enable managers to identify sequential errors and manage process changes.

If you need further information about how you can be involved in helping us to improve our 18 week compliance please contact XXXXX.

 

Progress Report

In 3^rd quarter 2009 our Trust plans to go-live with its new electronic patient record (its eRecord).

The Trust has engaged the xxxx to assist it in building an electronic patient record. The Trust’s key focus is on supporting staff in making further improvements to patient care, enhancing the patient journey and improving work practices.

A second key focus of the programme is putting in place a central patient record which will eventually replace paper records as the core source of information about a patient’s care and history.

The new eRecord will initially be used to gather patient demographic and visit information, results of investigations such as radiology and laboratory reports, medicines administration records, and operating theatre booking information. It will also be used to automate and speed up processes in the accident and emergency department and to ensure that hospital staff are better informed when a patient is admitted from A&E to one of our hospitals.

Trust managers have, since April 2008, been reviewing and improving processes involved in booking appointments, scheduling theatre activity, managing beds, ordering investigations, and prescribing medicines. This is in preparation for a higher degree of automation and more effective data capture.

Process-change is the most difficult and certainly the largest component of any major information systems implementation. It is critical that new processes are communicated, understood and standardised. It is also important that the people who need to use the new systems understand their roles and have been engaged and empowered in designing how they will work.

The Trust is aware of the difficulties inherent in such a project and have engaged two senior managers with extensive experience of leading meaningful process change programmes in the New Zealand and US health sectors. In addition the Trust’s partner, xxxx, brings to the Programme experience building and deploying the yyyyyy applications in more than 17 hospitals. This experience has put the organisation in a strong position to advise on getting the most from yyyyyy products, clinical engagement, and opportunities for process reform.

The Trust sees the challenge of unifying its electronic patient records as an essential first step to providing an up-to-date and coherent view of a patient’s history to other providers in the NHS. The long-term plan for the eRecord is that nursing notes, theatre records, and specialist information systems used within the Trust will be integrated so that summary information is available to all clinicians with access to the eRecord.

The eRecord Programme management and the Trust’s IM&T Department are working closely with Connecting for Health to ensure that Choose and Book will be thoroughly integrated and that the development of the eRecord at our Trust is in-line with plans to integrate health information systems on a wider scale in the future. The Trust has also had significant engagement with CfH in designing the local electronic prescribing module which will be the first implementation of yyyyyy’s electronic prescribing in the UK.

Where Process is King

It is fascinating to observe the culture with respect to process Vs outcome in the UK public sector. Too often it appears that people engaged in process, or even reponsible for managing those engaged in process driven work focus more on ensuring that adherance to the process is absolute than on the reason the process was developed in the first place. This way of working that laughed at so much in television series’ such as “Yes Minister” is alive and well and difficult for those from more outcomes driven cultures to understand.

I remember helping a healthcare funder/provider organisation in New Zealand, some years ago to develop an information management strategy that opened with the words:

Every person employed by the ___ should ask themself regularly “How has what I have done today helped to improve healthcare in our region”.

This focus on the prime reason why that organisation existed at all seems to be missing in the ethos of many who work in the NHS in England.

Our recent dealing with the Connecting for Health organisation which have resulted in iteration after iteration of question and answer sessions designed, not to help us and the people of our region, but it seems, to ensure ongoing employment for public servants is but one example. This overfocus on process with little regard for cost or the impact on healthcare outcomes woul dnot be justifiable in a world where perfomance is measured by production.

The problem may stem from allowing government bodies to have an over-involvement with operational provision of service, rather than ensuring that such bodies are responsibel for the development of guidelines or even statute that ensure that thoose who produce are able to do so in a sensible and joined-up way. Governments do not do service, public servants dont “get” service in the way that most of us understand the word.

To date probably several hundred man/woman hours expended jumping through hoops to get approval from CfH to test our system on the Spine. A system in use at perhaps a dozen hospital sin the UK already and connected to the Spine.

People kill people. Computers don’t.

I had to cringe when reading this article on the BBC website today: http://news.bbc.co.uk/1/hi/health/7477099.stm it seems like yet another silly attempt to drag down the reputation of the people and companies involved in trying to support the work of healthcare workers in the UK’s NHS. Another example of poor partisan journalism from this sad organisation.

The subject of the story was delay that was caused to the treatement of cancer patients in the process of migrating to a new computer system in Bart’s hospital. The “journalist” who wrote the article quoted a statement from a poorly constructed report that had been submitted to the Trust Board. The statement said:

The delay was “directly attributable” to problems with switching outpatient information to the new system, a report presented to the Trust board said.

I contend that the delay was not and could not be attributed to this cause. The delay must have been the result of poor planning, including the planning for contingent responses to issues that could be expected to occur during a large scale data migration.

 

In much the same way that problems at Heathrow Terminal 5 were attributable, without a shadow of doubt, to poor management, poor planning, and poor project oversight, this was the result of the same sequence of failures.

 

It is ludicrous to suggest that computer systems cause problems. Computer systems automate processes, reliably, as they are designed to do. They do not make mistakes they do not deviate from what their designers and builders specify. The world at the moment suffers from a malaise that manifests as this “computer says no” attitude that “journalists” love to reinforce.

 

Project managers should take note of this sort of failure, along with that at Terminal 5 and start to accept accountability for their actions (or lack thereof). Project planning is about identifying the events that will occur and the events that are likely to occur. It is about managing the risks, making plans for contingencies and identifying fallback arrangements.

 

The UK has a poor history of good project managment in my experience. The IT sector currently has the notion that project management is taught by trainers at Prince 2 methodology courses. This could not be further from the truth. I am repeatedly encountering people who consider themeselves project managers simply because they have completed one of these courses but who have little if any understanding of how projects are managed, the purpose of the methodology, their roles in project managment, and what it takes to support businesses in bringing home the bacon.

 

Just a thought. Imagine if air traffic controllers came to work and said “look we are so busy  planning that we will not be able to do any planning of flight paths this morning, just take off and land yourselves while we develop a plan.”

What really matters in healthcare informatics

I am leading a major process change initiative (named the eRecord Programme) at one of the biggest foundation Trusts in the UK. This programme encompasses the development of a strategy for the long term future state of clinical informatics support. Our main aim is to enable better healthcare outcomes for the people of our region and to improve on the experience of patients and staff as they journey through the healthcare system.

In this role I am often asked about the significance of press articles that question the quality of the computer applications being implemented in the “Connecting for Health” NHS initiative and I sometimes despair that, as we come close to the end of the first decade of the 21st century, so many people seem to think that it is the computer applications (electronic information systems)  that will make a difference in their organisations, rather than the fundamental changes in process that are enabled by access to the right information, at the right time and in the right place.

Computerised applications are simply tools, they never, ever, in and of themselves, provide a return on investment and anyone who thinks that they will is destined for disappointment. The same sort of disappointment that will occur if one thinks that anywhere in healthcare there is a one-size-fits-all suite of products that will support all of their healthcare information management challenges.

For those that are interested this is an overview of the work that I am currently engaged in:

Why an eRecord?

In 1999 and 2003 two publications were released by the US Institute of medicine, they highlighted a shocking level of misadventure that resulted ultimately in untimely deaths in that country.

While there are no formal studies on the same scale in the UK it is generally accepted that the causes of adverse events in healthcare are effectively the same. Some of them are:

• poorly defined processes that either encourage bad behaviour, or fail to encourage good behaviour;
• ineffective communication, collaboration and inclusion across the healthcare sector; and
• paucity of reliable information at the right time, in the right place and for the right people to support effective decision making.

Further it is widely recognised that healthcare outcomes improve if duplication is reduced, information is shared effectively, and processes are standardised, measurable and understood by participants in those processes. When these things are achieved all stakeholders can, through analysis, monitoring, and identifying trends, improve their own performance or that within their domain of control.

First Steps

The core of the eRecord programme that i am leading is to ensure that we know what the patients within our Trust have experienced or are experiencing on a real-time basis. What treatment have they received, who has or is providing it, and how they responded to interventions.

To do this we must ensure that the recording of information is a key part of the care process and that this occurs as and when that facts become known or change.

The Approach

Our programme of change will be supported through implementation of a software application supplied by a large US based company although, in the same way that a Vauxhall will get you from A to B as effectively as a Rolls Royce, it could as easliy have been supported by any number of applications in the marketplace with a shorter or longer list of “features”. This tool will provide all users with a vehicle to access demographic information about Trust patients, the results of tests performed for Trust patients, the attendances that Trust patients have had, and their current location if they are an inpatient. It will also enable users to order clinical tests consistently, quickly and simply for Trust patients and to record who is responsible for our patients at any specific time.

The programme will also be supported through our partnership with a large US healthcare system who have completed a significant amount of work in this area before, through the support of our IM&T Department, and through the support of the Trust’s training and communication team in Human Resources.

There are two key parts to the programme, the delivery of an Electronic Patient Record for the Trust that will:

• support processes in all Inpatient, Outpatient, and Day Patient areas
• provide a definitive source of data regarding the location of the patient and their demographics
• support work order processing and results reporting for clinicians and enable access to this information ubiquitously
• support improved medicines management through standardised prescribing, dispensing, and administration processes
• support better utilisation and scheduling of theatres
• support improved emergency and trauma management processes and the processes of admitting patients to the hospitals

The second part of the programme will involve automating the capture of outputs from various electronic diagnostic devices (such as EEG, ECG, and Lung function equipment) so that they can be linked to the patient record electronically and the task of ensuring that the large number of systems that support specialist care within our Trust are effectively integrated with our core source of demographic information or replaced with something that meets the users’ needs and is integrated.

We also know that we will want some visibility of information that is kept by healthcare providers and allied health providers who are affiliated with, but not under the authority of, our Trust.

Carers need this complete view, and our first steps of capturing and recording information about major care events that happen across all of our Trust operations is a cornerstone of delivering it.

The computer application tool that we are putting in place will provide the authoritative source of data for Trust information about our patients’ demographics, encounters in the Trust, tests and results, medicines, procedures, allergies, and alerts.

The next step for us is to incorporate, for clinical staff providing care, a view of clinical information that is stored in specialist clinical systems, examples of this type of clinical information include mole maps maintained by dermatologists, growth charts maintained by paediatricians, and birthing records maintained by midwives. In the longer term the clinical history of the patient when they have not been under the care of our Trust must also be available through such a view so that information essential to providing high quality healthcare can be seen by authorised carers.

All of this can technically be made accessible and presented via a single interface to the core Trust patient record. However there are a number of challenges as we move toward the target.

The first and most significant of the challenges we face is the realisation that we cannot replace all clinical applications with a single solution. Not only are there no solution packages that cater for every specialty but there are very human issues of proprietorship which ultimately impact buy-in and support for collaborative strategies.

We must recognise the need for authoritative sources of patient demographic information and clinical history; and that these authoritative sources, to deliver benefit, must be integrated rather than “owned” or controlled. When this occurs we will be committed to a strategy of integration rather than replacement in most cases.

Integration of patient demographics held in all systems is essential, currently this information can be updated and out of synch across literally dozens of systems within our own Trust. This situation makes it almost impossible to tie-together patient information and to present a single view of that information. A program of work has begun to identify how this integration will occur, how data will be cleaned up, and to obtain the resources and tools that will be needed.

The second key tool in developing a holistic view of patient information is one that will enable a federated view of information held in systems that are not either managed centrally or even run within the Trust at all. Our partners use a product designed specifically to achieve this and this tool, or something like it, will become a key part of our kit to develop the right information to our clinicians, at the right time and in the right place.

Progress will be discernable through the achievement of critical success factors. These include enabling co-existence and managed transition from the old state to the new; and maintaining a balance that ensures the ownership and commitment of stakeholders to the outcome. The challenges inherent in both will rely on our ability to deploy the right tools, to engage and communicate effectively with stakeholders and to define a well supported path to success.

Not a destination…

This programme of work is a journey, it is not a destination that will be reached within 3, 4 or even 5 years. The development of tools that enable delivery of information to clinicians; that support decision making of the most complex and critical nature will be ongoing, as information becomes ever more plentiful, the challenges of filtering and presenting it sensible and meaningfully continue to increase.