Spade or Shovel?...

Our approach to reducing the complexity and variation in the chemotherapy journey.

Helen Delimitros

Jennifer Todio

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HIC 2015

About Us – Epworth HealthCare

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Problems we faced…the why?

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Managing a Complex Process with Paper Records

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Managing Variation

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Managing Disparate Access to Information

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Pre Project Measures

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• Clinical experience and feedback

• Riskman Incidents

• Pharmacy Audits

• Manual Chart Audits

• Literature

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Contrast with Pharmacy Audit -Incident rate of 38 prescribing errors/1000 bed days, compared with 6/1000 reported in Riskman, compared with 0.17/1000 hospital wide!

Higher Incidence Rate for Oncology

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Oncology Medication Riskman Incidents made up 30% of Total Reported Incidents

Clinical Risk

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Prescribing errors with the potential to cause harm frequently go undetected.

Reported incidents do not reflect the profile of medication errors.

Only 1.3% of clinically important prescribing errors with the potential to do patient harm were reported in hospital incident systems.

Paper Chart Audit

• Assessed 100 charts for compliance against key COSA guidelines

o Patient ID Criteria

o Height/weight/BSA

o Diagnosis

o All drugs ordered

o Administration route and mode

o Prescriber name and signature

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Audit Findings

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0

20

40

60

80

100

120

Paper Chart Compliance %

Site 1 %

Site 2 %

Our Vision

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We wanted the Rainbow

Project Long Term Vision

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Receives Treatment Summaries; Nursing Care Plans through Document Interface

Order received through the ARIA Outbound Order’s Interface – Manual input eliminated

Nurse & Pharmacist

Review on line

EMRLegend ARIAPharmacy Ordering System

Changes to Drug Order easily

identified

One source of truth for drug

order

Drug Administration recorded on line and in real

time

Clinician Places Order using

Regimens +/-Other

Clinician has real time access to ARIA Patient

record

Toxicities, Treatment summary recorded

Access to Data for Management

Reports & Outcome Data

Technology Brief

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• Connecting the Radiation and Medical Oncology Records

Technology Brief

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• Chemotherapy Scheduling, Prescribing and Clinical Documentation at the Point of Care

• Interfaces with PAS, Radiology and Pathology

Next Challenge…How were we going to approach it? Was it a Job for a Spade or a Shovel?

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Depends on the job in hand

• Shovels are designed for

- Digging big holes

• Spades are designed for

- Defining edges

- Digging hard ground that

must be moved with

substantial force.

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Anticipated Challenges and Risks

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1. Private Hospital Model –Sponsorship & Uptake

2. Organisational Culture & Staff Adoption

3. Infrastructure & SupportModel

4. System Integration

Our Approach

• Started with the “Spade”o Used to define the edge – lead adopters; build

and refine; allow time for change to sink in;

o Minimised the risk of digging ourselves into a big hole (delicate nature of the private hospital model; immaturity with large scale IT change)

• Continued with the “Shovel”o Targeted remaining Oncologists & high Referrers

o 3-4 month roll out

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Implementation Timeline

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21-Oct-13 30-Sep-15

01-Jan-14 01-Apr-14 01-Jul-14 01-Oct-14 01-Jan-15 01-Apr-15 01-Jul-15

Feb 14

Scheduling Go-Live

Jan 15

5 Oncologists; Pharmacy;

Nursing

Jun-14 - Jul-14

Planning Next Phase

Feb-15 - May-15

Stabilisation/Review phase

Jun - Sep

Remaining Oncologists

Aug-15

19 Oncologists

Results/ Outcomes

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Results: Uptake to Date

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0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

% of Patients with Electronic Chemo Order by Oncologist

Results: Pre and Post

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Disconnected Records.Difficult to find information.

Connected Oncology Record.Fully electronic and indexed.

Pre Post

Regimens prescribed not peer reviewed.

100% of Regimens peer reviewed against standard/s.

100% compliant drug orders.Decision support.

Electronic – 1 Version.19/21 electronic prescribers.

Non compliant drug charts.No decision support.

Paper (11 Versions of chart); 0/21 electronic prescribers.

Handwritten Notes; Illegible; Not easily audited. “Chinese Whispers” …

Electronic Notes; Treatment Summary;100% audited. One source of truth.

Results: Oncology Treatment Summary

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Structured Template – Standardised across sites.Data populates automatically from inputs during

Patient Assessment and Treatment.

Results……Requirement for Ongoing Training, QA and Support

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Reported Incidents to Date…

8 Prescribing errors reported in Riskman for the project sites between Feb – Jun. • 1 was attributed to using the electronic chemotherapy prescribing

system ARIA

• 7 were due to paper prescribing processes

9 Dispensing errors reported in Riskman between Feb – Jun. • 1 attributed to an incorrectly configured Regimen (wrong diluent)

• 3 errors prevented by using evidence based regimens in the electronic ordering system.

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Too early to accurately measure

Comments from the floor

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“ This has got lots of good things. I so like it!

I’m going to save 10,000 hours from not having to collate data manually for

management reports

Who thinks this is going to be fantastic?! I do!!

It’s really good that I can see the Patient’s appointment for

Radiotherapy

I don’t want to ever go back to booking

in the diary now that I know how to

do it in ARIA!

“Love the fact that can see the planned treatment dates!”

“How good is that!”(Reviewing the diagnosis

and results)

“Awesome. That’s great!”(Creating the treatment summary)

Images from the floor

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Images from the floor

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Conclusion

• While you can manage with only a spade or shovel, we concluded that our project was successful because we used both.

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Team Acknowledgments

Phase 2 – Chemo Prescribing

Dr Stephen Vaughan (Lead Oncologist)

Dr Y Tran, Dr R Jennens, Dr K Khamly,

Dr B Shah, Dr S Kamel (Oncologists)

Chris Wall (ITS PM)

Andrew Fodor – CIS

Linda McGinn, Fran Cotching, RahniBurleigh & Susan Bourke – Lead Nurses

Jennifer Todio – Lead Pharmacist

Jonathan Hollis – Communication & Change

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Phase 1 - Scheduling

Paul Fenton - PM (Clinical)

Lindsay Wills (ITS PM)

Suzanne Pohlner (Training & Project Support)

Jonathan Hollis – Training & Communication

Bettina Lijovic – BA

Questions?

Thank you for listening!

…further Questions? Email Helen.Delimitros@epworth.org.au

Jennifer.Todio@epworth.org.au

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