Fire and Ice 24 July 2015

SNOMED …makes a good first clinical impression

• 2 partially publicly-funded ambulance operators (~70% MoH and ACC - opex only)

• About 600 ambulances nationally

• More than 400,000 emergency calls per year (more than 1,000 a day)

• 80% transported

• About 70% medical / 30% trauma

• St John covers 90% of the NZ population

• Shared control/communications centres (111) in Auckland, Wellington and Christchurch

Ambulance in New Zealand

• MDT system in ambulances obsolete

• Hand-written patient report forms often illegible and incomplete

• NHI Number not always collected

• Little patient information available at point of care

• GPs not advised of ambulance contacts

• Hospitals not always aware of incoming ED patients

• Ambulance clinical record not available electronically to the hospital, A&M or GP

• Hospitals do not advise ambulance of patient outcomes

• Difficult to extract data for education, clinical audit, research, performance improvement

The Problem

• CareMonX MDT and ePRF

• Valentia Technologies - Irish-based

• Purpose-built ambulance clinical record system

• Configured for NZ requirements

• Implemented in UK, Europe, Middle East

• Modern layered architecture

• Platform independent

• Part of an integrated suite of products

CareMonX MDT

CareMonX ePRF

The Solution

On the Road

Defibrillator

Wireless hub

CareMonX ePRF

CareMonX MDT

Standards based system• Standards allow us to easily share data with

other healthcare providers

Clinical Document Architecture

HISO 10052Ambulance

Care

HISO 10043CDA templates

HISO 10011eDischarge

HISO 10040.4Metadata

HISO 10046Consumer

Identity

HISO 10005HPI

HISO 10041.1Medications

Code systems and term sets• Code systems and term sets allow us to

describe an episode of care

SNOMED CT

Ministry of Health

Ambulance specific

UCUMStatistics NZ

LOINC NZMT

Use of SNOMED CT

• We use SNOMED to help describe:

What we thought

What we saw

What we did

Vital observations; e.g. GCS, HR, BP, SPO2• Observation name recorded using LOINC Code; e.g. 8867-4

Heart Rate• Simple observations recorded using UCUM; e.g. mmHg• More complex concepts recorded using SNOMED; e.g.

Heart Rhythm:   

426285000 Electrocardiogram: normal sinus rhythm (finding)164889003 Electrocardiogram: atrial fibrillation (finding)164890007 Electrocardiogram: atrial flutter (finding)164887001 Electrocardiogram: supraventricular arrhythmia (finding)164896001 Electrocardiogram: ventricular fibrillation (finding)164895002 Electrocardiogram: ventricular tachycardia (finding)427084000 Electrocardiogram: sinus tachycardia (finding)426177001 Electrocardiogram: sinus bradycardia (finding)426307007 Electrocardiogram: junctional rhythm (finding)164909002 Electrocardiogram: left bundle branch block (finding)164907000 Electrocardiogram: right bundle branch block (finding)164898000 Electrocardiogram: heart block (finding)

Use of SNOMED CT

• We use SNOMED to help describe:

What we thought

What we saw

What we did

Medications administered• Medication name recorded using NZMT Code; e.g.

• Dose recorded using UCUM; e.g. mL• Route of administration represented by a SNOMED

concept; e.g.

   

10370021000116107 Midazolam10446531000116106 Morphine24308091000116101 Naloxone

   

417255000 Intraosseous route (qualifier value)47625008 Intravenous route (qualifier value)46713006 Nasal route (qualifier value)

Use of SNOMED CT

• We use SNOMED to help describe:

What we thought

What we saw

What we did

Interventions performed fully coded using SNOMED concepts

• Procedure; e.g.

• Body structure; e.g.

• Laterality; e.g.

• Anatomical relationship; e.g.

• Intervention success; e.g.

   

173067007 Airway Management Cricothyroidotomy250980009 Cardioversion392231009 IV insertion

   

181373000 EJV362741001 Forearm243941009 Fourth intercostal

   

7771000 Left24028007 Right

   

49370004 Lateral261132002 Midclavicular

   

385669000 Successful385671000 Unsuccessful

Use of SNOMED CT

• We use SNOMED to help describe:

What we thought

What we saw

What we did

NZ Emergency Care Reference Set• Developed by Tom Morton & Andrew Munro from NMDHB• Based on work done by NEHTA in Australia• SNOMED concepts describing 23,240 reasons why people

turn up in EDNZ Ambulance Clinical Impression Reference Set• Developed by St John and WFA researchers• A subset of NZECRS• SNOMED concepts describing 465 reasons why ambulances

take people to ED• Medical and trauma – map to Read codes• As close to a diagnosis as a non-doctor can get• NOT presenting complaint, symptom or observation

• Transfer of Care at hospital or Medical Centre – CWS integration

• Patients left at home – delayed transfer of care

• Ambulance officer as an ad-hoc member of a shared care team

• GP advice – initially via HL7 2.4 messaging; later via HIE

• Ambulance Care Summary becomes part of the patient’s clinical record

• Close the loop with hospitals and ACC – clinical impression vs diagnosis;

treatments vs outcomes

• Research – ambulance planning; wider population and public health research

So what?

About the project

• Upgrade communications technology in ambulances • Replace MDT • Introduce electronic clinical record to replace paper form

(not WFA)

IT Health Board involvementSignificant MoH and ACC funding

TransitionStart-up Initiate Design Build

Timing

• Now – UAT of ePRF• August 10 – Trial implementations “pilot”• October 5 onwards – Staged national roll-out• Next year – version 2:

Access from 3rd party CWS GP advice Enhanced clinical audit Modifications and enhancements