PAPERLESS ED? AN EPIC EXPERIENCE Conference 2016... · AN EPIC EXPERIENCE Adrian Boyle Cambridge...
Transcript of PAPERLESS ED? AN EPIC EXPERIENCE Conference 2016... · AN EPIC EXPERIENCE Adrian Boyle Cambridge...
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PAPERLESS ED?AN EPIC EXPERIENCE
Adrian BoyleCambridge University Hospitals Foundation Trust@dradrianboyle
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We’d like you to come and speak at Bournemouth Great! What on? Violence? Quality?
Crowding? QIPS? QECC Update? Something really exciting like a SMACC talk?
IT Implementation
WTF?
Pleeeeeeeeaase!
Oh………ok
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Upgrading your IT is the most disruptive thing you’ll ever do
http://sites.psu.edu/siowfa15/wp-content/uploads/sites/29639/2015/10/hong-kong-sars-2-532360.jpghttp://sites.psu.edu/siowfa15/wp-content/uploads/sites/29639/2015/10/hong-kong-sars-2-532360.jpg
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£200m over 10 years*
Budget Out-turn Variance
Capital £28,990,000 £29,296,000 -£306,000
Revenue £36,273,000 £32,897,000 £3,376,000
TOTAL £65,263,000 £62,193,000 £3,070,000
HP£140m
Epic£40m
CUH£20m
* Do nothing = £110m
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Before…
• Notes go missing• Information is unavailable• Results reporting is cumbersome• Multiple poorly communicating IT systems
(12 in the ED, which no one person knew how to use)
• GP communication was poor
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wInTer is coming…
NHS England Five Year Forward mandates that the NHS should be completely paperless by 2020
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wInTer is coming…
Part of ‘Personalised Health and Care 2020’…..’all patient and care records will be digital, interoperable and real time by 2020’
‘Purpose of digitisation is not to digitise, it’s to improve quality, safety, efficiency, and patient experience’ Professor Wachter 2016
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The Addenbrookes and Rosie Hospital EPIC Implementation
• Huge and Complex Hospital, employing around 7,500 clinical staff
• Aimed for a ‘Big Bang’ implementation on the 25th of October 2014ED / Ward / Theatre / ICU / OPD
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Preparing for wInTer
• Team of around 50 clinician super-users‘Instructional Designers’ and ‘Analysts’
• Seconded 2 ED Consultants (50%) and one nurse (90%)
• Training of clinical staff: the playground• Mapping IT processes onto existing
pathways• Simulations of extreme scenarios
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Simplify your processes
• 19 different ways to refer people to an outpatient clinic
• Multiple different ways to request and receive a test
• We don’t work linearly, so don’t design linearly
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Patient arrives at the
ED by ambulance / police
Patient arrives at the
ED on foot
Initial Assessment
by PAT nurseInfection ControlPresenting ComplaintAVPU assessmentDecides on placement
Initial Assessment by pre-reg nurseInfection ControlPresenting ComplaintAVPU assessmentDecides on placement
Secondary Assessment by SAT nurse
Presenting complaint
Analgesia / ECG / Sometimes x-ray Liaise PA
Places Card in Box
Patient registered by receptionist at bedside who returns to reception and then brings out front sheet back to nursing staff
Patient registered by receptionist at reception. Card then placed by patient in box next to minors
Assessment 1
Assessment 2
Resus
Blue Chairs
Waiting room
Secondary Assessment by Minors nurse, pick up card from box
Presenting complaint
Analgesia / ECG / Sometimes x-ray / sometimes Liaise PA
Places card in Box
Medical Assessment
Arrive at an Inpatient bed
SAT Nurse
Receptionist
PAT Nurse
Junior Doctor
ENP
SpR / Consultant
Porter
Radiographer
X-ray
Ultrasound
CT
Cubicle nurse
HCA
Ambulance staff
Nurse in Charge
Ops centre person
Minors
Receptionist
Secondary Assessment by nurse
Presenting complaint /VS
Analgesia / ECG / Sometimes x-ray Liaise PA
Physician’s
Assistant
Cubicle nurse
Secondary Assessment by nurse
Presenting complaint /VS
Analgesia / ECG / Sometimes x-ray Liaise PA
Places Card in Box
Secondary Assessment by nurse
Presenting complaint /VS
Analgesia / ECG / Sometimes x-ray Liaise PA
Places Card in Box
Ambulance staff
Ambulance staff
Ambulance staff
Ambulance staff
Minors nurse
Secondary Assessment by Minors nurse, pick up card from box
Presenting complaint
Analgesia / ECG / Sometimes x-ray / sometimes Liaise PA
Minors nurse
Cubicle nurse
Secondary Assessment by Doctor
Physician’s
Assistant
Physician’s
Assistant
Physician’s
Assistant
Bloods/ Urinary Catheter
Bloods/ Urinary Catheter
Bloods/ Urinary Catheter
Bloods
PA cubicle
SpR/
Consultant
PorterMedical Assessment
Medical Assessment
SpR / Consultant
Junior Doctor
Junior Doctor
SpR / Consultant
Medical Assessment
Junior Doctor
SpR / Consultant
Medical Assessment
Junior Doctor
Porter
Porter
Porter
Nurse Coordinator
Update Jonah with x-ray request
Paper back-up
Co-ordinate transfers to ward and radiology
Request bed on phone
Co-ordinate treatments
Telephone handovers
Manage relatives
Request specialty Doctors to review
SpR / Consultant
Nurse in Charge
Discharge
Nurse Coordinator
Update Jonah with x-ray request
Paper back-up
Co-ordinate transfers to ward and radiology
Request bed on phone
Co-ordinate treatments
Telephone handovers
Manage relatives
Request specialty Doctors to review
In Patient Pharmacy
CDU
Nurse in Charge
Update Jonah with x-ray request
Paper back-up
Co-ordinate transfers to ward and radiology
Request bed on phone and Jonah
Co-ordinate treatments
Telephone handovers
Check Treatments
Check Coding
Check VTE assessment
Check swabs
Porter Receptionist
HCA / Cubicle nurse
Ops centre person
Ops centre person
Radiographer
Radiographer
Minors nurse
Treatments
Cubicle nurse
Treatments
Resus nurse
Treatments
Cubicle nurse
Treatments
Cubicle nurse
Treatments
Cubicle nurse
Treatments
Time
Pre-Reg
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Planning for wInTer
• Fixed ‘Go Live’ date of 25th of October 2014
• Planned ‘Major Incident’OPD Activity cut by 30%Elective theatre activity almost entirely suspendedED Activity cut by 0%
• Floor walkers
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So what happened?
Pause for 24 hours for password problems (HSCIC)
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Conflicting opinions about the implementation of EPIC
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The major problems we had
• The ‘Playground’ wasn’t fit for purpose• Collective underestimation of the
disruptiveness of this• A lot of competent doctors looked utterly
incompetent
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The major problems we had
• Interfaces with pathology didn’t work wellManual cross matching of blood300 GP microbiology tests of urines and sputums were not done
• Block contract payments• Complex prescribing
Warfarin and Insulin
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The Productivity Paradox
“You can see the computer age everywhere except in the productivity statistics.”
We are 20% less productive (Patients / Dr / Shift) than we were before
Nobel Prize winning economist Robert Solow, 1986
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Rants from Consultants
‘I will hold the executive to account for their botched and negligent implementation of the EPIC system’
Election statement for staff governor(successful)
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But did it matter?
• No discernible increase in HSMR / SHMI• VTE Recording
Associated with three VTE’s and one death
• Infection Control RecordingMRSAC.Diff
• Frailty and Dementia Scoring
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Harm incidents• 15 incidents where patient harm had been reported required
investigation/follow-up
• 2 incidents were removed, as investigations showed these were unrelated to Epic
• 9 incidents were rated as causing moderate harm, 5 as minor harm, and 1 graded as major (VTE SI – see right)
3 Serious Incidents (SI) reported to CCG•Business continuity
•Analyser interface
•Hospital Acquired Thrombosis• 3 patients - pulmonary thrombosis• Investigation completed / discussed with HM Coroner• None solely related to Epic
Patient safety summary
No harm recorded
Chart1
W/C 27/10/14
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W/C 01/06/15
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W/C 29/06/15
W/C 06/07/15
W/C 13/07/15
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W/C 27/07/15
W/C 03/08/15
W/C 10/08/15
W/C 17/08/15
W/C 24/08/15
W/C 31/08/15
W/C 07/09/15
W/C 14/09/15
W/C 21/09/15
W/C 28/09/15
Harm Incidents
Epic Harm Incidents
0
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EPIC Incidents by Week
W/CEPICEPIC - ConfigurationEPIC - Data EntryHPEPIC - MAREPIC - SoftwareEPIC - SupportEPIC - TrainingHP - infrastructure
W/C 27/10/149341154113
W/C 03/11/14948215213
W/C 10/11/142575141811
W/C 17/11/1455141305
W/C 24/11/1483413376
W/C 01/12/142142738115
W/C 08/12/141538137
W/C 15/12/14814223102
W/C 22/12/146102314
W/C 29/12/144339
W/C 05/01/1522121129
W/C 12/01/15111429
W/C 19/01/152221161
W/C 26/01/153733
W/C 29/12/14512
W/C 02/02/15252
W/C 09/02/1539
W/C 16/02/15231
W/C 23/02/151732
W/C 02/03/15342
W/C 09/03/15222
W/C 16/03/1523131
W/C 23/03/1531
W/C 30/03/157
W/C 06/04/1520
W/C 13/04/1522
W/C 20/04/1515
W/C 27/04/15211
W/C 30/03/151
W/C 04/05/157
W/C 11/05/15151
W/C 18/05/1516
W/C 25/05/1512
W/C 27/04/153
W/C 01/06/1512
W/C 08/06/155
W/C 15/06/1510
W/C 22/06/1510
W/C 29/06/152
W/C 06/07/1512
W/C 13/07/1510
W/C 20/07/1513
W/C 27/07/1514
W/C 29/06/154
W/C 03/08/1517
W/C 10/08/1511
W/C 17/08/1523
W/C 24/08/1515
W/C 07/09/156
W/C 14/09/157
W/C 21/09/154
W/C 28/09/155
W/C 31/08/151
W/C 28/09/155
EPIC Incidents by Week
EPIC
EPIC - Configuration
EPIC - Data Entry
HP
EPIC - MAR
EPIC - Software
EPIC - Support
EPIC - Training
HP - infrastructure
EPIC Incidents by Incident Category
EPIC Harm Incidents
WeekHarm Incidents
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W/C 03/11/142
W/C 10/11/151
W/C 17/11/161
W/C 24/11/141
W/C 01/12/140
W/C 08/12/145
W/C 15/12/140
W/C 22/12/140
W/C 29/12/140
W/C 05/01/152
W/C 12/01/150
W/C 19/01/150
W/C 26/01/151
W/C 02/02/150
W/C 09/02/151
W/C 16/02/150
W/C 23/02/150
W/C 02/03/150
W/C 09/03/150
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W/C 13/04/150
W/C 20/04/150
W/C 27/04/150
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W/C 11/05/150
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W/C 06/07/150
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W/C 31/08/150
W/C 07/09/150
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W/C 21/09/150
W/C 28/09/150
EPIC Harm Incidents
Harm Incidents
EPIC Harm Incidents
Actual Harm Incident Detail
Form NumberActual ImpactDate of IncidentPerson Affected StatusPatient SpecialtyIncident Ward / DepartmentIncident Clinical DepartmentIncident ClassIncident Sub ClassIncident DetailsAction TakenActions needed to minimise the chances of recurrenceFurther investigation notes / additional informationOther DetailsDate inputInjuries SustainedAction Closure Date
I130890Minor (green)8/7/15PatientHaemato-oncologyWard C10 (Haematological Oncology)Haemato-OncologySpecimensDelay in Reporting / Obtaining ResultThe patient has a complex background, having had a cord blood transplant with poor engraftment and severe immunosuppression. She developed a densely amnestic syndrome, with a pyrexia unresponsive to antibiotics. The working diagnosis is HHV-6 encephalitis. A lumbar puncture was performed at lunchtime on Friday 21/8/15, with the primary reason of obtaining CSF for HHV-6 PCR. The laboratory attempted to send this CSF to Bristol for analysis on Friday afternoon, but according to the technician named below this was impossible because - eHospital does not believe that you can do HHV-6 on CSF. It wouldn't allow us. It said that we had the wrong tube type. Staff attempted to re-place the order on eHospital at 16:18 but it could not be ticked as collected. This hurdle was apparently insurmountable, and nothing further was done. On Sunday 23/8/15 I (neurology SpR named below) attempted to find the results. All other LP tests were available, but there was no sign of the HHV-6 PCR even being in progress. I calle more...See section B above. The patient has been given the highly toxic Foscarnet, without definitive diagnosis.There must be a manual override available in this circumstance. Certainly it seems entirely inappropriate that it was just deemed - too difficult - to send the sample so seemingly nothing was done by the laboratory. In all documentation it was clear that this was the primary working diagnosis and the main reason for performing the lumbar puncture.Martin Strickland (Ward / Department: Histopathology) added the following on 06/10/2015:
INV-3654 - Epic needs to be updated so that CSF can be added as a sample source for HHV6 testing. We have sent this request inNovember 2014 and August 2015 The root cause of this complaint was the lack of EPIC order which meant the sample hasnot ordered for the correct test thus did not appear on send away or overdue list. This request is being managedWe havereminded the staff involved to record all communications/ procedures on EPIC (it was not clear until today whether or not thissample had ever been sent). This would have saved much time and confusion over if and when this sample was sentWe havesent some sample EPIC barcodes to Bristol PHE to see if they are able to scan them. This means that our reference reportswill have the correct laboratory number on them. This would have prevented the delay in reporting.The correct procedure forensuring the testing of unorderable requests on epic is to s more...Epic8/25/15Yes9/4/15
EPIC Incidents by Week (2)
W/CEPICEPIC - ConfigurationEPIC - Data EntryHPEPIC - MAREPIC - SoftwareEPIC - SupportEPIC - TrainingHP - infrastructure
W/C 27/10/149341154113
W/C 03/11/14948215213
W/C 10/11/142575141811
W/C 17/11/1455141305
W/C 24/11/1483413376
W/C 01/12/142142738115
W/C 08/12/141538137
W/C 15/12/14814223102
W/C 22/12/146102314
W/C 29/12/144339
W/C 05/01/1522121129
W/C 12/01/15111429
W/C 19/01/152221161
W/C 26/01/153733
W/C 29/12/14512
W/C 02/02/15252
W/C 09/02/1539
W/C 16/02/15231
W/C 23/02/151732
W/C 02/03/15342
W/C 09/03/15222
W/C 16/03/1523131
W/C 23/03/1531
W/C 30/03/157
W/C 06/04/1520
W/C 13/04/1522
W/C 20/04/1515
W/C 27/04/15211
W/C 30/03/151
W/C 04/05/157
W/C 11/05/15151
W/C 18/05/1516
W/C 25/05/1512
W/C 27/04/153
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W/C 08/06/155
W/C 15/06/1510
W/C 22/06/1510
W/C 29/06/152
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W/C 27/07/1514
W/C 29/06/154
W/C 03/08/1517
W/C 10/08/1511
W/C 17/08/1523
W/C 24/08/1515
W/C 07/09/156
W/C 14/09/157
W/C 21/09/154
W/C 28/09/155
W/C 31/08/151
W/C 28/09/155
EPIC Incidents by Week (2)
EPIC
EPIC - Configuration
EPIC - Data Entry
HP
EPIC - MAR
EPIC - Software
EPIC - Support
EPIC - Training
HP - infrastructure
EPIC Incidents by Incident Category
EPIC Harm Incidents (2)
WeekHarm Incidents
W/C 27/10/140
W/C 03/11/142
W/C 10/11/151
W/C 17/11/161
W/C 24/11/141
W/C 01/12/140
W/C 08/12/145
W/C 15/12/140
W/C 22/12/140
W/C 29/12/140
W/C 05/01/152
W/C 12/01/150
W/C 19/01/150
W/C 26/01/151
W/C 02/02/150
W/C 09/02/151
W/C 16/02/150
W/C 23/02/150
W/C 02/03/150
W/C 09/03/150
W/C 16/03/150
W/C 23/03/150
W/C 30/03/150
W/C 06/04/150
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W/C 27/04/150
W/C 04/05/150
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W/C 01/06/150
W/C 08/06/150
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W/C 06/07/150
W/C 13/07/150
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W/C 27/07/150
W/C 03/08/150
W/C 10/08/150
W/C 17/08/150
W/C 24/08/150
W/C 31/08/150
W/C 07/09/150
W/C 14/09/150
W/C 21/09/150
W/C 28/09/150
EPIC Harm Incidents (2)
Harm Incidents
EPIC Harm Incidents
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Computers are distracting!
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The major problems we have
• Training staff is a full day
• Wall mounted computers are in the wrong place and not used
• Able locums are harder to find
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The major problems we have (2)
• Non standardised workflows• Clinical productivity is reduced in all areas
by about 20%• Consent / ECGs are paper and then
scanned in• Our system doesn’t talk to the GPs
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Audit Standards
• Printing is a problem (standard 7)
• IT makes everything better…or worse
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Not all bad
For clinicians• Clinical Records much
easier to review• Virtual fracture clinic
4,500 appointments freed up200k / year saving
• Routine checking of x-ray reports and blood tests takes less than 2 hours / day
For patients• Reduced repetition of
history• Drug errors are less
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Then CQC came….
• CQC inspection visit April 2015• Report published in September 2015• CUHFT placed in special measures and
rated as ‘inadequate’
• CEO Dr Keith McNeil resigns
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With hindsight…
• Engage, engage, engage
• Test in advance and say ‘no, we aren’t ready!’
• Simplify your processesReferrals / Pathology / Radiology
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With Hindsight
• Train on a system that looks like your real system
• Train shortly before ‘go live’
• Train again• Train by peers who
actually understand what you do
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Big Bang or Phased Implementation?
Big Bang• Short term pain• Economies of support
staff• Planning and support
Phased Implementation• May be abandoned• Less disruptive
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@dradrianboyle
Paperless ED?�An EPIC ExperienceSlide Number 2Upgrading your IT is the most disruptive thing you’ll ever doSlide Number 4£200m over 10 years*Before…wInTer is coming…wInTer is coming…The Addenbrookes and Rosie Hospital EPIC ImplementationPreparing for wInTerSimplify your processesSlide Number 12Planning for wInTerSo what happened?Conflicting opinions about the implementation of EPICThe major problems we hadThe major problems we hadThe Productivity ParadoxRants from ConsultantsBut did it matter?Slide Number 21Slide Number 22Computers are distracting!The major problems we haveThe major problems we have (2)Audit StandardsNot all badThen CQC came….With hindsight…With HindsightBig Bang or Phased Implementation?Slide Number 32