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EXCLUSIVE -Enhanced clinician engagement in ICT design process for boosting ICT adoption in hospitals

Dr. Damian Claydon-Platt, Chief Clinical Information Officer at Epworth HealthCare, talks about the challenges in realising the benefits of ICT and the importance of having intuitive interfaces for clinicians so that safety, quality and efficiency of healthcare delivery is improved.

Can you tell us about your role?

Epworth HealthCare is Victoria’s largest not-for-profit private hospital group, with ten in-patient sites. I am the Chief Clinical Information Officer, responsible for all clinical facing information systems, and work very closely with the IT department and the CIO. I am also a practising clinician, with over 17 years’ experience, predominantly in the intensive care setting, which helps me stay aware of what is happening at the clinical coalface.

Can you tell us about ongoing ICT projects at Epworth?

To start, there’s always Business-as-usual (BAU) work going on, and maintenance of the IT infrastructure; LAN, WAN (Wide Area Network), Data warehousing, SANs (Storage Area Networks) etc. From a clinical systems perspective, we are continually exploring how to move forward with improved access to information, which has a lot of facets.

We are currently working to improve access to clinical images (including radiology, cardiology, gastroenterology, clinical photographs etc.) through the implementation of a Vendor Neutral Archive (VNA). There is ongoing work around clinical information capture for audit and health information exchange. And we are constantly reviewing our electronic medication management solution.

We are also exploring 3D-printing, robotic surgery, big data analytics and mobility. We are already using 3D-printed custom titanium implants at a few sites - both in maxillofacial reconstructive work and also spinal surgery. We have been using Da Vinci robots at three sites for a number of years. We have made some steps into apps, but we are still strategising, or scoping out projects with big data and mobility platforms; trying to understand how they fit into our current and future roadmaps.

Are you shifting your data and infrastructure to the cloud?

We haven’t moved to the public cloud yet – though we are using private cloud in-house. It’s a question of the value proposition. The (public) cloud obviously offers the benefits of high availability and scalability, but we are still working through how we would easily incorporate it into our architecture, and how to do that securely.

Until recently, there was concern over cloud security - especially with health information. Sensitive patient data needs to be stored securely, and in Australia, there are laws around movement of patient information across state or international borders. The complexity of having to ensure that those laws were respected made cloud less enticing.  

Historically, this led most healthcare organisations to provide all IT services in-house – not using outsourced IT infrastructure. Consequently, we have invested in internally hosted data centres, and have internal SANs for all of our data storage, high availability, and backup.

Are you connected to MyHealth Record?

We are connected with My Health record, though it is not really used much. Most GP Practice management software systems in Australia have been integrated with MyHealth Record for a while now. However, end-user (patient) uptake in Australia has been relatively slow. Only around 20% of the national population has registered so we are not close to critical mass yet.

Northern Territory (NT) with a smaller, more itinerant population, had a much earlier uptake of it. Once they reached around 50% of the population on to the MyHealth record, it became a far more useful source of information. The uptake increased pretty quickly then, because clinicians accessing it found it useful, and then also started uploading to it.

For MyHealth Record to be the first port of call for a clinician, it needs to be used by most of the patients’ treating clinicians. When you don’t have a high percentage of GPs or hospitals using it, it’s an incomplete record and consequently less enticing. It’s a bit of a catch-22 situation.

Furthermore, the value of the MyHealth Record for the population was probably not as well articulated as it could have been. Consequently, patients haven’t been driving it as much as they could have. The onus has been on clinicians and hospitals to use it, but without patients wanting that to be their unified source of information, uptake has not been as quick as perhaps it could have been.

What are the challenges faced in adoption of technology in healthcare?

Much of the delay in the uptake of technology in healthcare is due to the complexity of the information we deal with.  Many hospitals are still working on getting their fundamental clinical information systems sorted out. There have been a number of attempts on different occasions, and from various directions to promote uptake, but it appears always to be done on a state-by-state basis, and not a national approach.

In Victoria, the HealthSMART program tried to get 22 public hospitals to implement a standardised suite of clinical IT applications. But this turned out to be far more difficult than initially thought, because standardised solutions don’t work for all hospitals. Each hospital’s environment, patient population, staff, and processes are different. Their need for information systems, their readiness for technology and degree of sophistication vary widely.

At the end of the program, instead of the intended 22 hospitals, only four adopted these systems. Furthermore, because of a number of high profile failures, there’s now increased caution around spending on health IT. The combination of funding constraints and concerns about failure to realise benefits, means that decision makers have become cautious.

IT is unquestionably important. But how do you implement it in such a way that you can realise the desired benefits? How do you ensure that it does not interfere with workflows, but still improves the safety, quality and efficiency of healthcare delivery? The consequences of poor implementation can have a significantly negative impact on patient care. If a music streaming service fails, people come back tomorrow.  But if you have a breakdown in healthcare IT systems, especially clinical ones, a direct impact on patient care can result.

One major difference between public and private hospitals is that private hospitals don’t have many junior doctors. There are a majority of visiting specialists (in the private setting), and we don’t employ junior doctors who could do data entry and data collection work. There would be significant clinical pushback against any information system which requires senior clinicians to spend a lot of time navigating through multiple screens entering data, when they are currently used to quickly handwriting a paper record. Many of them don’t want to wrestle with a computer system in the middle of treating a patient, by having to enter data through interfaces that are not designed with convenience and usability in mind.

Due to the lack of intuitive interfaces, clinicians often find that the system interrupts patient care or simply adds to their workload. There’s no doubt that there are benefits to be gained, but these benefits often flow downstream – to other team members involved in patient care, who will better understand what’s going on. The benefits to the patient include improved safety, as well as quality and clarity of the information. But this comes at the expense of more work being done by the doctors. It is a complex issue. In some hospitals in America, they have put on data scribes, because data entry is not an efficient use of medical time. This approach has been almost universally well-received.

These days, clinicians also face the problem of information overload. When working clinically, I can pick up a history, read through it quickly and find the bits of information that I need. Some of that is by pattern recognition. I can turn the patient history on its side and quickly navigate through the notes based on the different colours on the paper’s margins. I know anaesthetic notes are purple stripes, progress notes are green. I don’t have to figure out where on the screen the dropdown menu is, or which tab I need to go to.

Each clinician needs different information.  In systems where you have everything available – i.e. pages and pages of data – relevant information can be lost in a sea of irrelevant information. The surgeon, respiratory physician, and cardiologist all need to look at different things. Each of them needs to find their small but relevant piece in that history. If accessing important information for each patient they see takes a few extra minutes, it adds up to a significant amount of time wasted overall.

To conclude, clinicians need to be engaged to a far greater degree in the IT design process from the start, so that systems can be intuitive, and useful. Hours of training should not be required when implementing such systems. Adoption of health IT solutions will continue to be difficult and slow, until such user-centred design principles are properly adopted and respected during development. 

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