Joe, a 78-year-old survivor of prostate cancer, suffers with side effects from radiation treatment, including a bladder burn that causes daily discomfort. After seeing the same specialist for more than a decade, he recently transitioned to a new physician.
You might expect his greatest concern to be the prospect of facing a bladder removal. Surprisingly, he’s more preoccupied about whether his new doctor will understand his history. “I just wish there was a way he could know me,” he says.
Joe’s story illustrates the rationale for a fundamental shift under way at Island Health, a health authority providing services to more than 765,000 people on Vancouver Island in B.C., including the islands of Georgia Strait and mainland communities.
Island Health is actively moving towards having a single, integrated electronic health record across the continuum of services that it provides – including primary care, home and community care, residential care, mental health and substance use, ambulatory care and acute care.
As part of this transformational One Patient, One Record, One Plan for Health and Care strategy, Island Health is currently working to develop a new view of patient information called Know Me.
“What’s really missing from a traditional electronic health record is the patient’s voice,” says Dr. Mary-Lyn Fyfe, Chief Medical Information Officer and a practicing physician at Island Health. “What’s their story about their experience? How can they tell us about what they would like for health and for care prior to us seeing them?”
The intent is to ensure that social factors impacting health and wellness, as well as information about personal goals, are incorporated into the health record. The concept is considered a first and is part of Island Health’s alliance with Cerner Corp., formed in February 2013, to advance the health authority’s integrated electronic health record (EHR) strategy.
“If I walk into a patient’s room, I know she has diabetes, hypertension, heart failure,” explains Dr. Fyfe, acknowledging the tendency for doctors to sometimes think of patients in terms of their medical conditions. “But what if I also know that she would really like us to have conversations when her son is present, or that she worries about being out of work too long because she can’t afford her rent? How would our conversation change if I knew that the only thing she really wants answered is, ‘Am I going to have to stay in hospital?’ Until we address that she just cannot listen to a thing I have said.”
The Know Me concept is less about patients accessing their personal health information and more about changing the conversation that takes places between providers and patients, adds Catherine Claiter-Larsen, Vice-President Quality and Chief Information Officer at Island Health. “It’s about triggering a conversation that doesn’t always happen today … so that we will know what matters to the people we serve and not just what’s the matter with them,” she says.
Island Health’s Know Me view is currently under development. Other Cerner Canadian firsts arising from the One Record, One Patient, One Plan for Health and Care strategy supported by Cerner include:
• PharmaNet integration, the ability to view drug-related information contained in a provincial data repository from within the patient record;
• integration with biomedical devices in a new patient care centre so that information from blood pressure machines, thermometers and other devices is now wirelessly transmitted to the health record;
• and, a new design methodology focused on work-flow validation, a process that engages clinicians and patients in furthering the design of the integrated electronic health record itself.
“I think this could be internationally leading,” said Claiter-Larsen, referring to workflow validation. “Instead of engaging clinicians in the bottom up design of a clinical information system, repeating the creating of that wheel over and over, we have interdisciplinary teams of experts who are validating an existing, well configured Cerner clinical information system.”
As part of the process, patients are asked to sit down with the project teams to discuss how advancements to the integrated electronic health record might work. For example, they might go through the steps that will take place if a patient were to arrive at Emergency and needed to be admitted for help with mental health or addiction issues. In addition to providing comment on the process itself, what makes sense and what doesn’t, patients also have the opportunity to provide feedback about how the proposed scenario makes them feel. “That’s quite different, to expose patients to the early build of an application and get their input,” she said.
Island Health’s journey towards establishing an integrated electronic health record started in 2006 with a decision to standardize on Cerner software. At the time, Cerner was installed in one of three geographical locations that make up the health authority, but was under-used because a parallel paper system was also maintained.
Like many organizations, Island Health was “plagued with multiple, disparate, duplicative information systems all over the place,” explains Claiter-Larsen. The recommendation at the time was to leverage the investment already made in Cerner in order to provide a thin but complete set of core clinical content across the entire region served by Island Health.
“We debunked the myth that clinical information systems had to be highly tailored to geographies, physical environments and scope of services provided,” she says, noting that the same configuration was used for a 500-bed hospital as well as the smallest ten-bed site on a tiny island.
“The pivotal point was that prior to completing those efforts (to standardize on Cerner), we had a long list of specialists who wanted their own best of breed system … Once we got the One Person, One Record solution in place, those requests for profession-and sector-specific systems faded away.”
Michael Nusbaum, a long time healthcare consultant and president of MH Nusbaum & Associates Ltd. in Victoria, B.C., says efforts to move towards an integrated patient record are often met with hesitation.
“There are always naysayers when you do these projects and I always tell them I’ll come back in a year and you tell me if you can live without this. If you can, beer is on me,” he says. “Let’s just say I’ve never ever lost a beer.”
Nusbaum refers to the One Patient, One Record integration challenge as a change management exercise that requires strong leadership as much as technology.
“That’s the beauty of this thing. It’s an ever-changing system,” he says, noting that every healthcare organization is working towards some form of integration. “The secret to success is instilling this notion of one record into the culture of the organization, from the most senior executive all the way down to the person who is cleaning the bed pan.”
One reason for Island Health’s success to date, he adds, is the dynamic team of Fyfe and Claiter-Larsen, who communicate well with all key stakeholders, including medical staff and patients. “They have done a fantastic job. Most of the health informatics industry in Canada looks very admirably on the work done by Island Health,” he says.
Another is that Island Health was prepared to start somewhere, knowing that technology is often out of date faster than it can be implemented.
“The important thing is you just have to draw your line as best you can with the information you have at the time and then make it work,” says Nusbaum. “When you achieve your objective, there’s always going to be someone else with a better mousetrap.”
Though there are many ways to achieve an integrated electronic health record, the current emphasis is on implementing a single vendor solution as much as possible. It’s an approach that shifts the burden for interoperability – the task of automating communication between disparate system components – away from the healthcare organization to the vendor, says Nusbaum.
Currently, Island Health is focused on developing the Know Me view as a way to improve the “health and care experience of Island Health residents.” To date, the integrated EHR at Island Health includes lab results, diagnostic image reports, transcribed documents, inpatient and outpatient medication profiles from the community pharmacy database, and limited electronic capture of vital signs and nursing documentation.
Next steps include the addition of standardized electronic documentation of clinical assessments; electronic ordering for tests, medications and specialist referrals; expanded capture of key vital sign information from the home, community and hospital settings; and, patient self-service capabilities.
At this point in the Island Health journey, 1,600 physicians and 13,000 clinical staff have active EHR accounts and wireless access is in place across all major hospital facilities. There are 9,600 devices on the health authority’s secure network, including 510 mobile carts.
Of the 68,000 transactions performed in the EHR each day, 2,700 are medical imaging test orders, 4,000 are for medication orders and 24,000 are lab orders. The number of concurrent users averages 1,700 at peak times.
The goal is to achieve a single patient story across the continuum of care by maintaining functionality in a single patient chart – without asking clinicians to open a separate application with a new ID and password. According to Island Health, the EHR will “apply evidence to real-time patient information creating intelligence to guide and support improved care planning, decisions and communications across care settings.”
“The focus in the next two years is to really accelerate our automation so that we achieve those quality objectives for improved care across the continuum,” says Fyfe. “We will be pursuing the appropriate pieces of a HIMSS Level 7 and achieve a HIMSS Level 7 across the entire care continuum.”
Looking ahead, Island Health recognizes its integrated EHR is only one part of a much broader healthcare picture that includes private physicians who may have invested in their own clinical information systems. “There are many other sources and systems that we need to connect with,” explains Claiter-Larsen. “Integration is still a huge topic, even for folks like us who have a single system for the services we provide.”