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Sunnybrook creates its own advanced EHR

By Jerry Zeidenberg

TORONTO – While other hospitals have been implementing commercial electronic health record systems, Sunnybrook Health Sciences Centre has created its own health information system – called SunnyCare. It has done this over the past few years, tying together best-of-breed components from the private sector and adding its own, home-grown software to create a solution like nothing else available in Canada.

“SunnyCare is a single, integrated workflow solution,” said Sam Marafioti, Sunnybrook’s Vice President and Chief Information Officer. “In my 30 years in hospital IT, I’ve never seen anything as powerful.”

A key element of the system will be rolled out next year – it’s the clinical documentation component that will extend electronic, clinical charting to every healthcare professional in the three-campus hospital.

That’s no small task, as there are currently over 6,500 clinicians and care-givers in the organization, working in acute care, rehab and long-term care settings.

But already, SunnyCare is providing online documenting to nearly 3,500 physicians, residents and allied health professionals in the organization. The charting ranges from consult notes and admission order sets to medication reconciliations and care plans to progress notes and discharge summaries.

“Clinical documentation is a crucial component of the solution,” said Marafioti. “It’s important for patients, physicians, staff alike.”

While electronic charting systems are available in other EHR platforms, SunnyCare is extending the solution to each and every care-giver in an integrated fashion. In short, everyone will be able to use the same system – that’s a real breakthrough, as healthcare has traditionally operated in a fragmented, siloed way.

“All forms have been re-designed to fit into this single workflow,” said Marafioti. “It’s designed by clinicians, for clinicians. SunnyCare gives them a single, integrated view.”

What’s more, Sunnybrook plans to make SunnyCare available to other healthcare organizations, just as it has offered them its patient portal, called MyChart. The MyChart portal is used in a variety of hospitals across Ontario, and in April, Sunnybrook announced its first MyChart customer outside of Ontario – Fraser Health, in British Columbia.

SunnyCare is a web application platform developed at Sunnybrook and certified by Canada Health Infoway as a jurisdictional class electronic medical record system. “SunnyCare meets clinician needs by integrating information from highly specialized, departmental systems and presents clinical workflows that are easy to use and can be accessed from desktop computers and mobile devices,” commented Oliver Tsai, Director of IT at Sunnybrook.

While SunnyCare supports electronic documentation, most nurses are currently charting on paper – as they are in many healthcare organizations. The goal is to switch everyone over to electronic documentation, and to support best-practice documentation standards.
That will promote information sharing among teams, and will reduce duplication of effort for clinicians and patients.

Sunnybrook has partnered with Orion Healthcare to integrate its clinical documentation engine into SunnyCare. Orion has been working closely with the team at Sunnybrook to customize its solution and integrate it with SunnyCare workflows.

“Electronic documentation will allow us to capture information once, and to share it, instead of asking patients the same questions over and over again,” commented Katherine Vandenbussche, a registered dietician at Sunnybrook and a Clinical Documentation Project Team Leader.

Not only will this save time and trouble for care-givers, but it will also provide a better experience for patients. She noted that patients sometimes get anxious if they’re asked to repeat the same information, such as names, addresses and birthdates, to different clinicians. “Enabling all clinicians to document in SunnyCare will better align with how we work together as an inter-professional team to provide the best care possible for our patients,” said Vandenbussche.

Sunnybrook is a leading-edge healthcare provider with three different campuses in Toronto – an uptown rehab hospital; a central site in mid-town Toronto, which houses a major trauma centre, cancer and cardiac care, research, a long-term facility, and a host of other medical programs; and a downtown orthopedic hospital.

“Using the principles of user-centred design, the development team and clinicians across Sunnybrook have invested a great deal of time in the design of SunnyCare’s clinical documentation workflows to support best-practice standards for various clinician groups,” said Laura Viola, Director of Sunnybrook’s Project Management Office and Client Services.

The participants include nurses, physicians, occupational therapists, physiotherapists, and many others, she said.

Medical and everyday language in charting was a significant issue for workflow. “What a doctor means when he or she uses a term may have a completely different meaning to a physiotherapist or occupational therapist,” said Dr. Chris Hobson, Medical Director for Orion Health.

Indeed, the design team started by identifying 39 different patient care categories where standardized terminologies could support inter-professional team documentation. This included service-related information used in areas like cardiology and respiratory medicine, as well as patient data and personal information – such as the name a person prefers to be called by, and what kinds of supports he or she has at home.

The ClinDoc team at Sunnybrook is using the standardized terminologies to streamline over 1,000 different forms across the interdisciplinary team, so that clinicians all speak a common language.

To ensure effective and efficient documentation workflows, where possible SunnyCare will use a template driven format instead of free-form notes. In many cases, check-boxes will be used, so that documenting can take place much faster than before while adhering to agreed-to standardized terminology.

As well, SunnyCare will pull data directly from medical devices. As a first step, vitals monitors will be integrated to SunnyCare so related clinical documentation will update automatically. This kind of device integration ensures a comprehensive “one-stop-shop” for patient clinical information, saving time for all clinicians and improving patient safety.

Moreover, SunnyCare clinical documentation will provide value across the inter-professional team. For example, embedded clinical workflow will allow orders to flow to a nursing kardex and work list, and will prompt clinicians with appropriate assessments and templates for documentation.

This is a leading-edge feature and required specialized, intelligent coding in SunnyCare, noted Marafioti. “Sunnybrook can quickly and seamlessly embed workflows to facilitate the clinician’s care delivery process,” he said.

Standardized, electronic information can also be analyzed more effectively, giving the hospital a greater ability to understand the condition of patients before, during and after hospital stays. This can be a powerful tool for improving service quality and for planning enhancements for future services.

Ultimately, adding interprofessional clinical documentation to SunnyCare’s existing functions will lead to a single, shareable electronic record for each patient, rather than a mixture of paper and digital notes in departmental silos.

Through this project, Sunnybrook may be achieving a first in Canada. No other major hospital has yet to create an electronic health record that encompasses standardized, electronic clinical documentation for each and every healthcare professional.
One of the first steps in creating a successful system of this sort is to gain the acceptance and buy-in of every clinical group.
Through a user centred design process, Sunnybrook has been asking all clinician groups to help design the new solution, so that everyone has input into the process and end result.

That’s meant regular, multi-departmental meetings, guided by experts in design and change management. As part of the process, Julie Waspe, a registered nurse and Clinical Informatics Specialist at Sunnybrook, noted there’s an iterative process going on, where models are sent out to clinicians to look at and comment on.

“We’re sending out wireframe models that show what the system is looking like, and we’re asking clinicians to comment on them,” said Waspe. “Users get to play with and interact with wireframes of the solution, which allows them to provide specific and detailed input about what their requirements are and how the clinical documentation team can improve the solution.”

In this way, there is a constant flow of information and communication among groups. And in the end, it becomes a group project, where clinician groups across the hospital have a say in the design. While a detailed change management and training plan will be put in place, user engagement and ownership of the solution has proven to be a powerful component of SunnyCare adoption.

Users like being consulted about how SunnyCare clinical documentation should work, and they see the potential benefits – the time savings and the ability to quickly see what others have already charted and build on it from an inter-professional perspective.

“It’s a big shift,” said Vandenbussche. “Many are moving from non-standardized paper notes to a standardized electronic document.” Nevertheless, the gains of the system appear to be outweighing any trepidation from users. “People are getting excited about it,” said Vandenbussche.

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