Going Paperless: Dreams and Reality

Josephine Raw

Introduction

Women's and Children's Health Service in Melbourne, Australia, is beginning to make the transition towards a paperless medical record.

Women's and Children's Health consists of The Royal Women's Hospital and The Royal Children's Hospital, each located on their own campus. The Royal Children's Hospital (RCH) is a specialist paediatric hospital and provides a full range of clinical services, tertiary care, and health promotion and prevention programs for children and adolescents. It is the major paediatric hospital in the state of Victoria, and patients are referred to RCH from all over Australia and the Asia-Pacific rim countries.

The hospital has 310 beds and treats approximately 32,000 inpatients (admitted patients) each year and 284,000 outpatients (non-admitted patients) per year. This includes 54,000 attendances to the Emergency Department.

The Royal Women's Hospital (RWH) is Australia's largest specialist hospital dedicated to improving the health of women of all ages and cultures, and newborn babies. The hospital provides clinical expertise and leadership in the areas of maternity services, gynaecology, and neonatal care. RWH has 213 beds and treats approximately 28,000 inpatients and 288,000 outpatients per year. There are 5,350 births per year.

The Australian Healthcare System

Australia has a national health system to provide equitable access to healthcare for all Australians. This is provided through the "medicare" system which allows Australians access to inpatient services as a public patient without any cost. The public healthcare system is supported by a private healthcare system. Approximately 43 percent of Australians hold private health insurance.¹

The Royal Women's and The Royal Children's Hospitals are public hospitals, and the majority of their funding comes from state and federal government grants. In the state of Victoria, the government pays for inpatient services according to Australian Refined Diagnosis Related Groups (ARDRGs); however, payment is capped at a certain activity level for each hospital. If inpatients services are provided beyond that level, payment is received at a declining marginal rate only.

In Victoria, the majority of outpatient services are also paid according to the categorisation of the type of clinic, this is a modified casemix funding system for outpatients.

Beyond case payment, any further funding of public hospitals is by a specified grant for certain activities or through government policy. Little additional funding is provided specifically for information technology developments.

Electronic Patient Record Strategies

Over the last five years in Australia, the federal government has begun focusing on information management within the health sector as part of their health online strategy. The mission of Health Online is "to improve the delivery of health care and achieve better quality of care and health outcomes though effective and innovative use of health information."²

A major initiative to come out of this national strategic plan was the establishment of a National Electronic Health Records Taskforce. The terms of reference of this taskforce included to:

• "Evaluate the benefits and difficulties of a national approach to electronic health records that respects the dignity of each health consumer and allows them to enjoy improved health outcomes delivered more effectively by health providers.
• Consult widely with stakeholders to identify the form and key components of an effective electronic health records system suitable for Australia.
• Develop specifications (including the function's--administrative, clinical and policy/planning uses--core data items, etc.) for the key components of electronic health record systems, drawing on work in progress and seeking advice from relevant sources.
• Describe the building blocks that will need to be put in place to enable electronic health record systems to operate (such as issues concerning record linkage, security/authentication, telecommunications, messaging, imaging standards and coding).
• Review progress that has already been achieved, define the additional work program that needs to be undertaken and determine who should undertake the work, including, where necessary, the creation of new working partnerships:
• to develop and implement the key components of electronic health records;
• to develop and establish the building blocks that will underpin the operation of electronic health records; and
• to define the implementation and ongoing governance arrangements for electronic health records.
• Develop a plan, nominate priorities and provide a timetable to develop electronic health records in Australia.
• Cost the plan and provide an indicative timetable.
• Report to Health Ministers by July 2000, recommending a way ahead for the development of nationally coordinated and integrated electronic health records for Australia."³

This taskforce proposed Health Connect, a health information network that would allow information to be collected, stored and retrieved by authorised healthcare providers, with the patient's consent.⁴

The first Health Connect trials commenced in 2001, and various trials are continuing throughout Australia. Individual states of Australia have also developed strategies to move towards an electronic patient record (EPR). The state of Victoria has only recently released its EPR strategy--HealthSMART.

The Australian healthcare system operates within a complex political environment, where until recently public organisations have tended to fund their own EPR developments in isolation.

Women's and Children's Health, like other healthcare organisations, has developed its own strategy to achieve the EPR. Our strategy is to use a phased approach commencing with paperless results. The definition of paperless results for Health Information Services (HIS) is no hard-copy laboratory results filed in the patient medical record. Laboratory Services can still print and distribute hard-copy results, clinicians can print hard-copy results for reference, although the ideal is no results printed on paper at any stage.

Following paperless results, the next phases of our electronic patient record are:

• Internally produced correspondence would only be available electronically. That is letters typed by our in-house transcription service and sent to referring doctors would no longer be printed out and filed in the medical record.
• Discharge summaries only available online.

This will progress to electronic collection of all clinical notes, medications, and observations, with any remaining paper being scanned (for example, letters or laboratory results received from outside the organisation).

Background

Our first step towards going paperless was to provide information already available in electronic format to the clinical desktop. A clinical viewer application was developed by WCH in partnership with a local vendor. This application is known as CLARA (C linical L ook-up a nd R esults A cknowledgement), and it uses Web-browser technology to provide patient information at the clinical desktop. It displays information from our clinical data repository, an Oracle database running on HP DS20.

The components of the clinical viewer application include:

• Provision of patient demographic information from our patient administration system (PAS)
• Admission history, ambulatory appointments, and elective surgery waiting list details, also from the PAS
• Summary details of patient attendances at the Emergency Department
• Clinical information from other databases including obstetric delivery and cardiac information
• Provision of electronic laboratory and imaging results including functionality that enables clinician acknowledgement/sign-off of results
• Electronic discharge summary application and display of patient consent for the release of information to referring doctors

CLARA was rolled out in February 2001 at the Royal Women's Hospital and in February 2002 in conjunction with our new PAS system at the Royal Children's Hospital.

The discharge summary application is a component of CLARA, and it enables information to be easily copied into a discharge summary that can then be automatically faxed to the referring doctor. Discharge summary templates have been developed for different clinical specialties to provide ease of data entry. The templates were designed with input from clinicians, HIM professionals, and clinical coders to ensure information captured met the needs of all different users.

Issues

A major component of any IT implementation is change management. Most people question why change is required and what it means to them in their work or life. Any benefits realisation requires change, and that change must be sustained by benefits. "People must change how they think, manage and act ...These changes will be difficult and often painful, and they will not happen by themselves. They must be planned and managed."

The issues faced during implementation included:

• User acceptance and clinician attitudes
• Managing staff implications associated with the changing roles and job responsibilities within Health Information Services
• Senior management support and commitment to the project
• Maintaining stakeholder buy-in
• Data quality and data entry issues
• Linkage of data and messaging standards

The single biggest challenge has been gaining clinical agreement on the electronic "results acknowledgement" process and overcoming issues such as escalation of "unsigned results." An analysis of the existing paper process was undertaken along with an audit to determine the rate of compliance with "sign-off" of paper results. The results of this audit were disappointing. The IT department appointed a project manager with a clinical background to assist in developing new business rules for acknowledgement of results.

The implementation of the clinical viewer has also created changes in work processes for clerical staff and to the roles and responsibilities of HIM staff. Medical transcriptionists no longer type discharge summaries as these are now created online by the clinician, and where referring doctor details include facsimile numbers (fax numbers), the summaries are automatically faxed to the referring doctor using fax server technology.

HIM staff originally took on the role of management of user passwords and system administration. This change in role was initiated to help with the transition of HIM skills from the paper-based department to an electronic department. However, additional resources were not available, and staff had difficulty maintaining an efficient service in both their existing and new work responsibilities. These tasks were eventually handed over to the IT department.

Data quality has not really been an issue for the general demographic and appointment information displayed within CLARA; however, data entry issues with the electronic discharge summary have caused some problems. Clinical users produce the discharge summaries, and some users do not understand that an error cannot be corrected by printing out the summary and amending the hard copy. Data issues have also been caused by the inability of the PAS system at one hospital to send GP information and fax numbers to the clinical data repository.

Results

At present, paper (hard copy) results are still filed within the medical record while the final issues of technical infrastructure are addressed, such as sufficient numbers of computers in clinical areas. There are obviously significant problems with paper results, including:

• Difficulty in auditing compliance with acknowledgement under a manual process
• Results filed incorrectly
• Duplicate and cumulative results are not always removed from the medical record
• Delays in filing, potentially impacting on patient care

Surveys of our clinical staff at one hospital reveal that the paper medical record is rarely used to access patient results; they always use CLARA, the electronic system. Despite this, there is still clinical resistance to stop filing the paper results.

However, at the other hospital, only 20 percent of clinical staff always use CLARA to access results, and 45 percent use CLARA more than 50 percent of the time. The clinicians state that for complex patients, the paper records is still preferred with clinicians reporting that it is generally quicker to find a specific result in the paper record than electronically. For recent results, CLARA is also the preferred method of access.

The advantages of paperless reporting include:

• Lower clerical staff costs due to reduction in staff required to file loose sheets. At WCH this has been estimated at $211,000 per annum.
• Reduction in the overall size of medical records because laboratory results are not filed (30 percent reduction estimated) impacting on physical storage requirements, estimated to be $17,000 per annum.
• Savings on cost of consumables, such as laboratory report stationery, printing consumables, estimated at $20,000 per year.
• Delivery of reports not required, thus a saving of $46,000 each year.

The total savings have been conservatively estimated at $294,000 per year, and this money could be reinvested to further support the development of the electronic patient record.

Conclusion

The implementation of CLARA has enabled improved patient care through availability of information and enhanced our ability to communicate with referring doctors.

While a complete electronic record is still a long way off, significant progress is being made. As each hurdle in implementation is overcome, better standards are developed to ensure the next phases occur more easily.

Endnotes

1. Duckett, SJ, 2004. The Australian Health Care System. 2 nd ed. Oxford University Press, Melbourne.
2. National Health Information Management Advisory Council, 2001. Health Online: a health information action plan for Australia, 2 nd ed. Commonwealth of Australia.
3. National Electronic Health Records Taskforce, 2000. A health information network for Australia. Commonwealth of Australia.
4. Health Connect Retrieved from www 14 May 2004. http://www.health.gov.au/healthconnect/index.html .
5. Thorp, John, 1998. The Information Paradox. McGraw Hill, Canada. p. 203.