Inside South Australia's e-health transformation project

Rolling out a state-wide electronic health record system is no mean feat for the CIO of SA Health, David Johnston. The government organisation last month switched on its Enterprise Patient Administration System (EPAS) that is set to transform 12 hospitals across South Australia.

“This would be the largest IT-enabled project that the state has ever undertaken,” Johnston told CIO Australia. “It’s a significant initiative because it means that if it works here then it’s completely applicable to other states or countries, other jurisdictions.

“It’s basically leaping the industry forward by about 40 years; health is where manufacturing used to be back in the 1960s. It’s one of the last industries that has held out in terms of its usage of technology.”

The e-health system launched on August 25 at Noarlunga Health Service, with more than 2000 electronic medical orders placed in the first day. The system has been configured for about 30,000 users, and around 1200 people who have been trained to use the system at the Noarlunga hospital. The complete rollout across all hospitals is to take place over the next two years.

SA Health customised the Allscripts’ Sunrise Clinical Manager system to create the EPAS. It can be used for both clinical and administrative hospital functions, assisting in 80 per cent of healthcare workers’ activities.

A complex, lengthy project

Johnston is seven years into $422 million, 10-year project, having spent five years implementing the underlying infrastructure to support EPAS and two years developing the e-health system.

“It was very clinically-oriented so it wasn’t the IT department going out and choosing a system. Less than 20 per cent of the budget was on technology so it’s a massive business change project; it’s not a technology project.”

More than 50 projects were executed in the lead up to EPAS. These included creating a mirror copy of its Adelaide-based data centre for failover and backup/recovery, having redundant fibre optic cables between all the hospitals and data centres, and standardising the PC fleet by moving to a rental model rather than purchasing disparate PCs.

The system is configured to work with the federal government’s personally controlled electronic health records (PCEHR) scheme, with eight metropolitan hospitals and one regional hospital now sending discharge summaries to the PCEHR.

“The PCHER has gotten a bit of criticism but I think that’s a bit short sighted. If you look longer term it’s going to be extremely useful. We’ve had no issues in terms of connecting to it,” Johnston said.

“There’s a lot of work that goes on behind the scenes because it has to translate patient numbers into individual healthcare identifiers, which are allocated by the federal government. But for us it’s seamless, it’s just simply a checkbox.”

Integration of systems is one of the biggest challenges in getting an e-health project of this size and scale up and running, Johnston said. Using an electronic master patient index, Johnston was able to standardise patient numbering to send information electronically to GPs through a secure messaging system.

The PCHER has gotten a bit of criticism but I think that’s a bit short sighted. If you look longer term it’s going to be extremely useful.David Johnston, CIO, SA Health

“We encrypt it and we have a provider registry where it can be delivered to them in a secure fashion via the Internet and be unpacked into the GP's system.”

An integration engine was used to create one interface for more than 200 systems. Instead of taking a point-to-point integration approach, Johnston decided to use a ‘hub and spoke model’.

“As we bring new systems on, we only write that one interface because the integration engine [the central hub] pushes the messages around and delivers them to the proper system,” he said.

“Point-to-point integration ends up looking literally like a bowl of spaghetti because over the years one system gets connected to another which then gets connected to another. If one thing goes wrong you can have all kinds of unpredictable impacts.”

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Standards and best practices for the “hundreds and hundreds” of clinical order sets also had to be agreed on so that there’s no conflicting information between the hospitals using the e-health system.

Johnston said 14 clinical working parties got together to establish the standard procedures and processes when caring for patients so when clinicians share and access information, they know it is based on international research.

It also prevents data duplication, Johnston said. Before EPAS, multiple tests were ordered because it was not visible to healthcare workers that there was a test ordered in another hospital or they weren’t able to immediately access the results of a recent test. “The costs of some of these tests are huge so we are expecting tests costs to drop significantly,” Johnston added.

Data integrity and quality was another challenge. Johnston said rules were written for the data cleansing team to properly check the consistency of data as it moved out of the legacy system and into the master patient index.

He said there’s technology that can automatically sift through large amounts of patient data and detect errors, but if there are not certain rules and work practices established then the data will mostly likely end up being of poor quality.

“A Canadian friend of mine was telling me that around Christmas he discovered there was an awful lot of people named ‘Santa’ entered into the patient database because for whatever reason the workers thought that was funny.”

When it comes to access and privacy, each user of the system is assigned a role when they set up an account which then gives the user certain access rights. For example, a nurse might be able to access basic information and a senior clinician might have full access to all health records.

Single sign on and twin-factor authentication is used to ensure a patient’s private information is only accessed by healthcare professionals. A staff member uses their access card and password to log on to the system. Also, a full audit log is done each time a staff member accesses a patient’s health record so that any changes can be easily tracked.

Bedside computers

SA Health, in partnership with Telstra, recently rolled out more than 3500 beside computers across 12 of the state’s hospitals, which has been the largest rollout in the world for this type of technology, according to Johnston.

Patients can use the computers for entertainment purposes where they can watch television and movies, listen to the radio, surf the Internet and make external phone calls.

The equipment for a bedside computer consists of a 17-inch touchscreen, keyboard and telephone, headphones and it is mounted to a wall or from the ceiling. The equipment can be bleached and cleaned for infection control.

With EPAS now rolled out at the Noarlunga hospital, the bedside computers can switch from being an entertainment package for patients to a clinical work station for healthcare workers. Staff members insert their cards for when they need to access clinical information.

“I was with the chief medical officer the other day and we walked into a ward at the Noarlunga hospital and there were no nurses behind the nurse's station; they were all by the patient's bedside and were interacting with patients using the bedside computers,” Johnston said.

The next stage for the bedside computers is to replace the telephone handsets with ones that have built-in barcode scanners so that staff can manage medication at the bedside, reducing the likelihood of errors occurring.

“You scan the wrist band of the patient and you can check the medications. The system then double checks that it’s the correct dosage, correct patient and correct medication.”

Johnston said he also plans to use Web cameras on the computers to enable low complexity discharges to occur early in the morning without the clinician physically visiting the patient.

“We will be looking at real-time observation so blood pressure, pulse, blood oxygen levels, etc being done in real time and then sent back to the nurse's station rather than needing to have nurses come and wake people up every four hours,” he said.

You scan the wrist band of the patient and you can check the medications. The system then double checks that it’s the correct dosage, correct patient and correct medication.

“Even things like patient videos where patients could access a video on how to manage diabetes, for example. That reduces the amount of time the clinician has to spend with the patient explaining what they are going to need to do to keep it under control.”

Follow Rebecca Merrett on Twitter: @Rebecca_Merrett

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