Melbourne’s Royal Children’s Hospital has seen a reduction in its mortality rate of 25 per cent since it went live with its Epic electronic medical record, and has registered similarly impressive figures for avoidable lab tests and medication prescribing and administration errors.
While the hospital is not claiming definitively that the reduction in the mortality rate is due to the EMR and may be part of an overall trend, there have been no changes to the patient population or other major intervention that can clearly account for it, RCH paediatrician and chief medical information officer Mike South said.
Professor South told the Health Informatics Conference (HIC 2019) in Melbourne this week that staff satisfaction with the system is upwards of 90 per cent, patient and family satisfaction with the hospital’s portal is also very high and there are also welcome financial and productivity benefits following the implementation.
RCH went live with the Epic EMR in April 2016 with a bang. The system was rolled out in every department at once, from inpatient wards to outpatient clinics, the hospital’s emergency department, intensive care units, theatres and anaesthesia, oncology, mental health, regional outreach clinics and hospital in the home.
Professor South believes the big bang methodology has advantages over the more incremental approach taken by other health services, in which certain functionality is turned on over time.
“We’ve noted that with those it is often hard to keep up the money stream that is needed to do those over a very long period of time,” Professor South said. “It is hard to keep the organisational focus on the importance of this and it is often hard to keep the momentum going for a long period of time. You don’t have that so much if you do it quickly.”
The Epic roll-out saw upwards of 1600 different paper forms replaced, along with multiple digital systems that were poorly integrated and required multiple log-ons. “Some of our clinicians had to log onto six different systems as well as use paper just to do their outpatients clinic,” he said.
While there very few forms left in the hospital – notably the patient consent form and a surgical scrub count sheet – the implementation saw not just the replacement of paper and fully electronic clinical documentation, but a whole host of functionality rolling out all at once.
This included electronic ordering, electronic medications management and blood management, barcode scanning for meds administration and blood administration, pathology sampling, integrated bedside monitoring devices, ventilators and anaesthetic machines, and a number of mobile apps.
Scheduling, eReferrals, integration with the My Health Record, a portal that is open to patients and families to read their medical record and see their test results and an external provider portal are also live.
Professor South said the big bang was a very big cultural change as well as a technical one but the hospital was keen to get the benefits and return on investment quickly. The decision was also driven by patient safety, he said.
“If you have patients whose journey is continually switching between electronic and paper you can introduce risk and we were keen to avoid that,” he said. “That wasn’t just our own view; we did a lot of extensive literature reviews looking at methodologies to implementation, we did site visits and we had an external reviewer who looked at this to make sure we were making the right decision.
“But also, we are a children’s hospital and we have a lot of experience with bandaids. We know that ultimately the pain in removing a bandaid is much shorter and is over quicker if you just rip it off.”
Benefits monitoring
RCH was keen to monitor the promised benefits of the new system and before the roll out surveyed every department in the hospital to see what staff thought could be better or helped with an EMR. Of the 140 or so suggestions, the implementation team whittled the list down to 15 or 20 concrete, measurable elements that were then assigned to a benefit owner responsible for ongoing monitoring.
A basic method was to compare measurements from two years or eight quarters before the implementation, and eight quarters afterwards. Data was collected and analysed through internal data systems along with the Health Roundtable to provide information on standardised mortality rates. The University of Melbourne provided statistical assistance.
One measurement was staff satisfaction, which Professor South places a great deal of importance on.
“If you have staff that hate the system and can’t use the system, then you won’t get the other benefits,” he said. “Getting that right is very important.
“Particularly in the US, computers and EHRs are getting a very bad reputation with users. That was not what we are finding.
“We have been surveying our staff repeatedly about how they find the system and even within three months of go-live three quarters of them said they were satisfied or very satisfied with the system. By 29 months we were up to 92 per cent. That is contrary to what is coming out of the US.”
There are some operational and financial benefits, such as an increase in productivity, he said. The hospital is now seeing more patients in its clinics and caring for more patients with the same number of beds. The emergency department’s waiting time has gone down and the hospital is also seeing an increase in its weighted inlier equivalent separations (WIES), which Victoria uses as its funding model, through better coding.
It is also receiving more money from privately insured patients. “It’s work we were doing before but we weren’t properly capturing it,” he said.
For patient and family engagement, by the end of August, 12,000 families will have signed up and be using the portal. Families are surveyed on their use of the portal, through which they can see test results after eight days as well as the child’s medical record, and the vast majority are satisfied or very satisfied with the functions of the portal, Professor South said.
“Even the ones who are dissatisfied are only dissatisfied because they’d like to see a lot more things, not because that they don’t like it.”
Clinical benefits
The clinical benefits being seen are very promising, he said. There has been an increase in reported clinical incidents to the Victorian Health Incident Management System (VHIMS) during the period but this is seen as a good thing, as it is part of a general trend of increasing reporting of clinical incidents.
“We are strongly encouraging our staff to report things more and more,” he said. “This is part of the general trend. After go live we had an option in the clinical reporting system tp say ‘this was an EMR problem’. In fact we only had in the first two years 26 reports [about the EMR] and they were all at the lower level of severity in the incident severity rating.”
A hugely important metric being measured is the number of tests being done on children per episode of care. As elsewhere, children may have a blood test or an x-ray when they don’t need it as they’ve had it done recently but there is no immediate access to that information.
The Epic EMR includes clinical decision support so the benefits team was hoping to see numbers of avoidable tests go down, and they have for both laboratory tests and imaging, Professor South said. This includes a 6.3 per cent reduction in lab tests and 12.5 per cent in imaging.
The in-built prescribing support and the barcoding for medication administration has also seen a big improvement in avoidable errors. Since the implementation, prescribing and administration errors have decreased by 13.4 per cent compared to the prior period.
The hospital also wanted to see if it could better catch deteriorating patients and intervene sooner. It is now seeing medical emergency team (MET) calls up by 13 per cent. To help with this, RCH has embedded an electronic observations chart based on a paper chart previously used to detect the deteriorating patient.
“This is something we translated from paper,” he said. “It was developed in Melbourne and has been shown on paper to have an impact on mortality. We were one of the first places around the world to actually showed that these track and trigger tools can affect mortality.
“In translating that into the EMR, we wanted to preserve that and in fact to do better. That might be calling for an urgent medical review or a medical emergency team call. Now the system puts up big red banner to say you need to do something, so we were hoping to see, paradoxically, our MET call numbers go up. It is a noisy signal but it does seem to be increasing.”
The mortality rate decrease is equally impressive. RCH has seen a reduction from 2.19 deaths per thousand admissions prior to the implementation to 1.7 two years later. That is a reduction of 22 per cent, and the most up to date figures as at the end of July 2019 show a further reduction to 1.63 deaths per thousand admissions or 25.5 per cent.
Professor South said analysis of standardised mortality rate, adjusted for severity of illness, using figures from the Health Roundtable showed a similar trend.
“In real person terms that is between 55 and 84 children,” he said. “As a scientist I now ask myself, what is the causality here? We are seeing all of these things going in the direction that we were hoping to see, but is it due to the EMR?
“This isn’t a randomised control trial and every patient has the EMR, but I am not aware of any change in our patient population or other big interventions in our hospital that could account for these changes, although you always have to keep an open mind.”
The next test
With the Epic system set to be implemented in a similar big bang for Royal Melbourne Hospital, the Royal Women’s Hospital and the Peter MacCallum Cancer Centre in May next year, it will soon become apparent if the Children’s experience is an outlier or not.
RMH in particular is a larger hospital, although there have been no negative reports as yet about its go-live of Epic in its emergency department in June.
Professor South said the wider roll-out at Parkville will have many benefits but will come with many challenges. The big bang approach is, for this hospital precinct at least, the way to go, he said.
“There are many things that can contribute to a successful implementation of an EMR, many different things, but we do think that the big bang implementation approach has some validation from this, that we have achieved the things that we were looking to do and quickly.
“I think we have the most concrete Australian data that health informatics definitely saves lives.”
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This is a very interesting report. I have seen this RCH implementation first hand and the hospital’s approach has been outstanding. As this article points how did they make it work as a Big Bang? From my understnading, it is one of the few (?only one) where social media involved the whole staff-cleaners to administrators-with a set deadline for implementation. The project continues to have ongoing ‘evaluations’.