Brisbane’s Princess Alexandra Hospital (PAH) has begun work on the next stage of its massive digital hospital roll-out, with planning under way for the implementation of electronic medications management and the replacement of its anaesthesia system early next year along with an intention to apply for HIMSS level 6 certification.

Nicknamed MARS – for Medications Management, Anaesthetics & Research Support – the roll-out is planned to go live next January, marking a crucial stage in the hospital’s move from predominantly paper to fully digital in just a few years.

Last November, the PAH became the first large-scale hospital in Australia to go digital, implementing what is known in Queensland as the “digital stack”, a set of components that includes an upgrade to the Cerner-based integrated electronic medical record (ieMR) and full integration of medical devices, with MARS to come next and in the future the implementation of Cerner’s mobility suite.

While PAH had already gone electronic in ICU through the iMDsoft MetaVision system, in March this year Health Minister Cameron Dick was able to announce that the PAH was now digital across all wards and departments, in what appears to have been a pretty seamless roll-out for such a large hospital. The PAH has close to 850 beds out of the Metro South Hospital and Health Service’s total of 1834.

While it would seem a daunting task for such a large hospital – the other digital hospitals are the private St Stephen’s in Hervey Bay, which has 96 beds, and the 330-bed Royal Children’s in Melbourne, which went live in April – Metro South’s CIO Michael Draheim said PAH had managed to leapfrog the other public hospitals by taking an end-to-end approach.

“We did our training – and we trained nearly 6000 staff through nearly 32,000 hours worth of training – in around about a 10-week period,” Mr Draheim said. “That included nursing, medical, allied health practitioners, operational staff and administration staff as well. From the time the decision was made to go digital to when we went live, it was just under 18 months.”

As one of the state’s most important tertiary hospitals, PAH was part of the original group of nine chosen for the roll-out of the ieMR in 2011. However, PAH’s relationship with the vendor goes back to 1999, when Cerner’s RadNet was first implemented for radiology along with another module to manage outpatients.

As part of the digital go-live, PAH has refreshed those modules to the latest versions and integrated them into the full stack, but has also rolled out the bulk of Cerner’s Millennium suite, including FirstNet for emergency (replacing EDIS), SurgiNet for surgery (replacing ORMIS), orders and results for pathology and radiology, the patient summary module known as Mpage and structured clinical notes in all departments, known as Powerchart.

However, while Cerner is a core component, the actual digital stack includes much more. PAH still has to use the legacy HBCIS patient administration system for admissions and the Auslab pathology system – Queensland Health intends to go out to tender for a new or upgraded statewide pathology system this year – and both have been integrated into the digital stack.

While the MetaVision ICU system has been running for some time, ICU has turned off its clinical documentation module and is now using Cerner’s Powerchart, Mr Draheim said. “That was [the clinicians’] request and they drove that. The reason they wanted to do it is that information is used by everyone throughout the hospital, so you are all on one system. Everyone is documenting in Powerchart.”

PAH has not yet adopted Cerner’s mobility solution but plans to in the future. At the moment, the hospital has rolled out hundreds of workstations on wheels (WOWs) that all clinicians are using for access to the EMR. Clinicians who have patients across multiple wards, such as endocrinologists, can trundle the WOWs along with them.

What Mr Draheim seems most proud of, however, is full medical device integration. “We have integrated bedside monitoring, so a nurse no longer transcribes or writes down observations. Observations go directly into the system after verification from either fixed monitors, if the patient is in a monitored bed, or from our Welch Allyn vital signs devices, and that is for blood pressure, pulse, temperature, respirations, levels of consciousness.

“That’s collected electronically and then that uploads automatically via WiFi. ECGs and clinical information from fixed patient monitoring is also fully digital.”

While it is still anecdotal and it is too early to measure benefits, nurses are saving more than 30 minutes per day per nurse in not having to transcribe observations, he said.

Going digital

Going digital so quickly was not originally in the 2011 plan announced for the roll-out of Cerner to seven hospital and health services, including PAH, Cairns, Mackay, Royal Brisbane and Women’s, Townsville and the Gold Coast, part of a $190 million project.

That roll-out was devised as an incremental one, with a medical record scanning function implemented at five hospitals including PAH in stage one and the introduction of electronic orders and results, and allergies and adverse reaction alerts, in stage two. Extra modules were then expected to be rolled incrementally in different sites rather than as a big bang in one hospital before moving on to the next.

However, a decision was subsequently made in mid 2014 to nominate PAH and Cairns to be “digital exemplars” and roll out the full digital hospital stack at the same time. PAH went live in November as planned, just 18 months after the decision was made. Cairns went live in March this year.

“There was initially what they called a release mode, and that was very much about giving components of functionality across different sites,” Mr Draheim said. “The previous government changed that and changed the focus from rolling out little bits everywhere, to rolling out a digital stack.

“We already had some entry-level functionality, so we were running in a sense two separate versions of Cerner. One of the versions was our old version from 1999 and the other version gave us some entry level functionality, which was really around scanning our inpatients records when the patient was discharged.

“That gave us a little bit of benefit, but not a lot of benefit. It allowed our clinicians to access an electronic version but it was really just a scanned copy of the paper notes within 48 hours of discharge.

“There were some other things around unstructured clinical documentation but while we were using it in a few other functional areas, we didn’t make that compulsory at our site, because we knew that we were coming along with a broader digital stack. The broader digital stack gave us a richer level of Cerner and other systems integration that allowed us to give people a much better experience and improved the access to data for analysis.”

Mr Draheim said Cerner is a core component, but his team has worked with a number of partners to integrate some legacy existing systems such as Auslab for pathology. “For our old HCBIS system, we still need to use part of that system but we’ve linked it to a number of other core components in Cerner,” he said.

In addition to the $190m spent on the release mode, the state government announced last year that it was investing a further $200 million to roll out the foundations of the digital ieMR to 12 more hospitals, including a ‘lite’ version at four small regional hospitals.

Digital transparency

A key part of the digital hospital roll-out is the new positive person and patient identification solution. Patients all now have a wristband and clinical staff use an Aztec barcode identifier.

“Our devices currently have the same type of identifier as well,” Mr Draheim said. “So for instance when you are doing the observations, you scan the patient, you scan yourself. It identifies this is the patient, this is the person taking the observations, and you scan the device as well so the device becomes part of that cycle. All of the information related to those things gets uplifted and goes into the system.”

When the EMM system is rolled out, the medications package will also be scanned, much like nurses are now doing when taking samples for pathology, he said. Then, the identification will be patient, person and product.

“We won’t be down to single dose, but we will be down to product,” Mr Draheim said. “Part of the original device integration component was setting us up for that. It will work the same way that you take a blood result. I scan the patient, I scan myself, I scan the label printer, which is a little handheld portable label printer.

“I have the blood tubes and I take the blood, and then print out the labels I need. I then put those labels on the tubes and I scan the labels and then send them off to pathology. When it arrives at pathology, they then scan them as being received and you can see then where the result is to go.

“We are using the phrase ‘digital transparency’ to baseline prospective rather than retrospective information. What we are seeing now is that people are collecting data more readily and we’re seeing a greater quantity of data as well. With that also, we’ve got some data analytical services and data warehousing in place as the foundation to utilise this information to support the clinical benefits we get from the system.”

PAH already had a fairly large armoury of Vocera’s messaging and communication devices, and at the moment Mr Draheim and his team are working on some unified communications components to integrate alerts from Cerner into Vocera.

“We’ve just held off on that at the moment, because certain things you want to slow down with a lot of things happening,” he said. “We do use other VOIP components as well and we’re looking to move Vocera to mobile devices which will allow us to use that as an adjunct.”

There has also been a large amount of work on the hospital’s high density wireless network to enable an extra 3000 devices, including WOWs, biomedical devices and printers, to be used wirelessly.

The WOWs have a replaceable lithium battery and battery charging stations have been distributed around the hospital and are also equipped with a scanner. Staff use Imprivata’s tap on, tap off technology to access the system, which Mr Draheim said has significantly saved time in accessing the system.

Full mobility through Cerner’s mobility suite is still in the planning stage, however. “With mobile technology, the last thing you want to do it push something that has been designed for a desktop large screen computer down to a mobile device screen,” Mr Draheim said. “They just don’t translate well.”

PAH has been connected to the My Health Record for a couple years now, with clinicians able to view a record through the state’s The Viewer portal in context and upload discharge summaries directly to the system using the HIPS middleware.

Challenges

While Mr Draheim and his team of 80-odd people appear to have done a super job in rolling the system out in such a short time, he admits there are some major challenges.

HBCIS still needs to be used for admissions and to register unique medical record numbers, and while it has long been known that it will have to be replaced eventually and is part of Queensland’s 20-year ICT strategy, a new PAS has yet to be budgeted for.

The interfacing and integration work proved some of the biggest challenges of the whole project, Mr Draheim said, along with some of the reporting work.

“We are getting our reporting well and truly bedded down now, but it’s just one of those things when you are looking at a system that runs end to end,” he said. “Historically we had systems that ran just in the emergency department, just in theatre, so information went in and information came out and you can measure those type of transactions.

“When you’ve got an integrated system, there’s 20, 30 different measurements, and you can have a whole different transaction running in parallel. It’s multi-dimensional.

“We have a registration component in the front end when you come in an emergency. We have a registration component when you come in as an outpatient, and we have a registration component when you come in through an inpatient admission. Cerner currently handles some of those things for us but then we have to communicate those things with HBCIS.

“When you’re utilising an older, 30-plus year old system like HBCIS, there are always complexities and challenges around managing that.”

Next steps

As a digital hospital exemplar, Mr Draheim and his team are well aware that they are doing the work on behalf of not just the PA Hospital but the whole state of Queensland.

As part of its digital transparency push, PAH has set up a public website at innovatepa.com.au where not just staff but the public can keep up to date with the roll-out and have a look at the vast array of resources the hospital has developed.

This includes an app for Android and iOS so doctors, nurses, allied health and admin staff can download quick reference guides as well as access the full Innovate PA site and its clinical updates.

PAH has also hosted numerous visits from other hospitals in Queensland and from NSW and Victoria. On average, the hospital has one or two visits or presentations a week, Mr Draheim said.

The next step is preparing the hospital’s 6000 clinical staff for MARS. In addition to integrating EMM into the EMR and providing detailed medications information at the point of care, there will be complete anaesthetics information visible within the EMR and increased visibility of information to support clinical trials and research studies.

The WinChart anaesthesia system will be replaced and the documentation of anaesthetics will be added to the EMR through the Cerner anaesthesia module and integration of specialist clinical devices.

The digital hospital project team is currently working with clinicians, Cerner and device suppliers to design, build and test the MARS applications, with MARS go live currently planned for early 2017.

Once that is completed, the PAH expects to apply for categorisation as level 6 on the HIMSS EMRAM score, hoping to be the first large-scale public hospital in Australia to achieve it, Mr Draheim said.