PAPERLESS ED? AN EPIC EXPERIENCE Conference 2016... · AN EPIC EXPERIENCE Adrian Boyle Cambridge...

PAPERLESS ED?AN EPIC EXPERIENCE

Adrian BoyleCambridge University Hospitals Foundation Trust@dradrianboyle

We’d like you to come and speak at Bournemouth Great! What on? Violence? Quality?

Crowding? QIPS? QECC Update? Something really exciting like a SMACC talk?

IT Implementation

WTF?

Pleeeeeeeeaase!

Oh………ok

Upgrading your IT is the most disruptive thing you’ll ever do

http://sites.psu.edu/siowfa15/wp-content/uploads/sites/29639/2015/10/hong-kong-sars-2-532360.jpghttp://sites.psu.edu/siowfa15/wp-content/uploads/sites/29639/2015/10/hong-kong-sars-2-532360.jpg

£200m over 10 years*

Budget Out-turn Variance

Capital £28,990,000 £29,296,000 -£306,000

Revenue £36,273,000 £32,897,000 £3,376,000

TOTAL £65,263,000 £62,193,000 £3,070,000

HP£140m

Epic£40m

CUH£20m

* Do nothing = £110m

Before…

• Notes go missing• Information is unavailable• Results reporting is cumbersome• Multiple poorly communicating IT systems

(12 in the ED, which no one person knew how to use)

• GP communication was poor

wInTer is coming…

NHS England Five Year Forward mandates that the NHS should be completely paperless by 2020

wInTer is coming…

Part of ‘Personalised Health and Care 2020’…..’all patient and care records will be digital, interoperable and real time by 2020’

‘Purpose of digitisation is not to digitise, it’s to improve quality, safety, efficiency, and patient experience’ Professor Wachter 2016

The Addenbrookes and Rosie Hospital EPIC Implementation

• Huge and Complex Hospital, employing around 7,500 clinical staff

• Aimed for a ‘Big Bang’ implementation on the 25th of October 2014ED / Ward / Theatre / ICU / OPD

Preparing for wInTer

• Team of around 50 clinician super-users‘Instructional Designers’ and ‘Analysts’

• Seconded 2 ED Consultants (50%) and one nurse (90%)

• Training of clinical staff: the playground• Mapping IT processes onto existing

pathways• Simulations of extreme scenarios

Simplify your processes

• 19 different ways to refer people to an outpatient clinic

• Multiple different ways to request and receive a test

• We don’t work linearly, so don’t design linearly

Patient arrives at the

ED by ambulance / police

Patient arrives at the

ED on foot

Initial Assessment

by PAT nurseInfection ControlPresenting ComplaintAVPU assessmentDecides on placement

Initial Assessment by pre-reg nurseInfection ControlPresenting ComplaintAVPU assessmentDecides on placement

Secondary Assessment by SAT nurse

Presenting complaint

Analgesia / ECG / Sometimes x-ray Liaise PA

Places Card in Box

Patient registered by receptionist at bedside who returns to reception and then brings out front sheet back to nursing staff

Patient registered by receptionist at reception. Card then placed by patient in box next to minors

Assessment 1

Assessment 2

Resus

Blue Chairs

Waiting room

Secondary Assessment by Minors nurse, pick up card from box


Analgesia / ECG / Sometimes x-ray / sometimes Liaise PA

Places card in Box

Medical Assessment

Arrive at an Inpatient bed

SAT Nurse

Receptionist

PAT Nurse

Junior Doctor

ENP

SpR / Consultant

Porter

Radiographer

X-ray

Ultrasound

CT

Cubicle nurse

HCA

Ambulance staff

Nurse in Charge

Ops centre person

Minors

Receptionist

Secondary Assessment by nurse

Presenting complaint /VS


Physician’s

Assistant

Cubicle nurse




Places Card in Box




Places Card in Box

Ambulance staff

Ambulance staff

Ambulance staff

Ambulance staff

Minors nurse

Secondary Assessment by Minors nurse, pick up card from box


Analgesia / ECG / Sometimes x-ray / sometimes Liaise PA

Minors nurse

Cubicle nurse

Secondary Assessment by Doctor

Physician’s

Assistant

Physician’s

Assistant

Physician’s

Assistant

Bloods/ Urinary Catheter



Bloods

PA cubicle

SpR/

Consultant

PorterMedical Assessment

Medical Assessment

SpR / Consultant

Junior Doctor

Junior Doctor

SpR / Consultant

Medical Assessment

Junior Doctor

SpR / Consultant

Medical Assessment

Junior Doctor

Porter

Porter

Porter

Nurse Coordinator

Update Jonah with x-ray request

Paper back-up

Co-ordinate transfers to ward and radiology

Request bed on phone

Co-ordinate treatments

Telephone handovers

Manage relatives

Request specialty Doctors to review

SpR / Consultant

Nurse in Charge

Discharge

Nurse Coordinator


Paper back-up


Request bed on phone


Telephone handovers

Manage relatives

Request specialty Doctors to review

In Patient Pharmacy

CDU

Nurse in Charge


Paper back-up


Request bed on phone and Jonah


Telephone handovers

Check Treatments

Check Coding

Check VTE assessment

Check swabs

Porter Receptionist

HCA / Cubicle nurse

Ops centre person

Ops centre person

Radiographer

Radiographer

Minors nurse

Treatments

Cubicle nurse

Treatments

Resus nurse

Treatments

Cubicle nurse

Treatments

Cubicle nurse

Treatments

Cubicle nurse

Treatments

Time

Pre-Reg

Planning for wInTer

• Fixed ‘Go Live’ date of 25th of October 2014

• Planned ‘Major Incident’OPD Activity cut by 30%Elective theatre activity almost entirely suspendedED Activity cut by 0%

• Floor walkers

So what happened?

Pause for 24 hours for password problems (HSCIC)

Conflicting opinions about the implementation of EPIC

The major problems we had

• The ‘Playground’ wasn’t fit for purpose• Collective underestimation of the

disruptiveness of this• A lot of competent doctors looked utterly

incompetent

The major problems we had

• Interfaces with pathology didn’t work wellManual cross matching of blood300 GP microbiology tests of urines and sputums were not done

• Block contract payments• Complex prescribing

Warfarin and Insulin

The Productivity Paradox

“You can see the computer age everywhere except in the productivity statistics.”

We are 20% less productive (Patients / Dr / Shift) than we were before

Nobel Prize winning economist Robert Solow, 1986

Rants from Consultants

‘I will hold the executive to account for their botched and negligent implementation of the EPIC system’

Election statement for staff governor(successful)

But did it matter?

• No discernible increase in HSMR / SHMI• VTE Recording

Associated with three VTE’s and one death

• Infection Control RecordingMRSAC.Diff

• Frailty and Dementia Scoring

Harm incidents• 15 incidents where patient harm had been reported required

investigation/follow-up

• 2 incidents were removed, as investigations showed these were unrelated to Epic

• 9 incidents were rated as causing moderate harm, 5 as minor harm, and 1 graded as major (VTE SI – see right)

3 Serious Incidents (SI) reported to CCG•Business continuity

•Analyser interface

•Hospital Acquired Thrombosis• 3 patients - pulmonary thrombosis• Investigation completed / discussed with HM Coroner• None solely related to Epic

Patient safety summary

No harm recorded

Chart1

W/C 27/10/14

W/C 03/11/14

W/C 10/11/15

W/C 17/11/16

W/C 24/11/14

W/C 01/12/14

W/C 08/12/14

W/C 15/12/14

W/C 22/12/14

W/C 29/12/14

W/C 05/01/15

W/C 12/01/15

W/C 19/01/15

W/C 26/01/15

W/C 02/02/15

W/C 09/02/15

W/C 16/02/15

W/C 23/02/15

W/C 02/03/15

W/C 09/03/15

W/C 16/03/15

W/C 23/03/15

W/C 30/03/15

W/C 06/04/15

W/C 13/04/15

W/C 20/04/15

W/C 27/04/15

W/C 04/05/15

W/C 11/05/15

W/C 18/05/15

W/C 25/05/15

W/C 01/06/15

W/C 08/06/15

W/C 15/06/15

W/C 22/06/15

W/C 29/06/15

W/C 06/07/15

W/C 13/07/15

W/C 20/07/15

W/C 27/07/15

W/C 03/08/15

W/C 10/08/15

W/C 17/08/15

W/C 24/08/15

W/C 31/08/15

W/C 07/09/15

W/C 14/09/15

W/C 21/09/15

W/C 28/09/15

Harm Incidents

Epic Harm Incidents

0

2

1

1

1

0

5

0

0

0

2

0

0

1

0

1

0

0

0

0

0

0

0

0

0

0

0

0

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0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

EPIC Incidents by Week

W/CEPICEPIC - ConfigurationEPIC - Data EntryHPEPIC - MAREPIC - SoftwareEPIC - SupportEPIC - TrainingHP - infrastructure

W/C 27/10/149341154113

W/C 03/11/14948215213

W/C 10/11/142575141811

W/C 17/11/1455141305

W/C 24/11/1483413376

W/C 01/12/142142738115

W/C 08/12/141538137

W/C 15/12/14814223102

W/C 22/12/146102314

W/C 29/12/144339

W/C 05/01/1522121129

W/C 12/01/15111429

W/C 19/01/152221161

W/C 26/01/153733

W/C 29/12/14512

W/C 02/02/15252

W/C 09/02/1539

W/C 16/02/15231

W/C 23/02/151732

W/C 02/03/15342

W/C 09/03/15222

W/C 16/03/1523131

W/C 23/03/1531

W/C 30/03/157

W/C 06/04/1520

W/C 13/04/1522

W/C 20/04/1515

W/C 27/04/15211

W/C 30/03/151

W/C 04/05/157

W/C 11/05/15151

W/C 18/05/1516

W/C 25/05/1512

W/C 27/04/153

W/C 01/06/1512

W/C 08/06/155

W/C 15/06/1510

W/C 22/06/1510

W/C 29/06/152

W/C 06/07/1512

W/C 13/07/1510

W/C 20/07/1513

W/C 27/07/1514

W/C 29/06/154

W/C 03/08/1517

W/C 10/08/1511

W/C 17/08/1523

W/C 24/08/1515

W/C 07/09/156

W/C 14/09/157

W/C 21/09/154

W/C 28/09/155

W/C 31/08/151

W/C 28/09/155

EPIC Incidents by Week

EPIC

EPIC - Configuration

EPIC - Data Entry

HP

EPIC - MAR

EPIC - Software

EPIC - Support

EPIC - Training

HP - infrastructure

EPIC Incidents by Incident Category

EPIC Harm Incidents

WeekHarm Incidents

W/C 27/10/140

W/C 03/11/142

W/C 10/11/151

W/C 17/11/161

W/C 24/11/141

W/C 01/12/140

W/C 08/12/145

W/C 15/12/140

W/C 22/12/140

W/C 29/12/140

W/C 05/01/152

W/C 12/01/150

W/C 19/01/150

W/C 26/01/151

W/C 02/02/150

W/C 09/02/151

W/C 16/02/150

W/C 23/02/150

W/C 02/03/150

W/C 09/03/150

W/C 16/03/150

W/C 23/03/150

W/C 30/03/150

W/C 06/04/150

W/C 13/04/150

W/C 20/04/150

W/C 27/04/150

W/C 04/05/150

W/C 11/05/150

W/C 18/05/150

W/C 25/05/150

W/C 01/06/150

W/C 08/06/150

W/C 15/06/150

W/C 22/06/150

W/C 29/06/150

W/C 06/07/150

W/C 13/07/150

W/C 20/07/150

W/C 27/07/150

W/C 03/08/151

W/C 10/08/150

W/C 17/08/150

W/C 24/08/150

W/C 31/08/150

W/C 07/09/150

W/C 14/09/150

W/C 21/09/150

W/C 28/09/150

EPIC Harm Incidents

Harm Incidents

EPIC Harm Incidents

Actual Harm Incident Detail

Form NumberActual ImpactDate of IncidentPerson Affected StatusPatient SpecialtyIncident Ward / DepartmentIncident Clinical DepartmentIncident ClassIncident Sub ClassIncident DetailsAction TakenActions needed to minimise the chances of recurrenceFurther investigation notes / additional informationOther DetailsDate inputInjuries SustainedAction Closure Date

I130890Minor (green)8/7/15PatientHaemato-oncologyWard C10 (Haematological Oncology)Haemato-OncologySpecimensDelay in Reporting / Obtaining ResultThe patient has a complex background, having had a cord blood transplant with poor engraftment and severe immunosuppression. She developed a densely amnestic syndrome, with a pyrexia unresponsive to antibiotics. The working diagnosis is HHV-6 encephalitis. A lumbar puncture was performed at lunchtime on Friday 21/8/15, with the primary reason of obtaining CSF for HHV-6 PCR. The laboratory attempted to send this CSF to Bristol for analysis on Friday afternoon, but according to the technician named below this was impossible because - eHospital does not believe that you can do HHV-6 on CSF. It wouldn't allow us. It said that we had the wrong tube type. Staff attempted to re-place the order on eHospital at 16:18 but it could not be ticked as collected. This hurdle was apparently insurmountable, and nothing further was done. On Sunday 23/8/15 I (neurology SpR named below) attempted to find the results. All other LP tests were available, but there was no sign of the HHV-6 PCR even being in progress. I calle more...See section B above. The patient has been given the highly toxic Foscarnet, without definitive diagnosis.There must be a manual override available in this circumstance. Certainly it seems entirely inappropriate that it was just deemed - too difficult - to send the sample so seemingly nothing was done by the laboratory. In all documentation it was clear that this was the primary working diagnosis and the main reason for performing the lumbar puncture.Martin Strickland (Ward / Department: Histopathology) added the following on 06/10/2015:

INV-3654 - Epic needs to be updated so that CSF can be added as a sample source for HHV6 testing. We have sent this request inNovember 2014 and August 2015 The root cause of this complaint was the lack of EPIC order which meant the sample hasnot ordered for the correct test thus did not appear on send away or overdue list. This request is being managedWe havereminded the staff involved to record all communications/ procedures on EPIC (it was not clear until today whether or not thissample had ever been sent). This would have saved much time and confusion over if and when this sample was sentWe havesent some sample EPIC barcodes to Bristol PHE to see if they are able to scan them. This means that our reference reportswill have the correct laboratory number on them. This would have prevented the delay in reporting.The correct procedure forensuring the testing of unorderable requests on epic is to s more...Epic8/25/15Yes9/4/15

EPIC Incidents by Week (2)

W/CEPICEPIC - ConfigurationEPIC - Data EntryHPEPIC - MAREPIC - SoftwareEPIC - SupportEPIC - TrainingHP - infrastructure

W/C 27/10/149341154113

W/C 03/11/14948215213

W/C 10/11/142575141811

W/C 17/11/1455141305

W/C 24/11/1483413376

W/C 01/12/142142738115

W/C 08/12/141538137

W/C 15/12/14814223102

W/C 22/12/146102314

W/C 29/12/144339

W/C 05/01/1522121129

W/C 12/01/15111429

W/C 19/01/152221161

W/C 26/01/153733

W/C 29/12/14512

W/C 02/02/15252

W/C 09/02/1539

W/C 16/02/15231

W/C 23/02/151732

W/C 02/03/15342

W/C 09/03/15222

W/C 16/03/1523131

W/C 23/03/1531

W/C 30/03/157

W/C 06/04/1520

W/C 13/04/1522

W/C 20/04/1515

W/C 27/04/15211

W/C 30/03/151

W/C 04/05/157

W/C 11/05/15151

W/C 18/05/1516

W/C 25/05/1512

W/C 27/04/153

W/C 01/06/1512

W/C 08/06/155

W/C 15/06/1510

W/C 22/06/1510

W/C 29/06/152

W/C 06/07/1512

W/C 13/07/1510

W/C 20/07/1513

W/C 27/07/1514

W/C 29/06/154

W/C 03/08/1517

W/C 10/08/1511

W/C 17/08/1523

W/C 24/08/1515

W/C 07/09/156

W/C 14/09/157

W/C 21/09/154

W/C 28/09/155

W/C 31/08/151

W/C 28/09/155

EPIC Incidents by Week (2)

EPIC

EPIC - Configuration

EPIC - Data Entry

HP

EPIC - MAR

EPIC - Software

EPIC - Support

EPIC - Training

HP - infrastructure

EPIC Incidents by Incident Category

EPIC Harm Incidents (2)

WeekHarm Incidents

W/C 27/10/140

W/C 03/11/142

W/C 10/11/151

W/C 17/11/161

W/C 24/11/141

W/C 01/12/140

W/C 08/12/145

W/C 15/12/140

W/C 22/12/140

W/C 29/12/140

W/C 05/01/152

W/C 12/01/150

W/C 19/01/150

W/C 26/01/151

W/C 02/02/150

W/C 09/02/151

W/C 16/02/150

W/C 23/02/150

W/C 02/03/150

W/C 09/03/150

W/C 16/03/150

W/C 23/03/150

W/C 30/03/150

W/C 06/04/150

W/C 13/04/150

W/C 20/04/150

W/C 27/04/150

W/C 04/05/150

W/C 11/05/150

W/C 18/05/150

W/C 25/05/150

W/C 01/06/150

W/C 08/06/150

W/C 15/06/150

W/C 22/06/150

W/C 29/06/150

W/C 06/07/150

W/C 13/07/150

W/C 20/07/150

W/C 27/07/150

W/C 03/08/150

W/C 10/08/150

W/C 17/08/150

W/C 24/08/150

W/C 31/08/150

W/C 07/09/150

W/C 14/09/150

W/C 21/09/150

W/C 28/09/150

EPIC Harm Incidents (2)

Harm Incidents

EPIC Harm Incidents

Computers are distracting!

The major problems we have

• Training staff is a full day

• Wall mounted computers are in the wrong place and not used

• Able locums are harder to find

The major problems we have (2)

• Non standardised workflows• Clinical productivity is reduced in all areas

by about 20%• Consent / ECGs are paper and then

scanned in• Our system doesn’t talk to the GPs

Audit Standards

• Printing is a problem (standard 7)

• IT makes everything better…or worse

Not all bad

For clinicians• Clinical Records much

easier to review• Virtual fracture clinic

4,500 appointments freed up200k / year saving

• Routine checking of x-ray reports and blood tests takes less than 2 hours / day

For patients• Reduced repetition of

history• Drug errors are less

Then CQC came….

• CQC inspection visit April 2015• Report published in September 2015• CUHFT placed in special measures and

rated as ‘inadequate’

• CEO Dr Keith McNeil resigns

With hindsight…

• Engage, engage, engage

• Test in advance and say ‘no, we aren’t ready!’

• Simplify your processesReferrals / Pathology / Radiology

With Hindsight

• Train on a system that looks like your real system

• Train shortly before ‘go live’

• Train again• Train by peers who

actually understand what you do

Big Bang or Phased Implementation?

Big Bang• Short term pain• Economies of support

staff• Planning and support

Phased Implementation• May be abandoned• Less disruptive

@dradrianboyle

Paperless ED?�An EPIC ExperienceSlide Number 2Upgrading your IT is the most disruptive thing you’ll ever doSlide Number 4£200m over 10 years*Before…wInTer is coming…wInTer is coming…The Addenbrookes and Rosie Hospital EPIC ImplementationPreparing for wInTerSimplify your processesSlide Number 12Planning for wInTerSo what happened?Conflicting opinions about the implementation of EPICThe major problems we hadThe major problems we hadThe Productivity ParadoxRants from ConsultantsBut did it matter?Slide Number 21Slide Number 22Computers are distracting!The major problems we haveThe major problems we have (2)Audit StandardsNot all badThen CQC came….With hindsight…With HindsightBig Bang or Phased Implementation?Slide Number 32

PAPERLESS ED? AN EPIC EXPERIENCE Conference 2016... · AN EPIC EXPERIENCE Adrian Boyle Cambridge...

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