ITAC 2016 Ingenious Award winner – Large Public category
Managing patient information in a complex healthcare environment is one of the most challenging computing tasks of all. Many medical workflows have still to be automated, and clinicians still rely heavily on paper. The University Health Network, (UHN) in collaboration with IT consulting firm SyLogix, won an Ingenious Award from ITAC and ITWC for not just digitizing a complex multi-person process, but transforming it along the way. Its UHN Advanced Clinical Documentation (ACD) mobile tool has revolutionized its patient care process.
The University Health Network is a research hospital affiliated with the University of Toronto. It needed a better way to prepare clinically obese patients for bariatric (weight loss) surgery and to monitor their care afterward, because the existing process was complex and primarily paper-based.
Preparing obese patients for bariatric surgery is a sensitive and intricate process. They must see practitioners from five different disciplines in a specific order.
Initially, they consult with a nurse before seeing a social worker, and then a dietitian. From there, they must be interviewed by a psych team, which may have been a psychiatrist, psychologist, or a psycometrist. Finally, they get to the surgeon, who must have all of the information collected by the other practitioners in an easily digestible form. After this process, the patient will continue to see practitioners for a post-surgical assessment for a duration of up to five years.
“This is a life-changing process for a patient,” explained Victoria Ramirez, senior project manager for IT transformation at UHN. The preparation involves everything from dietary changes to monitoring the patient’s mood and sleep patterns. “All of those steps, and the hand-off between those steps, are critical.”
Moving away from paper
There was no electronic record management system designed to support the creation and exchange of these records between all of the practitioners. Instead, they would collect information via paper-based questionnaires that could exceed 10 pages. The meetings would take place over a period of weeks or months, across different locations. The paper records would have to be created, collated and then transferred between practitioners who would then have to pore over reams of notes.
In 2012, when the Ministry of Health and Long-Term Care funded a mobile electronic tool to make this process more efficient, the UHN team began thinking about what it would look like.
Michael Caesar, senior director of information management at UHN, explained that the organization didn’t simply want to digitally replicate existing paper-based forms.
“This project tried to scrape away the old way of doing things, and look at it in a different way. We looked at what information the care providers need to care for the patient, when do they need it, what do they have to capture during their interaction with the patient and how is that information shared downstream?”
Early on in the process, the team decided to implement it in phases, developing modules for each clinical discipline, beginning with the nurses. In this way, they could roll the system out and incorporate what they learned from one phase into the next.
Patient interactions were a particularly important part of the design process. UHN didn’t want clinicians constantly turning their backs on patients to enter information. Instead, they wanted a technology solution that smoothed information transfer without getting in the way. Eventually, they decided on an iPad-based solution that would communicate clinical information gathered during sessions to a back-end system.
A focus on usability
The UHN team worked with the Toronto-based IT consulting firm SyLogix to help design the iOS-based application.
“There were lots of questionnaires, so the challenge was to design a mobile app that could capture that information in a user-friendly intuitive way,” recalled Jason Ching, the project manager at SyLogix who worked directly with UHN.
To help with user design, UHN brought in its Human Factors team, that sat in on simulated interviews with physicians to understand the information gathering process.
Even then, explained James Agnew, lead architect at the Centre for Global E-Health, a research division within UHN, the team developing the backend information system still needed a degree of flexibility because new information about the data gathering process and the clinicians’ needs continued to emerge throughout the project.
The UHN development team used the Clojure functional programming language together with CouchDB, which is a document-based NoSQL database. NoSQL databases offer a fluid data structure that can be changed on the fly, unlike relational table-based models that force developers into a rigid data structure.
“Our general reasons for going with a NoSQL database as opposed to something relational are really around our ability to react to a fairly complex data model,” Agnew said. “We are collecting a vast amount of data and over the course of the project the elements we wanted to collect changed quite a bit.”
Codifying the whole patient management process electronically enabled the development team to make the collection of data more uniform between different clinicians.
“In their paper-based scenario, the information they captured was quite different. They’d be asking different questions to get the same type of information,” said Andrew Gissing, project analyst at UHN. One clinician wouldn’t know what the other had been asking, which not only made things inconvenient for the patients, but also meant that clinicians may be working from different information.
“We standardized the information they were capturing,” Gissing said. The mobile tool enables a medical professional to easily see what information other clinicians have entered, and then discuss it with them.
Rethinking the information gathering process has also led to some longer-term benefits, explained Dr. Sanjeev Sockalingam, the psychiatry lead for the project.
“The ability to document post-operative assessments allows for historical data to be easily viewed and trended, and clinicians will be able to pick up on signals much faster with longitudinal data,” he said. “The ability to pull data to trend how the patient progresses is a quick win for the application”.
Integration was a big part of the project. The development team also had to ensure that the mobile tool was fully integrated with UHN’s existing electronic medical records, so that the data could be made available to other clinicians. It also automatically faxed clinical notes to primary care and referring physicians, and the software integrated with existing appointment scheduling software, enabling appointment details to be included as part of the patient’s overall record.
The project was completed in 2014, and the team has since had time since to evaluate its results. It found a 33 per cent increase in the number of patients seen on surgeon clinic days within three months of deployment, and the system slashed surgery wait times in half from 128 to 63 days.
On the financial side, Ramirez notes that dictation time used by clinicians fell by 80%, representing a total savings so far of $240,000.
“Healthcare has been a paper world for a long time, and we as hospitals are all faced with this challenge of moving to a digital one,” concluded Caesar.
Thanks to SyLogix and a stellar project management and in-house development team, UHN has created an example of how it should be done.