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Dr David Wrede, Lead for Dysplasia, Royal Women’s Hospital Melbourne delivered this presentation at the Clinical Redesign & Process Mapping conference. This conference provides case studies of succesful redesign projects to assist delegates in identifying the root causes of issues impacting patient journeys and then develop and implement sustainable change processes to improve the way health care is delivered. Find out more at www.healthcareconferences.com.au/clinicalredesign13
Citation preview
Dysplasia Service Redesign
– Simple but Complicated
Mr. C. David H. Wrede MA MB BChir(Cantab.) FRCS(Eng) MRCOG FRANZCOG
Consultant Gynaecologist
The Royal Women‟s Hospital, Melbourne
Overview
Introduction
Stakeholders
Background
What we do
Clinical Process
Challenges
Patient Needs
Look around
Fix the Easy Stuff
IT Systems
An Ideal System?
A word of warning
Implementation Risks
What is Available?
What we want
Future Plans
Conclusion
I have been a Slow Learner…
Advice from a self- confessed FAQ Gyno from Wonthaggi;
Have the Serenity to accept what you cannot change,
The Courage to change what you can,
And the WISDOM to know the difference.
TVR Cerbera
England Germany
Spot the Difference
Stakeholders Women (and their partners and family)
Screening Service
State Government
Hospital & Management
Doctors
Gynaecologists
GPs & referring Specialists
Pathologists
Cytologists
Virologists
Public Health
Nurses
In Hospital and the Community
What do we do in Dysplasia?
Manage women at identified risk of Cervical Cancer “Sharp end of the Cervical Cancer Screening Program”
Three Ways in; Abnormal Smear Test
Post-coital bleeding
Suspicious Cervical Appearance
Initial Consultation, Orientation of Patient, Assessment and Feed back
Only treat those at high-risk Best use of resource and minimises unnecessary morbidity
Early Discharge to Community
Encourage General Health Measures & Vaccination
Colposcopy
What are we looking for?
Treatment By Loop Diathermy -
LLETZ/LEEP
Precis of Current Process
Arrival, Clinic Admininstration
Data & research consent
Introduction, History,
Examination
Explanation
High grade finding confirmed
by pathology
Admission for Treatment
Conservative management and
clinical review
Normal or Low grade findings
Discharge to Community
Identified „Challenges‟
Demand Rising (despite HPV vaccination)
Impact of HPV Vaccination
Current Shortage of Resources
Clinical Inefficiency Process Based
Admin Based
Physical restrictions
Accumulated Medical Leave etc
Heritage and unsupported IT system (not an EMR)
Double Data Entry - Paper Record and Database
Lack of Integrative focus – patchy Quality Assurance
Non-integrated user information
Research Expectations
RENEWAL…of the whole Cervical Cancer Screening Program
Patient Based Issues
Cancerphobia and Anxiety
Includes the „worried well‟ and the over screened
Language & Cultural Diversity
Special Needs Patients
Abused women
Immuno-compromised
HIV, Bone Marrow & other Transplant patients,
Urban Aboriginal community
Refugees
Including women who have experienced Genital Mutilation
Learning Disability
Look at Ideas from Elsewhere One Stop Services
Office Gynaecology - ?European Style
See & Treat under Local Anaesthetic
Select & Treat Preferable now that we are aware of medium to long term morbidity of the
excision of cervical pre-cancer
Adapt Targets and Maximum Waiting Times from International Comparitors
Review or Concordance Meetings Colposcopy Doctors & Nurses, Pathologists and Cytologists
Get an EMR Best of Breed or Enterprise?
Integrated Patient & Medical Information Web based portals
Fix the Easy Stuff First Staff
Appointed Specialists in Adolescent Gynaecology, Sexual Health and Medical Gynaecology
Existing Expertise in Gynaecological Oncology, Laser Therapy and Data Collection and Quality Assurance
Introduce Performance Review
Quality Assurance Targets Use to advantage even when failing to meet them
Concordance Meetings Regular, recorded, followed up and audited
Audit - Retrospective studies initially
Integrate with existing Hospital Initiatives Gynae M&M, Incident Reporting and RCA systems
Research Work within Existing Gynaecological Oncology Research Collaborative
Current IT Systems Available
On-Dysplay – in use at RWH
Microsoft JET v3.5 used with Access97.
Microsoft Visual Basic v6.0
Hosted on network file server or a dedicated PC
RPA System
NZ System
Viewpoint (GE ?still available)
Compuscope (Irisoft UK)
iCIMS?
Cerner?
EPIC?
SharePoint on new or existing MicroSoft database?
Other local development??
An Ideal System
Intuitive Usage Minimal training requirements
Ease of adoption
Clinician control of environment Ease of Extension & Adaptation
Reflects modernisation & development of practice
Web enabled (with touch screen data entry?) Would allow data warehousing
Image capture; still & video
Interface with Colposcopy adjunct systems eg DiSYS, Zilico
Seamless Administratively; HL-7 compliant plus fail-safes
Automatic letter/e-mail production to patients & referring doctors
Easy Data Analysis Automatic production of metrics by practitioner/unit
Report Writer for specific queries/audits
Automatic data delivery to Research systems
Is there an ideal system
Replacement Options
Write new System from scratch – Min $250k!
Rewrite an existing system – if technically possible
Adapt one of several EPR‟s from mainstream providers eg Cerner, GE, iSoft
Adapt an image capture database from existing softwate eg Endobase (Olympus), Viewpoint (GE)
Purchase foreign system eg Compuscope from Irisoft (UK) Ltd
Design our system using emergent web native technology eg iCIMS
Risks within IT
Implementations
Lack of Usability/acceptance leading to under utilisation & poor data
Lack of adaptability/flexibility impairing workflow mirroring and clinical developments
Inability to function as inclusive research tool
Foreign Company with insufficient understanding/penetration of local market leading to poor support
Adoption of nascent technology without proper business plans leading to unmet specification and financial failure
Don‟t just mechanise (badly) the current process
Best of Breed approaches seen as high risk by Senior Officials
So try the alternative…?
IT and Health Reform
Information technology is a tool NOT a magic wand
Switching on Health IT systems does not automatically improve healthcare safety & efficiency See IoM, Ompudsman and PAC (UK) Reports
Healthcare is more complex than retail banking… And Secondary care is NOT scaled up General Practice
One size and/or system rarely suits all
Big IT companies always say „yes‟…until you switch it on, when it changes to „yes but‟, or „well no actually‟.
The Devil is in the detail
Get it wrong and you will pay big time…..
„Unforeseen‟ Consequences
“Royal Berkshire spends £30m on EPR”
“98 per cent of NPfIT benefits unrealised”
“Troubled HealthSMART System Finally Cancelled in Victoria”
“Electronic Medical Records Are Security „Disaster‟”
“Few Savings From Digital Health Records”
Einstein said it…
Repeating the same experiment again and again and
expecting a different result is the definition of stupidity.
Not everything that can be counted counts, and not
everything that counts can be counted.
If A is success in life then A=x+y+z where x is work, y is play
and z is keeping your mouth shut!
Old Processes New Processes
Wisdom of Mike Bracken
Policy
Processes
Systems
Users
Stasis
Users
Service (re)Design
System Development
Policy Check
Feedback
Our Preference is an Adaptable
Web-Native System eg iCIMS
Complete flexibility Adjusts to future guidelines & protocols
Adapts to Research needs & new projects
Can be extended to other related clinical activity
Automated Pathology downloads
Absorbs manual processes & forms
Can be maintained & updated by local Data Administrator
Maintains current interface Eases transition
Reduced Training Requirements
No changes to workflow (unless mutually agreed to be beneficial)
Native interoperability Ease of use at satellite clinics
Can automatically send data to registers
Automates periodic reporting
Plan of Future Progress
Implement new data system as EMR
Staged implementation to adjust for;
Renewal changes
Obtainable efficiency gains
Change of protocol
Consequence of Risk Management outcomes
Research Projects
Image Capture
Colposcopy Adjunct Technologies
Integrate with other outpatient services
Eg Hysteroscopy, PMB service, Vuulval Clinic
Review patient information & make it consistent
RWH website & patient portal with links
Shhhh….. Nurse Colposcopists…
Conclusion
Have a Strategy and plan of attack but,
Do the easy stuff quickly
Rapid returns and improved morale
Set goals & delivery
But don‟t try too much simultaneously
Expect setbacks
Have a Plan B
Apply gentle and unremitting pressure to change attitudes
and culture
Evidence required
Avoid Fashions for their own sake
Engage Youth for Innovation and Age for Caution
Keep Battering Away…
Resource Allocation
Be Imaginative
Missing Targets
Quietly inform those that need to know
Any New IT solution
Must improve not degrade workflow
User acceptance critical
Must have a flexible & friendly interface
Must reduce tasks, clicks & time spent not looking at the patient
Don‟t give up
– even when you are 2-0 down…