Shared e-health records: Mater Health
Services’ contribution to a National system
Penny NobleIntroduction
In 2010, the Australian Government’s Department of Health and Ageing (DoHA) initiated the development of a secure national system for personally-controlled electronic health (e-health) records. Broken into two phases, a key element of this two year initiative was the participation of nine healthcare sites. As part of the ‘Wave 2’ phase, each site was funded to build its own e-health record system. Through building their own local level e-health records the Wave 2 sites allowed for a staged approach to the rollout of the national e-health record system. As part of the next phase (the ‘transition phase’ to the national e-health record system), these sites were directed to: (a) deploy and test the national e-health record system infrastructure and standards in real world healthcare settings; (b) demonstrate tangible outcomes and benefits from funded e-health projects; (c) build stakeholder support and momentum behind the national e-health record system work program; and (d) provide a meaningful foundation for further enhancement and rollout of the national e-health record system. Mater Health Services (Mater) was one of the nine sites selected to develop a local level e-health record system. The Wave 2 funding grant from DoHA coincided with Mater’s own five year vision for e-health records.
Mater Shared Electronic Health
Record
Choosing to initiate e-health records in maternity care, Mater developed the Mater Shared Electronic Health Record (EHR), an online system that provides an elec-tronic alternative to the paper hand-held Pregnancy Health Record. Through web-based portals pregnant women, private obstetricians, general practitioners (GPs) and Mater Mothers’ Hospitals are able to collaborate on a woman’s pregnancy health information. The components of the Mater Shared EHR include:Mater Doctor Portal – enhancements made to an online information gateway for external healthcare providers; Mater Patient Portal – development of a webpage designed to give pregnant women access to their own maternity data as well as other information such as Mater Mothers’ Hospitals brochures; Matrix Pregnancy Health Record – enhance-ments made to Mater’s obstetric software used by internal clinicians to record electronic maternity information, as well as a redesign of the paper Pregnancy Health Record; and Verdi Clinical Portal – enhancements made
to this access point for Mater staff and Visiting Medical Officers was enhanced to enable viewing of the composite antenatal record.
In addition to these portals, Mater also created a clinical data repository to house the information being shared between Mater Mothers’ Hospitals and the external contributors.
Problems for Mater Shared EHR to
solve
The vision for a shared e-health record came from Mater identifying several issues with the paper Pregnancy Health Record. It was proposed that having a shared e-health record system would diminish these problems, if not eradicate them.
First problem – lost or unavailable information
Women delivering in a public Queensland maternity facility were required to carry the paper Pregnancy Health Record with them during their pregnancy. Consisting of a 20-page Queensland Health issued booklet in a blue plastic folder, this hand held record (aka the ‘blue book’) often becomes bulky and burdensome towards the end of a woman’s pregnancy, particularly if extra pages of notes are added. Due to its nature, it is not unusual for paperwork to go missing from this book. Additionally, 10% of women usually forget to bring it in and 1.4% are never filed in the patient’s hospital record after the birth. Mater’s current internal processes require that the hospital retains a copy of most (but not all) antenatal clinical information recorded in the booklet by Mater clinical staff. However, if these duplicates are lost, this represents a permanent loss of information. Privately delivering women had little access to their maternity information, having to rely on their obstetri-cian’s practice to retain their information and deliver it to Mater when the woman births. Unfortunately if a woman presented unexpectedly to the Pregnancy Assessment and Observation Unit for emergency care, Mater staff were ill-informed if they were unable to reach the patient’s obstetrician.
With Mater Shared EHR, women and providers can have simultaneous access to her maternity information anytime, anywhere.
Figure 1: Benefi ts of Mater Shared EHR: quality, safety, access, and effi ciency.
Note. The Mater Shared EHR benefi ts model was developed by Megan Forster.
Second problem – duplicated or poor data
With no single source of truth for documented clinical information, a number of duplicated clinical entries were logged in paper records and electronic information systems. Due to the multiple locations, it was possible for there to be disparity in the information recorded, particularly if the interpretation of handwritten notes differed between transcribers. For example, antenatal information was recorded in Mater’s clinical informa-tion portal (Matrix) on the first visit but Matrix was not updated during the pregnancy because relevant data fields were unavailable in the system. Consequently, infor-mation during the pregnancy was written into the paper Pregnancy Health Record then duplicated and stored in a paper record within Mater. The information from the initial visit was not reviewed or updated during the pregnancy, leading to reduced quality data throughout the pregnancy. The consequences of this inferior data could include shared care GPs receiving incorrect infor-mation, errors in the Perinatal Data Collection reporting within Mater, and impediments to undertaking quality activities as well as to future service and workforce planning.
With Mater Shared EHR and its clinical data reposi-tory, information from women and providers is stored in one source. Each party is then able to access the repository through their own portals, with these portals designed to meet either clinical or consumer needs.
Third problem – design did not meet user
requirements
The data fields in the paper Pregnancy Health Record and in Matrix did not clearly define what information should be entered. For example management plans could be recorded in multiple locations within the Pregnancy Health Record and this information wasn’t clearly evident to those involved at later stages in a woman’s pregnancy. A woman’s management plan could be outlined in the clinical notes box or the management plan section of the paper booklet within the Pregnancy Health Record; or in the progress notes of her medical record or on the risk identification form in the front of the progress notes; or in a dictated letter; or via a completed Maternity Care Plan form. Similarly, fields in Matrix did not exist to capture information after the initial visit. This meant that Matrix was ill-equipped to meet the electronic documenting requirements of Mater Mothers’ Hospital staff.As the Pregnancy Health Record was designed to be used by maternity healthcare providers, there was little informa-tion in it to primarily meet mothers’ needs (e.g. birth plan, acronyms and definitions, space to record her own notes).
With Mater Shared EHR, both the revised paper Pregnancy Health Record and the electronic system were designed to ensure the data fields met the entry require-ments of both clinicians and patients. Shared care GPs, private obstetricians, and Mater staff were involved in determining what fields were included and defining the
information entered into these fields. A patient represent-ative was invited to evaluate the personal notes section of Mater Shared EHR, as well as the gadgets and additional information available in Mater Patient Portal.
Griffith University was also engaged to complete a consumer survey to evaluate the functionality and benefits of Mater Patient Portal and Mater Shared EHR.
Benefi
ts of Mater Shared EHR
When implementing any new technology on campus, Mater aims to ensure that the technology will improve patient care without impeding clinical workflow. The Mater Shared EHR program incorporated clinician and patient opinion on the system’s functionality throughout development to ensure that the functionality would solve the above problems, as well as deliver additional benefits to all participating parties.A Benefits Manager was employed within the team to assess and measure the value of the project to the Mater business, external healthcare providers and patients. Four main benefit categories were found: access, quality, safety, efficiency.
Further evaluation revealed Mater Shared EHR to deliver the following benefits:
health identifier tools that enable Mater to quickly and easily verify credentials and patient identity
access to consolidated clinical information make it easier for Mater staff and GPs to gain an overview of the patient’s progress
improved clinical information sharing enhances timely decision making
improved continuity of care enabled by the transparent sharing of information between the patient’s providers
convenience of accessing information online BENEFITS: MATER SHARED EHR QUALITY SAFETY ACCESS EFFICIENCY Capability Capability
improved clinical efficiency through the reduction of time spent retrieving, collating and duplicating patient health information
tailored public health advice for the patient, viewable through Mater Patient Portal, provides information relevant to the patient’s particular health journey potential to improve the quality and safety of care through public health surveillance and evidence based research
overcoming problems with the Pregnancy Health Record such as illegibility and lost or forgotten records ensures that important clinical information is entered and displayed in easy to access and consistent locations.
Mater Shared EHR and external
healthcare providers
Working with practice system vendors Genie and PEN Computing Solutions, the Mater Shared EHR program developed the capability for external healthcare providers to share information with Mater directly from their practice systems. Private obstetricians using Genie can now send patient information to Mater directly from their desktop, whereas GPs can share information through the PEN PrimaryCare Sidebar® tool. The PrimaryCare Sidebar® is a resource that resides on a clinical desktop and integrates with Best Practice and Medical Director 3 clinical and billing systems. Enhancements were made to Mater Doctor Portal so that external healthcare providers are able to view the collated antenatal summary
consisting of Mater held information, patient entered information, and their own clinical data. Mater Doctor Portal 2.0 which incorporates information from Mater Shared EHR was launched to external clinicians on 23 May 2012. During the Wave 2 phase, Mater was required to recruit 79 GPs from 54 practices as well as nine private obstetricians from three practices. The interest in Mater Shared EHR from the medical community has been overwhelmingly positive. See Table 1 below for provider adoption statistics of Mater Shared EHR as at 1 February 2013.
Table 1: Provider adoption of Mater Shared EHR Provider adoption of Mater Shared EHR
9 private obstetric practices 15 private obstetricians 64 general practices 257 general practitioners
4,425 electronic documents have been shared with Mater from participating private obstetricians and general practitioners. Mater Mothers’ Hospital GP Maternity Shared Care Alignment Program (SCAP) was involved throughout the development of Mater Shared EHR. Using regular SCAP meetings, the provider facing team of Mater Shared EHR were able to gauge interest in the system, and a repre-sentative from SCAP was admitted to the Mater Shared EHR Steering Committee to ensure feedback from Mater’s GP community was incorporated into the system’s build.
The success of provider adoption of Mater Shared EHR can be contributed to:
Customised training. Engaging busy VMO and GP practices with very limited time frames to set-up and deliver training was difficult so the MDP project undertook to conduct an individual training/support needs assessment with the direct involvement of the individual Practice Manager (in most cases). We developed a customised approach to delivering the product to the practices. Informal and formal feedback from our users has indicated that this has been the most appropriate engagement approach.
Salesforce. The introduction and implementation of Salesforce (CRM) as a communication/relationship tracking tool has also contributed to the MDP project’s relationship with Mater’s Marketing Department and their interaction with our target market by providing a simple means of communicating common interactions with the GP and VMO community.
Already existing and used MDP. One of our greatest tools for selling Mater Shared EHR to our cohorts was the existing Mater Doctor Portal. As a fully functional/ developed product it provided a tangible product to demonstrate to GPs and VMOs. Without the Mater Doctor Portal we would have been forced to market conceptual/unproven deliverables.
Medicare Locals. The relationship the Provider Portals team built with Greater Metro South Brisbane Medicare Local (GMSBML) and Accoras1 was beneficial to meeting our GP and VMO targets, however an early lesson was the importance of clearly defining scope and stakeholder and funders requirements before the project commences. It is also important for future projects to perform deeper analysis of software and hardware products in use in general practice to ensure they have appropriate capability before installing new solutions. Once practices were engaged it is important to efficiently plan required visits to ensure that practice fatigue is kept to a minimum.
Mater Shared EHR and maternity
patients
Mater Shared EHR empowers pregnant women to take a more active role in their healthcare by providing them with better access to their own health information. Through Mater Patient Portal, women can access their Mater Shared EHR as well as tailored healthcare infor-mation such as Mater Mothers’ Hospitals brochures and approved external web links. Mater Patient Portal is not compulsory and is not exclusive to maternity patients. However, only maternity patients can register for a Mater Shared EHR. For a private patient, Mater Patient Portal allows for a more intimate relationship with Mater to develop as the expectant mother will have access to more hospital based information than ever before. For the public and shared care patient, it alleviates the need to carry a paper based record of their pregnancy. Expectant mothers are not required to register for Mater Patient Portal if they plan on delivering at either the public or 1 See www.accoras.com.au
the private Mater Mothers’ Hospitals. If the patient’s GP or private obstetrician is a participant of Mater Shared EHR, the patient will be able to choose to use the full functionality of Mater Shared EHR and conveniently access their pregnancy information from Mater and their healthcare provider online through their Mater Patient Portal account. However, if the patient’s GP or private obstetrician is not a participant of Mater Shared EHR, the patient can still choose to use their Mater Shared EHR to access their Mater pregnancy informa-tion online through their Mater Patient Portal account, but will only have partial functionality. Through Mater Patient Portal patients are able to: (a) access their health record electronically (view a summary of their health record online); (b) keep personal health notes (record questions that they may want to ask their pregnancy healthcare providers; record their Birth Plan); (c) access health information (Mater education brochures on a variety of pregnancy related topics; targeted information relevant to their stage of pregnancy; approved links to external websites with information considered of interest to pregnant women); (d) adjust access to their Mater Shared EHR (choose access controls that limits health-care professionals viewing the information on their Mater Shared EHR; review an audit trail of their Mater Shared EHR); (e) submit their preadmission forms online; and (f) view their demographic details and advise Mater of any changes to contact details (such as phone number, mailing address, email address, emergency contacts).
Consumer portals are becoming a point of differen-tiation in the market place and something organisations need to consider to enhance the patient journey. There has been a steady increase in registrations for a Mater Shared EHR by maternity patients since the launch of Mater Patient Portal on 25 June 2012. Table 2 below shows the adoption rate by pregnant women to Mater Shared EHR and Mater Patient Portal as at 1 February 2013.
Table 2: Patient adoption of Mater Shared HER Mater Shared EHR and Mater staff Patient adoption of Mater Shared EHR
3,833 Mater Patient Portal accounts have been created 1,782 women have applied for access to their Mater Shared EHR Approximately 75% of Mater Shared EHR participants are publicly funded and 25% are private
Mater Patient Portal has been viewed 162,234 times, for an average 7.5 minutes a visit
Over 35,000 views have been made internally of Mater Shared EHR Mater has matched 116,851 national Patient Individual Healthcare Identifi ers (IHIs) from the national Medicare Healthcare Identifi er Service.
Currently used within both the public and private Mater Mothers’ Hospitals by midwives, Matrix is the internal obstetric information system that electroni-cally captures the data held in the paper Pregnancy Health Record. Matrix captures data such as
demo-
graphics, appointment dates, obstetric history, family history, medical and surgical history, allergies, standard observations (e.g. blood pressure, presentation, fundal height), routine laboratory and ultrasound results, and antenatal admissions and visit data. The Mater Shared EHR program enhanced Matrix to enable midwives and doctors to electronically capture chronological antenatal visit information instead of being written into the paper based Pregnancy Health Record. The enhanced Matrix went live on 14 June 2012, and is now used to draw a patient’s obstetric data into their Mater Shared EHR, providing a consolidated electronic summary of the clinical information about a patient’s pregnancy in a single consistent place. Verdi is used internally to view a patient’s Mater Shared EHR which now contains infor-mation sourced from Matrix and from compliant GP and private obstetrician practice systems.
The Mater Shared EHR program also updated the paper based Pregnancy Health Record to better suit Mater providers and maternity patients. The Queensland Health version of the paper based Pregnancy Health Record consists of a 20 page booklet and a number of leaflets enclosed in a blue plastic sleeve and is issued by the Queensland Government to all public maternity patients in Queensland. The new Mater paper-based version of the Pregnancy Health Record customised the existing Queensland Government booklet to better suit the needs of an expectant mother delivering at one of the Mater Mothers’ Hospitals. An eight page booklet is now enclosed in a dark blue folder, with extra forms available to health-care providers online should they require them.
Part of the challenge in executing this project is to marry format and content; the record has to look right, to resemble that which clinicians are already familiar with, thus enabling them to see information quickly and intui-tively; however looks alone will not suffice. A significant challenge for us has been ensuring that all of the content which is captured by the Pregnancy Health Record is able to be captured and transferred electronically within Mater Shared EHR. The stakeholder consultation undertaken enabled Mater’s revised paper Pregnancy Health Record and shared electronic health record to align with the Queensland Statewide Maternity and Neonatal Clinical Network’s standards. With so many changes being made to the internal processes, it was important that clear communication and training take place to ensure the staff adopted the changes with as little inconvenience to them as possible. The Mater Shared EHR program employed a dedicated Change and Adoption Specialist to help internal staff through the improvements. This specialist used a number of different change management channels to encourage take up. So, what worked?
Cross system training: The Data Quality Specialist from within Mater’s Information Management Division was recruited to test and train on the new Matrix model. This proved to be very helpful.
Leadership of senior hospital staff promoting Mater Shared EHR at various forums: The Director of Gynaecology and Obstetrics was recruited early on to
become an advocate for the electronic health record. Using his position within Mater Mothers’ Hospitals as well as in the medical community to promote the system gave credibility to the enhancements and encouraged others to follow his example. Face-to-face training.
Regular internal communication via emails, weekly meetings, and teleconference calls: By providing frequent and transparent information about the progress of the upgrades, staff could feel secure about the changes to their work processes and that their comments were being heard.
Consulted the business on functionality before deployment so the staff were involved in the design of the system.
Internally, the business realises that this level of communication and training is not a one-off event. Each new employee within Mater Mothers’ Hospitals needs to undertake this education, and as the system is enhanced, older staff will need to be re-educated. Tools such as videos, cheat sheets, and intranet websites were developed to provide a foundation for future education of staff.
Mater and transition to national
e-health record system
The lessons learned during development of Mater Shared EHR were used, in part, to guide the implementation of the national e-health record system into the healthcare community. A National E-Health Transition Authority (NEHTA) funded team was engaged at Mater to recruit providers and consumers to the new system, as well as integrate the national e-health record system into the Mater clinical and patient workflow. While several tasks were undertaken to achieve this integration, the most complicated, yet beneficial development is the function-ality for Mater to view a patient’s personally-controlled electronic health record (PCEHR) through Mater’s internal clinical data system, Verdi. This involved creating a business-to-business (B2B) gateway using InterSystems’ Ensemble product. As well as enabling B2B information passage, the Mater Shared EHR program also developed an Information Requirements Specification (IRS)
document for a pregnancy health summary and antenatal visit summary in the national e-health record system. These documents consist of data set recommendations that Mater considers imperative to maternity care. It is hoped that Mater’s IRS documents will be used to guide the national e-health record template service.
To successfully register and enable healthcare providers and consumers to participate in the national e-health record system, the team at Mater has: (a) supported the engagement, education and training of providers and consumers; (b) supported the national e-health record system registration of providers (GPs, private obstetricians and internal Mater clinicians) and consumers (maternity and other cohorts); (c) supported the deployment and installation of conformant software including, but not limited to National Authentication
Service for Health (NASH) certificates, conformant data extract tools and conformant desktop software; (d) registered Mater internal providers to PCEHR to enable them to view PCEHR documents from the enhanced Verdi portal; and (e) provided support and oversight to the Medicare Locals in deploying enhanced GP desktop systems and data extraction tools and in the engagement, recruitment and registration of GPs and consumers to the PCEHR.
For the transition phase, Mater has been working in conjunction with GMSBML to recruit providers and patients to the national e-health record system. Working together on the national e-health record system has helped strengthen the relationship between Mater and the Medicare Local. For this phase of the program, Mater has been contracted to undertake best endeavours to recruit nine healthcare specialists to participate in the national e-health record system. Mater is also required to execute promotional activities that educate 5,000 maternity consumers about personally controlled electronic health records. In addition to Mater’s targets, GMSBML has been contracted to undertake best endeavours to recruit 50 GP practices to participate in the national e-health record system, and provide information to 95,000 consumers.
Opportunities and challenges
The strategic management of the project generated many insights and lessons learnt of value to the project and external stakeholders. An early insight is that the time-frames to deliver the project were going to be onerous. At the onset, the project start date was before the end of the previous Wave 2 project which meant only a light start was possible so as not to put the Mater Shared EHR related go lives at risk. It did not make sense to have it commence while the Wave 2 project still needed to complete another six weeks as many of the Mater’s resources were unavailable to focus on the new project and deliverables. NEHTA engaged Deloittes to help prepare the project documentation, including the draft project schedule, given the cross over in timing. Whilst this was intended to help, the timeframes for this process did not allow the Mater Brisbane to have adequate input to its construction to enable validation of the assump-tions which were used to create the contract. As such the timelines should have been based on 1 July 2012 start rather than May 2012, which resulted in the contract schedule becoming obsolete and necessitating a revised contract.
The Mater Shared EHR/ PCEHR Transition Program was made up of three projects: Technical Integration, Consumer Deployment & Adoption and Provider Deployment & Adoption. Apportioning project work according to these sub projects worked well as there was limited cross over between their deliverables. The Technical Integration team needed to work closely with the Verdi Clinical Portal team to establish the B2B connectivity with the PCEHR. The importance of securing a Senior Project Officer - Benefits Management was a
practice followed from the Wave 2 project. This resource was able to manage all steps of the benefits process and create a framework for the ongoing evaluation of the project.
Confusion around the national PCEHR implementa-tion affected the project. A lack of a naimplementa-tional advertising campaign made consumer deployment and adoption activities more difficult. There was also a lack of direction from the national partners regarding the benefits or deployment and adoption activities of the PCEHR. As was experienced with Mater Shared EHR there was no central website which enabled the team to be confident they had access to what was required during the Transition project. Aside from the e-room2, there were a number of websites which detailed technical information which created confusion, even our NEHTA contacts were often unable to identify what was the most up to date source of information. It was fortunate our Solution and Testing Manager was quite diligent in seeking the informa-tion required while the Verdi B2B soluinforma-tion was being developed. While the Mater eventually had success with recruitment of VMOs to the PCEHR due to its existing relationships, GP recruitment for GMSBML was more problematic. The following factors contributed to a lower than expected conversion rate for GP practices who expressed an interest in PCEHR, and those that had offi-cially completed their PCEHR registration:
Many providers were starting from a low base of knowledge of the PCEHR, and were needing more elapsed time to move to the stages of ‘understanding’ and ‘commitment’. This included the legal issues and questions needing to be addressed as part of the Provider Participation Agreements (PPAs).
The degree of paperwork was overwhelming for many practices which were left to themselves to step through the ‘pre-registration’ and ‘registration’ stages (including chasing the Australian Government Department of Human Services [DHS]/Medicare), at their own pace. This was due to GMSBML not having adequate resources in place to proactively follow-up and assist the practices, beyond some initial engagement and handing over information packs. For the majority of practices, the initial priority was on the first four qualifying criteria for the e-health practice incentive program (e-PIP), which included the PCEHR ‘pre-registration’ stage only by 1 February 2013. It is likely that prior to 1 May 2013 the final PCEHR ‘registration’ stage will get more focus from practices which are time poor.
A large number of practices were initially happy to just ‘wait and see’ before agreeing to commence the PCEHR ‘registration’ process.
The December 2012 - January 2013 holiday period is traditionally a difficult time of year to be engaging with consumers and providers which impacted the project team’s abilities to achieve the stated PCEHR registration targets.
Significant change and adoption activity has made a major contribution to the success of the project. The 2 See https://irmm.jrc.ec.europa.eu/collaboration/eRoomHelp/en/index.htm
project received widespread stakeholder support and involved the following change and adoption activities: establishing the Program Steering Committee; creating a detailed Stakeholder Map at the start of the project; and keeping key project staff informed and actively seeking their opinion and feedback. Some key challenges for PCEHR identified during the project period included: delays with NASH and certificates; environments in practices; and multiple PKIs required.
Program Manager role
During the two project periods I worked with a number of HIMs in non-traditional roles across the Program. Whilst my undergraduate HIM training was quite some time ago I continued to use transferrable skills from the degree in this role. Regular activities undertaken included:
regular meetings with my sponsor and business owner to discuss the project and review staffing levels weekly one-to-one meetings and fortnightly
Roundtable meetings with my project managers and team leads where we discussed current status and critical items that needed to be addressed
stakeholder meetings to review progress track the budget and forecast for the Program. My time in this role highlighted the need for plenty of patience, to be quick to pick up concepts and be able to interact effectively with individuals across the organisation and with our external partners. Given the short timeframes involved it was necessary to be good at building relationships that created partnerships. I needed to demonstrate leadership by letting the Program team know I supported them, was available to help remove any barriers and assist in resolving problems, to ensure they could continue moving their projects forward. Helping team members achieve something of value became relevant as the Mater Shared EHR was perceived to have more value by some members of the project teams who made the ‘sell’ more of a challenge for PCEHR. At the end of the day we had a job to do so once I outlined the boundaries I was open to suggestions from the team about the best way to achieve it. I am privileged to have worked on these two initiatives, which have laid the foundation to help improve continuity of care enabled by the transparent sharing of information between providers. It has been challenging and immensely rewarding with the teams involved achieving amazing results in the timeframe given the scope of work and many complex dependencies.
Penny Noble, BBus(HIM), MBA, CPPM Program Manager
Mater Shared Electronic Health Record / PCEHR Transition Mater Health Services
South Brisbane QLD 4101 email: Penny.Noble@mater.org.au. www.mater.org.au
