Download Shared Care Record View 1. What happened?

Case Study
Christchurch Innovations
Shared Care Record View
1. What happened?
After the 6.3 magnitude earthquake struck Christchurch on 22 February 2011,
people were not necessarily seen by their usual health providers. Many GP
practices and pharmacies were damaged and closed and community nursing
services severely disrupted. Damaged buildings meant that paper-based patient
records were inaccessible and electronic data dispersed. While large IT systems
were up and running again fairly quickly, smaller ones – such as those in general
practices and pharmacies – were lost or took much longer to restore. Patients
presenting for treatment at the various physical locations across the Canterbury
health system often came without referral and with no quick way to check their
medical records. The situation provided a strong lesson in the importance of having
timely and accurate information at points of care.
Decisions about people’s treatment and care therefore frequently had to be made in
the absence of full medical histories, diagnosis and prescription records. However,
there was considerable professional concern that delaying treatment to find
necessary documentation would cause more harm in a situation where patients
needed the Canterbury health system to work for them right then and there.
Although the underlying issue couldn’t be resolved immediately, the quake and its
aftermath prompted a new way of sharing health information. Canterbury District
Health Board (CDHB) quickly helped bring together a project team that included
people not only from CDHB, but also from Pegasus Health (representing general
practices), community pharmacies, Nurse Maude, software experts and Orion
Health. Together, we developed a secure system for sharing up-to-date patient
information across all health professionals providing care for any one patient.
The system, called the electronic Shared Care Record View, or eSCRV, displays
certain patient information and diagnostic test results sourced from many different
e-health systems on one screen. It is neither a central database nor a replacement
for existing systems. Much of the health information it handles is routinely collected.
When a patient comes in, eSCRV enables clinicians to see their relevant medical
history, including a summary of medical conditions, details of recent or long-term
illnesses, hospital visits, operations, date of last GP visit, tests and diagnostic
results and medications recently dispensed at community pharmacies. The
available information also includes details about home care visits, such as care
coordination information (eg, name of the provider and the type of care allocated).
eSCRV thus makes faster diagnosis, treatment and care possible. In helping health
professionals make informed, timely decisions, it contributes to improving patient
safety and health outcomes.
How is this different to what happened before?
Before the Canterbury earthquakes health providers generally agreed that a single patient
record accessible by all health professionals involved in caring for a patient would aid patient
safety. However, opinions on how this could be achieved differed. Concerns were also
expressed over the potential risk a single record posed to patient confidentiality and whether
such a system was affordable. These views and concerns prevented progress towards
achieving a single patient record.
Patient information therefore remained stored in a number of locations and databases,
leading to duplication, discrepancies and increased clinical risk. This situation also meant
wasted time for patients and clinicians because of each place of care having to collect the
same information. Wasted time meant delays in providing timely treatment. A small amount
of information was transferred between hospital and primary care services via referral and
discharge letters, but the opportunity to reconcile pharmaceutical and treatment regimens
was limited.
After the February quake CDHB’s Chief Medical Officer, Dr Nigel Millar, called on newly
motivated hospital specialists, nurses, pharmacists, GPs, allied health professionals and
community health service providers to participate in a series of workshops. Together, we
quickly drew up a matrix of all stakeholders in the Canterbury health system, the type of
patient information each held and what was already shared. The workshops began with
some stakeholders convinced that others had no clinical reason to see their data, but by the
end there was a new consensus. The participants collectively agreed that there were valid
reasons for sharing key patient information. All were confident that a new system for
electronically sharing patient records would improve patient care and safety by ensuring the
availability of complete and accurate information at the point of care.
The project team realised we could draw on the example and inspiration of “interRAI for
Aged Care”. This national project makes available a standard suite of assessment tools and
a central database that holds high-quality assessment data on the holistic care needs of
older people. InterRAI has been rolled out to 19 District Health Boards over the last two
years, and Canterbury was one of the first to start using it. After the quakes CDHB used it to
quickly generate a list of the most vulnerable older people living in Canterbury and then
contacted them to offer help.
2. What are the results?
Benefits to date
Just a few weeks on from the February earthquake, the project team began developing a
pilot phase of eSCRV. The pilot, which involved a small number of pharmacies, Nurse
Maude and CDHB staff sharing information, was well underway by October 2011, and
eSCRV is likely to be fully functional by July 2012. We anticipate that more than 90% of
Canterbury clinicians will use the system and most, if not all, are eagerly waiting for it.
This innovative solution to sharing patient information is the first of its kind in New Zealand.
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It is something of a mini-revolution because of its shift from a 19th-century paper-based
approach to health information to a 21st-century one that is electronically based and smartphone capable. It is also being accomplished without the huge transition required to move
numerous organisations to a single IT system.
The potential benefits, denoted by the pilot at this point, are enormous – faster, more
informed treatment for patients, improved patient safety and reduced clinical risk, and less
duplication and waste because of patients and clinical staff not having to repeat tests and
record information multiple times in multiple places. eSCRV can also act as a platform to
support integrated health care delivery and improve communication among health
professionals caring for the same patient. Because the system is designed with patients’
best interests in mind, security of information is paramount. As a built-in safeguard, all
access to information by authorised users is monitored and audited.
eSCRV will empower the broader health workforce, by making appropriate health
information more readily available, which is particularly important given current workforce
constraints.
Community pharmacies, for example, can obtain information about patient allergies much
faster. They can also access dispensing information entered into the system by other
Canterbury pharmacies.
Experience shows that differing IT systems are a major barrier to integrated care. eSCRV –
along with CDHB’s other integrative tools including HealthPathways, Electronic Referral
Management System (ERMS), and the Collaborative Care Management System (CCMS) –
has gone a long way towards establishing the platform for an integrated health system for
Canterbury.
From the perspective of health stakeholder behaviour, eSCRV is a substantial break-through
in terms of reform. This is because it covers the entire patient population rather than
selected populations. The system has also effectively lowered the barriers to integrated
health care brought about by different professionals across the health system’s public and
private sectors divvying up patient care according to their perceived roles. eSCRV, ERMS
and CCMS (the latter is still under development) all work on the premise of distributed
information – routing information through a single point rather than attempting to create oneto-one communication pathways between and across many disparate systems.
The benefits that eSCRV offers should further emergencies arise is obvious. While no one
wishes for another major earthquake, if it happens eSCRV will provide both clinicians and
patients with a sense of security and confidence, as well as faster and safer care.
Measuring success
The success of the pilot phase confirmed that rolling out the innovation in full will be
successful. Use of the system in the interim by Christchurch Hospital’s emergency
department and the 24 Hour Surgery has brought home to clinicians the true value of
eSCRV.
As noted earlier, surveys show that more than 90% of Canterbury clinicians intend to use the
system once it is fully underway.
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Feedback from those using the system so far shows that poor patient outcomes have
already been avoided through having the right information available at the right time at the
point of care.
A number of benefits across the entire health system have already been highlighted. These
include:

Improved patient safety and less clinical risk – as one survey respondent put it, “better
able to manage the patient in the context you are in”

Less duplication of tests and x-rays

A more humane process for patients because of fewer procedures and not having to
repeat their medical history many times over

Collaboration – practitioners, specialists and other stakeholders drawing on a range of
expertise and creative thinking to bring a new concept into being

Courage, ie, “to get better results, you must change the way you do things”

Managing within constrained resources, being resilient to adversity and learning from
setbacks.
Costs
The eSCRV development cost is around NZ$1 million (CDHB’s total operating budget is
approximately $1.4 billion per annum). This cost includes a considerable amount of clinical
staff time, over and above clinicians’ day jobs.
The cost is also partly attributable to eSCRV bringing together existing information for
clinicians to “view”, adding a small margin to normal business and communications costs.
However, those costs are offset by the new system being substantially more cost-effective
over time than the system used before the quakes.
After roll-out, ongoing costs will be minimal and easily absorbed by CDHB’s usual
information technology infrastructure. The flow of information typically required to complete
simple transactions, such as dispensing a prescription, will be minimised because each
clinician in the patient’s pathway has access to the previous clinician’s information and
thinking. For example, previously in hospitals, the time of two people – the prescriber and
community pharmacist – was taken up answering queries about prescriptions written on
discharge. Using eSCRV will avoid most of these queries because prescribers will have
access to information on patients’ current medications, and pharmacists will have access to
prescribers’ records.
3. What capability enabled it?
Critical success factors


Effective and timely intervention by a key clinical leader to address patient privacy
concerns
Shared trust and a high desire not to harm patients because of delayed treatment
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
Seeing, from the example of interRAI for Aged Care, that a new way of working is
possible.
Relationships
eSCRV is overseen by a clinically-led governance group that represents the major clinical
groups in the Canterbury health system. A small project team of key stakeholders worked on
developing the system and piloting it.
The relationship between the front-line users of the system and the software developers
Orion Healthcare has been extremely important. This close working relationship meant the
technology behind the system was developed to meet the needs of clinicians and to improve
patient care. It also meant that a number of protections could be built into the system to
ensure privacy of information. Orion’s implementation experience was invaluable in getting
the system up and running so quickly, and a pilot group of GPs, pharmacists and community
nurses played a vital role by lending their expertise and giving advice that has enabled Orion
to fine-tune eSCRV for roll-out.
Innovation experience and capability
Before the quakes the Canterbury health system had gained experience in developing
clinically-led, system-wide innovations and models. An example of existing capability –
supported by use of web technology – is the Canterbury health system’s patient referrals
pathways and its “Health-Pathways” website. The first of its kind in New Zealand, the
website was developed to support the bigger role GPs were taking in providing more
community-based health care and reducing acute and unnecessary hospital admissions.
Over 250 health professionals from across the Canterbury system developed and agreed on
patient pathways, which were then loaded onto the Health-Pathways website.
GPs using the website can find information on how to treat a range of conditions in their own
community-based practices and clinics, and receive advice on accessing more complex
services and referring patients to them.
The site now has 474 treatment plans/patient pathways and procedure information which
GPs can access from their desktop computers. The site attracts more than 11,000 visits and
74,000 page views a month from clinicians.
These patient pathways and the online access to them also support the delivery of a number
of services not previously possible. Eighteen thousand people per year are now cared for in
their own homes through the provision of acute demand care “packages”, reducing pressure
on constrained hospital facilities and resources. The acute medical admission rate across
Canterbury hospitals is now 30% lower than the national average because more of the
activity in the hospitals is now elective and waiting times for treatment have dropped right
across the system. The success of the Health-Pathways innovation has led to healthcare
providers across the whole South Island and in parts of Australia either adopting it or
intending to adopt it.
The experience of restoring health services after the February earthquake established a new
level of trust that made joint decision-making even easier. As one eSCRV project team
member said, “Through the earthquake response, we learned to break the rules. We learned
that we could trust each other and learned we could put our heads together”.
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Clinicians knew it was possible to work collaboratively, and they knew they would have
CDHB support when endeavouring to make the system better for patients.
The clinical risk posed by the lack of access to patients’ clinical records during the
emergency was the final catalyst needed to progress an idea that had been waiting in the
background and that had the potential to further and substantially transform the Canterbury
health system.
Tolerance for risk and experimentation
Tolerance for risk and experimentation in Canterbury was high before the quakes.
The Canterbury health system was in the midst of a process of transformation directed by
clinical leadership. Health professionals from across the whole system were engaged in
developing integrated patient pathways and innovative models of care with the aim of
improving health outcomes. Alliances, relationships and transparent partnerships were built
up through a shared commitment to the vision of one health system providing a seamless
flow of care. Our mantra has been “the right care, in the right place, at the right time, by right
person”.
At its core, our vision has focused on everyone working together to do the right thing for the
patient. The key measure of success in realising this aim at every point has been reducing
the time people waste waiting. Significant success had been made in this regard before the
quakes, and confidence was high that when solutions were developed, the necessary
support and funding would follow.
The collaborative response to the earthquakes and the absolute need to respond quickly to
changing need and circumstance further strengthened this conviction and thus the tolerance
for innovation. 4. What conditions enabled it?
eSCRV did not emerge in isolation or solely as a response to the Canterbury quakes. Over
the past several years, Canterbury has established a reputation for supporting and investing
in clinical innovation and in whole-of-system partnerships directed at improving patient care.
Our shared vision was developed through a series of visioning workshops and showcasing
innovative ideas and models of care in 2007.
Over 1,000 stakeholders, providers, consumers and health professionals from across
Canterbury’s health system participated and helped to set CDHB’s strategic direction by
committing to the “whole-of-system” approach that is so ingrained today.
Our ability to quickly implement eSCRV was made possible by the work we had done to get
all the health providers in Canterbury to see themselves as part of a single system with
common goals. This outcome was also made possible not only by empowering clinicians
and health professionals on the front-line of service provision, but also by re-orientating the
system toward the needs of the patient. This process required us to remove traditional
barriers and boundaries related to provider roles, service settings and funding.
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The transformation that has taken place in Canterbury over the past five years has given
health professionals across the system a clear mandate for fully developing the eSCRV.
The CDHB’s direction is not just about hospitals or individual providers, but also about a
resilient and sustainable health system.
Integration of services and service delivery models is real and tangible, and the benefits of
working collaboratively for the benefit of the patient and the system are evident every day as
duplication, waste and waiting times are visibly reduced.
The clinically led, system-wide partnerships, service-level alliances and work streams driving
the transformation across Canterbury are inspiring innovation and building the confidence
and trust that enabled rapid adoption of the eSCRV. More specifically, the transformation to
date is evident in:

The 470 clinically-led patient pathways developed across primary/secondary care to
streamline referral processes and improve outcomes for patients

Twenty-five thousand GP-referred diagnostics being delivered in 2010/2011, with a
broader range now available because of GP referrals improving access to diagnostics
and reducing waiting times for patients

The CDHB’s Acute Demand Management Service now providing over 18,000 packages
of care for acutely unwell people in the community rather than in the hospital

Minor surgery now being carried out in general practice surgeries, with (for example)
average waiting times for skin-lesion removal dropping from 196 days in 2007 to just 53
days in 2011

Our older people being better supported. In its first 11 months, CDBH’s new CREST
service provided over 750 older people with additional support on discharge from
hospital

Less acute-based activity in our hospitals – at 0.78, Canterbury’s acute medical
discharge rate is the lowest of any large DHB in the country, and is well below the
national average (1.0).
The transformation we’d achieved prior to the February earthquake was invaluable
immediately after it and in the months since. Without the gains we had made, the Canterbury
health system would not have averted crisis in the face of such destruction and could not
have coped with the loss of bed capacity and infrastructure. Without this environment, we
also would have been unable to commit to and develop the eSCRV.
Most important enabler and sustainer of innovation
The idea of a shared patient record existed before the earthquakes but it took the worst of
times to accelerate support for sharing patient information. A whole-of-system approach and
the focus on putting the patient first were already a central part of thinking across the
Canterbury health system; we just needed an additional motivational push to take the next
step with respect to sharing patient records. By investing in a culture of participation,
innovation, continuous quality improvement and system-wide partnerships, we have built up
considerable momentum and support for transformation in Canterbury.
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A critical success factor, particularly in our current extraordinary circumstances, has been
the ability to act responsively and decisively to support the immediate needs of our
population.
Flexibility in our approach over the past 18 months has enabled the Canterbury health
system to continue to deliver core health services in the face of significant disruption and
constraints. As we continue to respond to our challenging and dynamic environment, we
need to maintain this flexibility to keep supporting our vulnerable population.
Because traditional policy and service change processes can delay decision-making and
take it away from front-line service providers, we are seeking support from the National
Health Board to be more flexible in the way we fund, contract and deliver health services.
This change will allow us to respond proactively to issues, opportunities and innovations as
they present themselves. The post-earthquake situation means that we have a unique
opportunity in Canterbury to test innovations and alternative service delivery models. Doing
things differently will mean making some allowances, but it will also mean making the most
of opportunities.
5. What lies ahead?
In terms of the innovation itself – the eSCRV – as one eSCRV team leader said, it will be a
case of “tweaking the detail, not the vision”. We are well on track to roll out the system
across the Canterbury health sector by the end of 2012, with CDHB continuing to fund this
process. Plans are also underway to give St John Ambulance eSCRV access. We are
confident that over the winter months, eSCRV will help avoid acute hospital admissions by
making available key patient information.
As mentioned earlier, other South Island DHBs want to implement eSCRV, and we will be
pleased to provide them with whatever support we can. We consider that eSCRV could be
adopted throughout New Zealand, thereby integrating delivery and providing timely and
effective care regardless of where patients present. The system is scalable for the future and
could readily engage other clinical groups and their information systems. It also has the
capacity to support a direct patient or consumer view.
We also need to address the fact that the component missing from the system is
authentication of each healthcare provider within the New Zealand health care sector.
Meeting this need will require the Index of National Health providers to be up and running.
Another need requiring our attention is that of making sure all health care providers in
Canterbury can access the system. eSCRV will not realise its full potential until this is done.
Shortly after the February 2011 earthquake we began preparing our recovery plan. The
immediate focus was on managing the system, with reduced capacity, through the coming
winter. However, we also ensured that the plan continued to recognise the importance of
keeping constant the vision of an integrated health system and the need to plan according to
short, medium and long-term horizons.
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We consequently built the recovery plan around four elements:
1.
Stabilise
2.
Recover
3.
Transition
4.
Vision 2020.
In 2012, we moved into the transition phase of this plan. Most of the strategies detailed in
the transition section depend on the integrated nature of the Canterbury health system and
the ability of the CDHB to continue working in partnership with a range of people and
organisations that share our vision. The quakes created opportunities in this regard that
Canterbury is well positioned to take.
However, we are well aware that the next few years will continue to be challenging, which
means we need to ensure eSCRV is as robust as it can be. Health care buildings are
broken, capacity stretched, and the population is more fragile and more likely to require the
support of the health system. Fixing buildings while still needing them to deliver care is
complex, and each day Canterbury balances the immediate harm of denying access to
services for the population with the potential harm of occupying buildings that don’t comply
with the new building codes.
Our intention for the immediate future is to ramp up the development of a dynamic health
system that has the resilience, capacity and connected infrastructure to move the load of
health-care delivery to the point in the system that is best prepared to handle it on any one
day. This process is not a simple case of moving activity from hospitals to the community
because the community is stretched as well. What we need to be able to do is constantly rebalance the load to support every part of the system so that we can effectively manage and
minimise the gaps in care.
Delivering the right care, in the right place, at the right time, by the right person continues to
be the core direction, but the circumstances almost literally thrown up by the earthquakes
have highlighted the need to deliver a dynamic solution as the capacity of our system
continues to manage on the edge. Fortunately, Canterbury has the building blocks – its
integrated system of health care delivery – to achieve this.
For more information on Christchurch Innovations go to:
www.ssc.govt.nz/christchurch-innovations
Written in association with the Canterbury District Health Board, August 2012
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