Submission for an international honors award
Prepared for Department of Human Services (Government of SA)
General Information
South Australia - The Oacis Programme
South Australian Department of Human Services
(herein called “the Department”)
Adelaide, South Australia
Australia
Year: 2003
Status: Award Recipient
Category: Government & Non-profit Organizations
Nominating Company: Sybase
Short Summary
A state-wide clinical information system that allows clinicians to immediately access patient’s records in real time across the whole metropolitan public health system to provide a better quality health service to the community.
Introductory Overview
The objective of the Oacis Programme (herein called “the Programme”) was to revolutionise the way information is stored, distributed and accessed in the South Australian Healthcare System. The vision was an enterprise-wide, patient-centric clinical information system providing clinicians with access to cumulative patient information at the point of care.
Recognising the fragmentation and duplication of information and processes across all 134 hospitals in the State (an area of 984,000 sq kilometers), the Programme has been launched in the eight major public hospitals; all located in the metropolitan area (1,826 sq kilometers). These hospitals are significant as they service 75% of the 1.5 million people in the State.
The Programme was piloted in 1997 and was so successful in connecting the renal units of four major hospitals, overcoming institutional barriers and facilitating financial and physical efficiencies, that the Government approved long term funding in the year 2000.
The Department purchased and implemented a system to link the infrastructures of the hospitals involved, allowing each site to utilise the clinical information system effectively and, at the same time, incorporate data from existing internal systems.
The Programme, the largest of its type in Australia, has grown from one participating unit in four hospitals to over seventy units in eight hospitals over the last 18 months.
The Programme comprises a series of data delivery projects –
The Clinical Display module provides a single point of access to the integrated on-line patient record such as demographics, encounters, outpatient appointments, medications, laboratory results, radiology reports, theatre procedures and emergency department attendances. The clinician can view a comprehensive history in real time. The following modules stemmed from this platform.
Clinical Order Management module is an electronic ordering system for pharmaceutical, diagnostic, therapeutic, medical and surgical patient services and incorporates best practice information into multi-disciplinary order sets. This enables clinicians to order drugs, imaging procedures, laboratory and other diagnostic and therapeutic services without having to send a hand-written request that gets sequentially handled.
The Separation Summary module distributes information from the clinical information system to community wide General Practitioners (GPs) and other providers, about a patient’s hospital encounter to ensure continuity of ongoing health care.
The Clinical Reporting Repository module provides the capability to query, analyse, and explore the substantial clinical data held in the patient population data repository (the clinical data warehouse). This gives clinicians the ability to analyse things like drug prescribing patterns, clinical treatment pathways or ordering frequency. The repository facilitates tracking of trends over time and allows for research and reporting to be completed in a way that was previously not possible.
Using videoconferencing and the clinical information system functionality, medical specialists in metropolitan centres are able to cross geographical barriers and provide rural care.
The Programme has met its original aims and objectives and delivered an innovative and contiguous service, on infrastructure that is scalable and has the capacity to incorporate all state hospitals and community services in the future as the scope of the project continues to expand.
Benefits
The Programme benefits patients, clinicians and the Government by saving the three most valuable things on the planet – lives, time and money. Quality of care is improved, better outcomes are achieved, institutional barriers are broken down and the impediment of distance reduced.
The benefits of the Programme can be illustrated by the case of one individual. (provided by Dr Scott Germann, Principal Clinical Consultant, Hospital Systems Unit)
During October 2002 a patient, living 25 kilometres to the north of Adelaide, presented to the Emergency Department of their local hospital with chest pains. The patient was admitted, that morning, to the coronary care unit and several diagnostic investigations were performed (chest x-ray, blood tests).
Once test results were known the patient was transferred that afternoon to another hospital (20 kilometres away) for coronary angiography. Blockages in several coronary arteries were revealed and the patient was transferred to a major medical centre (30 kilometres away) for urgent cardiac surgery that evening.
The results of all the patient’s investigations were instantly available on transfer, did not need repeating, saving time in the patient’s management and, quite possibly, saving the patient’s life.
The clinicians who treated the patient were able to follow the patient’s progress after surgery, and when the patient transfers to a hospital closer to home for cardiac rehabilitation, the patient’s full medical history will be available to the patient’s caregivers.
Cost benefits of the Programme will appreciate over time through early intervention, prevention of adverse drug events and by achieving shorter length-of-stay in hospitals. The estimated total annual cost of preventable healthcare events in Australia, resulting from inadequate available information, is approximately 3 billion Australian dollars. If the Programme is able to prevent only 10% of these occurrences, the national healthcare spend could be reduced by 300 million Australian dollars. Preventing over-ordered and duplicated tests, and reducing staff intervention in data entry, printing, checking and searching for patient records, are delivering substantial cost savings to the healthcare system.
Improved safety, and higher standard of care, is the primary benefit to patients. Being able to view charts, information and results without having to wait for paper records to be delivered has resulted in the patient receiving a more thorough assessment, in less time, with holistic accuracy and less likelihood of duplication or error. Clinicians are engaging the patient in the consultation through direct visualisation of their own record using graphical representation of trends, history, etc. and improving confidence and increasing involvement of the patient.
Breaking down institutional and service barriers, the Programme addresses the issue of common information standards. There have been limited data standards in relation to how information is collected, captured, stored and maintained across the health system. The introduction of common policies, practices, definitions and interfaces has made analysis of data possible and provided evidence-based diagnostics for improved health outcomes.
Deploying resources most effectively, by analysing the gathered data in the Clinical Reporting Repository, will maximise the availability to assess the real health needs of the State’s population in an evidence-based fashion never before possible.
Some challenges for the Programme have included privacy and confidentiality issues. The security issues related to sharing data across an electronic environment, has led the Department to develop a Code of Fair Information Practice.
New challenges for the health system are to think and act in different ways that change the healthcare environment - from the traditional institutional focus to the broader issues of consumer-based healthcare.
The Importance of Information Technology
Information Technology enabled the Department to seamlessly integrate all metropolitan public hospitals and deliver an enterprise-wide solution for clinicians, the community, General Practitioners and affiliated health services.
Information Technology has provided an infrastructure that is flexible, scalable and is the conduit for the real time delivery of co-ordinated information not previously possible through any other process.
The introduction of common policies, practices, definitions and interfaces has made analysis of data possible and is providing evidence-based medicine for superior outcomes. A central electronic repository gives all institutions access via a wide area network. The system holds 1.8 million patient records on-line and 260 million clinical service results. In early 2003, there will be over 9,000 clinical users of the system covering over 70 clinical specialties. An average of 80,000 messages per day from feeder systems within the eight hospital sites are received, with over 40 standards-based interfaces.
Information Technology delivers reliable information at the point of decision making, improving and speeding up the decision making process. A significant value-add is the ability to analyse the gathered information and assess and improve the overall effectiveness of the healthcare system.
Remote technology (utilising the Internet and telecommunication technology), is delivering “virtual” care to patients located at remote sites throughout the State and is extending the reach of health services into isolated communities, including the relatively under-serviced Aboriginal/Torres Strait Islanders or Indigenous (waiting for PC clarification here) communities. For example, a satellite dialysis centre, 300km from the metropolitan area, provides haemodialysis maintenance to residents of local and remote communities. Using the technology remotely, through videoconferencing, in tandem with the clinical information system, renal clinicians in metropolitan centres are able to provide rural specialist care.
The Programme uses information technology to retrieve clinical information without having to rely on access to the physical patient medical record. The system is linked to pathology services provided both in and outside of public institutions, and clinicians can see tests ordered and the results of these in real-time.
Technology allows clinicians to engage the patient in the consultation and to view cumulative test results in an easily understood graph or chart format that shows the differences over time, ensuring patients are informed and confident on the status of their health and healthcare needs.
Applying automated mathematical technology is contributing to saving lives. The accepted standard of dialysis adequacy is an equation known as Kt/V and when the dialysis prescription is altered to deliver an adequate Kt/V, patients are more likely to be rehabilitated and survival statistics improve. Kt/V is a difficult equation, often avoided; now simple clinical information is entered into the computer, and the calculation is immediate. The result is stored and easily accessible for future reference. This single feature of the clinical information system has contributed greatly to more comprehensive patient care.
Originality
The Programme has fundamentally changed the healthcare information paradigm and irrevocably altered processes and practices between patients and providers.
John Mleczko, Director Hospital Systems Unit, Department of Human Services - Information Management Services, states that, “Oacis has been a huge change management project. Its enterprise approach to the way that health information is managed has resulted in a need to re-examine all current clinical processes to support patient care within the public hospital system.”
The Programme is the most advanced healthcare project in Australia. It involves deploying Australia’s first centralised clinical information system into all public hospitals in Adelaide, over a five-year period (2000-2005). The clinical information system involves a strategic change initiative for the delivery and structure of health services – moving from institution-based, to community-based needs.
The unique goal of the Programme is the provision of a coordinated healthcare service that is fully integrated and consumer centric, to create an environment where health carers and providers are united as a network around the needs of the individual.
By addressing the issue of common information standards for the first time, the Programme allows the Department to improve the quality of healthcare data using a disciplined approach and a common, agreed standard to streamline processes and have outcomes that are tracked and displayed.
The Programme can also generate de-identified data for research in accordance with international ethical and state legal requirements for research and privacy. The repository contains over five years of clinical information for the majority of Adelaide's population and can provide researchers with unparalleled access to the clinical history of an almost entire public hospital population set.
The beginning of such an ambitious project began in the early 1900s when one unit of one large public hospital need to replace an aged system. Engaging the support of the same units in three other hospitals, a search began for “something better”. After a worldwide search the group chose to trial a product called Oacis. The deciding factors included open architecture, excellent flexibility and a comprehensive ‘tool set’ to write additional features and customize the product to meet the mission statement, set at that time -
“establish a computer based record that includes all health information about an individual throughout his or her lifetime, including all care providers at all sites of care and in all media ie; data, text, image, voice and motion video”.
The success of the pilot launched in 1997, in meeting the immediate needs of the units as well as providing a springboard to the greater plan, lead to Government commitment of long term funding in 2000 and the evolution of the Programme to date.
Success
The Programme has achieved the majority of its goals and exceeded in some areas; it has grown in scope and is not yet fully implemented. The extended implementation of the clinical information system began in July 2001 with 5,500 clinical users trained by November 2002 and over 9,500 users will be trained by March 2003.
The Clinical Display module is fully operational and is being rolled out across seven of the eight hospitals. The Clinical Order Management and Separation Summary modules will be fully operational in March 2003.
The hospitals have succeeded in integrating their multiple diagnostic systems into the common central repository by agreeing on a common enterprise catalogue. The process was difficult and brought people together to critically evaluate both their own and the practices of others to agree on a shared and consistent standard. This shared standard impacts all record keeping of all health records and benefits the entire State by delivering accuracy for treatment as well as resource planning and analysis.
The users of the Programme talk about the benefits to patients and clinicians -
Dr Sue Johanson, Staff Specialist, Emergency Department, Lyell McEwin Health Service (April 2002), identified that immediate access to what the patient doesn’t know or is unable to tell you, saves lives. She said, “This system is particularly important in the emergency department because you often have to treat people on a time limited basis based on what you know at that moment. So the more you can know, the more chance you’ve got of making the right decision in terms of what needs to be done. Knowing what drugs people are taking is a huge advantage because very few people seem to know what drugs they are taking. It’s the same with unconscious patients. Oacis helps us make informed decisions.”
Dr Scott Germann, Anaesthetist, Flinders Medical Centre (April 2002) statestalks about the timeliness of the system. Dr Germann says, "I do a pre-admission clinic every Tuesday. The first thing I do before I see a patient is to access their Oacis information and, by and large, within thirty seconds I’ve got a pretty good idea what to expect when the patient walks into the room. Before I would have had to flick through the notes and finding the key bits. Instead of having to wade through a lot of other information, you now just bring up on screen what you need, see it, absorb it and dismiss it. I’ve found it particularly useful. When I first had a computer I found it user hostile, so I never used it. I needed to remember a whole series of passwords and that just didn’t perform. Now I’ve gotI have a computer and it’s got Oacis on it, and I can log on and get into the data I require within thirty seconds. From there it’s five seconds to select the patient I need. It helps me to channel my interrogation about various ailments.”
The acceptance of the Programme by the primary users is very positive –
Geoff Tattersall, CEO, Noarlunga Health Services, (April 2002) talks about acceptance of the Programme by the Doctors - he said, “Knowing about the patients who go between hospitals is one of the big benefits of the clinical information system. I’ve talked it over with the clinicians in our emergency department. It’s relevant to know that a patient has been prescribed a drug or undergone a test two days ago because it will impact on the need to replicate those tests or when making clinical decisions Even the doctors who start off being quite sceptical finish up supporting the system after they use it.”
The irrefutable success of the Programme is evidenced in the story of the patient who woke up 25 kilometres North of the city and went to bed 25 kilometres South of the city, after life saving heart by-pass surgery, via three hospitals in that one day. The goal of current information at the point of consultation, elimination of duplicate tests, streamlining of process, diagnosis and fast solution delivery for the individual were all achieved that day.
Future plans include the extension of the Programme to all 82 public hospitals within the State, 52 private health services, integrated with General Practitioners consulting rooms, all 85 community health services, 65 community mental health services, 109 day therapy and support services (including residential facilities), 48 family & youth services, 28 drug and alcohol services and 30 disability services. The Federal Government is exploring the introduction of a national electronic health system (HealthConnect). The Programme in South Australia is enabled to link to the national system in the future.
Difficulty
The key obstacles to success were overcoming doubts about continuity (ie a change of government or government changes in priorities), and overcoming deeply ingrained cultural values throughout the existing disparate health system.
The Programme needed to dispel distrust and secure long term funding in order to attract those who may oppose it and enable the Programme to receive the 100% commitment and support required meet its objectives.
A shared commitment was required through all hospitals, each an incorporated organisation with a different history. The Programme included a demanding and comprehensive process of change management to achieve both technical and process integration.
The complexity of the Public Health System, added to the complexity of the multi-vendors, multi-suppliers, government department bodies, and multi-institutions involved in the Programme, meant that systems and processes between organizations sometimes challenged timely supply and re-organisation of the sequence of events was required while delivery of essential resources was redressed.
Staff skills were an issue. The Department was skilled for the ongoing support of systems, not for specialised project work. A change of dynamics within the Department and a change in expertise within the Programme was required to drive procedures and meet deadlines.
As the Programme expands the physical challenges will amplify. Linking hospitals across a metropolitan infrastructure is different to approaching the integration of regional areas. In a State with an area of 984,000 sq kilometers, with 75% of the 1.5 million people serviced by the public health system, the task is onerous.
Unanticipated Challenges
There have been a few unanticipated challenges that required resolution for the Department to implement the clinical information system successfully.
The implementation of the Clinical Order Management module required the issue of electronic signatures and that was not as simple as initially expected. The Electronic Transaction Act 1999 required the Programme, especially in regard to the functionality of Clinical Order Management, to meet the provisions set in the Act. The I.T. requirement specified by the Commonwealth Health Insurance Commission (who issues this Act) is based on desired security functions of confidentiality, integrity, authentication and non-repudiation through a Public Key Infrastructure. Although the Public Key Infrastructure is a solution for security functions and commercial transactions, it does not fit within the public hospital system therefore an alternative solution was needed. The solution called for storage of the original electronic record, which differs from the previous processes, and to provide access, within any legal restrictions, to retrieve data held by the system for the Health Insurance Commission to execute its fiscal responsibilities.
A change in government, which usually means a change in the senior executives of the Department, took place during a crucial stage of the Programme. The Department had prior approval for extended implementation for the Programme from the previous government. A change of government followed the elections in February 2002, and the Department had to brief the new administration of the Programme and confirm its continuation. During this decision period the Programme could not move forward.
Other unexpected challenges came from the state of the infrastructure before implementation. Such issues included the local area networks, wide area networks and the personal computers in the hospitals, not being as good as initially thought. This meant that additional time and effort was required to analyse the problems and devise solutions.
There has also been a challenge at one hospital, managed by a private health care company, which has made implementation of the clinical information system more complex. This hospital has different systems that operate outside of the realm of the Department. Government bills and policy matters regarding privacy and confidentiality complicated the implementation of the clinical information system to that site. The Programme, working with other government bodies and the health care company, are currently developing resolutions that are expected to be resolved early in 2003.