As someone who was intermatly involved with he Canterbury and South Island implemetnation of the Orion/HealthOne toolset I can assure you there was lots of clinical input into systems. (Dr.) Nigel Millar provided significant clinical drive at executive (and practical) level and the project teams all incouded significant other Clinical input from both primary and secondary care.
The Orion vendor was enbedded into the Canterbury Health System and all Orion developers had days working at the hospitals with Doctors and Nurses on the ward to make sure they understood the clinical processes. Orion Health valued the clinical input we provided and, whilst not perfect, the result proved to be a huge step-up from its predecessors.
OH systems are not perfect (no software is perfect - they all come wih some compromise) and we will need to continue to invest in either improving them or step to a new strategy.
Just throwing my 2 cents in
Can we please remember that the administration teams should be a core part of any journey undertaken, as i have heard stories and seen the outcome where the project is so focused on the feedback and usage from clinical teams that it forgets the user group that spends a majority of their working day in the system and who end up having to bridge gaps to fit around the new âimprovedâ workflow.
What works well for a clinician may not work as well for a scheduler. It needs to be a fine balance and a compromise (if required) from both parties to get an ideal product.
I note that Cortex appear to be (finally) lifting themselves out of the iPad dead end by releasing a PWA. Potentially, this will mean it will be device-agnostic (including desktop). That could significantly change the equation for those looking to escape IE/SMT hell!!!
Orion Clinical Portal and associated products from the same company do not equate to an EMR in my book and should be replaced with a real EMR asap. Cortex may be providing a useful comms tool for now, capitalising on the deficiencies of Orion, but it would struggle, along with our old standalone PAS product from whomever owns it now, to compete with a tier 1 EMR product.
I havenât been impressed with the Tier 1 (or Tier 2) EMRs which Iâve had personal experience with. Without exception they are quite disappointing technically, clinically, and from a UX perspective. Oh, and all are horrifically expensive and require a tonne of clinical and technical FTE just to keep afloat.
Agreed. At MedInfo we heard from a number of countries that the introduction of large EMRâs increased clinician burnout, reduced efficiency (that was never fully regained) and, if not implemented properly, only served to magnify poor processes. They require close partnership with clinicians and users, including admin staff, in order to be effective and this is often not what you get from larger vendors who are less interested in customization, or it comes at significant extra cost. We should consider carefully the findings and learnings of others before we tread the EMR path.
It also means that we need to master interoperability in the form of policies, information standards, and clear requirements from purchasers. What I worry about is the changing nature of clinical work, and how processes get locked into software without a view to regularly adjust to accommodate improved and new processes (this shouldnât be expensive but it is).
Murray, I believe that humans are not very good at managing âsharabale/portable process definitionsâ. IMHO such systems are often hijacked by well meaning but errant tecnologists.
Better to better defined process building blocks that can be put together in flexible ways by small teams of technologists working with SME clinical staff.
Karen, I agree with you re âmaster interoperability in the form of policies, information standards, and clear requirements from purchasersâ - but we must be very clear that delivery of useful clinical tools (eg. Primary Secondary integration) does not get delayed because we have not find the ultimate in terminology servers or dot all the eyes in the FHIR standard.
Agree Chris. Hard part it working out what the technological debt (delay of feature delivery till after go live with main tool) should consist of and who pays the price for that debt.
How much has our no.8 wire approach cost the taxpayer over the last say, 30 years?
Have you considered the consumers âUXâ and what our fragmented system must look like to them?
Recently a family member was admitted to hospital with a serious internal infection. The antibiotic prescribed by the GP had caused a serious adverse reaction, so it was changed and after 6 nights in hospital on IV and another two weeks of treatment by âhospital in the homeâ, the patient made a full recovery. We were so grateful to all the clinicians involved who did an amazing job.
However, the next experience wasnât so good. Another visit to the GP a few months later for an unrelated problem resulted in the GP writing a prescription for the same antibiotic. The adverse reaction had been noted in the discharge summary and sent to the GP but clearly it hadnât made it into the GPâs EMR, at least not in a form that could proactively notify the busy GP. Fortunately, the patient, a retired RN, realised the error and told the GP. Disaster averted.
What I find frustrating about this is that the EMR systems of 30 years ago, pre-GUI and pre-internet, could have picked this up because they had rules-based decision support. These systems were character-cell and the UIâs werenât flash but if this example is anything to go by they were serving the patients of the day better than our no.8 wire systems serve patients today.
In answer to your question about how many tier one systems have I used, if you mean as a clinician using a production environment, the answer is none! But I have implemented many systems in hospitals working alongside clinicians who helped to set them up and subsequently used them. In all I have implemented Cerner in fifteen hospitals and InterSystems in three. These are full end-to-end hospital / community clinic implementations with numerous integrations, that are now being used by 10âs of thousands of clinicians serving 10âs of millions of patients.
Weâve been listening to these UX and cost arguments for years. In the meantime, our health IT goes backwards while other countries go forward. We need a better solution.
I can speak generally to a âTier 1 EMRâ experience, having used both Cerner and Epic products for 5 and 13 years, respectively.
Itâs not precisely as simple as âthe EMR increases burnoutâ, as rather the EMR can be used as a tool to burden clinicians with burnout-inducing levels of anguish. Both Epic and Cerner are full of useful functionality, tied together elegantly by questionable usability decisions. In the brutally siloed, revenue-capture environment of U.S. acute care medicine, they do an excellent job carrying a patient from the front door through the back door of a hospitalization, but do not necessarily connect well back into the rest of the world. In the Kaiser system in which Iâve worked, however, the Epic product is used throughout primary care, as well, and the integrated experience between primary care and secondary care improves collaboration and care delivery dramatically. Factors adding to burnout are related primarily to the volume of patients and responsibilities, with primary care drowning in their âInboxâ of clinical and patient communications, while secondary care drowns in âBest Practice Alertsâ related, primarily to âqualityâ and various payor documentation requirements.
Agree one of the dangers of a âTier 1 EMRâ is it is less likely to match the specific workflow of your institution, and rather it may impose the âaverageâ workflow of the customer base upon you. This may be part of why Epic installations outside of the U.S. have sometimes met with dismay, despite its successes in its parent market. Considering any EMR for secondary care in NZ would require recognition of the compromises required and the trade-offs between those changes in the context of the functionality improved.
While it can be perceived as a âflawâ to impose a certain workflow on an institution, there is another lens through which the imposition is a âbenefitâ â sometimes, things happen a certain way in other health systems for good reason! And, while there is always space for some local context owing to the differences in resources and capabilities, there ought to be relatively similar processes across hospitals in New Zealand â to improve the experience of clinicians rotating between them, and to allow for some benefits of scale.
Where I see the largest challenge in NZ to be is the intersection between acute care and community care, and handing off not just between care settings, but between different care organizations not currently organized under the same administrative umbrella.
Good points Ryan, very much in line with comments Iâve heard from clinicians during my 30-year career, implementing these systems internationally outside the US.
The number of different care organisations in NZ will be a challenge but that is the arrangement that consumers experience so MoH and Te Whatu Ora have a level of responsibility to ensure that the these organisation work together effectively. For IT this will mean facilitating the integration of data (not PDFs) between those different organisations in a way that supports clinical workflow and decision support in receiving systems.
For itâs own organisation, Te Whatu Ora will need to implement systems consistently across its regions to fully support multidisciplinary workflows and in doing so improve the quality of our electronic medical records.
AhâŚ.continuity of care in a fragmented system is a wicked problem! Some have hoped that interoperable information systems could be a big part of the solution but itâs not. Itâs a contributor to the solution. We still need to get rid of the silos, patch protection and tribal behaviours and thatâs a lifeâs work. Creating a single entity (Te Whatu Ora) with sub-entities will hopefully not become and exercise in shuffling the deck chairs around on a sinking ship. Personally, I hold a lot of hope that continuity of care has a chance in the new reformed health system. Data flows (youâre right, not pdf exchanges but real health information exchange via well-designed and well-maintained information systems) will help but shouldnât be viewed as the main solution.
The original plan (?Dream) was to create 4 regional Secondary OrionHealth Clinical Portal instances, integrate each of them with Primary/Community/Allied/ Private with HealthOne type functionality at each region and then throw a clinical portal over the 4 instances (including the H1 functionality.
Would have addressed the day to day clinical need across primary Secondary, including advanced care or Shared Care plans etc etc.
Still a bit PDF but a good chunk of it structured @Chris
Youâll have to dig out the documentation and preparatory work and take a look at lessons learned because now we have 4 (much bigger) regions that need that work done on a larger scale, not so?
Nope - the original plan Dream was for the four current regions. Trouble was that some regions did not build a regional instance of the Clinical Portal.
