The Implementation of Advanced Clinical Documentation for Bariatric Services at University Health Network: Lessons From the Field Vicky Ramirez, Giuseppe Cammisa e-Health 2013: Accelerating Change May 27, 2013

UHN Fast Facts Canada’s leading research and academic hospital 4 Sites: Toronto Western Hospital Toronto General Hospital Princess Margaret Cancer Centre Toronto Rehab Institute $1.8B revenue 762 beds 1,400 physicians 12,000 employees 966,000 amb visits $265M in research 4,465 OR visits 2

Advanced Clinical Documentation UHN Advanced Clinical Documentation Strategy

In support of UHN’s ACD strategic goals… UHN will be a global leader in reporting on patient outcomes The Bariatric iPad app is a foundational initiative aligned with the strategy This project has brought point-of-care ACD tools (mobile devices) to clinicians; streamlining their workflows, increasing efficiency and enhancing patient safety Use of the iPad app is supporting important learnings on monitoring patient outcomes in a more timely and efficient manner, while also laying the groundwork for a varied research agenda Research hospital of the future road map will be developed and implemented 4

ACD Bariatric Assessment Notes ACD IP EPR ACD OP EPR ACD Bariatric Assessment Notes 5

Program Overview

Registered Dietitians Psychometrists Psychologists Psychiatrists UHN has successfully established a bariatric surgery program and multidisciplinary centralized clinic for patient selection, pre-surgical preparation and post-operative follow up. Nurse Practitioners Social Workers Registered Dietitians Psychometrists Psychologists Psychiatrists Surgeons Endocrinologists Internists Data Analysts Support Staff 7

The Team

The Team 4 project team members 4 human factors staff 40 clinicians Privacy The Team Mobility Partner Clinicians Human Factors 4 project team members 4 human factors staff 7 technical team members 40 clinicians 4 privacy & security team members Security Technical Teams 9

Life before the iPad

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And the aftermath… 13

Challenges Patients repeatedly answering the same questions Clinicians’ persistent difficulties locating charts or finding information in a chart Other challenges: Interdisciplinary rounds Diminished productivity Outcomes monitoring Leveraging data for research 14

The Solution

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Methodology

Where we started Mapping the data flow Focus on outcome indicators Device & usability assessment Focus group sessions held; clinicians, project & technical teams attended Mapped the end-to-end data flow Inventoried existing and standardized forms (Boston Tool) Assessed data collected for clinical & research purposes Outcomes framework established Data is collected at specific intervals (before and after treatment, follow up) Outcomes Indicators developed Assessed usability of the application for documenting at the point-of-care Assessed utility of the device Infection control measures 18

Design Philosophy

Agile and responsive development iOS design driving clear, standard documentation Free-text to synoptic Function (Human Factors) vs. flash Multidisciplinary lens – enable the breakdown of care silos 20

Common Framework Elements 21

Benefits

Workflow: Before & After Early results: Summary report allows time at end of day to be used for other purposes ~30 minutes saved per clinician per day! Make a bar graph The problem: Back to back assessments resulted in charting being stockpiled until the end of day 23

Measuring Success: An Outcomes Approach Baseline surveys and observations Post-implementation surveys and observations Improving the ability to monitor and report on: Pre-Surgery Post-Surgery Health Status Time to Care Patient Errors Health Sustainability Patient & Clinician Satisfaction Data Collection & Access Cost Measures 24

Start small → gather learnings → grow access The Bariatric Journey Start small → gather learnings → grow access

Critical Success Factors Leading edge technology; the ‘fun’ factor End to end change management Rapid prototyping/Agile documentation Improving data collection & access Sustainability model (leveraging existing infrastructure, MDM strategy) Enhanced interprofessional collaboration Access to clinical summaries of peers Reduced duplication Time savings More comfort with iPad More overall productivity 26

Bariatric Assessment Notes Demo Point of Care Access & Innovative Technologies Reusable web services for the Bariatric project included patient appointments (pulled from PHS), demographics (pulled from NODR), etc. Enhanced Interprofessional Care Improved collaboration amongst care teams Documenting the care delivery value chain by mapping the patient journey Bariatric outcomes framework can be leveraged by any UHN program or service 27