1. 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

2. 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

3. Advanced Clinical Documentation
UHN
Advanced Clinical Documentation
Strategy

4. 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

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

6. Program Overview

7. 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

8. The Team

9. 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

10. Life before the iPad

12. 12

13. And the aftermath… 13

14. 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

15. The Solution

16. 16

17. Methodology

18. 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

19. Design Philosophy

20. 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

21. Common Framework Elements21

22. Benefits

23. 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

24. 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

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

26. 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

27. 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