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Andrew Hargreaves – Clinical Design Governance Manager

Mina Georgy – Design Lead

eMR Connect Program

Standardised eMeds System

Design

Improving Safety & Quality Outcomes

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Support for Local Health Districts

Design & Build

Safety and Quality

Change and Adoption

Project Management / Vendor Management

System Maintenance

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Promoting Safety and Quality

Detailed consideration must be given to impacts of electronic medical

records on quality of care and patient safety

• eHealth NSW safety principles

– Design a safe system

– Ensure people are equipped and trained to use it safely

– Use the system to improve safety and quality of care

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Clinical Design Governance

EVOLUTION

• Historical, centralised approach

– Longer design and documentation process

– Lack of clinical representation from each Local Health District

– Resulted in single state-wide design, with elements of local deviation

• Adopted a lead site model

– Lead site-led vs design by committee

– Empowerment of local governance structures

– Iterative review vs single development

– Resulted in self-regulating community of practice; a reference model design

with consistency in key areas

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• Promoting standardisation of appropriate design

elements– Promotes patient safety and quality of care

– Reduces inappropriate / unwarranted clinical variation

– Reduces re-training liability

– Reduces repetition of design activity

• Clinical risk management

– Managing the risk associated with variance

Delivering Safety and Quality

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Delivering Safety and Quality

• Stakeholder-led clinical governance frameworks

• Clinical leadership and engagement

• Considering impacts of eMR design and

implementation on– Patients

– Clinical staff

– NSW Health and LHD Policy and Legislation

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GOVERNANCE MODEL

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LHD-led group of application specialists and all project teams

Quality & Safety Experts, NSW Health Pillars and other Reference Group reps

Senior Executive and Senior Executive Clinicians across LHDs and NSW Health Pillars

Clinicians and NSW Pillars reps supported by application specialists

Design Assurance Governance Groups

AAGs

Clinical Ref

Groups

SQAG

eMR Connect SC

Consider impact and risk management recommendations, accountable for decisions

Develop vendor agnostic principles / standards, provide clinical validation of workflow

and design

Develop solution specific standards, oversight of solution design decisions from a

state perspective, manage operational governance

Peak safety and quality body, provide advice to Steering Committee on safety and quality

and clinical risk management, oversight of quality and safety impact assessments

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eMeds Design Standards

DEVELOPMENT PROCESS

Proposed Standard

Interim Standard

Final Standard

• Developed by clinical reference groups

• Reviewed and approved by clinical design governance process

• Optional for implementation in new and existing sites

• eMR Connect SC approve a standard as ‘Interim’

• Regular review cycle to optimise

• Required to be implemented in new sites; optional for existing sites

• Following successful implementation in a number of sites, standard approved as ‘Final’

• Regular review cycle• Required to be

implemented in new and existing sites within 1 year of publication

Smarter Safer BetterSt Vincent's Hospital Network

Justice Health Network

eMR Connect – NSW Footprint

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System blueprint for all Cerner implementations

Detailed future state process flows based on common lead site workflowsWorkflows

Documentation of lead site design decisionsConfiguration Decisions (DDMs)

Including documentation of detailed design guidance

Data and Build Content (DCWs)

NSW Design Specifications and Custom DevelopmentsDetailed design specifications for NSW specific build, e.g. prescription output,

downtime MAR etc.

eMeds / eMR Crossover and Integration PointsDocumentation of prerequisite eMR components and

associated design

eMeds Reference Model

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STRENGTHS

• Increased adoption of design

• Sites using solutions earlier

• Encourages diversity

• Access to a large number of

clinicians

Implementations in Federated System

CHALLENGES

• Permits divergence

• Duplication of effort

• Increased maintenance

• Governance is difficult

Multiple layers required

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Building on PartnershipsCLINICAL DESIGN

FOCUS GROUPS

Western Syd

CEC

NS / CC ACI

• Clinical Excellence Commission (CEC)

• Agency for Clinical Innovation (ACI)

NSW Health Pillars

• Senior Clinicians

• Project teams (application specialists, BAs)

• End users

Local Health Districts

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Design Principles

User CentredConsistency &

Simplicity

Iterative

DevelopmentUsability Testing

Evaluate &

Feedback Early

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Design

MethodologyGATHER REQUIREMENTS

DESIGN FOR USABILITY

EVALUATE

FEEDBACK

BUILD & DEPLOY

• Identify users

• Analyse user needs and scenarios

• Develop business & functional requirements

• Conceptual designs

• Detailed designs

• Evaluate early and continuously

• Measure usability, business &

effects

• Suggestion for changes

• Project planning based

on the outcome

• Iterative development

• Continuous focus on users and usability

• Usability testing & monitoring

PRIORITISE SCOPE

• Identify Business Objective

• Initial Concept

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Insulin

Paper

Chart

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Available Functionality

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Iterative PrototypingEARLY CONCEPTS

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Iterative Prototyping

INITIAL

WIREFRAME

(FEB 2016)

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MARCH 2016

Iterative Prototyping

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APRIL 2016

Iterative

Prototyping

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MAY 2016

Iterative

Prototyping

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JUNE 2016

Iterative

Prototyping

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FINAL

DESIGN

JULY 2016

Iterative

Prototyping

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WHAT WORKED WELL?

• Collaboration between eHealth NSW, LHDs and Pillars

Knowledge domain experts own design

Leveraging resources / expertise across LHD and eHealth NSW teams

• Broad stakeholder engagement across several clinician groups Clinician led – doctors, nurses, pharmacists represented

Usability testing

High level of clinical engagement

• Requirements gathering and design Design based on clinical business requirements rather than on current paper forms

Wider eMR touch-points identified early

Rapid prototyping and high visibility of progress allows for timely change

Lessons Learned

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WHAT CAN WE IMPROVE?

• Project management

Clearer agreements around scope, resources and timelines

Dedicated project management resources

Shared access to repositories

• Stakeholder engagement Group membership continued to grow/change throughout project

Not all clinicians groups present at each meeting

Engage actual system users much earlier in the project

• Requirements & Design Dedicated resources for rapidly prototyping wireframes and design concepts

Engage Human Factors experts and conduct usability testing much earlier in project

Lessons Learned

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Summary

• Standardisation is key to improving safety & quality in system design

• A clinical risk management methodology is required for difficult decisions

• A state-wide clinical governance framework facilitates appropriate decisions

& recommendations

• Standardisation in a federated environment is not without its challenges

• Creating meaningful partnerships with LHDs is critical to adoption

• Establishing speciality focus groups and applying best practice design

principles ensures state solutions meet clinicians needs