Dysplasia Service Redesign

– Simple but Complicated

Mr. C. David H. Wrede MA MB BChir(Cantab.) FRCS(Eng) MRCOG FRANZCOG

Consultant Gynaecologist

The Royal Women‟s Hospital, Melbourne

Overview

Introduction

Stakeholders

Background

What we do

Clinical Process

Challenges

Patient Needs

Look around

Fix the Easy Stuff

IT Systems

An Ideal System?

A word of warning

Implementation Risks

What is Available?

What we want

Future Plans

Conclusion

I have been a Slow Learner…

Advice from a self- confessed FAQ Gyno from Wonthaggi;

Have the Serenity to accept what you cannot change,

The Courage to change what you can,

And the WISDOM to know the difference.

TVR Cerbera

England Germany

Spot the Difference

Stakeholders Women (and their partners and family)

Screening Service

State Government

Hospital & Management

Doctors

Gynaecologists

GPs & referring Specialists

Pathologists

Cytologists

Virologists

Public Health

Nurses

In Hospital and the Community

What do we do in Dysplasia?

Manage women at identified risk of Cervical Cancer “Sharp end of the Cervical Cancer Screening Program”

Three Ways in; Abnormal Smear Test

Post-coital bleeding

Suspicious Cervical Appearance

Initial Consultation, Orientation of Patient, Assessment and Feed back

Only treat those at high-risk Best use of resource and minimises unnecessary morbidity

Early Discharge to Community

Encourage General Health Measures & Vaccination

Colposcopy

What are we looking for?

Treatment By Loop Diathermy -

LLETZ/LEEP

Precis of Current Process

Arrival, Clinic Admininstration

Data & research consent

Introduction, History,

Examination

Explanation

High grade finding confirmed

by pathology

Admission for Treatment

Conservative management and

clinical review

Normal or Low grade findings

Discharge to Community

Identified „Challenges‟

Demand Rising (despite HPV vaccination)

Impact of HPV Vaccination

Current Shortage of Resources

Clinical Inefficiency Process Based

Admin Based

Physical restrictions

Accumulated Medical Leave etc

Heritage and unsupported IT system (not an EMR)

Double Data Entry - Paper Record and Database

Lack of Integrative focus – patchy Quality Assurance

Non-integrated user information

Research Expectations

RENEWAL…of the whole Cervical Cancer Screening Program

Patient Based Issues

Cancerphobia and Anxiety

Includes the „worried well‟ and the over screened

Language & Cultural Diversity

Special Needs Patients

Abused women

Immuno-compromised

HIV, Bone Marrow & other Transplant patients,

Urban Aboriginal community

Refugees

Including women who have experienced Genital Mutilation

Learning Disability

Look at Ideas from Elsewhere One Stop Services

Office Gynaecology - ?European Style

See & Treat under Local Anaesthetic

Select & Treat Preferable now that we are aware of medium to long term morbidity of the

excision of cervical pre-cancer

Adapt Targets and Maximum Waiting Times from International Comparitors

Review or Concordance Meetings Colposcopy Doctors & Nurses, Pathologists and Cytologists

Get an EMR Best of Breed or Enterprise?

Integrated Patient & Medical Information Web based portals

Fix the Easy Stuff First Staff

Appointed Specialists in Adolescent Gynaecology, Sexual Health and Medical Gynaecology

Existing Expertise in Gynaecological Oncology, Laser Therapy and Data Collection and Quality Assurance

Introduce Performance Review

Quality Assurance Targets Use to advantage even when failing to meet them

Concordance Meetings Regular, recorded, followed up and audited

Audit - Retrospective studies initially

Integrate with existing Hospital Initiatives Gynae M&M, Incident Reporting and RCA systems

Research Work within Existing Gynaecological Oncology Research Collaborative

Current IT Systems Available

On-Dysplay – in use at RWH

Microsoft JET v3.5 used with Access97.

Microsoft Visual Basic v6.0

Hosted on network file server or a dedicated PC

RPA System

NZ System

Viewpoint (GE ?still available)

Compuscope (Irisoft UK)

iCIMS?

Cerner?

EPIC?

SharePoint on new or existing MicroSoft database?

Other local development??

An Ideal System

Intuitive Usage Minimal training requirements

Ease of adoption

Clinician control of environment Ease of Extension & Adaptation

Reflects modernisation & development of practice

Web enabled (with touch screen data entry?) Would allow data warehousing

Image capture; still & video

Interface with Colposcopy adjunct systems eg DiSYS, Zilico

Seamless Administratively; HL-7 compliant plus fail-safes

Automatic letter/e-mail production to patients & referring doctors

Easy Data Analysis Automatic production of metrics by practitioner/unit

Report Writer for specific queries/audits

Automatic data delivery to Research systems

Is there an ideal system

Replacement Options

Write new System from scratch – Min $250k!

Rewrite an existing system – if technically possible

Adapt one of several EPR‟s from mainstream providers eg Cerner, GE, iSoft

Adapt an image capture database from existing softwate eg Endobase (Olympus), Viewpoint (GE)

Purchase foreign system eg Compuscope from Irisoft (UK) Ltd

Design our system using emergent web native technology eg iCIMS

Risks within IT

Implementations

Lack of Usability/acceptance leading to under utilisation & poor data

Lack of adaptability/flexibility impairing workflow mirroring and clinical developments

Inability to function as inclusive research tool

Foreign Company with insufficient understanding/penetration of local market leading to poor support

Adoption of nascent technology without proper business plans leading to unmet specification and financial failure

Don‟t just mechanise (badly) the current process

Best of Breed approaches seen as high risk by Senior Officials

So try the alternative…?

IT and Health Reform

Information technology is a tool NOT a magic wand

Switching on Health IT systems does not automatically improve healthcare safety & efficiency See IoM, Ompudsman and PAC (UK) Reports

Healthcare is more complex than retail banking… And Secondary care is NOT scaled up General Practice

One size and/or system rarely suits all

Big IT companies always say „yes‟…until you switch it on, when it changes to „yes but‟, or „well no actually‟.

The Devil is in the detail

Get it wrong and you will pay big time…..

„Unforeseen‟ Consequences

“Royal Berkshire spends £30m on EPR”

“98 per cent of NPfIT benefits unrealised”

“Troubled HealthSMART System Finally Cancelled in Victoria”

“Electronic Medical Records Are Security „Disaster‟”

“Few Savings From Digital Health Records”

Einstein said it…

Repeating the same experiment again and again and

expecting a different result is the definition of stupidity.

Not everything that can be counted counts, and not

everything that counts can be counted.

If A is success in life then A=x+y+z where x is work, y is play

and z is keeping your mouth shut!

Old Processes New Processes

Wisdom of Mike Bracken

Policy

Processes

Systems

Users

Stasis

Users

Service (re)Design

System Development

Policy Check

Feedback

Our Preference is an Adaptable

Web-Native System eg iCIMS

Complete flexibility Adjusts to future guidelines & protocols

Adapts to Research needs & new projects

Can be extended to other related clinical activity

Automated Pathology downloads

Absorbs manual processes & forms

Can be maintained & updated by local Data Administrator

Maintains current interface Eases transition

Reduced Training Requirements

No changes to workflow (unless mutually agreed to be beneficial)

Native interoperability Ease of use at satellite clinics

Can automatically send data to registers

Automates periodic reporting

Plan of Future Progress

Implement new data system as EMR

Staged implementation to adjust for;

Renewal changes

Obtainable efficiency gains

Change of protocol

Consequence of Risk Management outcomes

Research Projects

Image Capture

Colposcopy Adjunct Technologies

Integrate with other outpatient services

Eg Hysteroscopy, PMB service, Vuulval Clinic

Review patient information & make it consistent

RWH website & patient portal with links

Shhhh….. Nurse Colposcopists…

Conclusion

Have a Strategy and plan of attack but,

Do the easy stuff quickly

Rapid returns and improved morale

Set goals & delivery

But don‟t try too much simultaneously

Expect setbacks

Have a Plan B

Apply gentle and unremitting pressure to change attitudes

and culture

Evidence required

Avoid Fashions for their own sake

Engage Youth for Innovation and Age for Caution

Keep Battering Away…

Resource Allocation

Be Imaginative

Missing Targets

Quietly inform those that need to know

Any New IT solution

Must improve not degrade workflow

User acceptance critical

Must have a flexible & friendly interface

Must reduce tasks, clicks & time spent not looking at the patient

Don‟t give up

– even when you are 2-0 down…