1 RHIAN OWEN, ANN BRENNAN, WENDY JONES Gregynog 2012A PILOT STUDY TO ASSESS THE BENEFITS AND BURDENS OF STRUCTURED PALLIATIVE CARE ANNOTATIONS WITHIN A SHARED ELECTRONIC PATIENT RECORD (EPR). RHIAN OWEN, ANN BRENNAN, WENDY JONES Gregynog 2012

2 Background Sugar Report - 2008Finlay Report and Objectives contained within. Implementation Board Demonstrate and Equitable Service Across Wales Services Functioning at Specialist Level.

3 Finlay Report Development of Cancer Information System Cymru (CANISC)Enable the Sharing of Clinical Information across Organisations involved in an Individual’s Care

4 Canisc Palliative Care ProjectSharing Information – Comply with Information Governance Best practice. Clinical Information – Comply with best practice guidance from : GMC NMC RCP Guidelines for records and record keeping (NMC 2009) Good Medical Practice: Providing good clinical care (GMC 2009) Access at: Mann R, Williams J. Standards in medical record keeping. Clin Med 2003;3(4):329-32 Department of Health 2008 A Clinician’s Guide to Record Standards – Part 1: Why standardise the structure and content of medical records?

5 Canisc Palliative Care ProjectStructured annotations could deliver the information that a multidisciplinary team requires to formalise action plans and communicate effectively with the wider teams both in the community and within secondary care.

6 Canisc Palliative Care ProjectABMU was chosen for the pilot as the community service in the East of the Health Board had been using structured first assessment annotations for some time. The experience there could inform the development of a generic specialist palliative care assessment. The format would be suitable for medical and nursing members of the team. The community service in the West of the Health Board had no experience of using an EPR so would therefore be ideal candidates to test out the draft annotation template.

7 Aims and Objectives Assess the benefits and burdens of the introduction of structured palliative care annotations in a shared electronic patient record into the daily working practice of a palliative care community team. Assess the usability of the first structured draft in clinical practice.

8 Work Plan Discuss plan with ABMU Palliative Care Senior Management Committee. Agree format of annotation template Meet Ty Olwen Community team but include other team members providing the OOH and 7/7 service.

9 Work Plan Train community service in use of Canisc.Meet with clerical staff to clarify need for all referrals to be entered into system within one working day of referral. Agree format of specialist assessment

10 Format of annotation templateHad to use existing Canisc screens “Old” medical history template chosen Structure agreed using Kings College London/NHS National Cancer Action Team Document as base. Holistic Common Assessment of Supportive and Palliative Care Needs for Adults with Cancer – Assessment Guidance 2007

11 Evaluation Criteria Focus Group discussionIndividual practitioner reflection obtained through “Survey Monkey” Collate information on use of system OOH

12 Timescales Meeting with ABMU Management April 2010Structured annotations undertaken from October 2010 Focus Group Meeting January 2011 Survey Monkey February 2011

13 Evaluation Focus Group

14 Positive Legibility For the teamFor clinicians on general wards if annotations printed out. For District Nurses if annotations printed out. Availability and Accessibility Weekend working Instant access without waiting for case record to be sent from another hospital site which could take up to one week.

15 Positive Sharing InformationInformation already obtained by other palliative care team Information from Oncology (limited from Singleton but Velindre Canisc record also provides pathology and radiology information) Time Management Time saved by ease of access to information

16 Negative Accessibility and Availability Out in the communityOn general wards In palliative care offices Canisc system shuts down whilst inputting data Unable to launch Canisc system. Chemocare not accessible Radis and Pathology not available.

17 Negative Time ManagementInitial reduction in number of patients seen due to time taken to write up annotations. Pressure to return to base to annotate consultation especially part time workers. Time to print out annotations for case records for inpatient hospice and insufficient printers. Prioritisation of parts of annotations to ensure something is documented within time available. Inability to save annotations as you type so if system shuts down long annotations may be lost and have to be retyped. Duplication of effort maintaining current medication and body chart in Health Record as not available on Canisc record. No spell check

18 General issues IT security Training time DuplicationNo safe system currently available to allow annotations in real time in the community.  Training time Considered to be approximately six weeks  Duplication Different parts of the service without access to Canisc therefore difficulties identifying what aspects of care can be recorded purely on Canisc and what have to be printed out for the health record.

19 General issues Lone Worker alerts Contact recording Current FormatCurrently not available and patient confidentiality issues need to be explored independent of the Canisc Project.  Contact recording Clarity required as to how to document every type of contact. Current Format Not appropriate for palliative care assessment No area for documenting preferred place of care.  Out of Hours Working CNSs do not have laptops and VPNs to access Canisc form home.

20 Survey Monkey AssessmentIndividual Opinion via Survey Monkey Community Service 8 members (7 nurses and 1 doctor) 4 responses Hospital Support Service 7 members (2 nurses and 5 doctors) 3 responses

21 Community QuestionnaireOverall experience – free text Would you prefer to return to paper only record? Three main benefits Three main disadvantages Did you access Canisc OOH? If yes to Q 5 how helpful was information? If yes to Q 5 did you add your actions as an anno? Did you follow assessment guidance? What changes would you suggest to current guidance?

22 Community Service 8 members – 4 responsesQ1 -Overall experience A B C D Teething problems, Writing disappearing, screen freezing, but vast improvement on paper Very good much easier than expected but system fails ? Wi-Fi and work lost. Generally a positive experience Good experience, made easier if I could type. Took time to get used to and where to enter data

23 Community Q2 - Would you prefer to return to paper only record? A B CNO DID NOT ANSWER

24 Community Q3 - Three main benefits: A B C D Ease of UseAccessing other team annos. Access to Oncology team entries Ease of accessing information Ease of Information retrieval, Accessing other annos Clarity of entries Speed of accessing information Legibility Legible Legibility and quicker to read

25 Q4 - Three main disadvantagesB C D Unable to write in notes in-between community visits System failure Only able to update at desktop Amount of time spent typing Limited number of departments using system Loss of work Takes more time to add entries Disruption of daily work pattern IPU not using Environment noisier No spell check Unable to write in notes in-between visits No lone worker facility Social contact decreasing Not able to record specific issues eg two manned visit Reduction in number of patients seen Unable to record contact with family after patient died. Disrupted team dynamics – working in typing pool.

26 Community Responses Questions 5 - 7A B C D Did you accessed Canisc OOH? YES If yes, how helpful was information? GREAT If yes, did you add your actions as an anno? EVERY TIME

27 Community Responses Questions 8 and 9B C D Did you follow assessment guidance? MOSTLY AT FIRST ASSESSMENT NOT ALWAYS APPROPRIATE TO ASK ALL QUESTIONS “YES” FOR FIRST BUT CURTAILED FOR SUBSEQUENT YES What changes would you change to current guidance? LONE WORKER ICON No answer NIL NONE

28 Hospital Support QuestionnaireOverall experience of having access to Canisc– free text What were the three main advantages to you when the community team began to annotate their assessments on Canisc? Have you accessed the Canisc Record OOH? What changes would you suggest to current assessment and annotation guidance? Would you prefer to retain a purely paper based record system? Could you envisage a totally paperless system working?

29 What changes would you suggest to current assessment and annotation guidance?B C Opinion title seems strange, No telephone option Have to use “other contacts “for everything else Use of different “boxes” Need the boxes to fit palliative care assessment, Need access to discharge letter Complete reconfiguring required with drug history page use CROSSCARE as an example.

30 Hospital Support Service 7 members – 3 responsesQ1 -Overall experience A B C Impressed overall. Aware there are issues but happy to start using. Overall positive, fast and easy access. Annotating long and ward PCs not connected to printers. Dual entry, accessing oncology is positive and enabled on the spot changes to patient management Improved access ,greatly readable, system clunky compared to GP systems

31 Hospital Support Q2 - What were the three main advantages to you when community service began annotations in Canisc? A B C Easy to access all encounters. Legibility. Accessible on wards and in office so no need to go back and find notes No delay, benefitted from community teams wisdom re use of Canisc, Accessing information without bothering hospice admin team Instant access Not waiting for notes, available everywhere, legibility

32 Have you accessed the Canisc Record OOH?B C YES , very useful when I received an advice call and I knew team would see my comments on the Monday YES YES, Helpful on weekends for hospice and community.

33 Q5 - Would you prefer to retain a purely paper based record system?NO No delay, benefitted from community teams wisdom re use of Canisc, Accessing information without bothering hospice admin team

34 Q6 -Could you envisage a totally paperless system working?B C NO – not at present, system not available to all clinical staff working in non-cancer. Nowhere to file letters and results YES – but all parts of the organisation would need access including in patient unit. YES

35 Conclusions There are benefits to both an individual service and to the wider organisation from the use of an Electronic Patient Record. Accessibility and legibility feature highly in the benefits. Structured Assessments are feasible but a palliative care specific template is required.

36 Conclusions A Paperless System is unrealistic and a “paper light” system should be the goal. Ways of reducing clinical time involved in “inputting data” need to be considered.

37 Conclusions Access can be a burden particularly for community services. Information Security issues will need to be addressed to facilitate use of the EPR in the community. Access for Primary care Colleagues continues to be challenge .

38 Thanks The ABMU Palliative Care Organisation but in particular the Community Service based at Ty Olwen deserve a special mention because they embraced a major change to their working practice. THANK YOU