The move to Electronic Health Records (EHRs) at Barwon Health has delivered real benefits, says Health Information Services (HIS) Operations Manager Michelle Martella.

Barwon Health administers to 390 acute beds at Geelong Hospital as well as 511 sub acute and aged care beds, 40 Mental Health beds and 18 community sites, servicing 400,000 people across the Barwon South West Region of Victoria. It began its project to replace traditional paper medical records in September 2007, and already had in place a unique patient identifier across all 23 sites.

Barwon Health has now reached a stage where most of the records and correspondence associated with a patient are digital.

Three operational units are almost completely paperless, being Palliative care, Intensive Care and the Emergency departments.

The revolution began when Barwon Health chose the Australian-developed BOSSnet Digital Medical Records (DMR) system from Core Medical Solutions (CMS). This was an evolution of The BOSS system that has been providing patient management and results review functionality to clinicians at Barwon Health since 2001. The BOSSnet DMR platform delivers a singular view of patient records by multiple users, it is not necessary to go to different applications to view results, correspondence, etc.

Whether the data is captured directly into the system, scanned in, or application switches to a separate system, the user only needs the one password, making it the one-stop-shop for viewing clinical information.

“For some staff it was possibly the biggest change in their career. The change was well managed and became a platform for strategic integration with other clinical system as part of our ongoing progression to a fully integrated EHR,” said Martella.

The medical world is a jumble of acronyms, and the digital revolution has added a few more to the mix.

For instance, Barwon Health refers to two stages of the migration: the Digital Medical Record (DMR) and the Electronic Health Record (EHR) The first is an umbrella term covering electronic capture and delivery of information that has traditionally been stored on paper and is now scanned, whereas the EHR adds information that is entered into the system electronically, such as the discharge summary, pathology/radiology, operation reports, outpatient letters, or data from external electronic systems.

The migration to digital has not been accompanied by a large back-scanning of patient records on paper. After undertaking a project to identify the essential documents that would need to be scanned, it was realised this could not be anything less than every single document on a patient’s record.

“We also considered scanning the old history on demand, as the patient presented to the organisation. This was a not viable option, given the old forms are not bar-coded and would become a flat file in the DMR, which would be difficult to navigate. The time spent to scan may not be beneficial if the patient never presented again,” said Martella. “The decision was made to make the pre-existing medical record a ‘closed file’ from the DMR go-live date. Think of it as a library book, for viewing purposes only. This has worked extremely well and has minimised any confusion as to where to look for clinical information.”

Barwon Health is enjoying many of the advantages of the migration to digital, not the least being a full read/write audit trial which is reportable to the millisecond.

“The EHR provides automation and streamlining in workflow, improved decision support, patient safety, quality care, increased reporting and research abilities and ultimately – patient outcomes,” said Martella.

“Reasons for a move to DMRs are often simply a cost management strategy to improve paper flow, and record storage or access. The reason for a move to scanned records should be part of a longer term strategy to move to a computable record that can be both accessible when needed, and able to provide automated clinical decision support at the point of care (e.g. clinical pathway automation). If these considerations are not part of the initial planning, a lot of the potential benefits will be lost, or will become costly additions at a later stage.”

Paper still has a role to play, as clinicians can still make notes on bar-coded Medical Records forms which are subsequently scanned. Non bar-coded forms can be scanned by manually searching for a barcode type. All of the paperwork for a current episode of care are kept in a ‘current' folder on the ward which a courier collects twice daily and delivers to HIS for scanning. The scanning workload is around 10000 sheets per day.

Clinician notes written to paper are scanned within 24 hours, and then the original sent to off-site storage. Full destruction is not being contemplated at this stage. The problem of having “siloed” sites of clinical information did result in some initial resistance to moving to a single electronic health record (EHR), with concerns regarding broadening access and patient confidentiality.
However while specialist systems that are well embedded are very much needed in these silo sites, having the information viewable in the one place, for all who are involved in a patients care, has seen a spread of support for sharing patient information and the ‘one stop shop’ DMR. Being a pioneer always results in some additional challenges, something definitely appreciated by Barwon Health after its early digital migration.

“If the health informatics standards covering scanned records, EHR structure and interoperability that are available now, were available then, the whole process would have been easier and allowed us to make more informed decisions about our needs, processes and priorities,” said Martella.

”We would have been able to identify the scope of relevant current standards, and been able to inform Standards Australia of required updates to those standards – leading to ongoing improvement and communication throughout the health information industry in Australia (using standards for ongoing process improvement). When Barwon started there were few standards that would have assisted, - this is no longer the case.”

Would a “big bang” approach to the changeover to full electronic health records (EHR) have been easier? Martella is not convinced it would.

“We will continue to progress down the path to a full EHR, but believe the stepping-stones we have cemented with the DMR will pave the way for a smoother and more successful EHR. The transition to remove paper totally presents a lot of obstacles to consider. The right and available technology to support bedside documentation, the impact to staff who are not confident computer users, clinical risks, improving (not hindering) workflow, and the enormous project resources, to name a few.”