dr. peter kennedy, deputy chief executive officer – cec, chair of emm steering committee - panel -...
DESCRIPTION
PANEL: NSW Health delivered this presentation at the 3rd Annual Electronic Medication Management Conference 2014. This conference is the nation’s only event to look solely at electronic prescribing and electronic medication management systems. For more information, please visit http://www.healthcareconferences.com.au/emed14TRANSCRIPT
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Electronic Medication Management (EMM) Program
State and local
implementation lessons
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Play EMM Video
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Introduction by Dr Peter Kennedy
Deputy Chief Executive Officer – CEC
Chair of NSW EMM Steering Committee
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Session agenda
• The role of eHealth in Supporting
Patient Safety
• The Clinical Perspective
• EMM Program Update
• Updates from our initial EMM sites
• Questions for the Panel
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E-health NSW: Changing Patient Trajectories
The Role of e-health in Supporting Patient Safety
Dr Peter Kennedy Deputy Chief Executive Officer Clinical Excellence Commission
25 March 2014 3rd Annual Electronic Medication Management Conference
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Data from HIMSS AnalyticsTM Database 2011 HIMSS Analytics
HIMSS Analytics Asia EMR Adoption Model
Stage 2
Stage 3
Stage 4
Stage 5
Stage 6
Stage 7
Stage 1
Stage 0
CDR, Controlled Medical Vocabulary,
CDS, may have Document Imaging; HIE capable
Nursing/clinical documentation (flow sheets), CDSS
(error checking), PACS available outside Radiology
CPOE, Clinical Decision Support (clinical protocols)
Full Complement of Radiology PACS
Physician documentation (structured templates), full
CDSS (variance & compliance), Closed Loop Med Admin
Complete EMR; CCD transactions to share data; Data
warehousing; Data continuity with ED, ambulatory, OP
Ancillaries – Lab, Rad, Pharmacy – All Installed
All Three Ancillaries Not Installed
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EM
RA
M A
ve
rage
S
tage
Sco
re
0
1
2
3
4
5
6
7Local Health District (n=17) average EMRAM* Scores
Mean
^The Healthcare Information and Management Systems Society
*EMR Adoption Model
• Overall low average (1.41) comparable when
very small / MPS sites excluded
• Goal NOT to get all hospitals to Level 6,
however HIMMS assessed 40 hospitals have
fulfilled the majority of pre-requisites
• EMRAM is acute care focused – handover to
and from Primary and Community Care important
Maturity
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The most mature EMR in the country. Usage growing
100 orders placed and results viewed per minute
Electronic Medical Record
January 2014 activity Mar-12 Jan-14 Mar-12 Jan-14 Mar-12 Jan-14 % change
Orders 127,000 131,000 3,861,000 4,000,000 46,000,000 48,000,000 4
Patient Charts Opened 180,000 206,000 5,462,000 6,200,000 65,544,000 75,000,000 14
Clinical documents created 16,500 21,000 502,000 640,000 6,024,000 7,700,000 28
Decision support alerts 6,900 10,600 211,000 323,000 2,532,000 3,900,000 54
Mar-12 Jan-14 % change
Average transaction time 0.95 0.52 45
Transactions (Millions) 139 233 68
Monthly AnnualDaily
Reduction is due to hardware and system upgrades
Growth in system use
Improved Performance: Growth in system use: Up 65% sine March 2012 Average transaction time: Down 45% since March 2012
Key activity per day: Orders: 131,000 up 4% since March 2012 Chart opens: 206,000 up 14% since March 2012 Clinical Documents Created: 23,000 up 28% since March 2012 Decision Support Alerts: 10,600 up 54% since March 2012
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Communication
Leadership Team Work
TeamSTEPPS
Courtesy of the Agency for Healthcare Research and Quality
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Situational Awareness
Shared Mental Model
Mutual Support
TeamSTEPPS
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Five Dysfunctions
of a Team
1
Absence of trust
2
Fear of conflict
3
Lack of commitment
4
Unwillingness to hold one
another accountable
5
Inattention to results
Patrick Lencioni
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Executive Sponsorship
Clinical Leadership
Technical Expertise
Equity
Principles for EMR Rollout
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Policy Ministry
Governance
Strategy and Architecture
Local Networks / Bandwidth
Central Infrastructure (Data Centres) and Operations (EMR)
eHealth NSW
Local Project Management, Implementation and Training
Program Management, Procurement
End User Computing (PCs, Mobile Devices, TeleHealth Endpoints, Wireless Networks, Phones)
Ownership
Work Practice Review
Standardisation and Content Knowledge
Education
Clinician Support
Benefits Realisation
ACI / CEC / HETI / NSW Kids and Families
Local Health Districts
Enab
lers
C
han
ge M
anag
emen
t Risk Category Owner
13
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IT Platform
eMR & eMM
Clinician led and data driven
HIE Patient Portal
Clinical Analytics Value added
Outcome measures Drives change
Validates process measures, projects & priorities
Business applications
Infrastructure
Standardisation
Technovigilance
Interoperability Is key to success
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It has to work for both Clinicians and Patients in
improving patient care and safety.
Key Themes for EMR Rollout
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Key Themes:
I. It is an opportunity to look at work practices and clinical practice
II. Will require increasing standardisation of care
III. Will provide opportunities for much better information on what we do and also in terms of outcomes
Key Themes for EMR Rollout
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Key Issues:
I. The Firewall and moving information between hospitals, General Practitioners and patients
II. Use of own devices
III. Standardisation
IV. Evaluation
Key Themes for EMR Rollout
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Key to Successful Implementation of Programs:
I. Training and education at facility level
II. Ongoing support at each facility
III. Adequate infrastructure at the facility level – devices, wireless network, speech recognition etc.
Key Themes for EMR Rollout
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We need to define with each project what are
the quality parameters that we want to achieve
from the implementation. We need to build
them into the development process.
Quality cannot be an afterthought,
it must be a driver.
Quality in the EMR
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IT is going to be introduced in to the
performance review process for all LHDs and
LHNs in NSW. This means there will be key
performance indicators and regular review of
progress at the 3 monthly meetings.
Executive Buy-In
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Associate Professor Kathy Gibson
Staff Specialist Rheumatologist
Liverpool Hospital
EMM Program Clinical Secretariat Lead
The clinical perspective
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Background
• In Australia, 2-4% of all hospital admissions are
medication related.
• Includes admissions due to adverse drug
reactions and those due to medication errors
which together are termed adverse drug events
(ADEs)
• Overall, about 43% of these are deemed
preventable (1)
• Errors occur at every step of the medication
management pathway
• But most occur during prescribing
1. Runciman WB et al. (2003) Adverse drug events and
medication errors in Australia Int J Qual Health Care 15 (suppl
1): i49-i59.
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• Australian research shows that
errors can be reduced by more than
55% with the introduction of
electronic systems to help manage
medication prescribing, dispensing
and administration (2)
2. Westbrook JI et al. (2012) Effects of two commercial electronic
prescribing systems on Prescribing error rates in Hospital patients:
A before and after study. PLoS Med 9 (1):e1001164.
doi:10.1371/journal.pmed.1001164
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What is EMM?
• Managing tasks and documents
involved in prescribing, administering
and dispensing medications to
patients using an electronic system
• Includes automated tools to assist in
choosing medications and doses to
be prescribed (decision support)
• Includes automated checking for
allergies and other patient factors that
make certain medications unsafe to
prescribe
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Why do it?
• Improve accuracy and visibility of
medication information being
communicated between professionals
and health care settings
• Improve communication with patients
about their medication
• Increase legibility of medication orders
• Reduce variance in prescribing practice
• Reduce medication errors and
associated adverse events
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CASE HISTORY 1
• 64 year old male patient brought to
the ED by ambulance with fever, low
oxygen levels and coughing up black
sputum
• History of end stage lung cancer self
discharged against medical advice 3
days before this presentation
• In ED patient confused and agitated
• Seen by the ED registrar and the
Oncology registrar and admission
arranged
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• ED registrar agreed to write the
medication chart because Oncology
registrar called away
• ED registrar looked up the patient’s
previous medications and recharted
them by hand
• Wrote oral Hydromorphone 20mg
• Previous dose was oral
Hydromorphone 2mg
• In ED two junior nurses checked the
chart and gave the patient oral
Morphine 20mg
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• Oral Morphine 20mg =
Hydromorphone 3mg
• Patient admitted to ward and
subsequently received oral
Hydromorphone 20mg as charted
and breakthrough subcutaneous
Hydromorphone 0.5mg (equivalent
to about 1.5mg oral
Hydromorphone) overnight
• Patient died the following morning
although not necessarily as a direct
result of high dose of
Hydromorphone
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So what went wrong?
• ED registrar incorrectly charted
20mg Hydromorphone instead of
2mg.
• 2 ED nurses gave Morphine 20mg
orally not Hydromorphone.
• Nobody overnight recognised the
error in the Hydromorphone dose
charted.
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• Case 1, Opiate prescribing • 20mg Hydromorphone vs 2mg
Hydromorphone – transcribing error
EMM system with (existing) record of usual
medication being taken on admission plus
medication reconciliation process could help
• 20mg oral Morphine vs 20mg oral
Hydromorphone – administration error
EMM system with alerts regarding look alike/sound
alike meds and/or rules that only allow prescription
of Hydromorphone using the trade name Dilaudid
How could an EMM system
help?
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• Lack of recognition of incorrect dose of
Hydromorphone overnight
EMM system could alert to high dose used
and should contain record of medications being
taken on admission for comparison/cross check
31
How could an EMM system
help?
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CASE HISTORY 2
• 66 year old female admitted to
investigate acute blurring of vision in
her left eye and headache
• On warfarin to thin her blood
because of chronic atrial fibrillation
• At admission changed to clexane
(short acting anticoagulant)
• Found to have a tumour in her brain
• Clexane correctly witheld 24 hours
before surgery
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• Clexane restarted 48 hours after
surgery at full dose
• A few hours after second Clexane dose
given patient acutely deteriorated due
to a large bleed into her brain
• Bleed drained in theatre and patient
sent to ICU but made no recovery and
died 12 days later
• The senior neurosurgeons consulted
stated that full dose anticoagulation
after this kind of brain surgery is
contraindicated for several weeks post-
op
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So what happened? • No clear verbal or written orders given to
junior staff regarding peri-op anticoagulant
management
• Policy to guide junior staff found to be
ambiguous
• The medication order for Clexane expired on
the day of surgery
• It was recharted on a new chart that day but
only the dose 24 hours after surgery was
marked to be witheld
• Therefore restarted the next day
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How could an EMM
system help?
• Case 2
• Full dose Clexane restarted 24 hours
after brain surgery
EMM can contain links to specific policy
on anticoagulation and could have rule
to prevent anticoagulation prescription
within specific time frame from surgery
• Clexane recharted by hand on day of
surgery
As above
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Will EMM prevent all errors?
• No! E-systems can introduce new errors
• Everybody (administrators, IT staff,
clinicians, trainers etc) needs to be
involved in testing, reviewing,
implementing and refining these
systems
• Everybody who prescribes, dispenses,
administers or takes a medication in a
hospital is a stakeholder as is everybody
involved in managing hospital care
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The Physician/Clinician
Champion
• What are they?
• Who are they?
• Why do we need them?
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The physician/clinician
champion can provide expert
input to project team
• Clinical expertise assists the team in
planning phases
• Knowledge of clinical process helps
define/change plan
• Risk anticipation and remedies can
be quickly identified
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The physician/clinician
champion can communicate to
and from physician colleagues
• Physicians and other clinicians may
“tune out” non-clinical experts
• Nobody carries more authority than
a respected colleague
• Physician/clinician champion can
listen, assess and translate
colleagues concerns
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The physician/clinician
champion can help make
critical decisions
• The effective clinician leader is a
highly-skilled decision maker
• Informed decisions require
background on the entire project
• Formal decisions should include
clinician input
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Are physician and IT project
leaders ready for this change?
Of course I will
be involved!
I’d love to have
physician input
and leadership!
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Are physician and IT project
leaders ready for this change?
I will tell you
exactly what you
need to do for
me!
We don’t need to brief
the physicians on
every problem…
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Are physician and IT project
leaders ready for this change?
My partners can
be so
unreasonable!
He needs to fix
those
demanding
physicians.
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Are physician and IT project
leaders ready for this change?
This needs to be
fixed by Friday
or we cancel the
project!
I don’t do surgery, I wish
he would stop trying to
be my project manager!
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Clinical IT projects:
A fork in the road for work
processes
Improve! Worsen!
It is never neutral!
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Recommendation: Appoint
clinical champions for all clinical
IT projects and especially EMM!
• Effective clinician input into clinical IT projects is necessary
• The clinician champion role can assist in the two most important factors in project success: – Executive leadership
– User involvement
• Clinician champion education for clinical IT project leadership needs to be developed
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Dr Robin Mann
EMM Program Director
Program progress and plans
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EMM Challenges
• Readiness
• Capacity and capability
– LHDs and vendors
• Product maturity
• Integration with existing architecture
• Federated delivery model
• Standardisation and reuse
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EMM Maturity
Hospital
Administer
Review
Prescribe
Check
Dispense
Discharge Reconcile
GP
Community
pharmacy
Community
services
Outpatient
care Su
pp
ort
ed b
y
Le
ve
l 1
EM
M
Su
pp
ort
ed b
y
Le
ve
l 2
EM
M
Su
pp
ort
ed b
y
na
tio
na
l se
rvic
es
Consumer
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EMM Program
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Dr Angus Ritchie
Silvia Fazekas
Cheryl McCullagh
Update from initial sites
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Dr Angus Ritchie
Renal Physician and EMM Clinical Lead
Concord Repatriation General Hospital, Sydney LHD
Initial site update
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Concord Update
• EMM Phase 1
• EMM Phase 2
• Enhanced IV functionality
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IV Enhancements
• What is an IV?
• Intermittent
• Continuous
• Sequenced
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IV Enhancements
After eMAR
documentation
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IV Enhancements
Proposed Display
Current Display
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Phase 1
• 2005 Project begins
• 2007 EMM two Aged Care wards
• 2010 EMM three more wards
• Road blocks
– iPharmacy-Pharmnet interface
– Functional deficits
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Phase 2
• Inpatient EMM – all wards
• Outpatient prescribing
• Medication history & reconciliation
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Phase 2
Sep 2012 Nov 2013
Project kick-off Conversion target
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Phase 2
Sep 2012 Nov 2013 Mar 2014
Project kick-off Conversion target New conversion target
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Phase 2
Sep 2012 Nov 2013
Mar 2014
TBC
Project kick-off Conversion target New conversion target
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Changes
• Bigger team
• Comprehensive scope
• Change management
• Timeline replanning
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Clinical Leadership
Usual Practice New Model
Paid for another role Dedicated funding
Specialty-specific view Big-picture view
Clinical work prioritised Clinical work balanced
Learn by experience Specific training
Slow, consultative decisions Rapid decision-making
Vague lines of reporting Clear lines of reporting
Reluctant to take ownership
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Clinical Leadership
Usual Practice New Model
Paid for another role Dedicated $
Specialty-specific view Big-picture view
Clinical work prioritised Clinical work balanced
Learn by experience Specific training
Slow, consultative decisions Rapid decision-making
Vague lines of reporting Clear lines of reporting
Reluctant to take ownership Take ownership of problems
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Clinical Leadership
Usual Practice New Model
Paid for another role Dedicated $
Specialty-specific view Big-picture view
Clinical work prioritised Clinical work balanced
Learn by experience Specific training
Slow, consultative decisions Authority to make decisions
Vague lines of reporting Clear lines of reporting
Reluctant to take ownership Take ownership of problems
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Current priorities
• IV Project leadership
• Change Control Board
• Medication reconciliation
– Admission conversion
– Discharge documentation
• “Form wars”
• Compliance (legal, regulatory)
• Evaluation
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Silvia Fazekas
eMEDS Project Manager
South Eastern Sydney Local Health District
Initial site update
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Cheryl McCullagh
Director Clinical Integration
Sydney Children’s Hospitals Network
Initial site update
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The MEMORY strategy describes the plan for implementation of a fully integrated health record across SCHN; it involves more than 20 projects in the next three years. Aims include:
safer care
better access, for multiple users
current complete records
reduced risk around missing or incomplete information
reduced errors
accessible to all from anywhere
improved reporting
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SINGLE EMR
CHW
SCH
2013 2014 2015 2016 2017
EMM + EMRP
Westmead
Clin-docs
build
Move to SurgiNet
PathNet c/compass
Move off iPM to SCHN stack
Voice Rec in ED
PAS: add Facility ID
PAS feed To CHW
EMM across Randwick
FirstNet Surginet
SCHN EMR Strategic Roadmap- 4 years
70
EIR
SCH scanning
PCEHR
Voice Rec in ED
EMR CHW
EMR SCHN
Backscanning lanier
END
END VR lanier
VR lanier
Email, Reports, Lync, MRD, Scanning, Coding, IT support, PCs, Printing, BYOD, PAS, shared patients
NAP forms
CCIS
CCIS TBA
NAP forms
EMR SCHN
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Implementation Process
EMM/EMRP Project Milestones
End-User Training
Go Live Aug 2015
Project Kick-off
10/03/14
System Review
12/03/14
Design Review
23/06/14
System Validation Sessions
29/09/14 8/12/14
Trainer & Conversion
Prep
16/02/15
Maintenance Training
6/04/15
Integration Testing 1
18/05/15
Post Conversion Assessment
16/11/15
Client Executive Session
10/3/14
Integration Testing 2
29/06/15
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Policy
Governance
Strategy and Architecture
Local Networks / Bandwidth
Central Infrastructure (Data Centres) and Operations (EMR)
Local Project Management, Implementation and Training
Program Management, Procurement
End User Computing (PCs, Mobile Devices, TeleHealth Endpoints, Wireless Networks, Phones)
Ownership
Work Practice Review
Standardisation and Content Knowledge
Education
Clinician Support
Benefits Realisation
Local Health Districts need to focus on all of these
EMM-the biggest leap in the EMR
Enab
lers
C
han
ge M
anag
emen
t Risk Category Owner
72
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What we have worked out so far
•Who reads email
•Face to face needs senior support
•Surgeons are hard to find
•Coherent, consistent and real reasons for change
•Champions need support too
•Little EMR changes are big clinical changes
•Only users can defend the decisions we make
•Long term credibility is more important that short term change
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The MEMORY strategy needs everyone
Addressing old risks adds different risks
Champion responsibilities
Communication, vigilance, feedback
Support
Sharing the messages
Keep the momentum forward
Eyes on the end goal
Focus on the journey
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MEMORY Strategy Stories
•Critical mass- 80%
•Story for each project
•Story for each site
•Lead with safety quality access
branding
video /E-learning ++++++
Professional group visits
Support from exec down
Champion Visibility
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MEMORY strategy outcomes
•HIMMS level 6
•The first implementation of paediatric
EMM in Australia
•The first implementation of full
documentation in paediatric oncology
•Electronically accessible records for all
patients
•Summary information available to GPs
and Families
•Lifetime e-record for all
children going forward
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Questions ?
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Questions for the panel?
Chaired by Dr Peter Kennedy
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Electronic Medication Management (EMM) Program
State and local
implementation lessons