The Perfect Order Dr Bruce Lockett - Sysmex New Zealand

The Perfect Order

300,000 patients 1500 GPs and Nurses 4 Hospitals Generate 3,000,000 tests annually (50:50) Through 4 Laboratories run from P/Nth Private laboratory based in PNH since 1996 Contractor on a capped budget◦ (In, but not of, the DHB) MCH Éclair installed 1998 now v4.5.2 MLC Éclair installed 2007 now v6.3.5

All labs suffer the same problem – Getting the Request Correct◦ Missing/incomplete patient information on therequest.◦ Incorrect sample collection.◦ Incorrect tests being done (data entry error).◦ Incorrect patient details entered in the system.◦ Results going to the wrong places.◦ (Inability for requestors to easily see previoustests.)◦ (Inability to guide the person making the request.)

◦ Accuracy of patient ID.◦ Accuracy of requested tests.◦ Accuracy of collection.◦ Accuracy of registration.◦ Accuracy of report delivery.◦ Almost all of which stems from the use ofpaper request forms. Our staff ‘translate’the request and, even if it is correct andlegible, sometimes get things wrong.

Dave Ayling:-Albert Street-YOSS-Manawatu Prison

(Locum)

Actually wanted a Chlamydia

To pull the exact data on the patient, thedoctor/nurse, and the location from the GPssystem. To match up the tests exactly in our systemwith what the GPs are ordering. To store this electronically so that thephlebotomists etc can view exactly what isrequired – even if the order has changedbefore it’s collected. To provide assistance at the time of request.

Planned implementation of Orion CDR.◦ No upgrades or development for Eclair. Antipathy towards MLC.◦ Thankfully not part of the MCH structure. Disinterest in lab matters.◦ Massive inertia.◦ Don’t have the same perspective about theimportance of lab results.◦ Internal and external political agendas. Plan by MCH to terminate Éclair.

Complicated working environment:◦ ED, Clinics, Wards, ICU, etc Physician resistance:◦ Something new.◦ Requires a change in work practice.◦ MLC is not part of MCH – diminished clout! Requires hardware investment by MCH. Requires a close relationship with MCH IT. Latent demand (?20%). Inability to control H/S overtesting.

Installed 2008 Orders module installed 2009 Trial period starting July 2009 with 2 GPs Started rollout July 2010 in Palmy Request that it be used November 2011 Require it’s use November 2012? Mandated introduction by MCH as a means ofdemand management.

Creates the order using the GP system (PMS)information:◦ Requestor √◦ Patient details √◦ Previous results viewable √◦ ‘Physician Assistance’ to manage the request process √◦ Amendable √◦ Result destination defined by the requestor √

Provides the patient and requestorinformation. Receives a message confirming the order. Receives the result. (Closes the ‘Audit Loop’?) Currently MT32 and Houston only.

Ordering from MedTechÉclair sits within Medtech for ease of use and continued access to MedTech

HistoryPrevious and pending tests are shown upon entering, along with options torepeat or amend orders

OrderingCommon tests are displayed on the first tab, with extended options availableunder the others. Doctors or departments can be copied in so that the requestorcan tell us exactly where and to whom they want results to go to.

Detailed informationFor tests such a cervical smears that require specific information, we create avariety of soft and hard stops to give us everything we need to assess thespecimen.

SearchingFor uncommon tests or for anything the requestor can’t find, we have the‘Additional’ tab. This allows one to text search all of the tests that we, or ourtertiary laboratory perform.

No free text requesting of tests.◦ (Don’t bother writing tests in the ‘clinicalinformation’ field, it will be ignored!) Everything is legible. Every test is in our system. Information crucial for a test is ALWAYSprovided.

Order formsAll the details of the patient and doctors/nurses are included on the form, aswell as instructions for patients if these are needed (e.g. Fasting)The barcode is the key part that allows us to match the order exactly.

Order formsThe lab forms also show the tubes that need to be collected.

Patient is identified as normal. Order number is scanned. Correct order is displayed (request may havebeen amended so form is not used). Correct samples are taken . Associate Order number with lab number. Send to the lab.

‘Specimen acknowledged’ and placed in theworkflow. (No data entry )

4-Jul-1118-Jul-111-Aug-1115-Aug-1129-Aug-1112-Sep-1126-Sep-1110-Oct-1124-Oct-117-Nov-1121-Nov-115-Dec-1119-Dec-112-Jan-1216-Jan-1230-Jan-1213-Feb-1227-Feb-1212-Mar-1226-Mar-129-Apr-1223-Apr-127-May-1221-May-124-Jun-1218-Jun-122-Jul-1216-Jul-1230-Jul-1213-Aug-1227-Aug-1210-Sep-12100.00%90.00%80.00%70.00%60.00%50.00%40.00%30.00%20.00%Éclair UseManawatuWanganuiWairarapaGisborneHorowhenuaOverall10.00%0.00%Éclair use from July 2011 to now

Éclair Use Manawatu Wanganui Wairarapa Gisborne Horowhenua31.62% 43.15% 7.44% 33.90% 0.00% 24.60%38.48% 47.08% 17.48% 42.59% 0.00% 27.03%44.14% 50.05% 23.05% 54.09% 0.00% 21.84%49.33% 55.63% 25.08% 62.18% 0.00% 21.35%55.27% 63.25% 27.67% 70.63% 0.00% 23.03%58.85% 65.34% 31.94% 74.83% 0.00% 21.68%59.74% 64.17% 39.37% 72.99% 0.00% 30.82%59.95% 69.40% 34.91% 72.00% 0.00% 20.99%60.17% 68.70% 37.86% 74.07% 0.00% 18.51%63.26% 69.19% 41.43% 75.56% 0.00% 14.14%64.15% 68.97% 47.47% 73.97% 0.00% 14.67%60.39% 69.49% 34.93% 76.72% 0.00% 32.17%56.47% 69.86% 36.13% 80.57% 29.79% 45.21%57.07% 68.22% 38.31% 76.64% 39.18% 44.45%61.60% 70.16% 44.40% 79.77% 46.88% 58.33%64.57% 70.64% 47.56% 81.41% 57.10% 59.17%Éclair use by month and region

11000.6105010000.59509008508007500.40.30.2Patients/dayÉclair%Trend7006500.16000Patients per Day (Palmy Éclair sites only)

3.660.00%3.550.00%3.440.00%3.330.00%3.23.120.00%310.00%2.90.00%Tests/RequestTests per Request (Palmy Éclair sites only)

Éclair Orders are error free. (The perfect order)◦ No longer necessary to spend time fixing problems.◦ Doctors get the tests they want, on the patients theywant, to the location of their choice. Fewer tests/request (marginal benefit). Fewer requests (easy access to results). Fewer phone calls for results. Fewer phone calls to amend requests. Data entry is performed at source.◦ Need fewer staff (reconfiguration 22-16 FTE).◦ Staff can cope easily with high volume periods.

PMS vendors◦ Not our customer but the GPs – we have no clout.◦ They see no revenue stream so aren’t keen.◦ Typically offer an unresponsive service to all.◦ Have other/conflicting priorities no matter what wemight want to do.◦ Make lots of promises and rarely deliver!

GP systems◦ Poor hardware (really need a new flat screen).◦ Poor/outdated software (IE).◦ Internet bandwidth (NOT at dial-up speed).◦ Firewalls and security.◦ Complicated practice set-ups e.g. Multi-roomterminal emulation, etc with multiple printers.◦ Technologically challenged GPs.◦ Technologically challenged nurses.

IT staff resource (well done Team!). Éclair programming tools are restrictive. Change to a robust high availability system asit cannot go down(even after an earthquake!). High speed lab–Éclair–network connections. SYSMEX relationship and communication(things get lost in translation!).

Hard to use(new form). Slower than requestsout of the PMS. More difficult toperform follow-uptasks due to lack ofintegration in the PMS. Need to upgradepractice IT structure. Now familiar and easy. Love automatic accessto Éclair result tree. Spend less/no timetidying up ‘lab errors’. Result destinations arealways correct. Love the ability tomake orders withoutthe patient present. Love the ability toamend orders.

Label generation in the phlebotomy room. Better integration with the PMSs to close theaudit loop and integrate with the task lists. Give the GPs the direct ability to downloadresults they see in the Éclair tree to their PMS. Download all lab results to the PMS when theyconnect (remove the need for TPMP). Develop Hospital Orders:◦ Trials at various sites.◦ Develop agreed ‘hard stops’ to control H/S.

Wharite peak