2011

Enabling new healthcare services through an “on-line” ICT tool

There has been a paradigm shift in relation to the needs and expectations for ICT systems in healthcare, particularly related to Electronic Patient Record systems (EPRs). This poses several challenges for vendors (such as DIPS ASA) for the design of EPRs aiming at supporting new and innovative healthcare services.

Background

Firstly, EPRs have primarily played the role of an (“off-line”) tool for documentation of treatment, results and clinical assessments, i.e. the patients’ interactions with the different parts of a health facility (hospitals, nursing homes etc) are documented – after the interactions have taken place. The most obvious illustration is that paper-based medication charts (containing information about medication) are scanned into the EPR after the patient has left the hospital. This is unfortunate as the medication chart is one of the most important tools for interdisciplinary collaboration in hospitals. For instance, prior to ward rounds (Norwegian: previsitten), the medication chart is an essential tool for interdisciplinary collaboration for obtaining status of a patient’s condition as well as discussing and deciding what actions to take.

Secondly, national strategies¹ as well as the new healthcare reform² involve increased pressure to integrate healthcare services throughout the sector. A particular concern is to standardise patient trajectories and healthcare delivery as a way of improving efficiency as well as reducing treatment time for patients. This is of particular concern for oncology departments as they treat cancer patients according to numerous standardized protocols.³ This is also closely related to LEAN⁴ projects run at the University Hospital North Norway (UNN) where several efficiency measures have been implemented, and where some have been particularly successful⁵. Still most of these initiatives are not connected to an overall ICT strategy where it is considered how the EPRs (i.e. DIPS) can support processes or enable new ones which otherwise wouldn’t be possible. Despite the undisputable potential with ICT for process and quality improvement, it is not entirely clear how the “good” process can be measured, what data is necessary, and for which purpose.

Thirdly, it is increasingly expected that patients or citizens should have easy access to information about themselves in the hospital-based EPRs, enabling them to engage in their own treatment and care. Currently the patients have a legal right to this information, but this is not sufficiently supported technically and organizationally. For instance, a key challenge is to design presentations that the patient/citizen can make sense of. In addition, given that patients have access to the EPR, it is also crucial to not only get information about what has happened during the stay, but also what will happen (cf. the standardized trajectories described above) during a patient stay at the hospital. A poignant illustration of this is patients suffering from chronic conditions/cancer diagnoses and therefore is supposed to go through standardized trajectories of treatment and care.

To illustrate the complexity of the processes involved in complex patient trajectories, the so-called “lungepakken” is presented below. A concrete goal has been to reduce the patient’s time in the trajectory from over 100 days to not more than 4 weeks.

Figure 1. The patient trajectory “lungepakken” at UNN.
(Click image for larger version).

Goals

This research project focuses on ICT as an (“online”) operational tool for health care service delivery. Here, ICT triggers the interactions of health staff and patients while they are happening and serves as a resource management tool. The shift from “off-line” to “on-line” ICT tools for health care represents a ground-breaking change with significant research challenges with implicated product and process innovation with potential for clear improvements in quality and efficiency of health service work.

To illustrate more specifically from the hospital (have in mind the work processes outlined in figure 1), a process-enabling/operational EPR promotes systems which (i) gather relevant status information about patients automatically from several information sources (ii) capture physicians’ orders (for prescriptions, treatment and specialized examinations), (iii) triggering actions to be followed-up for other healthcare staff (iv) record the completion of the physicians’ order by the distributed health workers when the action is complete.

Along the same lines, the EPR as an on-line tool may enable innovation in healthcare services in line with a LEAN approach. Hence the EPR may better support standardized patient trajectories, particularly related to patients suffering for long-term cancer diagnoses.

Accordingly, this research project may contribute with knowledge about on how the DIPS EPR may be designed to both support and redesign such a process. A careful selection of patient trajectories with potential for big impact will be implemented in the DIPS EPR as part of this.

The primary research question is:

How to enable new and innovative healthcare services for chronic patients through an “on-line” ICT tool?

Concrete goals:

G1: Evaluate existing ICT-based workflow support across healthcare levels related to patients suffering from cancer diagnoses
G2: Identify obstacles in cancer patient trajectories where there is a potential for ICT support.
G3: Develop strategies for standardization of services and technology across healthcare levels for given conditions
G4: Develop strategies for how to tailor the DIPS EPR for the support of crucial clinical tasks (for instance related to medication charts)
G5: Develop design suggestions for how an electronic medication chart may support seamless collaboration across professional boundaries
G6: Modify and implement suggested changes to the DIPS EPR
G7: Evaluate the new DIPS design in real working conditions
G8: Develop methods for designing and testing patient/citizen access to EPRs.

Methods

The project manager and research participants have many years of project experience with ICT in health research, focusing on co-generative learning and close collaboration with demanding participants. Based on participatory action research⁶, we want to approach the project through a qualitative, in-depth and longitudinal study in close collaboration with users at UNN and DIPS ASA.

The research group has experience from several extensive empirical studies at UNN⁷, Ahus⁸, Sørlandet sykehus⁹, St. Olavs Hospital¹⁰ as well as on the national ICT project level on core patient records (Norwegian: nasjonal kjernejournal).¹¹

Project manager

Gunnar Ellingsen (UiT)

Project members from partners

DIPS ASA: Trond Elde, Kristin Christoffersen and Sigurd From.
NST: Per Hasvold.

In addition:
The Oncology department at UNN.
The LEAN project at UNN.

Researchers

A new PhD candidate, Gunnar Ellingsen, Rune Pedersen.

Project start/stop

01.09.2011 – 31.12.2014

Time table

August 2011: Recruit PhD candidate
2011: Map out existing IT-bases workflow support across healthcare levels
2011: Involve users and LEAN consultants in suggestions for design improvement
2012: Map out strategies for tailoring DIPS EPR for the support of electronic medication charts.
2012: Identify necessary changes to be made in DIPS
2013: Modify and implement changes to the DIPS EPR
2014: Evaluate the new DIPS design in real working conditions
2014: Develop methods for designing and testing patient/citizen access to EPRs.

Deliverables

2011: 2 conference papers
2012: 2 conference and 1 journal paper
2013: 2 conference and 1 journal paper
2014: 1 conference and 2 journal papers
2014: New healthcare services established through a modified version of DIPS EPR

Budget

The project needs to be financed through TTL as collaboration between the Research group of Telemedicine and e-health, Institute of Clinical Medicine and DIPS ASA.

Contribution to health care

For large hospitals such as the University Hospital of North Norway (UNN), this project may serve as a foundation for innovation and redesign of the current work processes and may serve as an important supplement to the ongoing LEAN projects at UNN for delivering new and innovative healthcare services. The hospital will be able to offer its services to patients more efficiently with fewer obstacles due to a streamlined patient flow throughout the hospital.

The individual patient will experience less waiting time when hospitalized due to a standardized ICT-supported healthcare delivery.

Contribution to new industry

For DIPS ASA, the research project will provide a competitive advantage in the ICT-based healthcare market with an increasing number of large international ICT vendors. The project may thus contribute to positioning DIPS ASA as a future-oriented and innovative vendor. In addition, it may serve as a stepping stone for DIPS ASA to expand in a fiercely competitive international market.

The knowledge generated by this project will also be relevant beyond the context of health. Many large and complex organizations have not managed the paradigm shift from ICT as a documentation tool to an operational tool for process support. As such, this project may provide an example that will induce change in similar large-scale organizations.

Contact info

Gunnar Ellingsen, e-mail: Gunnar.Ellingsen (at) hn-ikt.no.

References

¹Helse- og omsorgsdepartementet: Samspill 2.0. Nasjonal strategi for elektronisk samhandling i helse-og omsorgssektoren 2008 – 2013
²Helse- og omsorgsdepartementet: Samhandlingsreformen. Rett behandling – på rett sted – til rett tid
³Pedersen, R.; Ellingsen, G. (2011): The Electronic Patient Record – sufficient quality for clinical research? (Accepted at ECIS 2011, the 19th European Conference on Information Systems – ICT and Sustainable Service Development Helsinki)
⁴”Sunn fornuft satt i system” - Strategi for pasientforløpsprosjektet ved UNN HF 2009 -2011
⁵See, for instance: ”Lungepakken” – et smidigere forløp for lungekreftpasienter ved UNN. Lunge: http://www.unn.no/prosjekt-lungepakken/category25200.html
⁶Jørn Braa, Eric Monteiro and Sundeep Sahay. Networks of action: sustainable health information systems across developing countries, MIS Quarterly, 28(3):337-362, 2004. Special issue on Action research.
⁷See, Meum, T., Monteiro, E. and Ellingsen, G. (2011): The Pendulum of Standardization (accepted for ECSCW 2011, the 12th European Conference on Computer-Supported Cooperative Work, 24-28. September Århus, Denmark)
⁸See, Pedersen, R.; Ellingsen, G. and Monteiro, E. (2011): The standardized nurse: mission impossible? (Accepted at IFIP 8.2 2011 in Turku Finland)
⁹See, Meum, T. and Ellingsen, G. (2011): Standardization in nursing practice: Cross-contextual information sharing (Accepted at ECIS 2011, Helsinki)
¹⁰See, Munkvold, G., Ellingsen, G. and Koksvik, H. (2006): Formalising work – reallocating redundancy. Proceedings of the ACM 2006 conference on CSCW, pp. 59-68, November 4-8, Banff, Alberta, Canada
¹¹See, Larsen, E. and Ellingsen, G. (2010): Facing the Lernaean Hydra: The nature of large-scale integration projects in healthcare. In Kautz, K and Nielsen P.A. (eds.): First Scandinavian Conference on Information Systems, SCIS 2010 Rebild, Denmark, August 20-22. Lecture Notes in Business Information Processing, Vol. 60, 93-110.

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