Advancing clinical research using electronic medical records (EMRs) - - PowerPoint PPT Presentation

Advancing clinical research using electronic medical records (EMRs) at a paediatric hospital

Ahuva Segal – Senior EMR Research Analyst Mike South – Chief Medical Information Officer

Outline

• Overview of RCH EMR Project
• Making our EMR work for researchers
• Discuss lessons learned
• Future plans
• Questions

Royal Children’s Hospital

• 340 beds (plus ~35 Hospital in the Home)
• Inpatient admissions 48,000
• Emergency Department presentations 80,000
• Ambulatory attendances 285,000
• Operations 19,000

Melbourne Children’s

It was hoped that the EMR would:

• Help deliver evidence-based in the safest possible care
• Standardise practice to reduce variation/duplication
• Be easy to use
• Reduce waste and increase efficiency
• Increase family engagement
• Support research (from Go-Live)

Project Implementation

Single, comprehensive, enterprise-wide EMR

Project implementation

Clinical transformation project, not an IT project

• Clinical systems replaced or integrated
• Data migrated from legacy systems
• New devices – COWs, handheld devices
• Training – 3800 staff (~300 research

staff)

• Use data in real-time to embed

evidence-based research at POC

• Use data to inform research/QI

projects

• Support research practices

Research and the EMR

Epic and Research

• Governed by:

– Health Records Act – Privacy Act

• Harsh fines for breaching

patient privacy

• Risk minimisation strategies:

– Honorary appointments – HREC Approval – Break-the-glass (BTG)

Epic and Research

Break the Glass (BTG)

• Epic security feature

which controls access to patient information

• Non-RCH research

staff will BTG to gain access to patient records

Patient-study association

• 304 studies currently built in the EMR
• 195 interventional / 109 observational studies

– 3054 patients - interventional studies – 6442 patients - observational studies

Only a small subset of EMR based research

RCH Research Studies

• EMR is not a Clinical Trial Management System (CTMS)
• Allows for representation of research on the Melbourne Children’s

Campus

CTMS

Adverse Event Reporting

Research-billable items

Making the EMR work for research

Reports – Bowel and Bladder Dysfunction

Project component Retrospective audit Baseline survey Screening method Patient registration Referral system Scanned medical record EMR Report using multiple criteria Number to screen 1489 638 Number eligible 281 352 Time period 3 months 3 months Duration of screen 7 months 3 days Year of data collection 2016 2017 Personnel 1 PhD student, full-time 2 medical students

SlicerDicer

SlicerDicer

Research Best Practice Advisories (BPAs)

• Pop up seen by clinicians and other staff to drive

better care and decision making

• Built to be triggered by study-specific criteria

PICNICC

• Low risk fever and neutropenia observational study

(PICNICC)

• Patients from RCH had blood samples collected for

RNA sequencing

• Started with making tissue bank order available in

ED

• Changed to a BPA in March, 2017

LOGIC: 1 AND 2 AND 3 AND 4 AND 10 AND 13 AND (11 OR 12) AND (5 OR (6 AND 7) OR (6 AND 8)) AND NOT 9

# Criteria

1 Staff member is ED Doctor/NP 2 Patient is in ED <4 hrs 3 Patient is associated to the Tissue Bank Study 4 Patient does not already have a tissue bank order for that encounter 5 Reason for attendance is FEVER - HAEM/ONC PT 6 Patient is on oncology plan 7 Fever > or = 38.0 documented during ED stay 8 Reason for attendance is fever 9 Patient does not already have an unsigned tissue bank order 10 Checks to see sample wasn’t collected past 24 hours (i.e., frequent flyers) 11 Patient is on AALL0932 or ALL1131 Maintenance Protocols. 12 Works together with Criteria 12. Outside of 9-5 Weekdays, patients on the Maintenance protocol will not have samples collected. During 9-5 weekdays the BPA will fire even for patients on these protocols. 13 Excludes patients with a problem on their problem list of Aplastic Anemia

PICNICC

PICNICC

10 20 30 40 50 60 70 No EMR Go-Live BPA Revised BPA % suitable samples collected Time point

Suggested Patient Instructions

Research documentation

SmartForms

Patient-Entered Questionnaires

Health Services Research

Oral antibiotics for fever CXRs in asthma CXRs and bronchodilators/steroids in bronchiolitis PPIs in gastro-oesophageal reflux AXR in nonspecific abdo pain

Clinical Research

Future projects

Clinical Informatics

Epidemiology Biostatistics

Digital Health Bioinformatics Biostatistics and Epidemiology Population Health Informatics

Melbourne Children’s Centre for Health Informatics

Clinical Care and Electronic Medical Record Service Delivery Digital Technologies Artificial Intelligence Clinical trials Cohort studies Data Linkage GenV LifeCourse Genomics

• Omics

Bioinformatics Health Services Research Quality Improvement

Melbourne Precinct Project

REDCap Integration

Adverse Event Reporting Part 2

Some users were very reluctant to give up specialised functionality

• Dedicated EMR team

– included RCH clinicians and researchers

• Strong engagement is required

Many of the challenges relate to the people and not the system!

• Work on data governance early
• Set research as an important priority
• Don’t leave research in the wilderness – incorporate into core functions
• Work doesn’t stop with Go Live – need to work hard to keep it on the

agenda

• Rubbish in, rubbish out
• There are many tools for data entry – the content is not necessarily

readily available for analysis

• Discrete items are easier than free text but still need to be

configured to save to database fields

• We tried to provided self-service data access where possible
• Allow resources for training relevant staff in the use of these tools

Acknowledgements

• EMR Team
• Murdoch Children’s Research Institute
• Children’s Hospital Foundation
• Victorian Government (Department of Health)
• Epic Application Managers and Technical Support
• Patients and their families
• Hospital staff
• Research assistants, coordinators and nurses
• RCH Office of Ethics and Governance

…and the many more who contributed to the EMR implementation.

What questions do you have?