In some ways the project didn’t appear to be anything special. It was, after all, just one of about 60 IT projects that Tracey MacArthur’s department is typically managing at any one time.
But this one turned out to be different. It was a unique way to apply information technology to alleviate overcrowding in hospital emergency departments. It brought medical and non-medical practitioners together to use a common system for mutual benefit.
The project was extremely successful in its initial implementation in two hospitals – almost too successful, in fact. But now, with funding by the Ontario government, the benefits of the Emergency Room Notification Project will be seen and felt by both patients and caregivers in a widening community of hospitals.
SIMS (Shared Information Management Services) is the information management and technology department shared among nine healthcare organizations in the Greater Toronto Area. Its roots date from 2004, when the Toronto Central Community Care Access Centre (TCCCAC) and University Health Network (UHN) joined their information management and technology services. Managing the SIMS partnership can be challenging because many bureaucracies are involved. UHN itself is a multi-tiered organization encompassing three hospitals – Toronto General, Toronto Western and Princess Margaret – as well as Toronto Medical Laboratories.
UHN is a very different organization from TCCCAC, which is a community-based, non-profit, operational service agency, funded by the Ministry of Health and Long-Term Care and governed by a provincially appointed board of directors. It provides one-stop access to health and personal support services to help individuals live independently in their homes, or assist them in making the transition to a long-term care facility.
The Emergency Room Notification Project created a seamless system for interaction between staff of the two organizations. SIMS knows of no other solution like it anywhere, says MacArthur, who is director of both SIMS’ Community Care Information Management group and the Project Management Office.
ORIGIN OF THE PROJECT
UHN and TCCCAC had a common problem. The clients that TCCCAC wanted to serve in downtown Toronto, many of them elderly and needing home care for chronic ailments, were repeatedly going to hospital emergency rooms instead of being treated at home.
“Many people who arrive at emergency rooms don’t need to be there, but they arrive because their issues aren’t addressed elsewhere,” says Camille Orridge, executive director of TCCCAC. “They have an acute episode, they go to the emergency department, they go back home, then they have another acute episode.
“Those are the types of clients that we needed to do something about. We thought that many of them could go home with our help and not have to be admitted to hospitals.” But who were these people? How could they be identified at the right time?
The existing process was a manual one that required emergency-room medical staff to examine the profile and history of each patient presenting at the emergency department to arrive at a referral decision. Only the obvious cases usually were identified as potential TCCCAC candidates and brought to the attention of community-care coordinators working in UHN’s hospitals. Less than one per cent of patients 75 years of age or older were contacted by TCCCAC either during or after their emergency visits.
That wasn’t just TCCCAC’s problem. Unnecessary visits were a burden to the emergency rooms. Patients often spent an unnecessarily long time there awaiting a TCCCAC assessment. As always, there were financial concerns – a ‘walk-in’ visit to an emergency room in Toronto costs an average of $175, excluding physician costs, and each day spent there costs an additional $330, excluding physicians.
SIMS’ Project Management Office and Systems Engineering teams were assigned to implement the solution. In April 2006, the Emergency Room Notification Project was identified as a priority by the Client-Centred Health Management Committee, a group of senior managers from all SIMS partner organizations that looks for opportunities to streamline care across the organizations.
The solution, developed through a series of discussions within the committee, was to bring the community-care coordinators into the fold of the medical communications system. And they would be brought into the emergency departments as well. Somebody from TCCCAC would be right there on the spot when a patient appeared who seemed to require care at home.
AUTOMATED NOTIFICATION
Timeliness was the key, and for that the practitioners on both sides needed an automated system. They called it the ER Notification system. It begins with a patient presenting in the emergency room, talking with a nurse at a computer. The nurse enters data on the patient’s identity and condition, including why the patient has presented to the hospital, whether he or she has recently received care at the hospital and whether the patient is currently receiving services from the TCCCAC.
The ER Notification system automatically builds a profile of the patient. It consolidates information from a number of UHN and TCCCAC databases within the UHN’s hospital information system, which is built on technologies from Misys Healthcare Systems.
The ER Notification system passes this profile through a business rules engine to determine whether the patient is a suitable candidate for TCCCAC referral and assessment. If so, a secure e-mail alert is automatically sent to a TCCCAC community-care coordinator’s wireless BlackBerry device. At the same time, a corresponding event is sent to the computerized whiteboards in the emergency departments, which track and display patient status. The whiteboards display a flag informing ER staff that the patient is awaiting a TCCCAC assessment. So right away, the potential home-care client is identified and there is a seamless transfer of initial responsibility to the TCCCAC staff from the medical staff.
The initial implementation was completed late in 2006 at two UHN emergency rooms. The result is that 99 per cent of patients 75 years of age or older are now contacted by TCCCAC staff either during or after their emergency visit. Since January 2006, there has been a 52-per-cent decrease in the number of patients who present at the Toronto General’s ER and a 31-per-cent decrease at the Toronto Western Hospital. Patients requiring a complete TCCCAC assessment or re-assessment are leaving the ER up to one and a half hours earlier than before.
KEEPING IT SIMPLE
MacArthur says the success of the Emergency Room Notification Project came from keeping things as simple as possible within the context of the web of complex organizations involved.
“We have learned that relatively simple technology can have a huge impact,” she says. “Rather than implement a new system, we made use of existing systems that the emergency departments and community-care coordinators already used, and we just added a series of algorithms and alerts.
“It was very important to us not to introduce a lot of additional steps for clinical staff. There was minimal effort required for training and adapting to the change. The community-care coordinators have a new queue they now need to manage, but it is a work queue, similar to an e-mail queue, which is quite intuitive so people find it easy to use.”
The same approach was applied to the project management – simple processes bind the work of disparate organizations.
Although the Project Management Office must juggle several dozen projects at a time, the methodology is common to all and the steps are clear. As was the case with the ER Notification Project, the management office develops the plan and has the concept approved by the business managers, in this case the senior management at UHN and TCCCAC.
Then each project goes through a series of phases in what MacArthur calls a stage-gated approach. Processes are based on Project Management Institute standards, and data exchange is governed by the HL7 messaging standard. At each phase – concept, identification of sponsors, scope definition, project design, development and testing, implementation – there is a unified authority that approves what is done and opens the gate for the next phase.
“That’s the beauty of our partnership; we have a single Project Management Council that overseas all our projects,” MacArthur says. “It has representatives from all over SIMS who deal with all of the nuts and bolts of each project. They provide feedback and make sure the scope and the budget are maintained and the project remains on schedule.”
The efficient methodology minimized the cost of the Emergency Room Notification Project, which came in at less than $200,000. MacArthur and Orridge also credit the skills of clinical and technical managers involved with the project, including James Agnew from SIMS’ Systems Engineering team, Heather Garnett from SIMS’ Project Management Office, Carol Miller from TCCCAC and Deb Davies from the Toronto General Hospital’s emergency department.
Orridge praises MacArthur’s management style, too.
“She is a great communicator, very responsive, keeps track of things,” Orridge says. “And she has a very nice way of telling curmudgeons like me, ‘That’s out of scope’ and, ‘No, you cannot have it all within two months,’ while at the same time talking about the positives, about moving forward. It’s a style of operating that I found very helpful.”
MacArthur and Orridge worked together to overcome the biggest management challenge of the ER Notification Project, which came not during implementation but afterward. The project actually became too successful.
“We had no idea of what the volume of referrals would be,” Orridge recalls. “We predicted growth but not the pace of the growth. For the first week after implementation, the filter was too wide. Too many clients were coming through. So we had to tweak the filter.”
SIMS’ Systems Engineering group adjusted the algorithms in the system and TCCCAC adjusted its staffing levels to manage the increased flow of home-care referrals as much as possible within its budget. Even without the filter opened its widest, the system improved client care and the operations of emergency departments to such an extent that MacArthur and Orridge stood side by side at the 2006 Canadian Information Productivity Awards Gala Banquet in Toronto, to accept a Silver Award of Excellence in the Innovation, Not For Profit category.
MacArthur says that future implementations of the ER Notification system will benefit from lessons learned in the first one, especially the need to anticipate results.
“It would have been better for us to have an understanding in advance of how much the number of people requiring service would increase,” she says. “But there was no benchmark data – there was nothing for us to look at.
“It will help us going forward now as we implement other sites to work with those organizations to make sure that we have the needed resources in place when we go live.”
The Ontario government’s Emergency Department Support Fund is supporting the expansion of the ER Notification system to other hospitals soon, initially in Toronto to Mount Sinai Hospital, St. Joseph’s Hospital and St. Michael’s Hospital. 079603
Lawrence Moule is a Toronto-based freelance journalist.