Once they get their hands on the patient’s file, they may struggle to read a colleague’s handwriting. Or when they finally manage to log in to a computer screen – and see something that raises a red flag – their attempts to double-check by pager can end up in a frustrating game of phone tag. And at the back of their minds, they keep wondering where those test results have got to.

But what if all the clinicians caring for a patient could access their relevant notes and test results simultaneously – on an iPad or iPhone – whether at the bedside or attending a conference? And a nurse could instant message their patient’s doctor by a means as simple – but more secure – than texting?

Clinical nurse specialist Danielle Spencer and senior nurse Christine Baxter enthusiastically presented at the recent Australasian Nurse Educators Conference on the trial this winter of a local clinician-developed app and platform – Cortex – that is making these ‘what ifs’ a working reality for the 180-plus clinicians working in Christchurch Hospital’s three general surgery wards.

The digital platform allows clinical notes to be taken at the bedside, diagnostic tests ordered, test results notified and accessed, and observations viewed – along with creating a patient journey timeline of clinical tasks, bedside notes and test results from admission to discharge.

Developed initially to support the role of the medical team, it soon became apparent that the app and platform would also benefit nurses and Allied Health by bringing the entire patient journey to all members of the team involved in their ‘circle of care’. (N.B. Nurses are yet to be able to use Cortex to record their nursing notes, although there are plans to add nursing documentation templates.)

Spencer says staff like to think of Cortex as “kind of like a clinical cockpit” or a common platform that allows clinicians to readily access the clinical information they need on a patient from the many digital clinical ‘silos’ that hold electronic information on a patient.  

She says previously on a ward round it was time-consuming and frustrating to access electronically stored blood results or observations as there were different logins for each ‘silo’. But with Cortex the clinician has a single login to the common platform and from there, depending on their health profession and seniority, a clinician can readily access the relevant and up-to-date clinical information they need about the patient’s journey and care.

Clinicians who are part of the patient’s ‘circle of care’ can also quickly and securely instant message the patient’s nurse, doctor, occupational therapist, pharmacist or social worker.   

“In the old-school ways, if I needed to contact the patient’s doctor I would have to look in the patient’s notes, then look on the board for their pager number, page them and then sit by the phone waiting for somebody to maybe reply,” says Spencer. Now she can send the patient’s doctor a message straight from the iPad and copy in other health team members – so if the main doctor is busy a colleague might pick up the message and come instead.

Members of the clinical team can also use Cortex to ‘tag’ another team member and request them to take on a clinical task. But Baxter says one of the business rules agreed on at the start was: “I own the task until the person I tag accepts it. If they don’t accept it, I still own it.” She says everybody has been very good with this rule and the clear lines of accountability are probably one of the reasons the trial has been so successful.

The trial of the app by the three general surgery wards was also spurred on by Christchurch Hospital building a new Acute Services Block, due to open late next year, which is designed to be ‘paper-lite’ and will not provide the clinical file storage space that would have been required in the ‘paper-heavy’ past. The trial began in late June this year in partnership with Sense Medical, the company that developed Cortex, which was founded in Christchurch and led by local clinicians.

Baxter says nurses on the general surgery wards were already using iPads at the bedside for MedChart (electronic prescribing and medication administration software) and Patientrack (software for recording vital signs observations), so those were available for the trial – although keeping them charged for 24/7 use was a challenge. Junior doctors were provided with a device, with the option to BYOD (bring your own device) also available.  Funding was found for one iPad per ward for non-surgical medical staff and funding was also found for iPads for Allied Health staff.

Training for busy nursing staff quickly evolved under Spencer, who soon realised that nurses preferred hands-on training by ‘having a play’ with the app on the iPad. “And it was that simple that most nurses walked out after 20 minutes, saying ‘I’ve got this’,” says Baxter.  “They said ‘This is easier than Facebook or Trade Me’.”

The trial saw the speedy uptake of Cortex by the general surgery wards’ 150 nursing staff, 60-plus doctors and 11 Allied Health staff. Baxter says within the first 35 days there were 91,000 views of patient records. Cortex users also managed to nearly ‘crash’ the local laboratory’s results portal Éclair, as the platform had made it so much easier for clinicians to view their patients’ lab results – just a simple click of a button – that there were an unexpected 13,000 views of results in just over a month.

Baxter says she had a login to Éclair [the results portal] for 15 years but had rarely used it in the past. “Because to do that, I would have to go find a computer, kick someone else off; it would then take at least 88 seconds to log in and fire up my computer before logging in to Éclair and searching for the patient’s results. But with Cortex I could do that at the bedside within 12 seconds.”

By the end of the first month, 97 per cent of acute admission notes were being done on Cortex, 5,400 bedside notes had been recorded, 2,000 test orders made and 3,900 tasks assigned via Cortex. “That is 3,900 times a colleague was not interrupted mid-task [to be paged or phoned] about a job,” says Baxter. “We think that’s huge. And so do our colleagues.”

Spencer says the feedback from nurses has been overwhelmingly positive – not only that it was fun to use but also that it allowed them to stay at the bedside of a deteriorating patient while messaging a doctor and not rush away to find a phone. And if the whole team turned up at that bedside, everybody could be given an iPad and view the patient notes while a nurse could continue to take and record vital signs.

The Cortex developers at Sense Medical were also able to respond with a digital solution to a serious adverse event that occurred during the trial – a failure in the paper-based system to ensure that a follow-up appointment for a patient was requested. Within four days the platform producers had expanded the Cortex discharge checklist to ensure a follow-up appointment request was electronically sent and monitored.

Other additional functions added to the platform after requests were notifications of when a doctor had seen a patient and updated their notes, plus a one-click button that gave nurses faster login – five seconds, compared with 72 seconds via the usual login route – to Patientrack for recording and updating patient observations.

The trial officially ended on 13 September, but Spencer and Baxter say nobody wanted to go back to the pre-Cortex days.

“We will walk before we lose our Cortex,” jokes Baxter. The platform continues to evolve in other ways, with doctors able to use ‘Siri’ to record their notes or tasks and plans to filter notes so you could just view doctor’s notes or delegated tasks or – in the future – nursing wound notes.

As clinicians from areas of the hospital come across Cortex, they are also smitten with the ‘clinical cockpit’ and keen to be on board.

“It has taken the hospital by storm,” says Spencer. “Everybody wants to be us.”

Nelson-Marlborough DHB is the last of the five South Island DHBs to join the system which was developed in the aftermath of the Canterbury earthquakes to mediate the sharing of patient information.  Shared information includes test results, hospital admissions, medications and general practice information.  Health Minister Jonathan Coleman said the system is currently accessed over 3000 times a day by health professionals in the South Island.

HealthOne was initially developed through a partnership between Canterbury DHB, Pegasus Health and Orion Health and has been rolled out across the South Island through the South Island Alliance. The initiative won the award for Best Technology Solution for the Public Sector at the recent NZ Hi-Tech Awards.

He said staff had been trying to restore systems, following clearing up after the fire, but had then faced further delays as issues with temperature control, air quality and humidity also needed to be sorted.

“We are being cautious as we don’t want to cause further damage to our servers,” he said. “These latest issues have likely added several more days to the first step of restoring the network, but these setbacks have shown us that there are lots of unknowns in the process. We still do not have a concrete time for having our systems back up and running.” 

Rotorua and Taupo Hospitals and the DHB’s community services are all affected by the outage.

Lees said the DHB has received lots of help from neighbouring DHBs, service providers and primary care and was really grateful for the level of support. 

He is reminding people to expect delays when they come to Rotorua or Taupo Hospital, as assessing and treating patients can take longer without electronic access to records.

Patients with scheduled elective surgery or outpatient appointments are being told to turn up as usual.  If appointments need to be cancelled the DHB would contact people directly.

It’s an age like no other for sharing intimate aspects of your life.

Five hundred ‘friends’ can read how hung-over a guy is after a night on the town. A mother can tweet pictures of her child’s chickenpox to the masses.

But if your district nurse wants to see your latest test results, the ED nurse your current medications, or your pharmacist double-check your GP’s prescription, the information can often be a frustrating series of phone calls and faxes away.

Consumers used to getting information at just a click of the mouse or slide of the finger are perplexed that basic information isn’t already being electronically shared between general practice, hospitals, and other health providers. In an age of Facebook, Twitter, and Instagram, there are still electronic and privacy barriers standing in the way of sharing basic health information electronically.

The slow and steady arrival of shared electronic health information is changing this in pockets all over the country as pilots in eReferrals to ePrescribing and other broader initiatives, like Canterbury’s electronic shared care record view (eSCRV) and electronic shared care plan pilots in Auckland and Christchurch, are tested and rolled out. Walking the tightrope between providing ease of access to shared clinical information and protecting the privacy of health consumers is the difficult balancing job the health sector is currently working through.

High profile cases have shown that maintaining privacy is a real issue, with some nurses and doctors not immune from exploiting electronic access to take a nosey at records they have no reason to see. In the past health professionals might have got away with a gossipy huddle around an x-ray or taking a peek at a file in the cabinet. And it may be that those involved in the recent cases were unaware that nowadays such privacy breaches leave digital footprints that lead investigators right to them.

Sue Wood (pictured) for one is a nurse leader who believes ignorance or uncomfortableness with IT is no excuse for the nursing profession not to take a lead role in eHealth developments like shared electronic health records.

The former director of nursing at MidCentral District Health Board is a bit of a nursing IT pioneer having brought the acuity software TrendCare to New Zealand. She is also the nursing representative on the IT Health Board which has set the eHealth vision of all

New Zealanders and their health providers having electronic access to a core set of personal health information by 2014.

Wood, now quality and patient safety director at Canterbury DHB, says patient portals, to electronic health information and incident management systems, are the way of the future. “And from the Minister (Health Minister Tony Ryall) it is an area that needs more emphasis.” Portals are also an area that still needs some work if the eVision goal is to be met by the end of 2014.

Wood is clear what should be core and common across any electronic shared health record or care plan development.

“As a nurse on the board I’ve been arguing for two years that assessment data needs to be core and that assessment isn’t biomedical examination (though I value that and it is a component of assessment),” says Wood. “We are looking for the psychosocial history, the context and how people learn … we are looking at those sorts of things to be included in (nursing) assessment.”

Wood says nurses’ psychosocial care of patients is core ‘bread and butter’ to nursing but it is totally invisible to others who do perceive nursing as an holistic profession. “We are perceived as biomedical.”

So nurses needed to be in at the beginning of system development and clearly articulate what they need so the IT teams can deliver software and eHealth tools that recognise what nurses “bring to the party” of patient care, like holistic assessment, supporting self-management and the “invisible” coaching of families.

Wood says nurses also need to leap forward and envisage future models of care ­­­– and the electronic systems needed to support them – as systems take time to be developed and are usually difficult to change. So nurses need to think where care will be in a decade, ensure to use a common universal language (like Snomed clinical terms) and avoid just turning existing paperwork into an electronic form.

IT security: most definitely a nursing role

Nurses also need to play an active part in IT security and privacy, says Brenda Hynes (pictured), project leader for PlunketPlus – the well child provider’s new electronic health record as well as the “Plunket book” of the future.

“But often when I talk to people about information security they say ‘that’s not nursing, we don’t need to worry about that,” says the nurse who is also Plunket’s general manager of service delivery.

Hynes challenges this, pointing out decisions about security directly impact on what happens in the field when a nurse picks up their tablet and tries to login to PlunketPlus.

“If you lock everything down …and you have to go through streams of passwords … that affects the performance that the nurse can do,” says Hynes. That’s why she believes nurses should be in on security decisions and examine the risks against the advantages of different levels of electronic security.

“An example of this is for us being able to access a whole spreadsheet of all client contacts and be able to email that. We could have locked that completely down and then our business analysts wouldn’t have been able to do their work or we could have opened it right up so nurses could access such spreadsheets.”

The decision was made that only business analysts could view such data to reduce the risk of a nurse accidentally emailing out all their contacts, a la ACC or EQC.

Hynes points out you can’t eliminate or control every risk – some you have to accept so nurses can do their work; with trust and staff education also key to preventing privacy breaches.

And ensuring notes are kept secure and private is a long given for nursing, says Hynes, with Plunket nurses locking them up every night in a filing cabinet and hospital nurses challenging any stranger hovering beside the notes trolley.

The ‘key’ to the ‘filing cabinet’ is now an electronic password – which has to be a complex one, requiring a mix of nine letters, symbols and numerals that has to be changed every 90 days.

Hynes shares an anecdote on why it’s probably best to have complex passwords based on her experience of asking a gathering of Plunket area managers last year how many of them used ‘Plunket’ backwards as their password. “All these hands shot up … and I said ‘oh dear you’ve just told me your password!’”

It was no small feat to introduce complex passwords for Plunket’s 1500 staff and 5000 volunteers. They were given three months notice of the changeover to the tighter password system. A series of meetings outlined why the new password system was needed and giving hints on how to make a memorable but secure password, like using a code built on the lyrics of your favourite song.

“So when you come in in the morning you do see people at their computers tapping away and nodding their head as if they are singing a song.” Hynes adds with pride only one person, of the 6500 or so involved, failed to register a new password prior to the changeover date.

Work began on PlunketPlus back in 2010 and it went live for the first time in September this year with ten nurses in Auckland, with 4000 clients between them, testing it in the field using electronic tablets.

Hynes admits it hasn’t been a fast process but prompting Plunket to take their time was the number of privacy breaches hitting the headlines last year. “That’s when we said hold on a minute we need to just review all our information security.” As a trusted organisation seeing more than 90 per cent of all new babies they wanted to ensure their system was secure – including paying for penetrating (PEN) testing to see whether people could hack into the tablets nurses use or Plunket’s server.

It has also developed a new incident management system that covers security breaches as well as privacy breaches.

So if somebody loses their smartphone – it’s an information security breach and needs to be reported straight away. It is Plunket policy that no client information is held on phones but the IT department would still promptly “kill” the phone to ensure numbers cannot be accessed.

Plunket’s policy is that client information is not emailed through non-encrypted platforms like Microsoft Outlook. Instead it uses several encrypted systems if it needs to report client information, for example SEEmail (Secure Electronic Environment Mail) to send encrypted sensitive information to Child, Youth and Family. Information held on PlunketPlus tablets is also encrypted and while nurses are encouraged to take their tablets home, so they become familiar with them as an IT tool, there is a hands-off policy from any family members keen to play games on them or take ‘selfies’.

In the future clients will also be able to access their child’s PlunketPlus record through a secure patient portal, similar to internet banking. But as that is the final stage of PlunketPlus work is yet to begin, says Hynes. But the vision is that parents will be able to read their child’s record, except for child safety information, and will also be able to contribute to the record, just like an electronic Plunket book, and record their child’s development milestones from rolling to first steps.

Meanwhile evaluation is ongoing during the live testing in readiness to refine and make PlunketPlus work as well as possible for nurses and their clients. Once that stage is completed Hynes expects it will take between 12 and 18 months to roll out across the country

With that roll out and the future patient portal will come the need to decide when and if information is withheld from clients. Hynes says the health privacy code means nurses already need to be clear with clients about the information they are gathering and why, and now will need add how it is being recorded and who will be able to see it.

IT road map not roadblock for privacy

Getting the fundamentals right from the start when it comes to privacy and electronic health records is probably not a bad idea.

Katrine Evans (pictured), the assistant Privacy Commissioner, points to the UK’s scrapped £12.7 billion health IT project as a cautionary tale of getting the fundamentals of sharing electronic health information all wrong.

Reasons for pulling the plug on the NHS project in 2011, after investing nearly a decade’s work, included health providers not having confidence the system would work properly and health professionals concerned there wasn’t adequate privacy protection.

Evans says people often expect the Privacy Commissioner’s office to be anti-IT but that is not at all the case. “Sometimes IT can actually significantly improve your privacy situation and it can be a road map rather than a roadblock.”

Retaining patient privacy is also more challenging today as the increasing complexity of health care means the average number of people involved in a person’s health care is estimated to have risen hugely from 2.5 people to 15.

“Managing the complexity of care is something that information sharing can help you to do but in the health relationship trust is absolutely central. This is not about the IT, this is about the people.”

Evans says also the fundamental privacy rules and rights of patients don’t change whether the information is being recorded with pen and paper or electronically.

“That’s the beauty of a principles-based system – it doesn’t matter what technology you use.”

She says her colleagues across the Tasman in Privacy Victoria summarised the health privacy relationship as: “the right information to the right people, for the right reason, in the right way and at the right time”. So privacy was not about blocking information but facilitating the right use of that information.

The key for health practitioners like nurses was to be transparent and communicate clearly to consumers why they are collecting the information, how it will be used and that it won’t be disclosed other than for reasons they have been informed about.

Accuracy was always important but what was different under shared electronic health records was if there was an error there was a need to have a system in place to ensure that any correction gets to all those who may have shared the record.

The increasingly mobile health workforce going out into the community with tablets, smartphones and mobiles also creates the potential for privacy breaches.

Evans says encryption is an increasingly available and easy way to ensure the loss of a work laptop is inconvenient but will not result in a breach of patient privacy.

But with health staff also bringing their own electronic devices to work employers had to have clear policies about ensuring sensitive information was not being carried on emails or texts on staff smartphones.

Evans adds that it is also important that any electronic security systems or policies are workable. “It needs to be a system that people can use and will use.” Make it too tough to do their jobs and you will force “workarounds” which can create security nightmares.

“People will take the path of least resistance, particularly very, very busy people like health professionals, so make it easy for people to do it right and it will also help to protect patient privacy.”

Again trust is key to the health practitioner/patient relationship and surveys in New Zealand continue to show, deservedly says Evans, very high levels of trust in our health system and health professionals.

“But all you need is a couple of big incidents and that trust can be damaged and it takes a very long time to rebuild it.”

Quake drives shared electronic health record

Christchurch is home to the country’s most extensive electronic shared care record known as eSCRV.

It was lessons learnt from the quakes that drove the development of eSCRV which district nurses for one are describing as “revolutionising” their work.

In post-quake Christchurch with hospital services stretched, some general practices and pharmacies closed (or their computer systems down), sharing health information was more important than ever but there was no simple mechanism to do so.

Sheree East (right), director of nursing for Christchurch community health service Nurse Maude, says post-quake there were not only particular concerns about the vulnerable elderly falling through the gaps but also valuable resources being wasted by double and even triple-up visits by services working in an information vacuum.

So that was a driver for Canterbury District Health Board to start work in 2011 on a shared health record with general practices, Nurse Maude and community pharmacies that evolved into eSCRV (electronic shared care record view – see box below).

East says creating a privacy framework was the first task in creating eSCRV including developing a matrix of which health professionals could access which parts of the shared records and when and why. Nurse Maude at present only contributes its care coordination data and not its nursing data but in return for being a contributing partner its nurses can access eSCRV. The first handful of Nurse Maude nurses started accessing the pilot shared record from late 2011 with all its district nurses coming on stream at the start of 2013 when the record went live.

“Nurses are telling me it has revolutionised their practice,” says East. “One told me it has added an hour a day back into her life. Which is huge when you look at productivity.”

That hour was largely saved by not having to chase up referrals to and from other providers for her clients.

East says consumers are often surprised to find their health professionals don’t already share health records and don’t realise that it just isn’t that easy to share information for privacy as well as IT reasons. “But they expect us to have a seamless service and to protect their physical health safety by having the relevant information.”

Instead most health professionals are still reliant on phone calls, faxes, and letters for sharing patient information. “When you are chasing pieces of paper around the system it makes you look really inefficient.”

This is all changing with eSCRV. District nurses are telling East they can be more clinically accurate when they can have a patient’s recent clinical record up on a screen in front of them while taking a patient history.

Likewise it saves on the patient’s time not having to repeat their entire health story and saves nurses time on the phone checking up on missing patient information or forgotten details. Test results now can also be quickly viewed and acted on. Also nurses can be proactive and stop unnecessary repeat testing or prompt testing if they see that health screening tests have been missed or lapsed.

East says one nurse pointed out that she believes an electronic system is more secure as she doesn’t have to rely on referrals by fax that could be lost or seen by people who shouldn’t. Or having to phone somebody to get information, with the risk they could misinterpret what they are reading, whereas now she can read it for herself. Nurse Maude district nurses are also part of the Canterbury pilot of working at a higher level of multidisciplinary collaboration with long-term condition consumers to develop electronic shared care plans.

East says the new ease of access to patient information also comes with responsibilities with a lot of time being into training into privacy plus how and when nurses can access eSCRV. Nurse Maude nurses ask permission of each patient to access their eSCRV and usually do so when the patient is present. Nursing notes are yet to be shared electronically but when they do if a nurse reviews and changes their notes the original notes are only “greyed out” so while not readable they are not lost from the system

Each nurse also has to sign an access deed that outlines their obligations to only access a patient’s shared care record to support direct patient care, to maintain confidentiality and not share their access code or password with anyone.

The need to do this was highlighted by an investigation finding seven breaches of cricketer Jesse Ryder’s files while in Christchurch Hospital with two staff identified as having accessed the record via another staff member’s log-on (see on-line only sidebar story).

The one positive of electronic records is, unlike the paper files of yesteryear, a snooper can now be traced.

“We are always going to have to rely on ethical practice of health practitioners and people working in the health sector that they have that respect for people’s information but we will also now have the digital footprint as well,” says East.

“At the end of the day we have to ensure we have informed everybody of their responsibility and they are committed to acting ethically and managing privacy as they should.”

Because while the world may be sharing like never before the patient’s right to privacy remains sacrosanct and unchanged.