What can we learn from the Parkville Precinct when it comes to digital healthcare?

Host:

G'day and welcome to Nous Cast, the podcast of Nous Group, an international management consultancy.

Today we're talking about digital health and how a group of hospitals in Melbourne came together to establish a united electronic medical record, or EMR. The group of hospitals are known as the Parkville Precinct and as you will hear, their combined efforts to establish an EMR helping to improve health outcomes for patients and making life a whole lot easier for clinicians.

Today, we'll be hearing from three people involved in the Parkville Precinct EMR project. Our first guest is Professor Shelley Dolan, who is CEO at The Royal Melbourne Hospital and was previously CEO of the Peter MacCallum Cancer Centre. Joining her will be Associate Professor Daryl Cheng, a consultant pediatrician and clinical informatician at Melbourne's Royal Children's Hospital, and facilitating the discussion will be Nous principal Dr. Paul Eleftheriou, who was a key part of the Nous team supporting the Parkville Precinct EMR project and was previously chief medical officer at Melbourne's Western Health. Let's get into it.

Dr. Paul Eleftheriou:

Good morning, Shelley and Daryl. Thank you so much for giving up your time to share your perspectives and indeed learnings about your journey with the EMR at the Parkville Precinct. And this is a really important time as the rest of the country evolves their digital health ecosystem. So we really do appreciate your time. And what I might do is start with you, Daryl, and we'd like you to take us back to a time when there wasn't an EMR at the Royal Children's and then more broadly across the precinct, and then focus on the experience you think patients had and the experience that staff had before the EMR. Can you please explore that with us?

Daryl Cheng:

Sure, and thanks, Paul, for having me. Before the EMR was at the Children's Hospital, we just had a lot of disparate systems. And I think the challenge with disparate systems is that it's inefficient and sometimes even potentially dangerous. We had paper, we had different logins for pathology, radiology. And as a junior doctor, we would figure out the shortest way with all the generic passwords to be able to find out and gather all the information to make a semblance of a patient journey for a ward round as an example.

And where the problems were in this space was that the disjointed nature meant that there was no flow and continuum of information from one part of the hospital to another, the emergency department, the intensive care, the ward base, the outpatients, and that had significant challenges both from an inefficiency perspective, but as I mentioned, a safety perspective as well.

One of the other things at a broader level at the precinct was that there was no communication between patients who would journey to other hospitals in our precinct for care, be that for oncology cancer care or as they graduated from a pediatric hospital to a adult hospital, they literally had to start again from scratch. And that was very challenging for some of the complex patients that we look after.

Dr. Paul Eleftheriou:

Thank you for those perspectives, Daryl, and I'm glad you covered not only the safety issues but also the improvements in benefits to patient care and not forgetting the staff experience. Shelly, did you want to chime in here, again, comparing pre and post EMR? You've been a CEO at Peter Mac and now obviously the CEO at Melbourne Health. What do you think the big differences have been pre and post?

Shelley Dolan:

So I absolutely agree with Daryl. One of the biggest changes is safety. One of the things we know looking at healthcare globally is that where safety concerns happen is transitions in care. And whenever there is a transfer of care between organizations or indeed between departments in an organization, that's when you get drops in information and gaps in care.

And the wonderful thing with an end-to-end EMR and indeed an EMR across four hospitals that all collaborate very closely is that you stop those gaps in care, and that is really important.

I guess the other two really important areas are patient involvement in care. So we have the patient portal and particularly for the Children's, the importance of parents and families being involved in that portal too. So patients can see their results, speak to their caring and clinical teams, and be much more involved in their care. And we know that makes a difference both to clinical outcomes and the experience of care. And then finally for our clinicians, of all craft groups, nurses, doctors, allied health professionals, managers, so much better. It's a really improved clinical experience for our clinical teams.

Dr. Paul Eleftheriou:

Thank you, Shelley. I think really well said. And Daryl, if you can pick up parts of what Shelley said and maybe zoom in on a typical pediatric patient given you're a pediatrician, is there a particular story that really resonates with you in the past, and since the EMR, that connectedness, that integration, that seamless journey that you think has really helped patients?

Daryl Cheng:

Yeah, and I can give you a whole myriad of examples where this is a huge challenge. We have actually a fantastic photo of a complex patient during the time where we use paper files. And you see they have 13 or 14 volumes of files as almost as one meter high spread across the hospital in medical records in different places. And that was really just emblematic of the disconnectedness before having a single unifying electronic medical record.

We take patients from country hospitals very often as a referral center, as a statewide tertiary center. And so we would have patients arrive with paper records from another hospital where we would have them arrive with minimal information around what had been happened or conversations that had been had with clinicians before being transferred across to the hospital. They would have their care in ED using a single ED-based system. And then when they were being moved to the ICU or ward, there was no information from the ED system. And so one of the key things there was that we saw significant challenges around deteriorating patients and patients that had unexpected turns simply because the information was not transferred across from one to the other.

We looked at our mortality rate and our complication rate after our electronic medical record was introduced at the Children's Hospital and we found a significant decrease in mortality. And that's a huge thing for all hospitals, but in particular Children's Hospital where the mortality rate is already lower. We don't think it's some magic system or magic that the electronic medical record has introduced, although the inefficiencies have been reduced. But what we think it is is the fact that the communication and the seamless nature of it has actually helped to alert people to the fact that there is a context and the background around each patient and that we can recognize deterioration more quickly, we can act on it in a more nuanced way and an appropriate way for that patient. And those things have been very, very powerful and tell a very powerful narrative.

Dr. Paul Eleftheriou:

Thanks, Daryl. A huge impact and again, huge impact for the patient, for the community, and for your staff more broadly. And it's a huge catchment across the precinct that benefits from this ecosystem.

Now, Shelley, I wouldn't mind moving to you again. And as one of the senior leaders across two of the health services in the precinct, but also as a key leader for the journey that you've all taken for a precinct-wide EMR, thinking about the project itself, i.e., coming together as four preeminent health services and having a roadmap to help you all be aligned and think about the future, what was the overall aim in your mind and what do you think you've achieved so far?

Shelley Dolan:

Yeah. So although it was four health services coming together, it's important to remember that the Children's had already had the Epic EMR for about four years, I think three or four years, and they were already really expert at it. And I remember several times talking to Mike South, the leader of the clinical council then about trying to learn from the Children's about how this was going to work across the precinct.

But to come back to the principles that we focused on, the most important thing I think is not to think of this as an ICT change, this is about clinical change, the raising of clinical standards and the changing of how you do things clinically. I think it's incredibly important to think of it as a clinical change management project rather than an IT change. And that meant that all of us were very guided by the clinicians in our hospitals, and so we had a clinical council and that originally was formed at the Children's and then clinicians, senior clinicians from all departments joined across the precinct.

And it was a really important principle that if we were going to change something material, it needed to go through that clinical council. We needed to have buy-in and ownership of our clinical colleagues. That was incredibly important.

I guess the other thing was that we all owned this and we all shared it. So there are some parts of Epic that are useful for the Children's or the Royal Women's that Peter Mac or the Royal Melbourne would never use, for example, some of the maternity modules. But it was incredibly important that we prioritized all of the important things to each health service. So no matter whether it was important to all four, if it was important to one, then it was a priority. So it was really coming together as four health services, keeping in mind what was most important for patients and families at all four of those health services and looking at it through a clinical lens.

Dr. Paul Eleftheriou:

Fantastic. Thank you, Shelley. And really that principle of the whole being greater than the sum of its parts has come through that response. And when we partnered on some of the elements that you talk about, do you also want to talk about the cultural principle because I think you're spot on. IT is a key enabler, it's a key tool, a very important one, but there's a real focus on culture, of course. Can you tell us about the cultural change that you've noticed?

Shelley Dolan:

Yes. So this is my third Epic implementation across the world, and it's really important to get the preparation right. So it's a big lead up to when you first switch it on as it were. And that's all about training and development, and it's really important for clinical teams to do that together. It can't be done just in a classroom or online. It is about looking at the change management process for whole departments.

So pathology for example, looking at new ways of working and involving all the elements of pathology. So that would be the pathologists themselves, but also the scientists, also the technicians, the people that receive samples, for example. It's looking at the whole pathway and learning how to do that differently with the end-to-end EMR.

So that preparation couldn't be more important. You can't go live and indeed Epic work with you very carefully on this, you can't go live unless you have done enough preparation across the whole organization to even start the process. And even when you've started, I would say that the first year to two years, you are still learning. And so you need to embed that, that you don't switch it on and it's perfect from day one. So you need to embed your helpers on the ground for all of those myriad of questions. Even though you've been trained, when it happens in reality, there are loads of questions. And so it is having those people on the ground who are expert in the clinical area, but also in Epic to be able to give you assistance in a timely way.

Dr. Paul Eleftheriou:

Thank you so much, Shelley. And really the key takeaway here in theme is partnership, right? Partnership with Epic, partnership with all the health services, with the clinicians on the ground, back of house and admin, and all those different parts of the system that make great care happen for the community and ensure that you get the best out of your EMR and the best out of your digital ecosystem.

And it's a really good segue for you, Daryl. As a senior clinician, but also someone who was really involved in the EMR early on, I wouldn't mind your perspectives on key enablers. What were the key aha moments for clinicians, do you think? And not just medical staff, we're talking about all clinicians and all patient facing staff. What are your thoughts?

Daryl Cheng:

Yeah, I think building on Shelley's points, you really can see the importance of enablers across the organization and even outside the organization, specifically talking to the clinical enablers. It makes a huge difference having a peer, having a conversation about the impact of an electronic medical record and the effect on workflows from someone who understands and has lived those workflows.

It's a different story for someone either from what is perceived as the top or someone from a non-clinical background trying to distill information down into a digestible format for a busy clinician. But it's another thing to have someone who has been in the trenches and who understands the pain points walking through that with them. And that was really a key focus for us and a key angle at which we came at it from, we needed to find peers, clinician champions, ambassadors, whatever you want to call them, to actually help their colleagues to walk this journey.

And that's across all disciplines. It wasn't just medical, it was across nursing, across allied health and other paramedical health professionals that we have in the building as well. And I think that's really important to understand that that is at the core, at the crux of what made this a success, as Shelley referenced earlier, it was the fact that the clinical enablers were priority and were put in place right from the start.

Our training, for example, of our medical staff, our nursing staff were done by people who were nurses and doctors. The doctors train the doctors, the nurses train the nurses and the allied health train the allied health. It wasn't a generic person coming in trying to read from a IT textbook about how the electronic medical record works.

Even today to this day, when we have our new rotations of doctors come through, doctors still train them. And the reason behind that for us at the Children's is that that is core to not only immediate knowledge transfer, but it's core to establishing a relationship for a lifetime of that clinician in the building or across the precinct now where they are able to grow and optimize their skills across the board and eventually they become the ones who then propagate that information and that knowledge to their new colleagues who join the organizations that we have.

And so that was really key. Another part of that was clinical leadership. We had key clinical leaders in the building across a whole range of disciplines, medical, surgery, anesthetics outpatients who could be the super champions, if I could call it that, to actually really be the point where people could go to ask their questions, give their ideas, tell about their pain points, and have open discussions to have two-way conversational feedback about how we could improve the system for everyone as opposed to just, "Here we go, here's the system. Too bad you're going to have to use it."

And those clinical things have been the legacy of this and we've carried those enablers across to many of the optimization change projects both within the EMR and beyond because it has been such a successful model of rolling out what is an enabler for health really when we're talking about the electronic medical record.

Dr. Paul Eleftheriou:

Thank you, Daryl. That is excellent advice, and a great advice for senior leaders across the country as many evolve into an end-to-end digital health ecosystem. And I wouldn't mind your advice on what things to avoid, what are the pitfalls that they should consider as they implement a single digital patient record, as they implement state-based EMRs and other digital health ecosystems, especially focusing on clinician engagement and change management. What are your words of advice there?

Daryl Cheng:

I think you have to pick your clinician leaders very wisely. They need to be people who can speak both an IT language and also can speak to their clinicians. They need to be respected for their clinical skill and also be excellent at their technical understanding of how the electronic medical record works and it can integrate into workflows.

The second thing that I think is really important is also that we can't over-promise and then under-deliver, we can't say the electronic medical record when it's introduced will change A, B, C, D, E and every pain point that a clinician has ever had since day dot. It is not going to do that. It is a tool, it is not a panacea or a magic wand that can fix problems that have nothing to do with the EMR. Sometimes even today, we have people coming and say, "Oh, if the EMR could fix this and fix that," when actually the root of the problem is a cultural issue or a process problem or a educational issue, it has nothing to do with the tool itself.

And so I think one of the key things we were very careful early on is that even introducing something like what Shelley mentioned around the patient portal, it wasn't that this would solve every communication problem with patients from here on in, but that it would be a avenue and a way that we could start to streamline that information and work step by step.

And clinicians in particular understand that this is not going to be the solver of all their research questions and all their quality improvement issues and every single inefficiency in terms of booking a patient in for theater. Then I think that that is going to be helpful to be able to slowly and stage by stage introduce this over time. And when they look back in its entirety, then the clinicians understand that this is a journey, not an instant fix.

Talking to every junior doctor that I come into contact with on the floor, there is not one of them who would prefer to go back to a system without the electronic medical record, and they understand that the electronic medical record is not perfect, but none of them would give it up for something else.

Dr. Paul Eleftheriou:

Yeah, that's really interesting. I bet both of you remember a time when we had paper x-rays and paper scripts for medication. It really is hard to imagine a time before the EMR, before a connected ecosystem, but certainly we've come a long way. Thanks again, Daryl. Really great points there.

So Shelley, I'll move on to you now. And we already mentioned the four preeminent health services across the precinct and how far you've come and certainly it's been no mean feat. But I'm curious again as to what you think the key ingredient was back then in keeping you connected and swimming in the same direction, but also going back to that concept of the whole being greater than the sum of its parts. What are your thoughts on key ingredients there?

Shelley Dolan:

I'm going to be very honest about this because I think it's important. We have enormous respect for each other as chief execs and executives across our four health services, and that obviously helps because we all like each other and we all have enormous respect for each other's brand and the enormous care and expertise in each individual hospital.

But running a very big collaborative project like this does bring out all the challenges that you can have when chief executives are used to leading everything within one health service. And so we did run into some issues. Remember that we were launching the three adult hospitals during the worst time in the pandemic in Victoria, and there were people in all of our health services saying, "We can't possibly go live. It will be dangerous. It will be unsafe." But we knew actually it was important for the management of patients during the pandemic.

And indeed, particularly at the Royal Melbourne, which had the biggest, I think, COVID load in the state as inpatients Epic was really important, the safe management of that. You have to hold your nerve, you have to lead with optimism and take... I totally agree with Daryl, never promise things that are completely undeliverable, but you have to take people with you and you have to give people confidence that this is going to work and this is going to be all right.

And it is natural that when people are being tried severely by the pandemic as we were, but there'll always be something, financial hardship or workforce issues, there will always be something that challenges health services. It is understandable that you can have times when the four leaders are not in close step with each other. And I think what we did, we only had one time like that that I remember, and we all came together physically and we closed the door and we said, "We are going to sort this out between the four of us before we leave this room."

And we did, and then we launched actually at the worst time of the pandemic and it was a success, but there was a lot of heavy lifting where people said, "We can't do this." It is a lot of work and it's that added work on top of people already working very hard. And I firmly believe even without a pandemic, people do feel that it's a lot of work and you need to go in every day and be full of optimism, be full of authentic caring about the people, but be very visible, and all of your leadership skills really come into play. And those moments of go live, because they're always at 2:00 in the morning or whatever, just to be safe if it doesn't work, you're there and you've got the whole of the executive there visible, all the senior leaders there so that you're supporting the team. And it's a huge celebration actually when you go live.

Dr. Paul Eleftheriou:

That's fantastic, Shelley, and thank you for highlighting the word optimism despite all the darkness of COVID. And I think the community would definitely thank you all as a precinct because without your EMR Epic and without that connected ecosystem, there'd be so many benefits that wouldn't have been achieved during that time. So thanks again.

And Daryl, I'll come to you. I know you've shared learnings as have many of you at the Parkville Precinct, shared learnings with your colleagues in New South Wales and ACT and other parts of the country. And notwithstanding there's some governance differences, but New South Wales are about to embark on a 10-year journey with more than 100 hospitals going live with Epic. What's your one final message to the leaders there?

Shelley Dolan:

I think I imagine that there are already established relationships, but if there aren't, that's important. There are always new people coming and going out there. So I think you might call it a community of practice or whatever, but ensuring that the chief medical officers are aligned, that the chief nursing officers are, that the chief operating officers, they're incredibly important to this, and that the CEOs, that that whole governance piece is set up and that you're working well together as teams at each level and at each layer almost before you start because this is a huge change management piece, and there will be times in each individual health authority or each network that it doesn't go as well or it will not go well all of the time.

And so it is really important to have that humility and that kind of reaching out to each other, recognizing that you can be the next one, that yours might be going swimmingly, but as soon as you take some pride in that, you will slip on a banana skin. So it's really having that camaraderie and collaboration that everybody is there for the citizens of New South Wales, and not for an individual organization or network. And that helping each other gives the best chance of success, I think.

Dr. Paul Eleftheriou:

Thank you for highlighting your earlier point about preparation, preparation, preparation and really being a partnership and working on the relationships. And finally, your earliest point, it's not just an ICT project, it's a big change management, people management, culture management project. So I'm glad you pointed that out.

And Daryl, from a clinical leadership point of view, what are your thoughts? What are your words of wisdom for colleagues in New South Wales?

Daryl Cheng:

I think clinical leadership is only really enabled by the fact that they have executive sponsorship. And I think that partnership between our clinical leaders and our executive who were 100% behind us all the way through made this possible.

If you have an executive group that is disconnected from a clinical leadership group or a ICT leadership group, it creates huge challenges because these issues in its truest form spread across the organization. Quality and safety is everyone's problem. Reducing inefficiency is everyone's challenge. And so making sure that there is close linkage between executive sponsorship with clinical leadership was paramount and we had that across the precinct and that made that project a significant success.

The other thing that's important is also Shirley talked about community of practice from a executive leadership perspective, there's also a community of practice from a clinical management perspective as well. We have good insights and tapping into different ideas from across the precinct and perspectives that we've never considered, especially across our Parkville Precinct where our four hospitals are very, very different hospitals with very different patient populations.

We have very different clinicians, but we have similar challenges that we need to solve across all these different patient subgroups. And I think that that's been a significant learning, that there is actually a great wealth of experience and knowledge even from people who don't walk the same, talk the same, but they are in the same kind of industry or craft group. They bring lots of insights to the table. And I've had more conversations with my colleagues across the precinct at a clinical leadership level than ever before the EMR, not only just about EMR-related clinical problems, but about approaching issues that we all have to deal with.

And I think I would hazard a guess that that would be the same at a executive level. This project has brought the team together across a whole range of projects that have expanded beyond the electronic medical record. And especially in New South Wales where they're going to a single digital patient record across the state, you're going to have these conversations with people from rural areas, remote areas, people from small hospitals and big hospitals, people from community outpatient clinics all the way to a tertiary, quaternary referral service. And having their insights is going to be really, really important across the board.

The last piece of advice around the clinical component is that the more that you can agree on, I use this word carefully because people see... sometimes they see this as a bastion to defend their special way of doing things in their particular hospital or their particular unit or department. And the more that we can agree on and not compromise, but see a common way forward, the more effective it's going to be in the long run. And here's the reason I say that. At its core, the electronic medical record is a tool that enables good healthcare. With that comes best practice. With that comes clinical data, and that information is very valuable and extremely important in the day and age we live in where it can help to shape the way we deliver care going into the future.

If we try and persist with our 100 special ways of doing things across our clinical groups, across different hospitals and units, we will end up with a problem on the other end where we are trying to utilize the skill sets that we have now obtained through machine learning and natural language processing and collection of data in predictive models and all these tools that can actually make our care safer and better. We will have disparate data collection from a whole range of different ways of doing things that actually make it not helpful and increasing inefficiency rather than improving. And so the more that we can improve at the front end of the, if I can call it the proximal end where we're starting off, the more ways that we can streamline to have a uniform way of collecting data or a uniform way of designing a workflow where we can all compromise a bit, but actually really what we're saying is that we've agreed on a minimum viable product or a minimum data set, the longer term benefits are significant.

And one of the mistakes that we are seeing, if I can call it a mistake, one of the things that we could, if I could give advice to our New South Wales colleagues or other colleagues who are going through this journey, if we could do things again, I would try and be even more streamlined when we first started because it will prevent the challenges that we face five or six years down the track where someone comes to me and goes, "Daryl, I want to look at all the diabetes patients across our precinct." And I go, "Well, if we had collected the data better and we'd agreed better at the start, I could actually help you answer that question."

And in hindsight, if you're able to do that, especially through a single digital patient record, you're going to have the benefits that will be reaped in five to seven to 10 years. Things that can't be seen now where people are just worried about how to transcribe a form or how to order a pathology request, but the long-term benefits at a organizational and a larger scale are significant if we can get the proximal ends right from a clinical perspective.

Dr. Paul Eleftheriou:

That's fantastic, Daryl. Really well said. And again, thank you both for those great words of advice. I'm sure even our policy makers and health ministers across the country will hopefully hear this and take a lot of value from it because there's a lot of investment and focus in digital health across the country in all our budgets, which is great to see.

It's a long journey, however, especially when you look at the variable paths people take across the country, but it's inspiring to see that governments across Australia, health services, leaders across the country are really aligning on how important digital health and an investment in that connected ecosystem is.

But I'll leave it there. Daryl and Shelley, thank you so, so much again. No doubt people listening in will find your advice valuable but also really pragmatic. We really appreciate your time. Have a great day, and thanks again.

Host:

That was Professor Shelley Dolan, Associate Professor Daryl Cheng and Nous principal, Dr. Paul Eleftheriou. You can read more about our thinking on digital health on our website. That's www.nousgroup.com. We'll also post a link in the episode notes.

That's all for this edition of Nous Cast. We'll catch you next time.