An update of an electronic patient record system was seized upon by a Vancouver health authority as the chance to introduce an integrated care plan, reports Claire Read

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When Vancouver Coastal Health (VCH) updated to the latest version of its community electronic patient record (EPR) system, staff were clear the move was more than a purely technical one.

“We didn’t want the opportunity to only be a technical application upgrade,” reports Betty Da Silva, interim executive director of clinical information services at Provincial Health Service Authority, which covers Vancouver and the rest of the western Canadian province of British Columbia.

“From a clinical perspective, there was recognition an integrated care plan that could be accessed and updated by clinicians across the community space was central to transforming the use of the EPR for clinicians.” She continues: “There was a need for all clinicians to know who was involved in a client’s care, and for that information to be shared across our different community programmes.”

VCH runs three main community programmes – home health, mental health and substance use, and public health. All involve multidisciplinary teams, but traditionally there has been no shared language on care planning. Though the organisation’s EPR has long had a module to create plans for a client’s care, few clinicians were using it.

“There was a lot of individual practice in how staff were documenting their care plans,” reports Deborah Jeske, transformation lead, Vancouver Coastal Health. “A lot of it was in case notes, which made it very difficult to retrieve and for people to find.”

With the software upgrade, leaders across VCH were determined to change this state of affairs – finally harnessing the full power of technology to improve this aspect of services. “We recognised the need to make sure we had a system design that could support a care plan that could cross boundaries,” says Ms Jeske.

’Clinicians get into habits of just doing things, and they forget what they’re actually doing in their thinking’

Staff from the transformation and IT teams came together with Civica, the provider of its Paris EPR system, to discuss how the software could support a more integrated approach to care planning.

More uniting than dividing

“We started by focusing on the clinical practice,” explains Ms Jeske. “We took the clinicians in our working group back to their practice in how they care for their clients.

“So for every patient you need to have some type of an intake process and identify who they are, and then you do some type of an assessment, and then you determine what their needs are, and then you determine what your goal needs to be, then you determine what interventions you’re going to engage in so you can meet that goal, and then you’re going to deliver that care.

“Clinicians get into habits of just doing things, and they forget what they’re actually doing in their thinking – they go from the assessment phase to applying the intervention so quickly in their mind they’ve actually forgotten what that process is.”

The exercise underscored that individual clinical disciplines have more uniting them than dividing them. Explains Ms Jeske: “It’s getting that understanding of where the similarities are, and helping clinicians recognise they are not all that different from the guy across from them; they’re doing work in the same way. They just use different language, they organise it differently, they communicate it differently, but it’s essentially all the same work.”

Adds Michele Hazzard, project manager for the initiative: “At the beginning, when we were first trying to introduce the idea of this integrated interdisciplinary care plan, there were many clinicians we talked to who said: ‘That doesn’t apply, we don’t do a care plan.’ But it was down to terminology – some had a care pathway instead.”

It took a month of weekly meetings to get clinical agreement on an interdisciplinary care process. That included agreement on the definitions and components of care planning and a care plan. From there, technical requirements for the refreshed EPR module were developed – with constant reference to the previously agreed definitions.

Patient journey

“What was really helpful was that whenever there was an issue around the inclusion of a particular component, we would go back to remember we’re creating an integrated, interdisciplinary care plan so that everyone can understand what is happening with the client,” says Ms Jeske.

“It helped us move away from the use of acronyms, or the use of language that was only meaningful to, say, one type of discipline. It helped us always stay focused on what we were actually trying to accomplish.”

’Whereas before clinicians would have been quite happy to work in their silos, they now recognise the value of integration and are much more engaged in developing something truly integrated’

The new care plan has now been agreed, and will be rolled out later this year. It is built on a model of needs, goals and interventions. The hope is it will improve care, making a patient’s journey between disciplines and sectors smoother, and removing unnecessarily repeated assessments.

While the focus initially is on community care, staff are already looking ahead to the potential involvement of primary care and acute services.

“The vision is to support really seamless care across community, primary care, even acute and ambulatory,” explains Ms Da Silva. “It’s really to support care planning across the continuum, whether that’s community clinicians having access to the information or directly reporting information. We want to support continuity of care, including effective discharge planning and decision making in the acute sector.”

This is a prospect which is more appealing to clinicians than ever before, according to Ms Jeske. “I think clinicians better see the value in making sure we’re all on the same page with these clients because they’ve become so complex, and we are getting discharges out of acute that require a much higher level of care than they did five, eight years ago.

“Whereas before clinicians would have been quite happy to work in their silos, they now recognise the value of integration and are much more engaged in developing something truly integrated.”

Turning an IT update into a care rethink