The typical busy morning shift at hospitals around the country can be a mad scramble of clinicians trying to access patient notes.
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.”