Electronic Outpatient Outcomes | i3 | institute for innovation + improvement

We are developing a system to better understand the purpose and outcomes of outpatient appointments to help us manage demand and improve practice

Opportunity

Waitemata DHB completes approximately 20,000 outpatient appointments each month and demand continues to grow. We need to understand the reasons for and outcomes of our outpatient appointments to better manage our resources and service quality. Clinician-confirmed diagnoses are critical to our understanding.

Traditionally our outpatient clinicians have used a paper outcome form - without a diagnosis - to record administrative outcomes of appointments eg whether a follow up appointment is required.

Our rheumatology outpatient service recognised the value of adding a clinician's diagnosis to their paper outcome forms. They trialled a paper outcome form with the diagnosis included, but this was difficult to expand to other services as it was complex for administrators to manage. In addition, the paper-based process was associated with risks that included lost forms, poor form legibility and errors associated with duplicate data entry.

Systematic electronic recording of outpatient diagnoses will help us to:

Improve Patient Outcomes

Monitor outcomes that matter to patients and clinicians for specific diagnoses
Monitor how we are doing against best clinical practice guidelines for specific diagnoses eg seeing people with specific diagnoses within clinically acceptable timeframes, making sure we see them enough times
Identify areas where we are doing really well / doing not so well
Monitor whether or not strategies / interventions to improve processes or outcomes are working

Improve Patient Experience

Provide better information to patients with a specific diagnosis about:

what services they can expect from us, eg how many follow-ups and over what period of time would be usual for this diagnosis
what outcomes they can expect from our service

Patients with specific diagnosis could provide us with information about what is of most importance to them, so that we can make sure that our service aligns with their needs
Minimise appointments unlikely to deliver much clinical benefit for patients with specific diagnoses

Aim

Develop, implement and evaluate an electronic version of the paper outcome form including diagnoses, with a single outpatient specialty over a three month period.

Intervention

We chose our outpatient Rheumatology team as they had previously added diagnoses to their paper outcome form.

Rheumatology Outcome Coding Form

We worked together to further develop their diagnoses list including SNOMED codes to make sure the information collected would be useful for our clinicians.

The proof of concept was a collaborative project with Orion Health under Waitemata DHB’s partnership agreement.

Electronic Outpatient Outcome Form (Concerto)

Impact

Seven doctors, two nurses and six administrators used and evaluated the form over 11 weeks. They completed a total of 463 forms.

eOutcomes Form Proof of Concept

We completed an evaluation to understand:

impact on administrative workflow
impact on clinical workflow
data capture and extraction

Impact on Workflow

The form reduced the number of administrative steps from eight to six steps by eliminating processing of paper forms
The administrative burden for our clinicians increased as the e-Outcome form took five minutes to complete compared to 1-2 minutes taken for the paper form

Data Capture and Extraction

We were able to extract reasons (diagnoses) and administrative outcomes (type of follow-ups required) from the e-Outcome form during the 11 week proof of concept

Benefits

Electronic visibility of diagnosis
Improved communication between clinicians and administrative staff
Better visibility and access to forms

Feedback

Clinicians and administrators told us:

"It’s certainly made bookings more accurate and timely – especially for short interval appointments" - Rheumatologist

"It helps to eliminate the sheer number of emails between clerk and clinician" - Administrator

"All the data was there and I also got to review the diagnosis … it was quite useful" - Rheumatologist

Lessons Learned

Our clinicians and administrative staff requested further improvements to the e-Outcome form. They asked us to:

reduce the number of clicks in the form
improve the screen layout
pre-populate the form as much as possible

The form needs to be:

intuitive, easy to use and viewable on a single screen without the need to scroll
integrated with our patient administration system (i.PM) to enable pre-population of data
as quick and easy to complete as possible (given that the paper form only takes seconds to complete) and involve as few clicks as possible