Out with paper, in with digital

Aim

The development of a centralised, digital solution to replace the decentralised, paper-based tool utilised for the state-wide Home Enteral Nutrition Service.

Outcomes

• Best practise youth engagement to guide the establishment of MSH Youth Advisory Program
• An organisation commitment and financial investment to the sustainable development of a MSH Youth Advisory Program

Background

The Home Enteral Nutrition Service (HENS) provides over 5,500 Queensland Health (QH) consumers with access to specialised nutritional products for home use. Consumers requirement for HENS is variable, with some persons only needing short-term access, whilst others are reliant on the service lifelong. The specialised nutritional products are prescribed by over 650 QH Dietitians for the improvement or maintenance of nutritional status in chronically or acutely unwell patients.

An external review of the HENS was undertaken in 2021, with opportunities for improvement identified across the entire program, including the prescription and ordering process. The clinician prescription and consumer registration processes required the utilisation of an Adobe form that was not supported by current the QH software version and relied on a specific individual, not routinely engaged with Dietetics, to undertake updates and modifications. The prescription process required clinicians to enter consumer demographics, select the appropriate nutritional products and consumables, manually calculate and enter the prescribed quantity, and email to the third-party logistics company. Each individual patient had an individual form, for a specified timeframe, for each nutrition prescription.

A separate local database was required to collate and store patient information and nutrition prescriptions. Consumers are required to initiate contact with the third-party logistics company to order their nutrition products, prescribed by the Dietitian. The consumer requires a copy of their HENS prescription and registration form to be able to confirm their requirements with the external company. The were several issues identified with the current state including no centralised repository of consumers accessing HENS; no ability to identify nutritional products in use by individual consumers; no ability to systematically collate the history of consumers clinical prescription; and significant variances in record maintenance and processes of Hospitals and Health Services (HHSs) across the state.

The challenges encountered by the third-party logistics company predominantly concerned the inaccuracies with the registration processes due to clinician errors and the manual data entry requirement to establish consumer and prescription details within the company’s external system. The lack of standardisation and visibility of the HENS program across the state, combined with the labour intensive, manual processes required to manage the program, and the complex interplay of multiple key stakeholders including clinicians, consumers and an external company, required an agile digital solution.

Discussion

Project success was facilitated by the Dietetic professions’ shared understanding of the problem, and the implications of the problem for stakeholders, specifically clinicians and consumers. The external review of the HENS program, lead by the Office of the Chief Allied Health Officer (OCAHO), highlighted the deficits and challenges of the current-state program, and created an environment focused on service improvement, equity and accountability. The context in which the digital solution was implemented was one of significant change. The major review of the HENS collimated in refinement of service eligibility and changes to the program funding arrangement, hence the opportunity to change the system clinicians utilised to provide the program to consumers was viewed through an improvement lens and met with acceptance by clinicians. The implementation of a digital solution was not without challenge. The reach required for successful implementation was reliant on the governing body’s endorsement, profession leadership and robust networks, project enabling factors deemed paramount to its success. The REDCap  application has limitations, particularly when adapting the use of the application for functions outside of its usual purpose. Compromises with end-user ease of navigation verses application function were required to be made during the development and build stage of the project.

The strengths of the digital solution included:

• accessibility for over 650 clinicians across the state due to the utilisation of a QH supported web-based application.
• centralised storage of consumer information and nutrition prescriptions enabling statewide distribution of HENS program correspondences with consumers. The ability to export data and demographics of all consumers, or a specific cohort of consumers, from a centralised repository has significantly reduced manual processes for clinicians.
• enhanced data collation and visibility for activity and financial management through the utilisation of standardised data collection methodology and the reporting functions of the application.
• centralised system allowing for statewide management of nutritional  products and consumables and procurement processes.

The weaknesses of the digital solution included:

• inability to prevent clinician-user errors when required steps are not completed as instructed
• complex reporting requirements require data manipulation for end-user functionality Improvements to the implementation of the initiative include the roll-out of all application functions from go-live.

Whilst the core requirement of the project focused on the clinician prescription and consumer registration process for go-live, the post-implementation roll-out of system functions for monitoring and reporting has potentially impacted clinician uptake of these capabilities. The HENS REDCap project developer has undertaken demonstrations with the Home Dialysis Service to showcase functionality and transferability of the initiative. Clinical services, in which defined consumables are required to be ordered for consumer use in the home, could utilise this initiative to improve efficiencies for clinicians, standardise practice and enhance accountability. Further opportunities for the initiative are progressing including development of functions for statewide monitoring and reporting of service quality indicators, including consumer reported experiences surveys, and integration with  PowerBI to enhance reporting functions. Future integration with the Queensland Master Patient Index (QMPI) database for the downstream automation of consumer demographics would also be ideal for the project.

References

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