WARD ROUNDS INFORMATION SYSTEMS

WARD ROUNDS INFORMATION SYSTEMS  The Ward Round Information System (WRIS) is designed to support the work of all clinical staff in their ward rounds activities. Brief Description:  The system, when activated, automatically populates from the resident clinical database a pro forma report with the most recent relevant data about the patient, such as vital signs, pathology reports, and other diagnostic measurements, presented as a web page. The clinical staff then write their progress notes into the web page which converts the text to SNOMED CT codes and other relevant concepts and entities. The clinician is given the opportunity to change any analyses done by the processor. This accepted data is loaded to the patient record. The essential elements of this system, that is computing an extract of the patient record, accepting narrative input, and analysing the text for coding, is a productivity gain of itself, but more importantly, it also constitutes the beginning of a hospital wide Handovers System for use throughout each step in the patient journey. This system has completed testing at the RPAH ICU  and is in daily operation for ward usage. The impact of this system for improving the quality and safety of handovers has the potential to be very significant. This system is installed and operational in the ICU at the RPAH and has recently been installed at the Children's Hospital, Westmead (Feb, 2007). The system has the potential to be expanded to compute ICD 10AM and DRG codes with further research.   The SNOMED CT codes will index the clinical records and so enable records to be retrieved based on their narrative content (much like a medical Google but more accurately with a rich knowledge of medical semantics).  SNOMED CT is a medical lexicon adopted as the Australian standard language for use in medical notes Project Aim: The two aims of this project are: (1)to improve the efficiency of conducting ward rounds by supplying only the sufficient and relevant data set needed when assessing a patient, (2)to index clinical notes with a standard encoding system (SNOMED or an alternative) so as to improve the precision of reporting and to support later search and analytics technologies.  Project Objective:  The objective aim of this project is to install a Ward Rounds Information System in a department so that at the time of ward rounds the clinicians can obtain an extract of the patient record that contains the most up-to-date and relevant information about the patients and no more, and then enter the clinical progress notes into the WRIS for indexing according to SNOMED or similar terminology.   Brief Project Methodology:  The methodology is 1. Reverse engineer the existing clinical information system and establish its internal structure and the methods it uses to store and retrieve data. 2. Interview the staff and establish the minimal set of timely data they need for ward rounds and/or handovers 3. Design with the advice of the staff the presentation layout they require for the output data. 4. Design the method for retrieving the desired data from the host  clinical information system. 5. Test the system with trusted staff and develop methods for operationalising the system. 6. Train all staff to use the system. 7. Collect feedback on the use of the system and ways to improve it.  How will this Project improve Patient Care: This project will improve patient care by ensuring staff have the most timely and relevant data for the instances of decision making in their ward rounds.  It will ensure staff get the right pieces of information for their tasks. This will ensure trainee staff learn more quickly the essential information needed for particular types of decision making.   It will save staff time having to search through voluminous collections of data to get the data items relevant to their immediate task.  It will help train staff to use a stable terminology consistently.  It will create a doorway into other new technologies such as fast semantic retrievals from the clinical notes, and comprehensive real-time data analytics.   It can ensure staff acknowledge receiving certain pieces of obligatory information and hence improve patient safety.