Authors (including presenting author) :
Chui AKF(1), Ku BPS(1), Pang BCH(1), Leung KMW(1), Ho WKH(1), Chan JKY(1), Pang JYW(1), Cai KY(1), Cheung NT(1)
Affiliation :
(1)Information Technology and Health Informatics Department, Hospital Authority Head Office
Introduction :
The escalating service demand, arising from the growth of the ageing population, imposes significant impact on the healthcare services in the Hospital Authority (HA). Coping with such increase in service demand, emerging service models like nurse-led clinics and pharmacist-led clinics become popular nowadays. After nurses and pharmacists assessed patients, they would document the clinical findings in the nursing note and pharmacist note respectively. However, there is no effective way to inform clinicians for their clinical findings. Clinicians need to retrieve the essential clinical documentation themselves which would be time-consuming or sometimes clinicians are even unaware of the existence of such clinical documentation. It would definitely affect the quality of patient care or even impose risk on patient safety. In order to improve the information gap between nurses/ pharmacists and clinicians, a new clinical note linkage feature has been developed in the Clinical Management System (CMS). Nurses/ pharmacists can link their nursing note/ pharmacist note to clinicians’ consultation note or discharge summary. Clinicians can view the corresponding linking notes upon their next patient consultation.
Objectives :
1. To foster the clinical communication between nurses/ pharmacists and clinicians 2. To develop a clinical note linkage for nursing Note/ pharmacist note records to link consultation note or discharge summary in the CMS
Methodology :
Thorough clinical workflow study has been commenced on the new service model. The proposal of note linkage in CMS was developed and has been discussed in the Workflow and Decision Support Task Force (WFDS TF) and the Clinical Operation Support Working Group (COS WG). Opinions were sought from the working group members and they supported our proposal of the note linkage feature and the Head Office Information Technology and Health Informatics Department (HO IT&HI) has started planning for the CMS enhancement in late 2018. The note linkage includes two steps: Firstly, after nurses/ pharmacists provided the corresponding services to patients and documented their findings in nursing note/ pharmacist note in CMS, they can choose the desired consultation note or discharge summary for linkage. An icon would be shown in the linked consultation note/ discharge summary to indicate that there is a note linkage. Afterwards, upon patient’s next follow up or admission, clinicians would access the consultation note or discharge summary function in CMS. Clinicians can click the icon to view the corresponding linked nursing note/ pharmacist note, so that relevant clinical findings documented by nurses/ pharmacists can be viewed timely. The development of the note linkage feature was started in May 2019. Progress of development has been ongoing reported to the WFDS TF and the COS WG.
Result & Outcome :
The clinical note linkage feature in CMS has been rolled out in all the HA hospitals since January 2020. It is currently a one to one note linkage within the same hospital, that is one nursing note/ pharmacist note can choose to link with one consultation note or discharge summary of the same hospital. The snapshot usage of June 2020 was 672 times for Nursing note and 106 times for Pharmacist Note. Suggestions were received from the Clinical Informatics Program Executive Group (CIPEG) and supported in the WFDS TF for enhancing the user interface, including changing the note linkage icon and simplify the “Linked to” information. The new user interface will be released in 1Q 2021. In view of the foreseeable tremendous demands for the patient care services, we believe that there would be potential for the enhanced linkage in the near future.
