How to improve patient flow and discharge planning with electronic journey boards

By Kate McDonald, originally featured on Pulse+IT

Image: iStock

An independent study of the implementation of Alcidion’s Miya Precision FHIR events platform at Melbourne’s Alfred Health has found that adopting electronic patient journey boards (ePJBs) with two-way integration with EMRs and PAS systems can improve patient flow.

The study was conducted by Monash University and the Digital Health CRC and involved an evaluation that formally reviewed the impact and effectiveness of the Alcidion ePJBs across The Alfred, Caulfield, and Sandringham sites.

The final report found that there were improvements to access to patient information, consistent ways of working across multiple wards and to discharge planning, as well as a reduction in outliers, or patients allocated beds outside their proper ward.

Alfred Health’s deputy chief information officer Billy Wickham told the HIC conference in Brisbane this month that the ePJBs were implemented across 30 inpatient wards at Alfred Health in both acute and sub acute settings in 2022 and 2023 as a step in the organisation’s digital transformation journey, following a significant uplift in the hospital’s Oracle Health (Cerner) EMR in 2018.

According to Alcidion, Miya Precision was chosen to address the challenges presented by outdated patient tracking systems, and to take advantage of FHIR based real-time bidirectional integration to aggregate data from the EMR and Alfred’s iPM patient administration system from Dedalus, along with numerous other systems to provide a single view of the patient’s information.

Alcidion’s chief marketing officer Nick White said Maya Precision can plug into the hospital’s existing applications, convert the data into FHIR, and put that data on a FHIR event bus. The patient flow application sits on top of the FHIR event bus and provides a view of the data in an aggregated form.

“It’s two way, real time integration, so if you write something into the patient flow system on the ward, that will be written back to the EMR or PAS or the relevant system,” Mr White said. “If you update it in the PAS or the EMR or one of the other systems … that will be pushed through into the patient flow system. It’s real time integration with all the systems.”

The Monash DHCRC study found that prior to the deployment of Miya Precision, wards experienced a 25 to 40 per cent discrepancy between patient information in the EMR and the whiteboards used to manage patient care.

Mr Wickham said with bi-directional integration between the EMR and the electronic journey boards, there is now 100 per cent alignment between these sources.

“This includes really important information that’s critical or essential at the time at the ward level, when guiding care,” he said. “Referral statuses – referrals have been made and key risks such as behaviours of concern, patient falls, pressure area care, fasting statuses, these sorts of things, they’re all integrated between the electronic journey board and the EMR.

“This also goes further to reduce duplication of work, so clinicians aren’t having to document in multiple places. ie record these statuses in the EMR and then have to update them on the manual whiteboards at the ward.”

There was also 67 per cent decrease in call duration within the health service’s bed assignment office, Mr Wickham said. “For anyone that has spent any time around or worked within the bed assignment office, you’ll know and appreciate that a lot of their time is spent gathering that information from the wards.

“Lots of phone calls across the day interrupting nursing staff on the wards to try and get those updates on current bed status and the many missed calls that go into that.

“The electronic journey boards have increased central visibility of that information, so bed assignment staff are able to see where there are vacant beds across the health service. This also goes further to support clinical leadership and operational leadership to make decisions in real time.”

Outliers, discharge planning and length of stay

The study also found the ePJBs could reduce outliers, or patients that are admitted to inappropriate wards. Mr White said studies have shown that when a patient is an outlier in a hospital, length of stay is typically twice that of the appropriate ward and there is a 40 per cent higher chance of mortality associated with being an outlier.

“There are obviously different conditions where this is going to be heightened,” he said. “I think stroke sits at the top. If you’re in the wrong ward as a stroke patient, it’s the worst possible scenario. So outliers are something that we focus on in our software to try and reduce.”

Mr Wickham said Alfred Health had seen a 7.78 per cent reduction in outliers following the implementation of the electronic journey boards. “About 15 years or so ago as a health service, we began an organisational-wide transformation journey to address patient flow challenges,” he said.

“I think many states and health services would have been a similar predicament at the time, and it was put to health services to hit their four-hour wait targets in ED. As a health service, we recognised that this wasn’t an issue just for the emergency department, this was something that the whole of the health service needed to address.”

The report also found reductions in length of stay even though Alfred Health is a top ranking hospital in terms of its focus on length of stay. Mr Wickham said that over the 12 months of the study, there was a reduction in length of stay, both in inpatient settings and ED as well, but a number of factors went into that. Still, “it’s a good indication of overall improved bed availability across the health service,” he said.

There were significant improvements in discharge planning, with the estimated date of discharge (EDD) now recorded almost every time. Mr White said numerous studies had shown that if you don’t have an EDD in a patient’s record, it essentially means that a longer length of stay.

“If you’re not planning for discharge, then you will probably have a longer length of stay,” he said. “That’s really where it lands at.”

Mr Wickham said there was an improvement from about 61 per cent to almost 100 per cent with the implementation of electronic journey boards.

“What’s really exciting … is that staff are now required to put into the electronic journey board a reason for changing that estimated discharge date, and they’re also required to record their discharge barriers that we can then centrally access and view to understand bottlenecks across the hospital, understand patterns and behaviour of clinical teams, staff on the wards and patient journeys.”

Consistency in ways of working

The final finding from the report was consistency in ways of working across the 30 wards. Mr Wickham said Alfred Health had completed a project many years ago to implement a somewhat standardised approach to patient journey boards.

“But inevitably, over time in different clinical areas, they evolve, they add things, they take things away, and the information becomes different from ward to ward,” he said.

“So we implemented nine standard boards across the health service. And importantly, within those nine standard boards, there’s 80 per cent consistency, so 80 per cent … is the same from ward to ward, and then those variations exist within that 20 per cent.

“For clinical staff as they are moving around from one ward to the other, from clinical teams seeing their patients on one ward to another, they are going to see some consistency in the information, the way that’s displayed, and therefore make better and quicker decisions.”

Mr White said Alcidion had 200 different columns in Miya Precision’s catalogue that health services can choose from to show how information should be displayed.

“Typically, what you’ll do is you’ll have a look at clinical workflow and choose the columns that are relevant for the clinical workflow,” he said. “80 per cent of those columns are exactly the same from ward to ward, and then 20 per cent are for that particular clinical workflow.

“In a maternity ward, we might have some columns that are relevant for the maternity clinical workflow, so nine variations, which means our clinical staff can go from ward to ward, and what they’re going to look at on the board is already familiar to them.

“There might be some slight nuances for that clinical workflow that they can pick up on pretty quickly.”