Gary's HASTools EDIS extension software

see also:

• Emergency Department Information Systems (EDIS) for Australia
• Gary's HAS Tools screen shots

• a separate front end developed using Delphi software (currently in RAD Studio XE one of the most powerful native Windows compilers available) and designed to be an extension of iSoft HASS EDIS product.
• the system has an emphasis on efficient data entry, clinical decision support and patient flow management and in addition, provides a powerful reporting tool.
• currently works on v.9.4x of the HASS EDIS using Sybase and MS SQL Server database backends, and if I can get a test site, I will create a version for Oracle databases.
• multi-tiered, object-oriented, rapid application development architecture designed to use Embarcadero's MIDAS client dataset technology which means no additional database systems licence fees as with use of Omnis, and means simple end user installation (once the exe file is customised for a hospital's requirements) with only the exe file - no extra dll files or Windows registry edits required.
• currently is native Windows 32, but with potential for native Win8 multitouch support, Win 64, and Mac OS versions in 2014.
• the advantages of native application development instead of web-based application development include:
  • a much faster development cycle,
  • a far richer user experience which is totally independent of which version of browser the user is using
  • rapid user logon and switching via staff ID readers or keyboard shortcut (eg F9 key) without having to alter current view of the application.
• offers multicampus support even when each campus EDIS data is on different database servers
• has a multitude of additional functionality for improved efficiency for clinicians and more versatile reporting.
• allows rapid switching between campuses, even on different databases
• graphical display of patients in a department map with ability to move patients between locations.
  • if you have used one of these, you will never want to go back to a system without one!
• integrated clinical calculators such as resuscitation equipment and drugs, etc
• integration of clinical guidelines (eg. to this wiki) linked to either triage symptom code or final diagnosis code
• intelligent compensible billing reports for TAC, WC, DVA patients which assesses procedures performed and whether a consultant has seen the patient or not. The data is provided in Excel format for finance department to import into their systems.
• contact Gary.Ayton at wh.org.au (replace at with @) for further information.

• an EDIS MUST make ED staff more efficient otherwise it is not worth having
• an EDIS should improve patient care and support patient flow and clinical decisions
• an EDIS should be responsive to changing business needs and rules - there is no point having a six month time frame to create an enhancement for such events such as altered business rules relating to swine flu epidemic, new targets such as NEAT, etc.
• IT systems which should be hospital-wide should not have a dedicated EDIS solution but the EDIS should leverage from these systems
  • electronic notes
    • there is little point having an EDIS that forces clinical staff to laboriously type all their clinical notes into the system if these will not be available to inpatient units because they are not part of an hospital wide electronic medical record - this is counter-productive, and a better solution would be document scanning. This is particularly the case when such notes may actually increase patient risk as they not only make staff less efficient with less patient care time available, but they may not convey critical importance to other staff because they lack ability to create emphasis, or rely on words to convey meaning.
  • electronic results checking system
    • there is little point having a dedicated electronic results checking/auditing system if the rest of the hospital does not also utilise the same system - a large risk for hospitals is follow up of abnormal pathology and radiology results - you can't just rely on an EDIS tool to manage this.
    • nevertheless, in the absence of hospital-wide electronic order entry systems, this functionality has been added very successfully to the HASTools functionality (see below).
  • electronic prescribing
    • there is no point having a dedicated EDIS electronic prescribing solution if the rest of the hospital will not have ready access to medications and iv fluids given in the ED.

• ability to consolidate data such as alerts, past visits and discharge letters from a second campus EDIS database and rapidly make available to clinicians on both the printed cas card and the screen.
• instant visual display of how busy your campus is compared to a 2nd campus - very handy for re-directing GP referred patients to a less busy campus
• can also rapidly choose to utilise a different campus without starting another application

• ability to display only those patients who are paediatric, adult, EOU or streamed to fast track

• from a simple SQL statement saved in a database record, end users can automatically, and without database skills achieve the following from the single base report:
  • summarise data according to a specified time period category such as hour of day, day of week, date, month, year, or even by 8 hour shifts
  • choose only adults, only paeds or both groups
  • export the resulting data to MS Excel spreadsheet for further data analysis or charting
  • drill down on summary data to display the actual patient attendance records, then further drill down on the attendance record to get a list of past visits and discharge letters to make interpretation of the data more efficient.
  • randomly select x number of patients from the result set for quality of care auditing or research purposes

• busy ED's may have over 150 EFT of staff, many of whom rotate every 3 months.
• this feature allows someone to double click on an treating doctor, nurse, clerk, mental health care worker and display their photo ID and their HAS staff level (eg. registrar, intern, etc).
• this has proven of great help in finding who is looking after a patient, and also helps to improve staff morale by breaking down communication barriers.

• just right click on a patient and if this functionality is enabled, it will open the third party software on the current patient

• the system provides an excellent user interface to assist staff in determining who should be seen next according to triage category and arrival time, and allows rapid data entry of treating nurse or treating doctor with time stamp as well as a prompt to back date time stamp if current time is not the actual time seen.
• the problem in busy urban EDs in particular, is that patients with triage 4 or 5 may wait more than 8 hours before they manage to get to the top of the screen of next to be seen as new arrivals with higher acuity take priority.
• HASTools addressed this issue in two ways:
  • patients waiting in excess of a specified waiting time for their triage category had a secondary urgency code (normally equal to their triage category) upgraded by one which would allow a triage 4 patient to be placed ahead of a newly arrived triage 3 patient if they had been waiting more than 90 minutes already.
  • patients waiting more than 6 hours are automatically placed at the top of the queue irrespective of triage category.

• examples include:
  • warnings to ensure senior consultation prior to discharge for certain patient groups such as triage 1-2, age , 3 months, unscheduled representations within 48 hours
  • patient alerts such as allergies

• unfortunately, it is not uncommon for IT systems to go down in hospitals despite their 24×7 operation
• such outages have a critical impact on the efficiency of an ED
• HASTool's was architected specifically to help mitigate this by allowing the data to be held in a local cache on the client computer and this can be viewed and a detailed handover report can be printed to allow manual contingency plans to be efficiently enacted.
• all other systems including HAS EDIS (which results in the dreaded black padlock and requires ctrl-alt-del to kill the application if there is an outage) and Citrix-based systems will suddenly lose data for the ED and the ED staff will then have no idea of which patients are in the ED or who have not been seen yet, or even who is attending them.
• HASTools addresses these issues and in addition has an active database lock surveillance system which helps to reduce database deadlocks.

• a dedicated screen to assist in clinical handovers which normally create a high risk scenario for patient care
• the screen allows rapid access to path/radiology results, time of impatient consults, inpatient registrar paging, bed request input, change of attending doctor and a check list to prompt clinicians regarding risk management issues such as - medication and fluid charts completed, abnormal results communicated to inpatient units, and lastly, and perhaps most importantly, a live note of the patient summary which is visible on the main daily list screen and on the HAS EDIS clinical screen.

• clinicians can easily and rapidly add a patient or a procedure to an electronic log book which can later be exported to MS Excel for CME purposes - it is just a simple right click on a procedure or a patient, log on if not already logged on, and optionally add a note to yourself.

• want to reduce the time it takes to complete the injury surveillance data screen by over 90% for most patients - let the intelligent speed buttons do all the work for you!

• integrated system allows easy import of spreadsheet-based rosters from medical workforce units with efficient linking to paging numbers based on either position (eg. night medical registrar) or staff member.
• ED staff can then rapidly determine who is rostered on that day, and can rapidly send a pager message via HASTools and automatically, a consultation is added to the HAS EDIS database with consultation type (eg. general medicine), time stamp and pager number used.

• allows more detailed auditing of EOU/SSU utilisation including by ED consultant or by careplan.

• ability to create a To DO task relating to a patient (either in ED or discharged)
• task remains visible until tagged as completed, even if patient has been discharged
• very useful for managing high levels of handovers, as well as for those times when pathology phones through an important result on a discharged patient - those little pieces of paper we usually use tend to get lost, or we go home before the medical record arrives and an opportunity to avoid adverse patient outcomes is potentially lost.

• finding dedicated certificates is often frustrating
• the road trauma certificates are sophisticated and include pictures of the body
• HASTools prints an almost exact replica with typed patient details and attending doctor and hospital details leaving only a few fields for the doctor to complete and sign on the printed form.

• using a simple webcam at patient registration, the system is then able to print the photo ID onto cas card, Bradma label and also display on the screen as part of the daily list or on any of the patient attendance screens such as the clinical handover screen.
• this functionality improves patient care by:
  • reducing mis-identification of patients when calling them in from the waiting room - how many times does the wrong patient respond to your verbal call and then due to communication issues fail to correct the error resulting in incorrect clinical expectations, incorrect investigations and worse, incorrect identification of pathology specimens.
  • reducing the risk that staff place the incorrect Bradma label on a pathology or radiology order resulting in situations such as the wrong patient getting a CT scan despite the other usual checking systems in place - once the incorrect Bradma label is used, it is difficult to prevent the subsequent system errors. The photo ID on the label will help prompt the doctor to realise the label is not for that patient.
  • electronic systems do not mitigate the above, they just make it MORE efficient for staff to make mistakes such as typing a discharge letter after accidentally selecting a different patient, discharging the wrong patient or printing a sick certificate. The risk escalates with electronic order entry systems and electronic prescribing. A photo ID displayed on the computer screen should help to reduce such errors.
  • photo ID on the handover screen helps ensure the verbal handover is relating to the correct patient and aso acts as an aide memoire, particularly when handovers in busy ED's can be more than 50 patients at a time.
  • the photo ID capability will also potentially assist in serious burns patients such as occurred in the Black Saturday bushfires when early photography proved to be critical in later identification of patients.
  • the photo ID could also assist in the management of patients with dementia or recommended under the Mental Health Act who go walkabout in the hospital, or worse, abscond and third parties such as police are enlisted to find them.

• the default log on to the system is generic and can be set to allow full use apart from editing discharged patients accessed via the search screen (this currently requires a super-user log on).
• in addition, whilst logged on generically, a user can log on as a specific user by clicking on a button (or hopefully in the near future by RFID proximity tags such as staff ID tags).
• this means that the audit trail of main edits includes the staff ID.
• it is also of benefit to the staff member as their HAS EDIS ID is automatically used for processes such as creating a patient expect, and for other staff lookup processes, their ID is automatically located for them.
• there is the capability to ensure that the main government required edits are ONLY possible if a specific user is logged in, while other actions such as moving patients on the department map, updating handover information, etc does not require a specific user to be logged in.
• this hybrid approach gives the best of both worlds - fast efficient general use while sensitive data can be mandated for individual user audit trails.

• efficient, easy to use interface to ensure rapid selection of pathology and radiology tests using either:
  • order sets - just click a button and default tests will be added to checkboxes which user can uncheck or add more to
  • checkboxes for common tests
  • extended lookup for less common tests via usual HAS EDIS style touch screen button interface
• utilises the handover clinical comments field as the clinical notes to be printed on the request form, further improving efficiency
• provides all needed patient-centric data for the forms including interpreter status, LMO, ED treating staff, Medicare number, etc.
• provides specimen tube information for each test to assist ED staff
• provides Kestrel pathology test codes as well as bar code images of each of these to assist pathology staff efficiency
• intelligently determines which shift is currently in progress and looks up the ED roster database and prints the current ED duty consultant names and extensions on the radiology forms to make it more efficient for radiology staff to contact them.
• intelligently determines whether or not to print various support items on radiology forms such as:
  • request for pregnancy status if female and of child-bearing age - this information will be flagged for user update within the HASTools application from triage, to patient list, to clinical screen and finally the order entry form, thereby being the first Australian EDIS application to emphasise the importance of pregnancy status throughout the ED process, not only as a risk tool to prevent inadvertent exposure to radiation, but also to remind staff or possible life threatening pregnancy-related conditions such as ectopic pregnancy, and to help prevent inadvertent use of teratogenic medications within the ED.
  • request for metformin usage status, contrast allergy and creatinine level if a contrast CT is selected
  • request for additional data on IHD risk factors and cardiovascular medications if request is a myocardial perfusion study such as a MIBI scan.
• prints the name, staff position and provider number of the person printing the form (ie. the person currently logged in).
• see HASTools EDIS Order Entry Help

• helps avoid inadvertently ordering path/radiology or labels for the wrong patient
• computer systems can make it MUCH EASIER for staff to make mistakes by allowing them to quickly click on the wrong patient, and because a patient name in itself may not be sufficient to trigger their consciousness that an error has been made, it is critical that additional measures be taken to address this.
• BEFORE a staff member can order any of the above, as a double check that they clicked on the correct patient, the user is displayed a dialog box containing the essential patient details including triage notes and clinical handover notes, as well as a photo of the patient if webcam functionality is used.
• BEFORE a CT scan is allowed to be ordered, the system checks for compatibility of the CT scan type with the triage symptom code, if it seems incompatible (ie. perhaps the wrong patient still has been selected despite the above), the user is given a last chance to triple check that this is indeed the correct patient.

• iterates through the procedure table to determine if eligible for ED Admission, if no procedures found, present the doctor discharging the patient home with a easy to use dialog containing checkboxes to further check if that presentation was eligible for an ED Admission.
• if deemed eligible, automatically sets disposition and depart codes to HOME - ED ADMIT and alerts the clerks to update PMI system by automatically printing an ED Admission form with the reason for ED Admit, time stamped and with user name printed.
• the system handles type B,C,E and O admissions with minimal staff effort.

• forget user names and passwords which are just one more detail that staff need to remember, and time consuming to type, and in the end, do not provide the security level governments tend to prefer to ensure managers do not manipulate data without being able to be held accountable via audit trails.
• forget using a swipecard to log off Windows and switch to another Windows user - that is far too time consuming - sorry Citrix fans - Citrix user switching is just not efficient enough in the ED, particularly during handover periods when you are iterating through the list of patients yet may wish to log on as a different user part way - not a great time to switch and lose current screen view!
• just buy a cheap (~$A150) PC/SC industry standard 125kHz Omnikey smartcard proximity reader such as a Omnikey 5325 CL USB reader or Omnikey 5125 USB Prox reader¹⁾, install the PC/SC Windows drivers, and add each staff member's ID badge electronic code number to the HAS staff lookup table, and you are set to go.
• HASTools is fully functional without a specific user logged on (ie. you can view patients, use the department map, search for patients, run reports, etc), you just cannot edit VEMD sensitive data unless a user logs on, and now with RFID, this is just a swipe of their staff ID badge onto the reader, and either time out or F9 to log user off to return to read only state.
• this is how ED software should run - optimised to provide efficient work environments

• bed managers are automatically paged when a bed request is made and again at intervals for patients with prolonged ED length of stay
• bed managers can also be automatically paged on arrival of a triage 1 patient to assist in managing the new 4 hour ED length of stay KPI

• automatically refreshing, read only view of patients' journey in ED optimised for display on 50“ 1920×1080 LCD panels

• for instance, automatic creation of occupancy charts comparing workloads in each campus ED such as this page

• via redcoal SMS texting services
• medical registrars can be automatically notified of the arrival of triage 1 patients for instance

• pages the medical registrar with a reminder each hour they have not come to ED and clicked on the consults that they have attended that patient.
• this also helps patient flow auditing by forcing registrars to enter the time they attended.

• accurate capture of discharge time is problematic as it relies on medical staff to complete mandatory data fields and this prevents the nursing staff discharging a patient in real time.
• a clever solution to resolve this dilemma has been implemented which not only simplifies nursing computer work while keeping the “discharged patient” still visible in the system for medical staff to complete the record, but helps ensure the actual discharge time is recorded, and not the time that the medical staff finally got around to completing the data entry.

• senior doctor can allocate themselves to a patient and commence treatment / investigations and the waiting time to see doctor is ceased but ED staff can still see that the patient has not been allocated to a definitive treating doctor, and the patient remains in the waiting queue as per their triage priority
• ability to write brief rapid assessment notes which can then be printed on the ED card when the definitive treating Dr is allocated to the patient

• this system allows those doctors who wish to hand write their notes to continue to do so, or, allow type written notes to be recorded electronically with the assistance of stored user-created templates and then printed onto the ED card and further annotated with hand drawn images as required.
• the ED card can then be scanned into the EMR as per usual scanning processes

• displays important events on a timeline for a given patient including:
  • arrival / triage
  • hourly flags including the important 4hr NEAT target flag
  • time seen by ED senior Dr for rapid assessment and initialisation of Mx plan
  • time seen by treating nurse
  • time when first placed into a non-waiting room loaction
  • time pathology/radiology/procedures performed
  • time seen by treating Dr
  • time consults requested
  • time bed request
  • time transfer to EOU

• end user only needs to copy a shortcut to their computer and the software will self-install in seconds and notify user when a new version is available
• new versions are automatically installed when user closes application and re-starts it.
• no additional licences required, thus can be used on wards and in administrator's offices

• database deadlock detection and minimisation functionality
  • continuously monitors locks on the database and if these become excessive, halts further database requests
• troubleshooting tool
  • detects common issues such as network cable unplugged, incorrect Window's user which may impact printing or file server access issues, database locks.
• quick links to major websites
  • eg. ozemedicine wiki, Australian Therapeutic guidelins, MIMS drug database, intranet pharmaceutical approval system
• drug and resuscitation calculators
  • automatically determines approximate weight for child's age and advises on resuscitation tubes, drugs, and fluids
• clinical guideline linked to symptom or diagnosis codes
  • automatically opens web sites linked to the patient's allocated code
• links to online patient information sheets
• asthma discharge plan creation
• sick certificates and carer's certificates
• discharge letters with option of user-created templates
• log interesting Xrays and generate report with quick links to view the PACS images
• view full audit trail of edits in a user friendly view
• view audit trail of deleted patients to determine if someone using EDIS has accidentally deleted them

• allows ward staff and administrators, as well as thouse with smartphones and WiFi access to view in real time the ED information such as:
  • ED bed requests
  • ED workload
  • ED current patient list
• available within Western Health's intranet via web page