Marand had the honour of being part of a great change that the University Children’s Hospital Ljubljana (UCHL) went through – going from a paper-based to a paperless hospital. One of the specialists who guided us and the hospital during this process was a paediatrician, doctor Gorazd Kalan. He’s been a doctor for more than 26 years. He specialised in paediatrics and intensive care medicine and has been working as a paediatric intensivist at UCHL for the last 25 years. From 2010 to 2018 he was the director of paediatric intensive care unit at UCHL.
We invited him to help us better understand why it is so important for hospitals to become paperless, which healthcare applications can help solve doctors’ and medical teams’ challenges and thus improve their work and patient outcomes, and what are the benefits of being vendor-neutral.
Dr. Kalan, can you tell us what a director needs in order to successfully manage a hospital ward?
‘First you need a dedicated team of professionals; doctors, nurses, physiotherapists and additional supporting staff. This team then needs a modern, up-to-date technical support, good software and hardware connected into a network. Good clinical information system enables us to use our medical devices in the most optimal possible way.
Having a good clinical information system also includes having different applications installed on our smart phones and computers which help us improve the processes in a hospital. Me and my colleagues decided to start using a clinical information system about 10 years ago with the goal of improving our main clinical processes and someday become a paperless hospital.’
Why have you decided that your hospital should become paperless?
‘The decision to take UCHL on a journey to someday become a paperless hospital was not very intentional. But when we managed to convince the hospital’s upper management and our main investor – the Ministry of Health – that our medical devices cannot be optimally used without the support of good software, our journey began.
While implementing the software we also realised that modular software is better than monolithic because it enabled us to gradually cover certain specific functionalities and processes in the hospital.’
What was your role in UCHL’s journey to becoming a paperless hospital?
‘Within the University Medical Centre Ljubljana, UCHL is like a small clinic on its own. It’s the only tertiary institution of this kind, where paediatric patients with the gravest conditions are being treated. I was a member of a smaller group inside the hospital which defined the needs and functionalities to be covered by the software.
So, first we had to set priorities; what should be developed first, what should be implemented on a broader scale, which functionalities can be used at the hospital in general and which only at certain departments. Gradually, we added functionality after functionality to more and more specialities and covered more and more processes running in the hospital.’
How do you see the role of doctors in health digitisation?
‘Health digitalisation in hospitals has two phases; the development of software and its implementation. Since doctors are the end users of the software, they should play a big role in this process. They should define the needs and functionalities covered directly by the software in the development phase.
Before the process starts, doctors and other clinical personnel must see the benefits of digitisation, especially because the implementation phase is so demanding. Doctors and other clinical personnel suddenly have more work; they simultaneously must work the old way; on paper, and the new way; using technology. But when they see how big of an impact an optimised clinical information system has on their interaction with patients, they will join the journey to a paperless hospital.’
How did you know what exactly your hospital needed? Where did you find the most suitable product/system? Were you already using any technology before, and why?
‘Almost 20 years ago, me and my friends developed our first healthcare application. First, we created a simple patients’ database. Then we developed a new application, which used the data from this database to draw report charts. Other wards had similar applications, and even though they were not connected into a network, we still had a chance to experience how software can help us with our work.
Some of us also travelled abroad and worked in big modern hospitals or clinical centres in Germany, England, the Netherlands, Scandinavia and USA, where clinical information systems were already in use. We were able to see the benefits and wanted to develop something similar in our hospital in Slovenia. Since we use modern technology and all sorts of applications in our everyday lives, why not use it in hospitals when interacting with our patients? It’s the reality we cannot run away from.’
What was the biggest challenge for the hospital and for the staff to stop using paper and digitise? How did UCHL solve it?
‘This transition process has many challenges. First, we had to convince the upper management that our hospital needs the clinical information system and that it is worth investing in. In healthcare, there’s always a lack of money. Many times, the top priority are medical devices which help patients directly, e.g. ultrasound machines or respirators etc. Implementing clinical information system takes time and money. The results cannot be seen in weeks – it takes months to implement the software.
Next challenge was the implementation of the software. In our case it took us years, not months. As I mentioned before, the implementation also meant twice as much work. We had to cure and take care of our patients, and on top of that, we had to learn how to use the software and gradually implement it into our daily work.
One of the challenges by developing and implementing the software to our system was the need to have IT professionals to come work with us in a hospital to help us speed the development and implementation process.’
Can you tell us what changed in regard to your working process; working in a paperless vs. paper-based environment?
‘Very soon we realised that the transition from paper based to paperless has an impact on the working process. One very important change in the process is remote work. Doctors can now prescribe some medications or laboratory tests from another room or from ward to ward, for one patient or for a group of patients. Doctors and other medical professionals have access to the data from all devices connected into the system network. They can see laboratory results, radiology tests etc. They can track the movement of the patient from ward to ward, and some even have access to this information from home.
Another change was transparency. After some time, the process became more transparent. All decisions made by medical staff are now tracked; the system knows exactly who did what, when and to whom.’
Which of your challenges or problems have specific applications solved, and in what way?
‘Applications solved many of our problems. One example is the documentation management. Every patient has his own electronic health record (EHR) where all the documents – from admission record to specialist’s observation results – are stored.
Another challenge that we solved with applications is the management of laboratory tests. Doctors can order any possible laboratory tests with any laboratory inside the network directly. While many laboratories are performing the same or similar tests, the system allows doctors and nurses to choose which test is the most appropriate and suitable for a certain patient. The results then come back to the patient’s EHR. If there is something critical, a doctor is notified by alert. Before we had to ask the nurse to call to the laboratory and order tests and she or he also had a lot of paper work. The new system shortened this process for three to four steps.’
Can you tell us more about the ePMA case, using labels and scanners for infusion pumps?
‘ePMA (the electronic prescribing medication application) is the best and the most demanding module we’ve developed. As we know, medications don’t only have positive impacts on patients, so we developed this application which helps us choose the best possible medication for the patient. The system offers me a specific medication for the patient, depending on his health condition that is written in his electronic health record. This also means that I as a doctor don’t need to memorise so many medications anymore.
The ePMA also ensures that the prescriptions are precise, it suggests you the form of a medication, the dosage, interval of the dosage and at what time the therapy should start. These instructions are accessible for nurses at the patient’s bed.
Furthermore, the clinical information system and ePMA enable the clinical pharmacist to see medication related activities and intervene. This is very important, because more and more clinical pharmacists are involved in the daily work. This gives an additional value to our work. Clinical pharmacists see the prescribed meds and help us with additional knowledge about which are dangerous, which can cause interactions, which should be diluted, which should be applied slowly, which quicker and so on.
Using labels and scanners helps us ensure patient safety. Every prescription goes to the pharmacy, where pharmacists prepare the medication for a certain patient. Every medication is labelled with the barcode and returned to the ward. Then a nurse uses the application to scan the medication’s barcode, her barcode and the patient’s barcode. This not only makes the process more transparent, it also reduces the possibility of making mistakes of giving the wrong medicine to the patient.
In ‘paper times’ doctors wrote prescriptions on paper, nurses collected the prescriptions in the ward, rewrote them on a new piece of paper and sent them to the pharmacy. Pharmacists transcribed these prescriptions to the syringe or on the box of tablets that was sent back to the ward, where the nurse had to correctly rewrite everything on the patient’s chart once again. We measured that in the ICU (Intensive care unit) with 10 beds, we needed 2 nurses for 3 hours a day only for the process described. Now the process is much faster and nurses have more time to care for patients.
This is one of the best examples of how a good clinical information system with good applications can improve work quality and enable even more safety for the patients and for the healthcare professionals.’
How do you see the role of doctors in the future; from the information technology point of view?
‘First, the clinical information system and applications should improve the quality and safety in the healthcare world.
Second, the system will extend the lifespan of doctors’ professional careers. Nowadays, doctors can start working independently when they are 30 years old and once they reach the age of 60 or 65, many specialists cannot work on the same level anymore. With this technology they won’t have to memorise so many facts to perform their jobs. With the clinical decision support in the form of an artificial intelligence I believe the younger and older doctors will be able to manage more complex problems on their own.
Doctors will also be able to deal with more patients, since the information technology will enable patients to become more and more involved in their healing, especially when dealing with chronic diseases. They will have a chance to know their disease better, to control it better. They will be able to stay in touch with their doctor from remote locations and won't have so many reasons to see the doctor in person.’
We hosted a webinar ‘Plymouth's Integrated digital care record (IDCR): a foundation for an open platform architecture’ with Andy Blofield, the CIO at University Hospitals Plymouth NHS Trust who shared his perspective on setting up a single Integrated Digital Care Record (IDCR). He believes an IDCR is a necessary step in the journey towards a fully digitalised, paperless hospital.