TAPAS Project Proposal

Project Information

Project: TAPAS
Project Time-frame: 2005/1/1 to 2006/3/31
Summary: Development and Deployment of a Virtual Practice Network Server to support family physicians on call. This project is funded by the BC Ministry of Health Services Electronic Medical Summary Project and will be developed using that emerging standard. It is being developed in conjunction with Univeristy of Victoria, Univeristy of British Columbia, and the Vancouver Coastal Health Authority. The project will develop an open source family practice server will contain electronic medical summaries and be accessible to physicians and staff in a office or call group through a desktop application and can securely syncronize select data to PalmOS Personal Digital Assistants (PDA) so it is accessible to full service physicains while on they are on call.
Attached Worksheets:
Related Documents:
See also the TAPAS proposal to the eMS project.

Background and Motivation

What is the setting and history behind this project?
Family doctors are primarily paper based, that is they write notes in paper charts that are passive and are locked up at night in the office, inaccessible. This project will support family physicians gain access to their chart summaries while on call. It will serve as a first implementation for several ideas in the VCH Primary Care IT Strategy.

This project is developed in conjunction with three other projects: the Electronic Medical Summary Project (e-MS), the North Shore Mobile Health Network (NSMobile), and EGADSS. The Electronic Medical Summary project is a provincially funded standards project to develop a core data set for electronic transmission between physicians / care providers. The North Shore Mobile Health Network is a call group of full service family doctors who are exploring the use of PDAs to assist paper based practices, particularly to help manage diabetes and to help with on call communication. EGADSS is the Evidence-based Guideline And Decision Support System, another open source project from the UBC Family Medicine Informatics group and will be linked to the TAPAS project.
 
What is the problem to be addressed?
When physicians are on call, they have a limited access to information about the patients that they are responsible for. Indeed, in a large call group, a physician on call may know nothing about more than 90% of the patients. Better access to clinical information (patient summaries) while on call should help aid decision-making in practice. This project addresses this problem by downloading patient summaries to the physician's PDA, which can be accessed while on call. Further, on call communication will be supported through the addition of communication tools on the PDA that syncronize back to the Virtual Practice Network Server securely.
What are some current approaches to this problem?
There are clinic managment systems and electronic medical record systems (EMRs) in existence that can been accessed outside of the office (eg through the web). These allow for messaging between providers. Few provide tools to support access to patient data on the PDA.

Paper systems are currently the norm in practice. Physicians will write note down in a notepad or on loose paper and then have to remember to give or fax these to colleagues the next morning. Paper systems do not allow access to any kind of medical summary information.
Why is this problem worth solving or worth solving better?
Access to patient information while on call has the potential to improve patient outcomes (eg more appropriate investigations, treatments, less hospital visits, reduced morbidity and mortality).
 
Adoption of clinical information systems is a challenging process with a lot of data entry and process change before benefits are seen. The TAPAS model is designed to allow a practice group to explore the use of IT tools to improve a specific portion of their practice - smaller potential gains, but less risk and quicker returns. This will help the physicians learn about change and improve and be more prepared to move to an EMR in the future, should they choose to.
How will this product be better than previous approaches?
This will be an open source, standards based system for family physicians. It will be used in conjunction with a change management framework to improve the adoption of technology in a manner that supports clinical quality improvement.

As an open source project, the components will be available royalty free and can be shared and reused by other projects. The PDA interface for medical summaries, for example, could be used by existing EMR systems to support physicians while on call.
 
 

Goal

What is the goal of this project?
This project will create a Virtual Practice Network Server with additional Applications that will support ehanced decision making and delivery of care.

 

What are the defining features and benefits of this product?
  • Open Source licensed system that will be availble to primary care practices to support a "Virtual Practice" - a group of physicians that share the care of a group of patients. This group can be co-located (share an office) or share patients through a call group.
  • The system provides web access to the server for all members of the group, plus syncing from a PalmOS PDA (Tungsten C being the main platform for the development of version 1) for the physicians in the group.
 
 

Scope

We intend to focus on the development of the tools which allow for secure storage and transfer of information to the PDA and that will develop a limited feature set to support after hours call (including a call system, secure patient based messaging, and e-MS). Change management, training, and support are already established as part of the NSMobile project. This document focuses on the primarily on the infostructure for the project.

In Scope

Out of Scope

Server: Build a stand alone primary care on secure server leveraging existing open source tools and products that use industry standard security systems. Work with members of the NS Mobile physician group to extract patient demographics from their billing systems to pre-populate the database where possible.

Develop a robust security model for the local implementation of the solution which provides view access to patient medical summaries on the PDA for physician groups identified as pilot participants.

Dealing with more complex security / privacy policies of enterprise roll outs and larger scales such sending of data between health authorities or provinces. Those issues will be managed by VCH and the Ministry of Health in future iterations.

Extend the development of a Privacy Impact Assessment (PIA) for Phase 1 of the Virtual Practice Network to Phase 2 which incorporates e-MS standards and functionality.

Messaging/Flags: Provide the ability to provide “patient condition flags” which are tagged to specific patient summaries and also have provider messaging that would allow for provider specific messaging that is not necessarily tied to a patient (e.g. MD to MD or MD to MOA). Ability to view, print, and delete messages from within the web interface. Ability to view from the PDA interface.

Development of a messaging system that works outside of the Virtual Practice Network Server. This could be explored for a Phase 3.

Patient Summaries: Use the existing e-MS standard from VIHA. Use a subset of the standard for display on the PDA summary. Extend the standard only if necessary for on callcommunication.

Development of new standards. Adjustment of the clinical content in the e-MS. Mapping the e-MS.

View Access: Provide secure, web based access to the on call schedule to affiliated allied health professionals who may require such as pharmacy, wards, nursing homes, etc.

Provide PDA or edit access to medical summaries to anyone but physicians in the call group.

Migration of patient demographics from existing billing system to e-MS.

Population of e-MS content for physicians.

**It is suggested that the physicians / office staff begin populating their e-MS based on high acuity patients only.

Development of a sustainability plan / migration strategy for data before the end of the pilot with the NS Mobile physicians.

**Patient data will not be lost at the end of this project.

Development of a provincially scalable system. This is a grassroots, bottom-up, local implementation solution to support primary care physicians in the delivery of after hours call by their group. It will be able to connect to the VCH strategies through the use of clinical data standards.  While this is consistent with the larger strategy, it is expected that more funding will flow to make that strategy a reality.

Training of key “super users” on the system and provide online animated tutorials for training.

Major change management issues will be the responsibility of the existing NS Mobile group as they roll out their system through the community, including training of hospital staff, etc. This work is in scope of the NS Mobile group's original proposal but can be leveraged / expanded upon for Phase 2 of the Virtual Practice Network Server.

 

Risks and Rewards

The main risks of the project are included in the chart below.

Risk

Mitigation Strategy
  • Security and Privacy

There are significant security issues in using PDAs for clinical data that will need to be addressed.
    • Several have already been addressed by PalmSource in the current release of their OS.
    • Issues such as proper authentication will need to be addressed as will adequate user training.
    • All clinical data on the PDA will be encrypted.
    • PDA syncing to the server will use a form of two factor authentication: the user password and the PDA itself.
  • Clinical adoption of the summary tool

A strategy will need to be developed to promote adoption of tools by physicians.
    • The roll out of this tool is planned to complement the change management workshops with the NSMobile groups (this would also be the case as this tool is rolled out to other physician groups)
    • User interfaces will be designed with physicians to ensure that they support efficient workflows The workload can be reduced while still providing a significant impact by encouraging physicians to focus on their most active and acute patients and build up their summaries over time. It is expected that significant impact would be seen if the physicians simply targeted patient groups with multiple chronic illnesses, diagnoses of Cancer, etc. Populating the database from their current electronic information (i.e. the billing systems) will also aid the adoption.
    • Adding tools that leverage the e-MS data – such as adding an automatic consultation letter generation tools and clinical decision support for patients would also promote use of the system.
    • Understanding that the adoption of the e-MS as a standard within BC will further encourage physicians to use and maintain patient data in the system as they can see that the data could be migrated to a full EMR in the future, should the decide to use one.
  • Lack of a Central Repository

Currently the e-MS project does not allow for a central repository. This has been mandated by the BCMA.
    • The model chosen for the Virtual Practice Network Server is consistent with existing EMR strategies and does not produce a central repository.  Instead, it creates a local repository for the practice network.
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