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Clinical IT in Aged Care Product Trial - Trial of a System for Monitoring Clinical Well-Being - Report

Report of the product trial of a system for monitoring clinical well-being

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Simple clinical measurements, such as blood pressure, heart rate and weight, when graphed over time and used in conjunction with other care plan information such as current medications, can help GPs and aged care staff to quickly identify and manage significant changes in clinical status, resulting in improvements to the quality, timeliness and appropriateness of clinical care. In addition, a common medication chart shared by the GP, pharmacist and staff in aged care homes has the potential to eliminate miscommunication, transcription errors and, ultimately adverse drug events.

This trial explored the use of a device developed by the University of New South Wales for use in community care which was modified for use in residential aged care. The device was designed to gather information relating to a resident's clinical status (such as pulse oximetry, ECG, blood pressure, lung function and weight). This information was intended to form the basis of an electronic health record available to GPs and staff in aged care homes. Together with an electronic medication chart it was to assist in care planning and medication management.

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Situation

With increasing demands to exchange clinical information with a range of authorised care providers, it is becoming more important for aged care homes to develop their capability to more effectively gather, use and pass on clinical information to authorised care providers, a process which is limited by the current, predominantly manual practice of monitoring clinical status. Simple recordings such as heart rate, blood pressure and weight, when graphed over time and viewed in conjunction with other information such as current medications can help GPs and aged care staff to more rapidly identify and manage significant changes in clinical status with an end result of improving the quality, timeliness and appropriateness of clinical care as well as reducing the number of admissions to hospital emergency departments.

Anecdotal evidence from staff in aged care homes suggests that residents are over medicated and that care programs are not monitored or changed often enough. It was thought that, with regular monitoring of clinical well-being, communication between staff in aged care homes, GPs and pharmacists would improve and that medication plans would be more responsive to residents' needs.

The Clinical IT in Aged Care project provided $302,500 to the University of NSW for the trial of MedCare, a mobile point-of-care device to monitor and record data on residents' wellbeing. Additional funds (cash and in kind) for the project were provided by consortium members, including generous in-kind contributions by the participating aged care homes.

Consortium Members

The University of NSW led the project with the Biomedical Systems Laboratory providing project management services and developing user specifications, systems integration and knowledge management systems.

Participating homes included Uniting Care's Mirinjani Village in Canberra, Goodwin Aged Care in Canberra, Ardmillan Place, Essendon Ageing in Place and Health Care Facility in Victoria, Montefiore Homes in Hunters Hill and Maroubra. Each of the participating homes was involved in the user needs analysis, design specification, trialling and evaluation. Associate Professor Marc Budge (ANU and Canberra Hospital) and Dr Gideon Caplan (UNSW and Prince of Wales Hospital) took on the role of Clinical Director in each of their respective States.
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Aim of the Trial

The trial aimed to introduce extensive and systematic monitoring of residents' vital signs and overall well-being in the aged care environment, to document test results over time through the use of an automated care plan and to improve communications concerning medication management across the continuum of care through the use of information technology.

The potential quality of care outcomes examined for this trial included:

• Improved monitoring, documentation and clinical management of residents.
• Increased treatment compliance by residents and staff due to increased understanding of the effectiveness of treatment.
• Enhanced communication with GPs assisting in more timely review of care and medication orders in conjunction with evidence of clinical status.
• Informed development of care plans and documented care.

The Trial Setting

The trial was conducted in five homes across three states and territories, Victoria, NSW and the ACT; Ardmillan Place, Montefiore Homes, Goodwin Aged Care Services Inc. and Uniting Care. Approximately 75 residents from these facilities were enrolled in the trial. The homes involved offered a variety of services to residents from a wide range of ethnic, cultural, religious and socio-economic backgrounds, and together reflected a good cross-section of the industry. The number of residents participating in the trial was significantly lower than originally planned due to the difficulty of recruitment logistics.

Recruiting residents involved informed consent from the resident or guardian and the participation by the resident's GP, along with the pharmacist supporting the facility's medication needs.

32 GPs enrolled in the program, along with 4 pharmacists. The ratio of GPs to residents was higher than optimal, minimising the benefits to the GPs in the trial.
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The Solution

An essential component of the project was to integrate the MedCare system, which was previously used in community care, for monitoring well-being in the current residential aged care environment. The equipment was significantly modified for mobility and access to residents in aged care homes.

The system is essentially a mobile clinical workstation device that contains a laptop computer with the necessary equipment for performing and recording clinical measurements attached, including:

• blood pressure;
• single lead ECG;
• body temperature;
• weight;
• lung function; and
• pulse oximetry.

Additional facilities for recording blood glucose and questionnaire data as well as a number of resident health and mood assessment tools were also included. The system also supported prescribed, PRN and nursing-initiated medication administration by clinical staff who were identified using biometric fingerprint recognition. The medication administration history was similar to the paper-based medication charts routinely signed by clinical staff in the aged care home. For the purpose of the trial, the clinical measurement tasks were carried out during medication rounds.

The MedCare equipment was connected to a laptop PC which was mounted on a medication trolley with a battery source located below. The PC provided the interface to interact with the workstation and perform clinical measurements. Operation of the system was via touch screen. User authentication for access to medication dispensing information was via finger-tip scanning.

Trial of a System for Monitoring Clinical Well-Being

Data was synchronised with a central database via an Internet connection between medication rounds.

All clinincians and health care providers involved in the trial had rights-based access to the relevant resident information (via the web or through faxed or emailed reports) and were able to view the clinical measurement results and medication charts for their allocated residents. GPs were able to remotely prescribe and change a resident's medication. The prescribing component incorporated a medication formulary that allowed for quick entry of medications and a reduction of typing errors for the GP. As well as managing medication plans, GPs could use the system to request specific monitoring of residents to occur during medication rounds.
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Involvement of Clinical Staff, Pharmacists and GPs

The process of recruitment and training was performed separately for the clinical staff, pharmacists and GPs.

The participation of staff in aged care homes started with the initial user needs analysis phase which involved discussions about the current business problems. This phase led to an understanding of the user requirements and a better appreciation of how an integrated system could assist workflow within the participating aged care homes. Consequently, none of the staff involved at this point declined participation in the trial. A total of 57 staff were recruited for the trial, 13 of whom were administrative staff.

GPs received an Information Statement and Consent Form. The number of residents cared for per GP varied although the majority of GPs cared for only one resident. Some aged care homes had a higher tendency for multiple residents per GP.

Overall, four pharmacists were recruited for the trial. The pharmacists were those who normally serviced the aged care homes. Pharmacists were provided with an Information Statement and Consent Form. In general, all pharmacists were receptive and supportive of the trial and its objectives

Each group of users (staff in aged care homes, GPs and pharmacists) were provided with training on the functionality of the system and their interactions with it. Training for staff in aged care homes was held in groups at each of the participating homes. System training and education for GPs and pharmacists occurred in between recruitment and deployment for each site. All GPs were trained by the research staff in their surgery on a one-to-one basis. Face-to-face training was conducted by the research staff for the respective pharmacists at all but one pharmacy where training was provided over the phone. User manuals were developed for both the client system and the website and were distributed to clinical staff, GPs and pharmacists during training.
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Involvement of Residents

Recruitment of residents relied primarily on aged care home staff through their in-kind contribution although a lot of assistance was provided by the Nurse Coordinators engaged by the research team. Residents with dementia or those prone to wandering were excluded while cognitively impaired residents were not excluded although consent was required from their carers or appointed guardians for the resident's participation. Prior approval was first sought from a resident's usual GP before the resident or guardian's consent was sought. A Resident Information Statement and Consent Form, and a Guardian Information Statement and Consent Form were used during this process.

Generally residents and their carers or guardians were informed about the trial through correspondence before being contacted or approached sometime later.

Key Success Factors

Encouraging GP involvement was critical to the success of the project. In their 'post trial' interviews, GPs suggested that increased remote monitoring would lead to more medication reviews. They also felt that remote monitoring could improve the quality of discussions with staff in aged care homes regarding the residents' conditions leading to improved clinical management of residents.

A detailed understanding of the operations within an aged care facility is essential to managing a complex system implementation, a view that was reinforced during the user needs analysis at the commencement of the trial. Whilst this resulted in some changes to the system's functionality, it resulted in a higher level of participation by staff than would have been achieved otherwise.
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Lessons Learned

Staff in aged care homes, GPs and pharmacists were individually involved in the planning and deployment of the trial. In retrospect, it was apparent that all would have benefited from combined engagement so that each could understand the activities of the others and contribute to improving the overall workflows. In addition, inter-disciplinary orientation and training across the clinical workflow would assist each system user to better understand the capabilities and constraints of the others.

The socio-technical issues for clinical monitoring within aged care facilities are complex and challenging. Technology must be robust and reliable and designed specifically for aged care homes. Clinical staff were generally very positive of the perceived benefits of the monitoring system, but would quickly lose confidence if the equipment malfunctioned. The monitoring system, which worked well in the laboratory and in the community, needed some simple yet time-consuming adjustment to function reliably in an aged care home.

On-going training and support in the use of the systems is essential for all clinical participants. It is absolutely paramount for technology being implemented in any health setting, that the majority of its technical issues are resolved before evaluation can take place.

Recruiting GPs was difficult. Incentives such as continuing education points and EPC payments will overcome some reluctance so long as a large proportion of the GPs patients are participating in such programs.

Whilst staff in aged care homes identified sufficient potential benefits in medication management to overcome their reluctance to engage in monitoring activities, it takes time to obtain GP buy in for such a large project. However GPs became increasingly motivated to use the system and some GPs began to consistently review patient data over the web.

Pharmacists were enthusiastic participants in the process but they stressed the need for the medication management process to be interoperable with the pharmacy systems.

To obtain maximum benefit from the clinical monitoring and medication management system, all residents in the medications round need to be enrolled. In this trial, because of the requirement for informed consent both from the resident and their GP, only a fraction of residents participated. This meant that duplicate trolleys were often used and separate rounds put in place for the participant group. These constraints placed a substantial additional workload burden on staff managing the medications rounds. In a realistic deployment of the clinical monitoring and medications management system these problems would not be encountered and significant time efficiencies as well as a reduction in medication errors would be expected.

This product trial summary was prepared as part of the Australian Government Department of Health and Ageing's Clinical IT in Aged Care Project. The product trials aimed to assess improvements to the care provided to residents in aged care homes as a result of the implementation of technology. The use of the IT product in this trial should not be taken as an endorsement of the product.
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