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Taking delivery of a real-time electronic client health record solution
“Moving to a digital platform will improve the consistency of our nursing practise – it will enable us to offer a more streamlined and responsive service.”Andrea McLeod, Chief Operating Officer
Founded over 100 years ago, the Royal New Zealand Plunket Society is New Zealand's largest provider of support services for the development, health and wellbeing of children between the ages of 0-5. Their Well Child health service plays a vital role in the lives of young families: 62,000+ babies are born in New Zealand every year and more than 90 percent of their parents access some aspect of the Plunket service.
Over 700 Plunket nurses and health care workers provide face-to-face support through home and clinic visits, mobile clinics and through PlunketLine, a free telephone advice service for all NZ parents.
As a basic requirement, the Well Child Framework includes seven core contacts for each child before their fifth birthday. These visits capture a child's developmental milestones: undertaking nursing assessments, recording weight, height and health outcomes. Nurses handwrite clinical notes and record data into the child's 50 page Plunket Health Record (PHR). Client appointments are scheduled manually and are mostly recorded in paper diaries.
To maintain their clients' privacy, Plunket nurses collect the paper files they need before they start their visits each day, returning them to their base office at the end of the day to be stored securely.
Although Plunket's model of care has evolved over the years, they still retained a paper based system. This meant that with over 55,000 new babies added to the service every year, Plunket were responsible for storing hundreds of thousands of paper files for a set regulatory period.
While Plunket has a legacy contact system, it holds just that - contact details. The more specific details of a child's progress remain in the painstakingly maintained Plunket Health Records. Should an authorised health professional require information on a child, the relevant pages of that file are faxed, scanned and emailed, or if the family or child relocates, the entire PHR file is transferred to the nearest Plunket branch via courier or post.
As a health provider Plunket is required by the Ministry of Health to perform regular audits on their current client health records - the manual auditing of files is a time consuming task.
Andrea McLeod, Chief Operating Officer for Plunket, was very conscious of the risks inherent in their paper based system. "We didn't have an easy way of monitoring the consistency and quality of the data entered in the client files from one nurse to the next. From a health statistics point of view accuracy of health data is paramount. By moving to electronic records we became more efficient, holding real-time data that we could share with not only our staff and funders, but other necessary health providers. It also put us in a better position to respond rapidly to health trends, or a public health situation, something that was previously problematic because of our paper-based records."
In terms of technology, Plunket had a strong vision of where their service needed to go, and a good grasp of how to get there. In 2014 they decided the time was right to make the move.
The organisation needed an electronic system that fully supported the Well Child Service Framework and transformed the way its frontline staff recorded and accessed client health information. The system needed to fully replace the traditional paper records and diaries.
It had to be integrated and interactive, highly efficient, give Plunket access to digital information, and provide nurses with the ability to work online or offline seamlessly. To increase the value of the data, critical metrics, as well as out-of-the-ordinary information needed to be tracked, analysed and reported on by child, district and demographic. Reporting and auditing processes needed to be both streamlined and compliant, and real-time reporting made available to both internal and external stakeholders.
Overall the solution needed to fit into the existing business model, be easy to use, reliable, robust and secure.
The solution is the Plunket Well Child electronic Plunket Health Record (ePHR). It encompasses the use of Windows based tablets, a custom developed Windows 8.1 app (a very user-friendly app specially designed for the nurses), and incorporates Microsoft Dynamics CRM (customer relationship management) Online.
Plunket engaged Fusion5 to tailor Dynamics CRM to support the ePHR system. Marker Metro, a team of local specialist Windows app developers, were contracted to design and build the custom 'front end' application. The new app presented a simplified and streamlined version of the ePHR to the nurses in the field.
Building a solution like this takes teamwork, especially when it requires collaboration between three organisations - Plunket, Marker Metro and Fusion5. Aside from having regular meetings, chat, Trello and Basecamp were used to stay on the same page and work together.
"We've been genuinely pleased with the relationship and feel it's been a collaborative one. We've worked in partnership - it's been really positive," said McLeod.
Plunket had worked with Marker Metro prior to this project, and had a high level of respect for their team, and a complete trust in their abilities.
Although they were the 'new kid on the block' for this particular project, Fusion5’s Dynamics CRM team proved equal to the job. "The relationship with Fusion5 is one that we want to continue. We believe that we've been given good advice when we've requested it, and they've made recommendations that will stand us in good stead when we move forward with other planned developments."
Originally Plunket looked at other technology, however after developing a proof of concept with the Windows 8.1 app and CRM, coupled with the fact that the solution has the ability to integrate with Plunket's existing enterprise solutions/infrastructure, it was an easy choice to move forward with the Windows 8.1 app / CRM Online custom built solution.
The custom built Windows 8.1 application authenticates with Azure Active Directory, and allows for scenarios such as Single Sign On. The application then communicates with Microsoft Dynamics CRM Online through the exposed WCF service and stores the data locally in a SQLite database.
McLeod said choosing Dynamics CRM Online was easy. "Our organisation already had experience using Microsoft products: PlunketLine has operated for over 10 years on Microsoft CRM. Our experience to date provided us with a good level of comfort, so it wasn't as if it was new and scary."
While the app fits into the existing Plunket business model, the ongoing process of collaborative review and modification ensured that Plunket achieved the greatest benefits of implementing a digital solution for their nurses.
Coupled with the development of the ePHR application, as part of the larger technology programme Plunket are now deploying around 800 Windows tablets to their care delivery staff across New Zealand.
The average age of a Plunket nurse is around 50 years. Many are new to using technology as a work tool so it was important that the solution be highly intuitive. The app needed to provide just the right amount of interaction and functionality to make life easier, without requiring an understanding of the CRM in the background.
To encourage uptake of the new solution Plunket provided their nurses with tablets before the solution rollout.
The driving principles for this project revolved around taking a proven paper-based workflow used for capturing child client health records and information, and creating a digital version. The 'home page' provides a visual display and entry points for appointments, recent activity and clients. Icons and images allow nurses to quickly and easily identify statuses, hazards and information at a glance. A wizard-style enrolment form steps the nurse through capturing a child's details, and identifies family/whanau relationships as well as those with the community and wider medical/support services and practitioners. Automating key workflows means that a child's age based milestones are presented in an individual delivery plan. Day-to-day client management is provided through the calendar and scheduling functions and additional activities are possible, like taking a child's photo and linking it to their record. Boxes for additional notes and observations are also provided. Any potential hazards that a nurse might face during the day appears on the client profile and client appointments. This provides the nurses with at-a-glance risk mitigation for environmental, health and safety hazards: from aggressive dogs to muddy driveways.
Over time, as paper-based records no longer need to be collected and returned for filing, nurses will use the regained time to see additional clients, or simply spend more time on each visit.
The Windows app synchronises all records to the CRM which means the client's data is protected and secure. Additional 'break-glass' functionality allows authorised staff (for example, a stand-in nurse) a 24 hour window of access to client information, with a full audit trail. At the same time, administration users with direct access to CRM can only see the level of data detail they are permitted to view.
Plunket is leading innovation in healthcare by being the first public health services provider in New Zealand to utilize Azure services. Although Dynamics CRM is hosted offshore, Plunket data is repatriated back to New Zealand on a daily basis to meet its legal obligations as a health service provider.
After their face-to-face and online training, the Plunket nurses applied their time, tools and skills to electronically enrol approximately 160 new Northland babies every month. The rollout to the rest of New Zealand was scheduled for completion by mid-2016 - all Plunket nurses throughout New Zealand should be using the solution.
The second phase of the project will see the migration of client data from the existing paper based system to the ePHR. McLeod also envisages a future where a client-facing portal for parents sends out automated appointment reminders, alerts people about impending car seat upgrades, local parenting courses, and online enrolments for other Plunket services.
Although the demise of the paper record may be mourned by some, in the short term Plunket slashed its considerable printing and stationery costs, and in the long term, can free up a significant amount of floor space.
Primarily, the solution effectively and efficiently meets the needs of the organisation, its nurses and customers. It also helps Plunket keep pace with the rest of the health sector, while further enhancing the valuable service they provide to the children of New Zealand.
"This is only the starting point of our technology journey," says McLeod. "Things change rapidly in the health sector and this technology gives us flexibility to deliver the service that's needed today."
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