Clinicians at South Tees are trailblazing the use of this innovative web based application which is used at the bedside to read and update patients records via wireless devices.

The system supports all healthcare professionals involved in the care of patients with spinal injuries from clinical staff, specialist nurses and social
workers to managers and administration staff. Each patient at the unit has an integrated care pathway supported by the EPR system where staff, with appropriate access rights, can access real time information ensuring the best patient care is provided.

Using the IMS Spinal system, with just a few clicks, nurses can get an immediate picture of where the patient is on their care pathway, record patient assessments, tailor rehabilitation planning and run off reports to send with patients to other departments.

It is easy to record nursing notes and generally retrieve the information required to ensure the best care is provided for each patient. The patient care pathways are managed electronically and with real time information allowing staff to always put the patient first.

The system was introduced initially for all new patients admitted to the Spinal Unit. The electronic record includes all a patient’s personal details and comprehensively captures all assessment information at the point of care.

The system combines assessment information taken throughout the patient’s stay with historical care information. This information is gathered across the multi disciplinary team involved in the complex care of spinal patients and supports the work of consultants, nurses, physiotherapists and occupational therapists.

The information collected on the system is also used by administration staff to code each patient’s episode of care and provide discharge documentation.

Because information is in real time and easy to access, the patient experience has been greatly transformed as staff are able to spend more time on care planning and monitoring the delivery of care to each patient.

MAXIMS Spinal System functionality includes:

• The provision of administration protocols and guidelines to ensure staff are able to give each patient the same experience and that key information is gathered when being admitted to the Spinal Unit.
• Staff definable Patient needs assessment and patient centred goal planning. This ensures each patient has tailored, comprehensive and focussed rehabilitation plans which all disciplines can see and work with, therefore ensuring each patient is given optimum care before discharge.
• Real time information on monitoring patient progress against individually set care plan goals which are used to proactively manage the care of each patient.
• Information is captured at the bedside and point of care which ensures accuracy and speeds up the patient care process.
• Provision of management reports such as Discharge Documentation and information on patients which is produced for theatre visits. This saves time and avoids mistakes that might be made re keying patient information.
• A Report Writer which is used to produce management reports tailored to the South Tees Trust’s needs.

South Tees EPR system is a ‘live’ record of active patients, and is currently operating as a standalone system, although a link to the Trust’s PAS system can be enabled for automatic download of demographic data. The system currently houses 200 electronic episodes for 300 patients.

IT Manager Darren Watson said: "The depth of access to a patient’s record is controlled by role-based security which relies on users having a legitimate relationship with the patient. Clinically-qualified staff will be able to access most parts of a record while ward clerks, for example, will only have access to a patient’s basic demographic details. They don’t need access to clinical information."

"Wherever possible, we have removed paper alternatives, to ensure there is no ambiguity where information is to be found," says Darren. "It also helps ensure information isn’t lost, omitted or overlooked and that the clarity and completeness of the electronic record isn’t disrupted.”

"The system also automatically tracks who has opened a record. It records the date, time, and at which workstation a record was opened. This is a key part of the security and confidentiality measures we have built in, and something you couldn’t do with paper records."
Along with the obvious benefits to the care of the patient, the EPR system is able to provide accurate information on patients, leaving no ambiguity over hand written notes. This accurate information has greatly improved the ability to code each patient episode as daily notes can be read easily ensuring the Spinal Unit receives the correct funding. Also patient data requested from departments, for example handling information required through the Freedom of Information policy, can be reached easily.

As well as providing access remotely to the EPR system when the clinicians are visiting patients in outreach clinics, future developments include more specialties moving onto the paperless patient EPR system such as Therapies. Other future developments being considered are the ability to add digital images to the patient record.

“This is one of the most exciting developments in patient care. Access to relevant entries is rapid, efficient and importantly legible! Summary of the neurological status is immediately available and relevant past medical history is there at the drop of a menu. The system also improves communication within the multidisciplinary team, during day to day function. Accurate discharge summaries are automatically prepared from operational data, significantly reducing error and improving completeness. Audit of the service of the centre will be significantly improved to the benefit of current and future patients.”

Professor C G Greenough, Consultant Orthopaedic Surgeon

"We knew our goal was to have a totally multi-disciplinary system where everybody had access to the patient record in the centre. We wanted to have real time information on our patients at our finger tips ensuring the patients care was put first. We involved experienced clinical staff
and each discipline worked on what they wanted the system to deliver."