The Otago Clinical Audit and Outcomes Research Unit (Otago Clinical Audit Unit) is a non-profit organization with five staff. Founded in 1987, and part of the renowned Dunedin School of Medicine at the University of Otago, New Zealand, the unit audits the surgical practice of a number of private and public hospitals and provides the Otago Clinical Audit Software to hospitals throughout Australasia.

Surgical audits have become a crucial component of modern surgical practice. Audit assists in ensuring that surgical procedures conform to the highest standards, by collecting, verifying and reporting surgical data for peer review.

Such audits, involving feedback from other surgeons, are an integral requirement for the ongoing professional development of a surgeon. Paul Pope, Manager, Otago Clinical Audit and Outcomes Research Unit, says, “Surgeons require continuous medical education (CME) throughout their lives to enhance their craft and practice, and clinical audit is a good way of improving a surgeon’s craft.” Additionally, the professional body of the Royal Australasian College of Surgeons sets down a requirement for surgeons to perform audits to improve their practice.

The Department of Surgery at Dunedin Public Hospital has had a systematic, computerized surgical audit in place since October 1984. However, to improve the process, software was specially designed to collect surgical information in a way that did not intrude on a surgeon’s busy schedule. 

Through the years, the audit unit has developed the Otago Clinical Audit System for the evaluation of a full range of surgical specialties, which it has sold to hospitals throughout Australasia. In early 2005, Otago Clinical Audit Unit formed a joint venture with Microsoft Gold Certified Partner Intergen to help enhance its audit system. Chris Auld, Director of Strategy and Innovation, Intergen, says, “We wanted to build an enterprise-grade application that took advantage of Otago Clinical Audit Unit’s long history of performing audits and our IT expertise.”

Previously, Otago Clinical Audit Unit had used a DOS-based application to support its audit system and Microsoft Office Access 2003 as the supporting database for storing information. Chris says, “The audit system built on DOS was a basic application that could not support the rigorous hospital environment. However, Access 2003 was user-friendly and required minimal training to use. But, different users could not access the same data concurrently.”

Additionally, the Access 2003 audit system had limited integration with existing hospital information management systems. This resulted in extensive manual data entry from paper-based hospital reports.

Paul says, “The task of inputting data into the system was mostly performed by administrative staff because doctors found it tedious. As a result, doctors became more distanced from the audit process.” 

There was a need to enhance the management and usability of its audit system through greater automation and the incorporation of a robust, enterprise-class database.

Solution
In early 2005, Intergen built an audit system based on Microsoft SQL Server 2005 database and Microsoft .NET smart client. Auld says, “Microsoft was chosen as an operating environment because it is broadly adopted across a wide variety of organizations, therefore most hospitals in our environment.”

He adds, “Microsoft provided the best balance of rich tool support without being excessively expensive. Thus we can use it as a building block to enhance the existing Otago Clinical Audit System.” The first recipient of the revamped audit system, which was created by five IT developers from Intergen, was the Dunedin School of Medicine, University of Otago, New Zealand.

During the phased roll-out to five surgical departments from 2006 to 2007, one Intergen staff member and one University of Otago staff were actively involved in the integration of the audit system into its existing Patient Management System (PMS)—containing digitized patient records. Given the audit system’s open architecture, minimal coding or configuration was required.

Within the surgical departments, the audit system is managed by two administrators and used by 60 surgeons and registrars (qualified doctors on two-year hospital training). The audit system connects to Windows XP desktop clients to facilitate data input.

Surgeons or registrars enter information about surgical procedures; additionally, patient information is acquired through its PMS interface. The administrator or audit coordinator controls the activation and production of reports for peer review. Paul comments, “The monthly peer review process looks at all of the different activities and clinical issues that have occurred in a patient’s surgery. The peer review process gives a summary of the surgical work of the surgeon collected over 1-2 months. The peer review process is an important opportunity for experienced and junior surgeons to discuss their work.” 

Training involved familiarizing users with information entry, as well as teaching administrators to manage the audit process. “User training is shorter now because most users understand how it works,” says Chris.

Otago Clinical Audit is actively introducing the audit system to hospitals across Australia and New Zealand. For deployment in other hospitals, Intergen targets a deployment time of one to three months—which includes the migration of data. Chris adds, “Organizational and technological factors usually determine the speed of deployment. It’s a case-by-case basis; some projects will be difficult to deploy because acceptance from various departments is required.”

Paul adds, “Initially, our focus is to use the audit tool to enhance surgeon performance, however as audit users gather more data they are able to acquire information on hospital efficiency and resource allocation.”

Additionally, data collected can be used for clinical research. Across different hospitals, the information collected in large databases is used to analyze surgical procedures, their outcomes and diagnoses. Paul continues, “The search and reporting parameters of the Otago Clinical Audit System give precise answers to specific surgical procedures, their diagnosis or complications.”

Benefits
With the incorporation of the SQL Server 2005 database, the Otago Clinical Audit System has improved the analysis of surgical performance and facilitated research across different hospitals. “With a SQL Server database we can now track trends and a myriad of health activities you’d find in a clinical process,” says Pope.

Penetrative analysis
In the past, the Microsoft Access system had only two report parameters for analysis which limited insights gained from its surgical practice. Paul enthuses, “The Otago Clinical Audit software has 28 report parameters. There has been a massive leap in our ability to analyze surgical performance and hospital services. By using information such as patient background, surgery details, outcomes, and post-operative work, we can even evaluate the operational efficiency of a surgical department. This gives us a broader and much richer scope for reporting and research.”

Comprehensive management of audits
Previously, audits were inefficiently managed by multiple administrators and the surgeons themselves. Paul says, “Now a single administrator can manage the centralized audit system and facilitate the audit process.” Administrators have also replaced surgeons in generating the peer review reports. Paul adds, “This means that the peer review process is very transparent, surgeon reports are created through links to collected data rather than through selective filtering of information.”

Data needed to generate reports, such as patient information, admission and discharge details, is captured from in-house PMS—reducing the amount of data entry required. To make it easier to input surgery details, terminals were set up in the wards and operating theatres to increase the number of data-entry locations.

“Surgeons with individual computers can input additional information into the system in their own time,” says Pope. “Additionally, auto generation of discharge and operation notes for surgery patients has eliminated or reduced the need for surgeons to handwrite such reports,” he adds.

More secure data services
Enhanced security ensures only authorized personnel can see the records. The audit system is kept separate from other hospital information systems to safeguard doctor privacy. Additionally, full audit logging prevents tampering of entered information.

Extended research capabilities
The system can be linked to a data warehouse containing information from various hospitals. By using this information, hospitals can perform research or benchmark their performance against other hospitals. The region-wide data warehouse is managed by the Otago Clinical Audit Unit and Intergen for its clients.

“The data warehouse function offered through the audit system provides an extensive, secure source of valuable data to healthcare organizations and hospitals to perform research that wasn’t available previously,” says Chris.

Improved provision of healthcare services
The audit system improves surgeon performance by facilitating constructive communication among surgeons as well as sharing of knowledge with more experienced practitioners. “Peer reviews facilitate mentoring of young clinicians through discussions with experienced surgeons,” says Paul. He adds, “By using the audit system, Dunedin has created a transparent peer review process, and because we’re a University responsible for teaching, we can instil an ethic of life-long professional development in surgical practice.”

“While trying to improve surgeon performance, we collected a database that helped hospitals answer questions about clinical management, determining surgical workloads, monitoring registrar training, and evaluating efficiency. In fact, we worked with a Gynaecology unit at Dunedin Public Hospital to advise its staff on efficient resource allocation based on past usage patterns,” says Paul.

For more information

Intergen
www.intergen.co.nz

Business Solutions Enquiries:
Wayne Forgesson
Business Development Director
04 472 2021

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