MetaVision results

This paper aimed to contribute to the development of a sociotechnical understanding and a robust implementation strategy of integration in health care by analysing how clinical practice and the history of existing systems play a crucial role in integration efforts. The authors use the implementation and integration of the large-scale Electronic Medication Management System (EMMS) MetaVision in the Health Authority Northern Norway, as an empirical example, with a focus on the integration challenges between the EMMS and the existing Electronic Patient Record (EPR) system. The MetaVision EMMS covers emergency units, intensive care and anaesthesia departments, operating rooms, outpatient clinics and clinical wards. The authors found that integration involves a lot of socio-technical and organisational issues that need to be addressed and highlight the importance of considering different stakeholders’ perspective as well as routine changes when large-scale integration projects are planned.

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A retrospective analysis of nutrition adequacy in adult mechanically ventilated critically ill patients before and after the implementation of an electronic nutritional protocol in MetaVision was performed at Gelderse Vallei Hospital in the Netherlands. The study was designed to address the effects of this protocol on energy and protein adequacy, electrolyte abnormalities, glucose regulation, workload and outcome. The computerized nutrition protocol provided automatic initiation suggestions and hourly feedback of energy and protein intake from feeding calories and non-nutritional calories such as glucose infusion, propofol and citrate renal replacement therapy (trisodium citrate). The authors found that the implementation of the electronic nutritional protocol reduced the rate of mechanically ventilated patients fed above target without reducing protein intake or increasing the rates of feeding below target, while reducing the incidence of electrolyte abnormalities. There were no statistical significant differences for other clinical outcomes. The protocol markedly reduced the time that dietitians spent on critically ill patients, as they no longer had to perform calculations to commence feeding.

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An observational cohort study examined the implementation and outcomes, including patient and family satisfaction, of the first Dutch tele-ICU.  Since 6 December 2010, Onze Lieve Vrouwe Gasthuis (OLVG) intensivists provide remote care outside office hours for patients in MC Zuiderzee (MC-Z) Lelystad’s ICU using MetaVision’s remote ICU solution. The tele-intensivist has an audio–video connection to every bed, as well as a connection to a separate room in MC-Z for conversations with medical and nursing staff or with family. The tele-intensivist has access to all the medical information, decision support software and to the MetaVision PDMS, which is used at both hospitals but is not connected on a patient level. Local nurses, consultants and the tele-intensivist simultaneously use MetaVision. After collecting data for two years, the number of patients admitted for post-operative recovery reasons in the ICU was found to have decreased over time, explainable by a more stringent application of admission and discharge criteria by the tele-intensivist. The authors found this to be in accordance with the literature that shows a more efficient use of intensive care facilities in a 24/7 intensivist-led ICU compared to an ‘open format’. Due to a lack of data on severity of disease before implementation of the tele-intensive care, a standardized mortality ratio (SMR) from that period could not be calculated for comparison with the study period. However, the authors found that in comparison with other ICUs in the Netherlands, there was no signal of excess mortality based on the SMR calculated for the years 2012 and 2013 during the study period, within the given confidence intervals.  A survey of patient and family satisfaction, performed as part of the study, revealed that the tele-ICU solution was favourably received by patients and family members. The authors feel that the main strength of this descriptive study is that it is the first evaluation of a tele-ICU outside the USA.

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Anaesthesiology residents are required to present a case log of all anaesthesias delivered and procedures performed in order to complete their training. In Israel, in contrast to the USA, UK and Canada, there is no central database for logging residents’ activities, and residents are expected to independently log the details of their cases and submit the log for board certification. Hadassah – Hebrew University Medical Center in Israel performed a study to evaluate the use and usability of a newly introduced system embedded in MetaVision that generates Quick Response (QR) codes for case logging. The QR code for each case contains all the relevant data for the syllabus based anaesthesia case log and could be scanned with a smartphone or tablet using a barcode scanner app. The data was then pasted into a spreadsheet file using a spreadsheet app, and the file could be saved locally and/or to the Cloud for backup. As part of the study, residents voluntarily answered anonymous questionnaires three times: before the QR code logging system was introduced, in order to assess their pre-existing case logging practices; three months post introduction, to assess QR code use and satisfaction; and again for usability and satisfaction after six months. The study found the system was being used by most of the residents three and six months after it was introduced. Usability was rated as very good or good, and high satisfaction was reported due to the system enabling residents to control their case logs and to do the logging immediately after finishing a case. The overall rate of case logging increased from 46.2% of residents before the introduction of the QR code system to 96% after six months. MetaVision enabled creation of the QR codes using VBScript coding.

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Massachusetts General Hospital performed a prospective observational assessment to compare relay and retention of critical patient information between the outgoing and incoming anaesthesiologist before and after introduction of an electronic handoff checklist. The goal of the checklist, which was implemented via MetaVision, was to prompt discussion and improve communication at the transfer of care. The checklist contained the minimum amount of essential information required at handoff, and access to the checklist was designed to fit into the standard handoff process. The authors found that relay and retention of specific information improved with use of the checklist, with major improvements occurring in the areas of intraoperative medications and fluid balance, and communication. Use of the checklist, which was voluntary, was sustained at nearly 75%, and clinicians felt that quality of communication and identification of perioperative concerns at the end-of-shift handoff were significantly better after the introduction of the checklist. The study found that retention of information was also improved with use of the checklist. The study authors assess that “It is likely that some of the items on the checklist showed significant increase in transfer as a result of being brought forward from other parts of the anesthesia record, a unique benefit of an AIMS-based checklist…With use of the electronic checklist, information for patient weight, airway management, IV access, estimated blood loss, urine output, and antibiotic administration was displayed from previous entries in the record, and several of these items showed statistically significant improvements in information transfer with use of the checklist.” Data on checklist usage were collected from MetaVision.

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A study performed at Hôpital Pitié-Salpétrière in France examined the objectives, conception and expected benefits of electronic medical records (EMR) in the Intensive Care Unit. The study discusses how the right EMR can help address the complexity of managing ICU patients, and focuses on MetaVision as its primary example. Using two studies of patient outcomes based on paper records compared to the MetaVision EMR, the authors point out that while the impact of EMRs on mortality, ICU length of stay and duration of mechanical ventilation varies from study to study, the data suggest that the use of EMRs is advantageous. Due to the difficulty of designing multi-centre randomised controlled studies, the authors recommend retrospective case-control studies with a tight matching between patients as a next step.

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A study conducted at Paul Brousse Hospital in France evaluated the impact of implementing MetaVision upon standard ICU patient outcomes, and found a 20% reduction in length of stay. MetaVision was customised in order to trace the model followed before implementation by creating screens for various clinical, biological and radiological parameters, and for guidelines, procedures and policies such as blood glucose control, enteral and parenteral feeding, insulin infusion rate, and antibiotics administration. According to the study, “We believe that the clinically relevant differences concerning the length of stay in our ICU resulted from an improved quality of care following the implementation of ICIS [sic].”

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With the goal of making residents more involved with meeting their educational needs, Massachusetts General Hospital developed a program where residents choose their preferred OR case assignments. The system creates resident profiles, based on MetaVision records and Accreditation Council for Graduate Medical Education (ACGME) case logs, to facilitate attending review of case experience. MGH also developed an ACGME case-log visualisation tool in order to easily compare each resident’s experience to both case minimums and peer group averages. The study found that these decision support systems successfully distributed responsibility between residents and attending for creating appropriate assignments.

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Massachusetts General Hospital performed a study which developed and internally validated an intraoperative predictive model for unplanned postoperative ICU use based on MetaVision data. The authors conclude, “Our study has demonstrated that it is feasible to use near real-time AIMS data to reliably identify patients who may require postoperative ICU care from those who do not.”

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