E-Records in a community palliative care service – A step toward the future

With developments in software and mobile technology applications, the challenge of access to up to date clinical information for clinicians in community settings are rapidly being resolved. South East Palliative Care, a community palliative care service in southern metropolitan Melbourne has now implemented a fully electronic medical record supporting enhanced clinical information management. Along with the e-Record, mobile technology is being used to inform clinical care in people’s homes and for after hours support, enabling full remote access to the patient’s entire medical record by clinicians. Read only access is also available to Royal District Nursing Services Customer Service Centre and Clinical Nurse Consultant, supporting their role in delivering after hours and shared care. Data entry can be undertaken prospectively, which has led to efficiency gains, and assessment tools have been standardized. Interdisciplinary Care Planning has also been enhanced with the care planning tool available in the system. Data collection for VINAH reporting and PCOC are included in the software, supporting automatic download for both these suites of data.

A national user group for the software includes all current services using the software, to ensure that new developments are standardized across the system, which will enhance transferability of information in the future.

The challenges of implementing the system will be explored including approaches to change management. Plans for ongoing systems improvements, including the development of clinical and operational reporting systems, and further development and inclusion of tools supporting documentation of clinical assessments will be explored.