national electronic health record - home - ehealth ireland · 2017-04-19 · tom attends for his...

Office of the CIO

National Electronic Health Record

Persona Development Project

Mental Health Services Focused Scenarios April 2017

EHR Persona Development Project

Delivering eHealth Ireland | Office of the Chief Information Officer #EHRPersonas #HSEMasterclass 2

Mental Health Services Focused Persona

Overview and Scenario

Persona Overview Summary of Scenario(s) Suggested Discussion / Elaboration Topics

Tom Clancy 21 years old History of recreational drug use. Family history of hypertension.

1 Has been feeling a bit anxious recently, been more tired than usual and has been having difficulty concentrating. Behaving strangely - attends GP who refers him to an Early Intervention Programme for First Episode Psychosis

2 Presentation at ED following self-harm. No admission required but follow up conducted by Community Mental Health Nurse

3 Treatment in ED following overdose, assessment and admission to the psychiatric unit

— Is the described EHR usage appropriate? If not what would you change?

— Are there any other key EHR interactions that should be included in this patient’s journey? Why are they important?

— Would you change any of the clinical elements of the described patient journey? Are there any major gaps you would like to include?

Discuss items in the General Topics section in the context of this patient journey.

— Does any member of the team delivering this service work across acute and community organisations? If so are there any specific considerations with respect to EHR usage if separate acute and community systems are procured?

— What concerns/challenges are there around privacy of mental health related information and consent around who can access what information?



Actors: Patient (Tom), GP, Consultant Psychiatrist, Psychologist, Community Mental Health Nurse, Psychiatric Social Worker

Tom is home in Mayo for the holidays and whilst out with friends he starts to act bizarrely, so one of his friends accompanies him home. His mum convinces him to go to the family GP and an appointment is made for the next day. The GP suspects psychosis and uses the national eReferral system to refer Tom to the First Episode Psychosis (FEP) service in Dublin South which is near his college accommodation. This is a community-based service; the target is to see new referrals within 72 hours. Tom already has access to his own National Shared Record and has previously set up his communication preferences as email and/or text. He receives an email with his appointment details, which includes a link to a map. Tom attends for his appointment where he is seen by Matt O’Donohue, a Consultant Psychiatrist. Matt accesses Tom’s National Shared Record to review his medical history to date and information about the recent GP visit. A comprehensive assessment of Tom’s mental health and social care needs, including risk assessment, is carried out; the Community EHR is used to capture the details of the assessment. Matt agrees a care plan with Tom; this is documented in the Community EHR and is available to Tom as well as other healthcare professionals across the different care settings/organisations through the care collaboration tool in the National Shared Record. The care plan includes diagnoses, goals, planned interventions and details on who is involved in his care. Planned interventions include behavioural family therapy (BFT), cognitive behavioural therapy (CBT), medication, physical health monitoring, education about psychosis, advice on coping strategies and relapse prevention. A crisis plan is also documented; this describes relapse indicators and how to manage crisis situations for Tom; this plan will be available across all care settings/organisations. A key worker is assigned to coordinate Tom’s care.

Bio: 21 year old student at the Dublin Institute of Technology. From Mayo. The middle child in family of four

Health Status: History of recreational drug use. Family history of hypertension. Has been feeling a bit anxious recently, been more tired than usual and has been having difficulty concentrating.

Goals: Remain in college and complete his course. Have friends and normal relationships. Wants to travel after college. Frustrations/Fears: Worried about being, and being seen to be, different Personality

Emotional Rational

Organised Disorganised

Extrovert Introvert

At A Glance Age: 21

Location: South Dublin

Family Status: Single

Education: In College

Employment Status: Student

Tom Clancy

Scenario: Presents with first episode of psychosis

Technology: Broadband Access

Low High Internet Usage Low High Tech Comfort

Smartphone/Tablet



The benefits and possible side effects of the different anti-psychotic medications are discussed with Tom. The Community EHR provides access to up to date evidence to support this discussion. The medication is prescribed in the Community EHR; Tom is to be started on a low dose and the Community EHR will be used to titrate upwards within the recommended dose range. The prescription is electronically communicated to the Community Pharmacy of Tom’s choice. Tom will use an app to document his compliance with taking the medication; the app will update the care plan in the National Shared Record. The Community EHR facilitates best practice by prompting for the baseline measurements and investigations that are recommended prior to commencing medication. This includes starting a weight chart, measuring waist circumference, pulse and blood pressure, blood tests, assessment for movement disorders, and assessment of nutritional status and level of physical activity. Because a family history of hypertension is stored in the Community EHR an additional recommendation to offer Tom an ECG is prompted. The blood tests are ordered via MedLIS which is accessed directly from the Community EHR; bar-coded sample labels are produced by the Community EHR. The Community EHR is used by the mental health team to record their findings when performing the various assessments. The Community EHR schedules reminders for the default recommended interventions required for ongoing monitoring; these can be changed as required during dose titration. A clinical trial to assess the feasibility of using a smartphone app to deliver CBT is in progress. Because Tom meets the criteria for this study the team are prompted by the Community EHR to discuss this with Tom. Tom agrees to participate in the trial; his consent is captured electronically in the Community EHR and he is told that the instructions for downloading the app, as well as detailed information about the trial, have been added to his Community EHR and National Shared Record. Over the next few months Tom uses an app to complete various self-assessment questionnaires, e.g. Positive and Negative Syndrome Scale (PANSS) which measures psychotic symptoms. The app uploads information to the National Shared Record so that Tom’s key worker and others involved in his care can monitor his progress. Tom’s key worker communicates with him on a regular basis; he does this via Skype calls, phone calls, emails, texts, and also visits him at home. The signal in Tom’s student accommodation can be variable so the key worker often has to work on the Community EHR in off-line mode – this provides him with access to the information he needs and any assessments and notes entered whilst of-line are synchronised when a signal is available again. Regular care plan reviews are held. Participants are Tom, his parents, GP, Psychiatrist, Psychologist, Community Mental Health Nurse, Psychiatric Social Worker. The integrated diary management function of the Community EHR facilitates scheduling of these reviews. The care collaboration tool in the National Shared Record also supports multi-user input to a draft agenda, provides a dashboard of consolidated information for use during the meeting, and documentation templates for the discussion and outcomes.



Actors: Patient (Tom), ED Doctor, NCHD Psychiatrist (Dr Wilson), Community Mental Health Nurse (Nora)

Lisa presented to the emergency department in St. James’s Hospital, following an episode of deliberate self-harm. He had impulsively cut his hands with a razor following an argument with a flatmate. Another flatmate, Derek, convinced Tom to go to the ED. While the ED in St. Vincent’s Hospital is their nearest, Derek is able to check online to see the potential wait times and decides that they would be better off going to St. James’s Hospital instead. On arrival at the ED, Tom provides his details to the registration clerk who uses the information to locate his existing National Shared Record and Acute EHR. His arrival in ED is recorded and this updates the departmental whiteboard. A nurse triages Tom and undertakes IP&C screening as per departmental policy. The nurse enters the rest of Tom’s assessment into the electronic record. The ED doctor reviews the whiteboard and notes that Tom is waiting to be seen. He drills down into his Acute EHR record and views the information recorded during triage, then checks Tom’s National Shared Record where he can see a summary of his medical and surgical history, current medications, allergies, etc. He notices that there appears to be masked information contained in his record. He examines his injuries and fortunately, his wound was superficial and does not need any suturing. He asks Tom about the masked information in his National Shared Record but Tom indicates that she does not want him to view the information. The ED records his findings and clinical notes in the Acute EHR and given his episode of self-harm and the masked information in her National Shared Record, he makes a request for the NCHD psychiatrist on-call to see Tom and make an assessment. The NCHD psychiatrist on call, Dr Wilson, receives the request on his tablet and confirms that he will attend as soon as possible.




Emotional Rational


Extrovert Introvert

At A Glance Age: 21





Tom Clancy

Scenario: Presentation at ED and Psychiatrist Evaluation



Smartphone/Tablet



The ED doctor receives notification of the acceptance and asks Tom to wait for his colleague. Dr Wilson assesses Tom. He accesses his Acute EHR and the National Shared Record. He asks him about the masked information in his record. Tom explains the incident and previous encounters he has had and gives Dr Wilson permission to unmask the records. Dr Wilson enters his credentials into the National Shared Record in order to view the masked information and notes that he has been given permission by Tom to view the masked information. Dr Wilson conducts a clinical risk assessment using a tool held in the Acute EHR. As he completes the assessment, the information is recorded in the Acute EHR and key information is automatically added to Tom’s National Shared Record. Dr Wilson can see in the care collaboration tool in the National Shared record that there is a care plan involving Tom, his parents, GP, a Psychiatrist, a Psychologist, a Community Mental Health Nurse and a Psychiatric Social Worker. Dr Wilson creates a discharge summary on the Acute EHR outline the findings from his encounter with Tom. It is added to the encounter recorded on the National Shared Record. A discharge summary is sent electronically via Healthlink to Tom’s GP regarding his presentation to ED. The community mental health nurse, Nora accesses the National Shared Record and reviews the full assessment, risk assessment, formulation and follow-up plan made by Dr Wilson the night before she meets with Tom. Nora is able to view the information as Tom has given permission for mental health professionals to view all mental health related information. She visits Tom at home the next morning for follow up review. Following the review appointment, Nora agrees to meet Tom on a weekly basis to support him, to work with the technique in managing and coping with emotions, and solution-focused therapy. Nora enters her progress notes in the Community EHR. Tom agrees to be reviewed by Matt O’Donohue, his Consultant Psychiatrist in the outpatient clinic in St. Vincent’s Hospital for follow-up review 2 weeks following his presentation in ED. Nora accesses her Community EHR on her laptop and refers Tom to Matt using the national eReferral link embedded in the Community EHR. Nora receives confirmation that an appointment has been created for Tom in the outpatient clinic. Tom also receives an email with his appointment details.



Actors: Patient (Tom), Paramedic, ED Doctor, Psychiatric Team, Bed Manager, Porter

Tom was found collapsed by his flatmate Derek. It appears he had taken an overdose of recreational drugs. Derek contacts the emergency services. Tom is still unconscious when the ambulance arrives. Derek is able to provide the paramedic with basic information about Tom such as his full name and his addresses here in Dublin and at home in Mayo. Using the basic demographic details, one of the paramedics searches the National Shared Record and finds Tom’s record. He is able to review information about Tom except for mental health information that is masked. He retrieves as much of Tom’s health profile as he is permitted to see and reviews his summary medical history, current problem list, allergies and medications. He is able to see that he is on antidepressants. Tom is brought to the Emergency Department (ED) in St. James’s Hospital. As part of the transfer to ED, the paramedic provides the triage nurse with Tom’s IHI number, enabling them to search for Tom on their Acute EHR and also to pull up Tom’s National Shared Record. He is assessed by the ED doctor and is stabilised. Vitals are monitored and the information is captured automatically in the Acute EHR and the ED doctor reviews the information and makes an additional note on the Acute EHR. He also captures information relating to medication administered. He has noticed that there is masked information in Tom’s National Shared Record and the standardised best practice/decision support tools built in to the assessment process he has been detailing in the Acute EHR indicate that a psychiatric team assessment is required. The ED doctor is given the option in the Acute EHR to trigger a psychiatric team consultation. He takes that option. An alert is issued to the liaison team.




Emotional Rational


Extrovert Introvert

At A Glance Age: 21





Tom Clancy

Scenario: Emergency admission following overdose



Smartphone/Tablet



The referral is prioritised against all other clinical needs and a member of the psychiatric team (Raymond) receives an alert on their portable device. The alert includes a link to Tom’s record in the Acute EHR and a link to his National Shared Record. Raymond clicks on the link to view Tom’s National Shared Record. As a mental health professional, he can see all Tom’s information as he had previously agreed to allow all mental health related information to be viewable by mental health professionals. He reviews the information en route to Tom. Tom is stable and is fully conscious. Raymond engages with him and carries out an assessment as another of his colleagues arrives. They interact with the Acute EHR as he follows a clinical decision support pathway built in to the system. Raymond records his notes and decision in the Acute EHR. They recommend admission to the acute unit for acute psychosis and substance abuse. The care plan is discussed with Tom and they tell him that his community mental health nurse, Nora, will be informed and involved in the care plan. This helps put Tom at ease. Once the decision to admit has been recorded in the Acute EHR, the Bed Manager has been alerted. He has constant access to a real time bed state for the Hospital Group on her tablet and checks for a suitable bed in the psychiatric ward. He notes that there is an available bed and allocates Tom to the vacant bed as a pending admission. This action triggers an order to a Porter to transfer Tom. The Porter receives notification of the transfer on his hand held device. The notification tells him the patient’s identification number, where they are currently located and where they are being transferred to. He finds Tom and transfers him to the psychiatric unit.

national electronic health record - home - ehealth ireland · 2017-04-19 · tom attends for his...

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