Our experience implementing the National Cancer Information System (NCIS) in Galway University Hospitals

Written by Peter Kidd, National Cancer Information System Project Manager, Galway University Hospitals

Introduction: what is NCIS?

The National Cancer Information System (NCIS) is managed by the National Cancer Control Program (NCCP). Galway University Hospitals (GUH) become involved during the tendering and procurement phase. GUH was represented on the national working group by nurses, pharmacists and physicians. The vision was and remains to create a longitudinal record of cancer care for citizens of Ireland attending 26 hospital sites in Ireland.

NCIS is in-fact two software systems designed to transfer information back and forth to one another.

NCIS Chart has primacy. I like to oversimplify the analogy by explaining that NCIS Chart is the bulky patient record that paperbased systems must store. It contains demographic information and notes about multidisciplinary meetings where a suspected or confirmed cancer case is discussed. As users of NCIS Chart begin to revise their “old ways of doing things” dependence on legacy systems may be minimised. Information such as heights, weights, extravasation events, telephone triage and nutritional assessments for example may all be recorded on NCIS Chart. And now for NCIS Med.

Multidisciplinary meetings (MDMs) documented in NCIS Chart

NCIS Med is the BD CATO™ system which is in use across 400 pharmacies in Europe, North America and the Middle East. It is been used successfully in the Mater for several years. BD Cato™ was also recently introduced in St Vincents Private Hospital. BD Cato™ is an integrated solution that allows for the planning, prescribing, verification, manufacture and administration of Systemic Anticancer Therapy (SACT). This is the engine that drives quality use of SACT ensuring standardisation of treatment and protecting against illegible prescriptions or non-standard treatment by doctors in training.

St Luke hospital was the first hospital to go live with NCIS Med (BD Cato™) early in 2019 using commercially prepared SACT. Galway University Hospitals followed in November 2019 with roll-out of NCIS Chart and NCIS Med. Galway University hospitals manufactures most of its chemotherapy on-site.

Why NCIS?

Quite simply cancer treatment is an incredibly complex and expensive business and it represents the single biggest threat to patient safety when implemented incorrectly. The bedding in of NCIS is also a risk in itself as clinicians switch from one system to the other. However, I believe that an NCIS which is implemented with patience, humility and understanding will ultimately result in:

1. Safer more equitable treatment across the country and within hospitals
2. Real-time access to secure patient’s notes across the country when required
3. Better, faster treatment and diagnosis
4. Better more economic use of people and medicines
5. Business intelligence to assist in future scheduling of treatment which should ultimately result in better patient journeys.

What’s our story in terms of rollout of NCIS Chart and NCIS Med?

It is perhaps interesting to reflect back on this period and note that our project survived both COVID-19 and the cyberattack of 2021! It must be said we would not have progressed this far without excellent staff and a very productive working relationship with the NCIS team in the NCCP. Roll-out was gradual and progressive. This progressive rollout was essential for a number of reasons:

1. As the first adaptor and adaptor of NCIS Chart and NCIS Med we would be the first to experience any growing pains associated with NCIS in its entirety.
2. GUH continues to be challenged by medical, pharmacy and nursing staffing challenges that limit the rapid switch-on, switchoff model of implementation.
3. Most importantly it was deemed essential that staff understood that we would support their needs to adapt and change to a new system by being available to continuously feedback any issue to the NCCP.

Milestones achieved or abandoned to date as follows:

1. Achieved: 3674 doses of SACT have been administered to 367 patients since 2019 (367 patients).
2. Achieved: Areas of extensive use expanded from day ward to medical oncology ward
3. Achieved: Six multidisciplinary meetings (MDMs) now live on NCIS Chart (and six to go). 929 patient discussions documented.
4. Achieved: First multi-site MDM with Mayo University Hospital went live in 2020 (gynaecology)
5. Achieved: Business intelligence dashboard live in 2020. This dashboard synchronises data across several systems
6. Achieved: Better Patient Journeys dashboard live in 2020. This in my eyes is essential if we are to optimise chair use, staff productivity, improve scheduling and ultimately dramatically reduce patient waiting times on the day of treatment.
7. Abandoned: The Labs interface has been put on hold at present (this decision was taken by other hospitals also)

What can we learn from this project and other hospitals?

As NCIS continues to rollout across the country there is much we can learn from one another. St James and Beaumont are now live with NCIS Med and NCIS Chart respectively. The NCCP have wisely commissioned a national user group that meets every 6 to 8 weeks to share their implementation stories and experience. This open learning and exchange of ideas is essential to the success of the project.

If we were to embark on the project again, I personally would like to see:

1. Faster appointments of staff to replace designated project workers
2. A leaner process of national user registration and setup from day one
3. A national hardware commissioning team for ensuring that all PCs and peripherals were set up in the first week of the project.
4. The mandatory appointment of oncology and haematology physician leads with dedicated time to lead on therapy planning, prescribing and physician training using an “all new starts for NCIS approach” within 6 weeks of go-live.

What are our plans for the future?

We still have much work to do. Haematology inpatients represent our next cohort to go live. Additional hardware has been slow in coming due to global supply chain difficulties. However I am confident that by the time this article is published hardware will be onsite and operational. GUH has a large clinical trials business and this too should be administered through NCIS. No doubt we have much to learn in this regard.

The installation of any widespread clinical information system in a highly politically charged environment is not without its challenges. Nevertheless, as the project has grown from toddler to adolescent the interest amongst clinicians has grown. Like any teenager, whilst appreciating that there will be growing pains, there is also now an understanding that there is no going back and that the decades ahead hold much promise if managed well.

NCIS, a new national cancer care information system. Is that it?

I don’t believe it is. I believe whilst NCIS on its own stands to dramatically improve the quality and safety of cancer care in this country it also has an unutilised potential to dramatically improve staff productivity in a system where staff are already working under enormous pressure. The solution lies in the deployment of healthcare systems engineering to visualise patient journeys and interval workloads on doctors, nurses and pharmacists. The science behind this is known as healthcare systems engineering. Healthcare systems engineering is the fusion of generic improvement methodologies such as Lean and Six-sigma and the theory of constraints with industry standard systems engineering (ISO/IEC 15288).

This robust method for dealing with complex adaptive systems found in health care is an essential tool for eradicating unnecessary queues and coordinating the scheduling of complex patient journeys. It is the science behind this discipline that helps to neutralise the politics in decision making. The evidence base for a way forward is crystalised. It is not easy, it requires considerable expertise but it has been done (1,2,3). What is needed is the vision to support this initiative at a national level. The financial cost of doing so in a large hospital represents < 0.1WTE senior pharmacist per annum. The financial cost of not doing it is likely to be in the hundreds of thousands of euros per annum.

References

1. Dodds, S. “Systems engineering in healthcare – a personal UK perspective”. Future Healthc J Oct 2018, 5 (3) 160-163; DOI: 10.7861/futurehosp.5-3-160
2. “Healthcare Systems Engineering Case Study. South West Wales Cancer Centre uses Health Care Systems Engineering (HCSE) Tools and Methodology to Deliver Better Services for Patients”. GIG Cymru NHS Wales. March 2017.
3. Kidd P, Gallagher D. “Using Systems Engineering to Create Resilience in COVID-19 Swabbing Capacity at University Hospital Galway”. Journal of Improvement Science 2021: 82; 1-20.

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