Scarborough Health Network’s (SHN) Rowntree Palliative Care Centre and its partners in Scarborough Palliative Care (SPC) have developed a unique, innovative solution to delivering more integrated services for the hundreds of patients across the community who receive palliative care. By connecting the SPC partners through SHN’s Epic clinical information system for documentation and managing digital health records, the organizations are now able to make more expedited referrals, communicate more collaboratively, and care for and transfer patients between each other more seamlessly. Sharing one health record helps to avoid preventable Emergency Department visits, support patients to die in their location of preference, and improve the overall patient/family experience. In fact, this marks the first time in Ontario that a hospital network has fully integrated a community organization into its Epic system to improve the delivery of palliative care. In the first three months since launching in June 2024, the integrated system has served over 200 new palliative patients.

“This is a great example of how we can use digital solutions to improve patient care and what’s possible in local health system integration,” said Michele James, Executive Vice President, People and Transformation. “I am so proud of our SHN Rowntree Palliative Care Centre team and the collaborative effort put forward by all our partners, which truly benefits our patients and families who need palliative care services in Scarborough.”

Connecting the dots for better patient care 

SHN and our five partners that provide palliative care services in the Scarborough area – Scarborough Centre for Health Communities (SCHC), Yee Hong Peter K. Kwok Hospice, Scarborough Academic Family Health Team, Ontario Health atHome, and Shepherd Village – have a long history of working together, as the nature of a palliative diagnosis often necessitates the patient moving between different care settings and resources provided by different organizations. All partners are affiliated with the Scarborough Ontario Health Team (SOHT). However, because the partners worked from different IT systems and processes that did not ‘talk’ to one another, transferring patients between organizations often meant added delays and redundancies in their healthcare journey. For example, patients may have been required to provide all their information repeated times, which could lead to missed information or inaccuracies.

“As partner organizations, we wanted to be more in sync to better support these transitions, which was the drive behind launching Scarborough Palliative Care (SPC). Our aim was to address the fragmentation of patient records that can disrupt continuity of care and find a new way to offer the best possible healthcare experience” said Sari Greenwood, SHN Director for Palliative Care.”

“Our solution was to come together within the same health information system to enable more cohesive palliative services. This kind of collaboration helps reduce preventable Emergency Department visits, supports patients to die in their location of preference, and improves the overall experience for patients and their families.”

Through SPC, the six organizations and their client/family advisor agreed to a more formal collaborative in which each partner connected to SHN’s Epic clinical information system. This has allowed them to all begin viewing and working from the same record, no matter what services patients are receiving.

Going a step further to be the province’s first

In addition to bringing all six organizations together to view records, there was also the opportunity for SHN to fully integrate one of the SPC partners within Epic. While SHN launched Epic as part of a regional implementation with several other hospitals in 2021, integrating with a community healthcare organization was uncharted territory.

“Our Rowntree Palliative Care Centre has a particularly close, interconnected relationship with Scarborough Centre for Healthy Communities which includes a number of joint initiatives, sharing physicians across both organizations, and providing complementary services that see a lot of the same patients. This tight connection opened the possibility of exploring a full Epic connection,” said Dr. Raymond Berry, SHN Division Head for Palliative Care.

After the feasibility assessment came months of highly-technical programming work by the SHN team, followed by many hours of training to get SCHC staff ready. The result is a first for Ontario – a community partner organization plugged directly into a health network’s Epic clinical information system.

“SCHC is now able to see health records for patients receiving palliative services during a stay in an SHN hospital, and when a patient arrives to the hospital, the team there has instant access to everything that has happened in the community” said Dr. Berry. “This means we are providing coordinated care that removes the problems inherent in having disparate systems that don’t ‘talk’ to each other.”

A game-changer for patient information sharing

One of the benefits of the new solution is that it allows for better data collection and analysis, which can help identify gaps, trends, and opportunities for improvement in palliative care. For example, the partners can track how long it takes for patients to receive palliative care services after a referral, how often patients are transferred between settings, and more. The partners can then use this data to inform their planning, decision-making, and quality improvement initiatives.

The integration also supports the use of mobile tools, like tablets and smartphones, enabling healthcare providers to bring health records with them to patients who need to receive treatment in their homes. The providers can then make updates right there on-the-spot instead of taking notes that must be transcribed into the system later.

The feedback from these cross-organization care interactions has been very positive, with a clear sense that use over time will lead to further improvements. 

“This exciting achievement is a testament to the collaborative spirit and innovation of SHN’s Rowntree Palliative Care Centre and our SPC partners,” said Greenwood. “We hope that this solution we have built together can inspire and inform other regions and sectors that are looking to enhance patient information sharing and system integration into the future.”

Accessing care

Patients may be referred by a primary care provider to palliative care services in Scarborough through the SPC Common Referral Form and fax. For patients who want to learn more, SHN and our SPC partners are here to have a conversation. Please call 437-290-8063 for general inquiries or help with initiating a referral.

SHN is home to the Rowntree Palliative Care Centre, which focuses on providing person- and family-centered palliative care support through outpatient services and resources, as well as to patients staying in our hospitals. For more information, visit shn.ca/areas-of-care/palliative-care.