clinical health information forum facing the future · pdf filedr charles gutteridge, ......
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Clinical health information
forum
Facing the future
9.30 am
Welcome and introductions
Dr Jonathan Richardson
Chair Clinical Health Information forum
Free prize draw at 3.45 pm
Win an iPod, hamper or the mystery prize
Clinical health information forum: Facing the future
9.45 am - Coleman Suite How eHealth supports the capture, processing and communication of information to improve decisions and outcomes: Examples from the work of Institute of Digital Healthcare (IDH)
Prof Jeremy Wyatt, co-director Institute of Digital Healthcare and Professor of eHealth Innovation
10.15 am - Coleman Suite Managing for health: The promise of the digital record
Dr Charles Gutteridge, national clinical director for informatics
10.45 am - Coleman Suite Changing Practice in Mental Health
Dr Jonathan Richardson, Clinical Director of Informatics ,Northumberland Tyne and Wear NHS Foundation Trust
11.00 am - Coleman Suite Break and browse
11.30 am - Boyne 1 Workshop one
Does technology help clinicians deliver better care?
Delivered by Jeremy Nettles, chair and Jon Lindberg, head of healthcare, Intellect UK
John Burdon Suite Workshop two
How technology has enabled the prison service to achieve efficiency savings and deliver better patient care?
Delivered by Michael McGonnell, deputy lead, Commissioning Offender Health
Coleman Suite Market stalls
Free prize draw at 3.45 pm
Win an iPod, hamper or the mystery prize
Clinical health information forum: Facing the future
12.15 pm - Coleman Suite Lunch & look
12.15 pm - Boyne 3 Optional workshop A [30 minutes]
Testing the NHS Commissioning Board’s Commissioning Intelligence Model
Delivered by Nick Allan-Smith, NHS Commissioning Board
12.45 pm - Boyne 3 Optional workshop B [30 minutes]
Testing the NHS Commissioning Board’s Commissioning Intelligence Model
Delivered by Nick Allan-Smith, NHS Commissioning Board
1.15 pm - Coleman Suite The third healthcare revolution: Clinical systems Sir Muir Gray, CBE, director better value healthcare, co-director NHS QIPP Programme, Right Care Workstream (via DVD)
1.30 pm - Coleman Suite Consumer Health Informatics – what’s that?
Mark Duman, chair, Patient Information Forum
Free prize draw at 3.45 pm
Win an iPod, hamper or the mystery prize
Clinical health information forum: Facing the future
2.00 pm - Boyne 1 Workshop three
What are the information governance barriers to delivering effective care?
Delivered by Jeremy Nettles, chair and Jon Lindberg, head of healthcare, Intellect UK
John Burdon Suite Workshop four
How technology has enabled the prison service to achieve efficiency savings and deliver better patient care?
Delivered by Michael McGonnell, deputy lead, Commissioning Offender Health
Coleman Suite Market stalls
2.45 pm - Coleman Suite Informatics: Future direction
Dr Graham Evans, director of informatics and chief information officer, NHS North East
3.15 pm - Coleman Suite The clinical network
Prof Sir John Burn, lead clinician, NHS North East
3.45 pm - Coleman Suite Concluding remarks including prize draw Dr Jonathan Richardson, consultant in old age psychiatry, acting chair clinical health information forum
Free prize draw at 3.45 pm
Win an iPod, hamper or the mystery prize
Clinical health information forum: 2011 survey
The top 5 topics you would like the meeting to cover are:
• Finding out about emerging technologies in health informatics
• Exploring the way in which health informatics technology
can support transformational change
• Highlighting new ways to use health informatics technology
• How to get clinicians involved in IT enabled change
• Providing clinical expertise for IT enabled change programmes
Free prize draw at 3.45 pm
Win an iPod, hamper or the mystery prize
Clinical health information forum: 2012 survey •98% of respondents want the forum to continue
•83% of members cascade information they learn at the CHIF to colleagues
•75% of respondents are currently involved in implementing IT projects
•50% of members feel that clinicians take on a prominent role in IT projects in their organisation
•63% of respondent advised there is a clinical informatics/clinical information lead in their organisation
•75% of respondents would be interested in profession-specific sub-groups
Free prize draw at 3.45 pm
Win an iPod, hamper or the mystery prize
Clinical health information
forum
Facing the future
Book now for the next meeting
e-health Insider CCIO workshop on 19 June 2012
How eHealth supports the capture, processing and
communication of information to improve decisions
and outcomes
Professor Jeremy Wyatt
Supporting the capture, processing
and communication of information to
improve decisions and outcomes
Dr Jeremy Wyatt DM(Oxon) FRCP(Lon) ACMI Fellow
Professor of eHealth innovation & Co-director
What is “digital healthcare” ?
“The redesign of health systems and services
supported by appropriate digital technologies”
“Appropriate digital technologies”
Technologies that improve information, communication, or
decision making, including:
Electronic records shared between professions, organisations
or with the public
Decision support for professionals & patients (eg. reminders,
alerts, risk predictions)
Telemonitoring, mobile health & self-care devices
Web-based health promotion & eLearning eg. NHS Local
Virtual reality, serious games, robotic surgery…
What is it all about ?
“Helping patients, health professionals and organisations use information to improve the quality, outcome and efficiency of care”
“Information: organised data and knowledge used to support decisions and actions”
(Shortliffe 1990)
Information cycles in healthcare
Patient care
Records
Insights
Knowledge
Capture data Analyse records
Assemble knowledge Apply knowledge
Learn & apply lessons
Retrieve data
Clinical practice,
self care
Clinical audit,
quality cycle
Research, EBM & behaviour change
Cluster trial of GP teledermatology to prevent
unnecessary referrals in 560 patients
With Depts. of Medical Informatics and Primary Care, AMC Amsterdam
SMS data capture from patients
Aim: is SMS a reliable, valid method to capture
research data from young women ?
Sent msgs about infant feeding to 350 women in
Tayside every 2 weeks; free response number
Reliability: compared SMS responses to:
– Duplicate msgs in 48 women 1 day later
– Phone calls to 62 women
Validity: compared SMS responses to:
– HV records at 2 weeks
– Other factors correlated / not correlated with feeding
method
Funded by NHS Scotland CSO
Whitford H et al, JAMIA 2012
Results 1
Feasibility: 2/350 women could only be contacted by home
phone during study (no mobile, other preferred not to text)
Acceptability: of 74 women asked about use of SMS
messages at end of study:
– 97.3% (n=72) found method convenient
– 100% (n=74) found it easy
– 96% (n=71) that it was not a nuisance
– 100% that it was not time consuming
Comments:
– “I thought it was great, so easy and quick, if you didn’t have time to reply
straight away you didn’t have to and just one letter to reply”
– “Good way for busy mums, modern, easier than paper and email”
Results 2
Reliability reasonable for numerical question:
kappas between 0.76 (95% CI 0.56 to 0.96)
and 0.80 (0.59 to 1.00)
Validity excellent compared with health
visitor data (k = 0.85 (0.73 to 0.97))
Correlational validity as expected between
SMS responses and other demographic /
clinical measures
Information design
As font legibility declines, reading slows and people give more attention to
the words and less to their meaning
Italic text and bold text are less legible than plain text
White text on a shaded or dark background makes text less legible,
unless a bolder typeface is used
EXTENSIVE USE OF CAPITAL LETTERS SLOWS DOWN READING SO
ROAD SIGNS LOOK LIKE THIS: Warwick University
Underline covers up descenders for the letters g, j, p, q and y as well
as commas, & colons; so reduces legibility
Double justification to achieve an even right margin reduces legibility
and reading speed compared to unjustified text of the same font size
For a given
font size,
short lines
or long lines with many words are more difficult to read than lines of
about 10 words
Cramming lines of text so close together that there is no space between them confuses the eye, reduces legibility and slows reading, making errors more likely.
Case study: Quality of Life in breast cancer
Aims:
1. Develop a graphical profile to “diagnose” and
communicate defective QoL
2. Use this to identify which services each
person needs to reduce their QoL defects
3. Quantify the impact of this in a randomised
trial of 200 women after breast surgery
With Monika Klinkhammer-Schalke & Wilfried
Lorenz, Regensburg, Germany
Klinkhammer M et al, B J Surgery 2012
Quality of Life profile
Based on: Wyatt JC, Wright P. Medical Records 1: Design
should help use of patient data. Lancet 1998; 352: 1375-8
QoL trial results
Proportion of women with overall QoL above 50
points at 6 months:
• 15% more QoL profile
women above 50 points
than controls (p<0.05)
• NNT = 7
• Most marked effects in
emotion and coping
• Can we apply this in UK,
and to other conditions ?
Implanted CardioMEMS sensor & transmitter in distal branch of descending PA
External device sending data to home hub; on screen questions and chart
Telehealth devices
SR of 46
RCTs in
HF –
mortality
More acceptable, effective
prescribing alerts
Randomised experiment in 24 junior doctors,
each viewing 30 prescribing scenarios, some with
prescribing alerts
Compared same alert text, some interruptive,
others non-interruptive
Funded by Connecting for Health, carried out by
an Academic F2 doctor
Scott G et al, JAMIA 2011
Interruptive alert
Interruptive
Non-interruptive
Results
Doctors receiving interruptive alert 10 X less likely to
make prescribing error as those receiving no alert (p
< 0.001)
Doctors receiving non-interruptive alert 5 X less likely
to make error (p < 0.001) – still useful
Non-interruptive alerts more acceptable
Potential impact in NHS M&E SHA
Assumptions:
Population of NHS M&E = 15M
Emergency admission rate is 9.2% pa. (HES)
65 admissions per 1000 due to ADRs, of which 72% are avoidable. Each
ADR admission lasts median 8 nights, case fatality is 2.3% (BMJ 2005)
GP error is responsible for 50% of ADR admissions; 75% of GPs currently
turn off their interruptive alert system (conjecture)
Non-interruptive alerts reduce prescribing errors to one fifth (our results)
Current position Non interruptive
alerts Savings
Avoidable ADR admissions pa. 64584 45209 19375
Avoidable ADR deaths pa. 1485 1040 446
Avoidable bed nights pa. 516672 361670 155002
Plausible eH technologies that failed
Diagnostic decision support (Wyatt, MedInfo
‘89)
Integrated medicines management for a
children’s hospital (Koppel, JAMA 2005)
MSN messenger triage (Eminovic, JTT 2006)
Smart home applications (Martin, Cochrane
review 2008): “The effects of smart technologies
to support people in their homes are not known.
Better quality research is needed.”
33/30
Instant messaging triage by NHS Direct nurse
Avoiding technology push
1. Start with the information problem:
Who is concerned ? individual decisions
communication, team work
Where in the info cycle does problem occur, & why? data capture, presentation
data analysis
knowledge assembly, use
2. Decide if ICT can help, and how
3. Pilot system, evaluate benefits
Disciplines represented in IDH
eHealth innovation group
Discipline People
Health psychology KC, SI, JW
Evidence synthesis, practice guidelines SS, JW
Clinical knowledge and decision support JW
Pharmacy / cyber-pharmacy KY
Internal medicine / medical informatics SS, JW
Evaluation & research methods JW
Usability engineering SP
Global health promotion GCM
Conclusions
Innovation often requires a shift of perspective
Disruptive innovation entails significant workflow changes
Digital Healthcare concerns psychology as much as technology
We need to design, develop, evaluate and deploy new digital healthcare solutions
Key IDH activities include NHS engagement, rigorous R&D, innovation & education – new MSc
Zebra shadows from hot air balloon
National Geographic
Case study: persuading students to join
NHS Organ Transplant register
Persuasive features:
1. URL includes https, dundee.ac.uk
2. University Logo
3. No advertising
4. References
5. Address & contact details
6. Privacy Statement
7. Articles all dated
8. Site certified (W3C / Health on Net)
889 students recruited in 5 days to internet-based trial
Same joining rate (38%) in persuasive & control groups
• Overall, 336 decided to register, including:
• 126 (49%) of 260 blood donors (HR 1.46, p=0.02)
• 65 (38%) of 173 who know a donor/recipient (NS)
• 68 (23%) of 296 who initially said “maybe”
• 22 (10%) of 232 who initially said “no” !
Interpretation:
• NHS should target young blood donors
• Fogg’s guidelines do not apply in this setting
Funded by NHS Chief Scientist Scotland
Nind et al, JMIR 2012 (submitted)
RCT of impact on joining decisions
Where I’ve come from: service & research
1980 1985 1990 1995 2000 2005 2010
NHS
Publishers
Other
Edin. Dept AI
Westminster
Brompton / IBM
Stanford
ICRF
UCL
Amsterdam
Uni Dundee
MBBS MRCP
ILTARS
ACORN
NICE
eHealth
MRC fellow
eH, DSS RCTs
KM Centre
ICRF clin units
Cochrane, BMJ Clin Evidence
NeLH CfHEP
Evaln book
DaT
HIC Director
SCT
eHealth Innovation Group strategy
1. Engage with the real
problem, users & context
2. Use theory to clarify
problem & identify
potential solutions
3. Co-design, test solutions
4. Pilot studies (safety,
feasibility)
5. Large scale RCT
Based on MRC Framework for
Complex interventions 2008
Engage with
problem
Apply theory,
identify potential
solutions
Co-design &
test solutions
Pilot studies
Large scale
trials
Engagement with problem owners
Europe: EU Commission (Argos project); WHO
Bellagio eHealth group
National: NHSDirect Innovation Committee;
Connecting for Health evaluation programme
Regional: NHS iTAPP & STH Boards
Local: Arden Telehealth Board; informatics
strategy
Evaluation adviser for:
– NHS: Simple Telehealth, NHS local, Let’s Get Moving
pilot
– SMEs: Psychology Online, Poikos Technology, etc.
– Industry: Medtronic, GE Healthcare
Some health problems we are working on
Health problem Approach
Long term conditions & self management
Who benefits from NHS Simple Telehealth ? Public acceptance of telehealth NHS local / diabetes patient portal (WMS) Uptake of NHS cardiac rehabilitation services
Drug related admissions Predicting chemotherapy-related nausea, neutropenia (WMS) Reducing prescribing errors RCT
Obesity Does NHS “Let’s Get Moving” work ? Reducing weight gain in 1st year students
Back pain & arthritis Making sense of back / hip / knee MRIs (WMS)
Mental health Self assessment & communication of risk (WMS)
Cancer Direct improvement of quality of life RCT
Health promotion Faster development of effective interventions: • Persuasive web sites - NHS Organ Donor Register RCT • SMS to improve diet of children in Mexico / 2nd world
Emergency care in community
Jewellery carrying encoded personal data
Other R&D activities
Challenge Approach
Enhancing NHS uptake of effective digital healthcare Systematic reviews on telehealth Summaries for NHS staff, Guardian network readers
Psychology of decision support Reducing automation bias Making alerts less intrusive
Targeting services to those who most need them Alternative formats for risk information about the elderly (WMS)
Making clinical reports safer, more informative Using information design to maximise impact on clinical decisions
What should guidelines tell us ? Persuasive wording; focus on what / who / where / when
Neuromarketing to benefit society Faster development of more acceptable, effective interventions, eg. SMS wording / schedule [WMS]
Exploiting routine NHS data (EU TRANSFOM project €7M)
When can we safely apply SPC, data mining, forum mining ?
Global eHealth Bellagio declaration, Kenya / Rwanda RCTs
UK survey of EHR hospital
implementation Methods:
Jha instrument (NEJMed 2009) sent to random
sample of UK acute hospital Trusts
Freedom of Information officer for each Trust
coordinated response
Calculated Jha score for each hospital: % of EHR
functions that reached Jha’s stage 1 (whole hospital
implemented) or stage 2 (1 ward or dept.). Maximum
= 32
Preliminary results:
70% response rate - 117 hospitals
Teaching status: 60 (51%) teaching
Size: mean 617 beds, median 556, IQR 450-781
English hospitals: 49 (48%) Foundation Trusts
Preliminary EHR survey
results Mean EHR implementation score: 39%
(normally distributed, SD 14%, median 38%,
IQR 27%-50%)
Variation of score with hospital characteristics:
– No difference if hospital in England (CfH) vs. Wales
(Informing HC) / Scotland (eH Strategy) / NI
– Big difference with teaching status: mean 45% for
teaching, 34% for other hospitals (p = 0.001, t test)
– No difference with hospital size, Foundation status
– ANOVA confirms teaching status is only significant
predictor of EHR implementation
– 88% of variance in score accounted for by other
factors
Avoiding over optimism
We all welcome evaluations that conform
with our expectations, however poorly
conducted, but…
Conveniently forget to cite (or even
publish) studies with disappointing
results
Ioannidis JP. Contradicted and initially stronger effects in highly cited
clinical research. JAMA. 2005;294:218-28.
Improvement in study methods over time
year1970 1980 1990 2000
1
10
100
1000
Diagnostic Odds Ratio (log scale)
Liu JLY, Wyatt JC, Deeks JJ, Clamp SE, Keen J, Verde P , Altman DG. Systematic reviews of clinical decision tools for acute abdominal pain. Health Technology Assessment 2006
Randomised trial of Quality of Life
profile
QoL randomised trial flow chart
Post-op patient with
breast cancer
Baseline QoL
assessment
3 month QoL
assessment 6 month QoL assessment
(end point)
12 month QoL
assessment
9 month QoL
assessment
CP orders ad hoc QoL
therapies
QoL profiles & reports sent
to CPs
No further QoL therapies
No further QoL therapies
Control
patients
QoL profile
patients
Breast cancer specific therapies (including physiotherapy) suggested by local guidelines
QoL therapies guided by QoL
profile & report
All patients
Key:
QoL: quality of life
CP: coordinating practitioner (=GP)
Digital healthcare innovation opportunities
Health
promotion Screening Test choice &
interpretation
Prognosis;
drug choice &
dose, self care
Supported
self care
Clinical activities:
Appropriate technologies ?
Web sites,
SMS msgs
MSN triage,
kiosks Telemedicine,
decision
support
Prescribing
alerts, telehealth,
prediction rules
Virtual ward
or hospice
Healthy Symptoms Diagnosis Long term condition
End of life
Lifeline
Why digital healthcare ?
Old model of care
Focus on acute conditions, reactive
management
Hospital centred, disjointed
episodes
Doctor dependent
Patient as passive recipient; self
care infrequent
Information & Communications
Technology (ICT) used rarely
Technology dominates
New model
Focus on long term conditions,
prevention & continuing care
Integrated with people’s lives in
homes & communities
Team based, shared record
Patient as partner; self care
encouraged & supported
Dependent on ICT & devices
Clinical needs dominate
The healthcare information cycle
Patient (self) care
Records
Insights, evidence
Knowledge
Knowledge access,
application
Capturing more accurate
requirements from 303 general
practitioners Time trade-off experiment (conjoint analysis)
on 303 GP members of Medix, a UK-wide medical
ISP
Each GP chose between systems with different: – reliability (95%, 99%, 99.9%)
– places to access (One location in a single health
care premises, anywhere within single healthcare
premises, anywhere, including home use)
– who could access (clinical staff alone, clinical and
NHS administrative staff, access by NHS and social
services staff)
GP acceptance of system features
Wyatt, Batley & Keen, J Eval in Clin Practice 2010. doi:10.1111/j.1365-
2753.2009.01217.x
GPs wanted a
system 14s faster
to compensate for
access by social
care staff !
Wyatt et al. J Eval Clin Practice 2010
Managing for health: The promise of the digital
record
Dr Charles Gutteridge, national clinical director for
informatics
Dr Charles Gutteridge Clinical Informatics
Managing for health:
The promise
of the
digital record
Patients in your heart
Patients in mind
Patients and families
Dr Charles Gutteridge Clinical Informatics
Dr Charles Gutteridge Clinical Informatics
Management matters – securing influence
17 years
From bench to universal application
We don’t have that much time
Dr Charles Gutteridge Clinical Informatics
314114000
Dr Charles Gutteridge Clinical Informatics
230063004
Dr Charles Gutteridge Clinical Informatics
160643000
Dr Charles Gutteridge Clinical Informatics
Machine readable
31411400 Recommendation to reduce meat intake
230063004 Heavy cigarette smoker
16064300 Anaerobic exercise 3+times/week
Dr Charles Gutteridge Clinical Informatics
Dr Charles Gutteridge Clinical Informatics
Better health is not a science problem
Dr Charles Gutteridge Clinical Informatics
Using data collected at the point of care
Dr Charles Gutteridge Clinical Informatics
0
10
20
30
40
50
60
70
80
01 June 2008 01 June 2009 01 June 2010 01 June 2011 31 May 2012
Scatter plot : AGE at presentation against DATE of presentation 1030 A&E attendances involving 397 patients who had 15 or fewer
completed episodes between October 2008 and December 2011
Linking activity to service use
Dr Charles Gutteridge Clinical Informatics
0
10
20
30
40
50
60
70
0 50 100 150 200 250 300 350 400 450
Total consults per patient 406 patients who attended A&E between Oct-2008 and Dec-2011
for whom the diagnostic SNOMED CT code selected was [417357006 Sickling disorder due to hemoglobin S]
or one of its 31 more specific descendents
Health is about knowledge
What is ahead for me?
What does this mean for me?
What should I do?
How did I do....what is next?
Dr Charles Gutteridge Clinical Informatics
Health cycling for patients
Me
Personalised data
Interpretation Choices
Health actions
Dr Charles Gutteridge Clinical Informatics
Dr Charles Gutteridge Clinical Informatics
Health cycling for clinicians
Me
Personalised data
Interpretation Choices
Health actions
Dr Charles Gutteridge Clinical Informatics
Practical skills
Clinician as coach
Expert data clinicians
Innovation for patient
controlled data
North East & Yorkshire & Humber LSP – Accenture PACS supplier – Agfa RIS supplier – HSS 14 trusts
London LSP – BT PACS supplier - Philips (later replaced by Sectra) RIS supplier – iSoft 21 trusts
North West & West Midlands LSP was CSC Alliance PACS supplier – GE RIS supplier – HSS 40 trusts
South LSP – Fujitsu (later replaced by CSCA) PACS supplier – GE RIS supplier – HSS 35 trusts
How PACS and RIS were delivered
•LSP: local service provider – a company under contract to supply all of the requirements of the PACS programme within a region.
East of England & East Midlands LSP – Accenture PACS supplier – Agfa RIS supplier – HSS 17 trusts
Dr Charles Gutteridge Clinical Informatics
Where did we get to?
5 cluster contracts from 10yr contracts in 2004
128 trusts with PACS (42 pre 2006)
4 cluster data stores - archive 2m studies/month
87 trusts have RIS systems
Performance management and benefits realisation
IS integration since June 2009
Interim data sharing solution via IEP available for all 2010
Dr Charles Gutteridge Clinical Informatics
New Storage Solutions: Cloud based?
Variety of options, min storage, scalable,
supplier linked, utility based etc
Dr Charles Gutteridge Clinical Informatics
Grid computing for image analysis
Dr Charles Gutteridge Clinical Informatics
Advice on-line
Dr Charles Gutteridge Clinical Informatics
Dr Charles Gutteridge Clinical Informatics
Feedback
Dr Charles Gutteridge Clinical Informatics
Dr Charles Gutteridge Clinical Informatics
Comparing cleanliness ratings with infection rates
Greaves et al, 2012 Arch Int Med
NHS Choices Measure Other variable Spearman
Rho p value
Patient perception of cleanliness
Rate of MRSA bacteraemia (per 1,000 bed days)
-0.30 <0.001
Patient perception of cleanliness
Rate of C. difficile infection (per 1,000 bed days)
-0.16 0.04
Dr Charles Gutteridge Clinical Informatics
Dr Charles Gutteridge Clinical Informatics
Enabling patient knowledge
Explicit strategies for empowerment
Digital data for patients
Clinical goal setting
Data exchange
Listening
Dr Charles Gutteridge Clinical Informatics
Tailored for patients
Dr Charles Gutteridge Clinical Informatics
Dr Charles Gutteridge Clinical Informatics Dr Charles Gutteridge Clinical Informatics
Clinical goals
Dr Charles Gutteridge Clinical Informatics
Listening and descriptive logic
Dr Charles Gutteridge Clinical Informatics
The ‘right now’ challenge
Dr Charles Gutteridge Clinical Informatics
Creating local networks
Getting smarter
Semantic networks for health
Changing Practice In Mental
Health Informatics 10.45am
Dr Jonathan Richardson
Consultant In Old Age Psychiatry
Clinical Director of Informatics
Northumberland Tyne and Wear NHS Foundation Trust
and
Chair Royal College of Psychiatrists Informatics committee
Free prize draw at 3.45 pm
Win an iPod, hamper or the mystery prize
Overview
• Electronic patient record
• Clinical dashboards
• Current provision
• Progress
• Future approach
“By all means keep a … for amusement,
but keep the more reliable ….. for work".
BMJ,..99.
“By all means keep a car for amusement,
but keep the more reliable horse for work".
BMJ,1899.
Ref Loudon I, Doctors and Their Transport, 1750-1914, Medical History, 2001, 45: 185-206
The purposes of the clinical record
• To record risk assessments to protect
the patient and others
• To record the advice given to general practitioners, other clinicians and other agencies
• To record the information received from others, including carers
• To store a record to which the patient may have access
• To inform medico-legal investigations
• To inform clinical audit, governance and accreditation
• To inform bodies handling complaints and inquiries
• To inform research
• To inform analyses of clinical activity
• To allow contributions to national data-sets, morbidity registers
• To act as a working document for day-today recording of patient care
• To store a chronological account of the patient’s life, illnesses, its context and who did what and to what effect
• To enable the clinician to communicate with him- or herself
• To aid communication between team members
• To allow continuity of approach in a continuing illness
• To record any special factors that appear to affect the patient or the patient’s response to treatment
• To record any factors that might render the patient more vulnerable to an adverse reaction to management or treatment
Improving standards in clinical record-keeping,Ian Pullen & John Loudon,Advances in Psychiatric Treatment (2006), vol. 12, 280–286
• 15% of outpatient
appointments were
affected by missing
clinical information
• In 20% of these
cases patients were
exposed to risk (as
judged by the
doctors involved).
Brief history of RiO in Newcastle
1997 – Trust completed clinical information system procurement –
began implementation of InteHealth
2002 – Migrated from InteHealth to RiO
2003 – Started clinical rollout in Community Mental Health and Early
Intervention In Psychosis teams
2006 – NTW Trust formed through merger -
• One of the largest MH Trusts in the country
• Direct contract with supplier
2010 – Trust achieved Foundation Trust status
2011 – Currently
• 3500 users covering a population of 1.2 million
• At peak approx. 900 concurrent users
• Complete coverage by March 2012 including a diverse range
of services.
Enhancing RiO Access Data Collection
• Variety of data collection methods used
• Recurring themes raised in all areas
• Directorate
• Medical
• Trust – All users email
– Over 700 responses
Team / Ward Data
Medical Staff Data Trust Survey
Recurring
Themes
Clinical Forms
• Lean workshop over 80 clinicians and patient user groups
• Went live with core documentation for 3500 users in October 2011
• Care Programme Approach Association National Award
• Review planned in March 2012
Data Entry/Mobile Access
• Vodafone mobile access solution available
Clinical Standards
• Developed NTW Clinical Standards for Electronic Record Keeping
Scanning and Document Capture
• Upgrade of the scanned document section 2012
Clinical Coding
• Work stream planned during 2012
Northumberland/Partnership Working
• Access Newcastle Social Services summary of risk, directly from RiO
Speed of RiO
• Upgrade to v6 included full hardware upgrade
Progress on issues
Differences in and out of the
national programme for IT
RiO in NPfIT
• Clinical and risk
management information
in one place
• Available to multiple
users at multiple sites at
all times
• Changes often in a
challenging time frame
RiO out of NPfIT
• Local configuration
• Enables a sociotechnical
approach
• Changes made in a
realistic time frame
Good quality information is a driver of
performance for clinical teams and
helps ensure the best possible care for
patients.
• providing timely, relevant information for clinical teams, presented in
easy to understand formats, with high visual impact
• utilising multiple sources of existing data, even across organisational
boundaries
• providing clinical information across multidisciplinary teams
• displaying information in ‘real time’ without delay for data cleansing
• allowing local configuration and comparison against national data sets
• permitting regular changes to displays, as required by the local teams,
to keep the information relevant and up to date
Clinical Dashboards help to drive this process by:
Clinical Dashboards
Acute Mental Health Ward Dashboard
Early Benefits
Benefit Baseline 2009 September 2010
Length of stay 102 days overall
for 01/12/2008 -
30/11/2009
90 days overall* for 01/12/2009 -
31/10/2010
Falls assessment
recorded
19%** 77%
Risk assessment recorded 17% 93%
MDT assessment recorded 54% 87%
*11 months **March 2010
NTW dashboards
©
Patient view
©
Lessons learned from Clinical Dashboards
Care Pathway
Access
Assessment
&
Formulation
Treatment,
maintenance
& support
Transitions
between
services /
pathways
Disengagement
& Discharge
Quality Standards
Care Pathways
EPR RiO
Quality Standards
Care Pathways
EPR RiO
Data
Warehouse
Quality Standards
Care Pathways
ESR
Safe guarding
Acute Trust
EPR RiO
Data
Warehouse
Quality Standards
Care Pathways
ESR
Safe guarding
Acute Trust
EPR RiO
Clinical Dashboard
Spreadsheets
Data
Warehouse
Standardised Quality outputs
Q and P Dashboard Data
Quality
Data
Quality
Quality Standards
RiO Champions
Care Pathways
ESR
Safe guarding
Acute Trust
EPR RiO
Clinical Dashboard
Spreadsheets
Data
Warehouse
Standardised Quality outputs
Q and P Dashboard
NTW Caldicott and Health Informatics Groups
Urgent and Planned Care Caldicott and Health Informatics Groups
Data
Quality
Data
Quality
External Communication
Clinical System Content Build Maintenance
Clinical requirements
Business requirements
= Design/Build/Test/Train = major change = minor change
<<------------------------------------------------- RiO --------------------------------------- >>
• 9th of November National Mental Health Informatics
Network Congress
• Royal College of Psychiatrists
• Department of Health Informatics Directorate
• NHS Information Centre
• British Computer Society.
• British Computer Society- Hosting
• Royal College of Psychiatrists- sponsored
• Executive committee
• Links to the National Mental Health Information Board
National Mental Health Informatics
Network
Clinical health information forum
Facing the future
11.00 am - Coleman Suite Break and browse
11.30 am - Boyne 1 Workshop one
Does technology help clinicians deliver better care?
Delivered by Jeremy Nettles, chair and Jon Lindberg, head of healthcare, Intellect UK
John Burdon Suite Workshop two
How technology has enabled the prison service to achieve efficiency savings and deliver better patient care?
Delivered by Michael McGonnell, deputy lead, Commissioning Offender Health
Coleman Suite Market stalls
12.15 pm - Coleman Suite Lunch & look
12.15 pm - Boyne 3 Optional workshop A [30 minutes]
Testing the NHS Commissioning Board’s Commissioning Intelligence Model
Delivered by Nick Allan-Smith, NHS Commissioning Board
12.45 pm - Boyne 3 Optional workshop B [30 minutes]
Testing the NHS Commissioning Board’s Commissioning Intelligence Model
Delivered by Nick Allan-Smith, NHS Commissioning Board
1.15 pm - Coleman Suite The third healthcare revolution Sir Muir Gray, CBE, director better value healthcare, co-director NHS QIPP Programme, Right Care Workstream (via DVD)
Free prize draw at 3.45 pm
Win an iPod, hamper or the mystery prize
The third healthcare revolution: Clinical systems
Professor Sir Muir Gray CBE, director Better Value
Healthcare, co-director, NHS QIPP Programme,
Right Care workstream
Great innovations of the first and second
healthcare revolution
• MRI and CT scanning • Statins • Antibiotics • Coronary artery bypass
graft surgery and stents • Stents • Hip and knee
replacement • Chemotherapy • Radiotherapy • Randomised controlled
trials • Systematic reviews
The First The Second
- All health services, world wide, face 5 major problems-
• FAILURE TO PREVENT PREVENTABLE DISEASE • INEQUALITIES AND INEQUITY • PATIENT HARM • WASTE OF RESOURCES • UNWARRANTED VARIATION IN
– QUALITY, SAFETY & OUTCOME, – ACTIVITY & COST
2011
Need & Demand
€
Carbon
BetterValueHealthcare
• Is epilepsy care in Northumberland better than epilepsy care in Durham?
• Who is responsible for the service for people with bipolar disorder in Middlesbrough?
• Did the service for people who are breathless North of the Tyne improve last year?
• Is the service for frail elderly people getting better in Sunderland and who is responsible?
• How many asthma services should there be in the North East and is that different from the number of services for frail elderly people
Systems based health care
BetterValueHealthcare
A SYSTEM is a set of activities with a common set of objectives and an annual report (also known as a programme or service)
A NETWORK is a set of individuals and organisations that deliver the system’s objectives (a team is a set of individuals or departments within one organisation)
A PATHWAY is the route patients usually follow through the system/network
Definitions
BetterValueHealthcare
Objectives Criteria Standards Performance Minimal Achievable Excellent (Annual Report)
•To diagnose asthma quickly & accurately
BetterValueHealthcare
A healthcare system is a set of activities with a common set of objectives; an example of a set of objectives, for an asthma healthcare system is set out below: •To prevent asthma •To diagnose asthma quickly and accurately •To slow the process of the disease by effective and safe treatment •To help the individual afflicted adapt to the challenges •To control symptoms and the effects of disabilities •To involve patients, both individually and collectively, in their care •To make the best use of resources •To promote and support research •To support the development of staff •To report annually to the population served
BetterValueHealthcare
Hierarchy Network
Dr Jones is a respiratory physician in the Derby Hospital Trust and last year she saw 346 people with COPD and to provide evidence based, patient centred care, and to improve effectiveness, productivity and safety
Dr Jones estimated that there are 1000 people with COPD in South Derbyshire and a population based audit showed that there were 100 people who were not
referred who would benefit ; she needs to practise population medicine
Dr Jones, the co-ordinator of the South Derbyshire COPD Network and Service has responsibility, authority and resources ( i day a week and support ) for Network development Localisation of the Map of Medicine Quality of patient information Professional development of generalists, and pharmacists Production of the Annual Report of the service
She is keen to improve her performance from being 27th out of the 106 COPD services, and of greater importance, 6th out of the 23 services in the prosperous counties
BetterValueHealthcare
Map of Medicine - COPD
Neither markets nor bureaucracies can
solve the challenges of complexity
Order from www.offoxpress.com Or find the kindle version on the Amazon Kindle store
Consumer health informatics – what’s that?
Mark Duman, chair, Patient Information Forum
Consumer Health Informatics – what’s that?
Mark Duman
www.pifonline.org.uk
16 May 2012
Agenda
• What is PiF?
• Consumer Health Information and it’s role in:
• Choice
• Shared Decision Making
• Record Access
• Challenges for CHI and health infomaticians
PiF Guides Shared Personal
Health Records – Jun’12
Activities: 1. Literature review 2. Workshops/ Interviews with people,
policy, clinicians & commissioners 3. Provider survey Content: • Where we are today • Vision for the future • Definitions & current legal framework • Case studies • What’s needed for this to work • Signpost to other resources
Information vs. Informatics
Consumer Health Information (CHI)
Information and support around:
• Health & wellbeing (e.g. leading a healthy lifestyle or prevention)
• Conditions & treatment options (including self-care)
• Services - how to choose & use them
Q. Where do you make the most daily choices?
What patients want… (Picker, 1m patient study)
• Fast access to health advice
• Effective treatment delivered by staff you can trust
• Involvement in decisions & respect for patients’ preferences
• Clear, comprehensible information & support for self-care
• Physical comfort and clean, safe environment
• Emotional support and alleviation of anxiety
• Involvement of family and friends and support for carers
• Continuity of care and smooth transitions.
Darzi (2008)
“An NHS that gives patients and the public more information and choice, works in partnership and has quality of
care at its heart.” High Quality Care for All
137/42
NHS Constitution – Rights (2009)
…to be given information about your proposed treatment in advance, including any significant risks and any alternative treatments which may be available, and the risks involved in doing nothing.
…to be involved in discussions and decisions about your healthcare, and to be given information to enable you to do this.
White Paper (July 2010)
“First, patients will be at the heart of everything we do. So they will have more choice and control, helped by easy access to the information they need about the best GPs and hospitals. Patients will be in charge of making decisions about their care.” (Page 1)
Informed Choice?
Case study: a hepa...what? • Excellent consult with general surgeon
• “I want you to see a hepatologist”
• Where to start?
?!
Case study: a hepa...what? • Excellent consult with general surgeon
• “I want you to see a hepatologist”
• Where to start?
• ‘Hepatologist Manchester’ into Google
• British Liver Trust – database; difficult to keep current, no performance rating; just name...
• Speciality, publications, extra-curricular activities?
• Choose & Book – NW only
• Ask your GP – ‘I don’t know if I can do that!’
• Still awaiting copy of referral letter
• ‘He’s not in clinic today’
Shared Decision Making
2.3 “shared decision-making” to become the norm.
International evidence shows that involving patients in their care and treatment improves their health outcomes,17 boosts their satisfaction with services received, and increases not just their knowledge and understanding of their health status but also their adherence to a chosen treatment.18 It can also bring significant reductions in cost, as highlighted in the Wanless Report,19 and in evidence from various programmes to improve the management of long-term conditions.20
www.nhsdirect.nhs.uk/DecisionAids
Record Access
2.11 We will enable patients to have control of their health records. This will start with access to the records held by their GP and over time this will extend to health records held by all providers. The patient will determine who else can access their records and will easily be able to see changes when they are made to their records. We will consult on arrangements, including appropriate confidentiality safeguards, later this year.
Personal Health Records Motivate Consumers to Act • 1 in 14 Americans use a personal health record (PHR)
• They know more about their health, ask more questions, and take better care of themselves
• 1 in 3 PHR users take a specific action to improve their health
• Most pronounced among hard to reach - multiple chronic conditions, less education, lower incomes
• Usage rates of these tools are relatively low but have doubled over the last two years.
1,849 people California HealthCare Foundation
15 Dec 2009 – 10 Jan 2010
• Information not recognised as a ‘therapy’
• Not integrated into care provision
• Lack of quality standards
• Focus on measuring provision not delivery & outcomes
• Fixation on products not behaviours
• Requisite CHI expertise mainly unrecognised
But CHI faces many challenges...
Information: first line therapy?
Integrate into delivery
http://healthguides.mapofmedicine.com/choices/map/hypertension1.html
Consumers Tapping Social Media To Access Health Information • PwC survey: one-third of US
consumers use social media to access health information
• Nearly 90% ages 18 - 24 say they would trust health information on social media websites
• More than 80% say they would use social media to share health information.
www.ihealthbeat.org/articles/2012/4/17/consumers-tapping-social-media-to-access-health-
information.aspx; 17 April 2012
Parents of Children With Cancer Distrust Online Health Info, Study Says
• Forthcoming study in Sociology of Health and Illness finds that parents of children with cancer try to avoid online health information.
• Researchers say parents may distrust or be afraid of information on the "worst-case scenario" for their child's condition.
www.ihealthbeat.org/articles/2012/3/23/parents-of-children-with-cancer- distrust-online-health-info-study-says.aspx#ixzz1uypTGNX5; 23 March 2012
"One of the reasons we were
interested in exploring this
issue is that so much research
and media coverage had
examined how the Internet was
breaking down barriers
between patients and
caregivers and their physicians.
But that wasn't that case in our
study.”
Elizabeth Gage, Professor of community health
and health behavior , Buffalo School of Public
Health and Health Professions
www.theinformationstandard.org
Production
• To high standards
• With user involvement
Distribution
• Using appropriate media
• Available at the right place & time
Delivery
• Integrated into clinical care
• With professional support
Outcomes
• Clinical effectiveness
• Safety
• Patient experience
• Behaviour change
Feedback
• Evaluation
• Review
The whole pathway needs attention
Behaviour change
Despite concerted efforts to tackle the “effectiveness of consultations between patients and clinicians,” the biggest problem is the “reluctance of clinical staff to provide active support for patient engagement.”
Recommends replacing annual review with 2 visits
• data collection (1)
• delivery of the test results
• agree action plan, goals and objectives (2)
• patient decides next appointment
www.rcgp.org.uk/PDF/CIRC_Care_Planning.pdf (Sep 11)
Internet Skills Performance Tests: Are People Ready for eHealth? • General population lacks the skills to keep up
• Lack of information and strategic Internet skills, which, in the context of health, are very important
• Also problematic for younger generations, despite considered skilled Internet users
• The results of the study strongly call for policies to increase the level of Internet skills.
www.jmir.org/2011/2/e35/ ; 01Nov09-28Feb10, 88 subjects in NL
CHI Charter (work in progress)
1. ...is an intervention that impacts health & wellbeing
2. ...must adhere to quality standards
3. ...provision must be integrated into health & care delivery
4. ...must be delivered in a supportive setting
5. ...must be measured in terms of impact on health outcomes.
Much awaited...
Challenges for health infomaticians
1. Do you recognise information as a therapy?
2. What benefits do your systems deliver to patients?
3. How well are you communicating these?
4. Are you and your patients digitally monitoring your health and wellbeing?
Consumer Health Informatics – what’s that?
Mark Duman
www.pifonline.org.uk
16 May 2012
Clinical health information forum
Facing the future
2.00 pm - Boyne 1 Workshop three
What are the information governance barriers to delivering effective care?
Delivered by Jeremy Nettles, chair and Jon Lindberg, head of healthcare, Intellect UK
John Burdon Suite Workshop four
How technology has enabled the prison service to achieve efficiency savings and deliver better patient care?
Delivered by Michael McGonnell, deputy lead, Commissioning Offender Health
Coleman Suite Market stalls
2.45 pm - Coleman Suite Informatics: Future direction
Dr Graham Evans, director of informatics and chief information officer, NHS North East
3.15 pm - Coleman Suite The clinical network
Prof Sir John Burn, lead clinician, NHS North East
3.45 pm - Coleman Suite Concluding remarks including prize draw Dr Jonathan Richardson, consultant in old age psychiatry, acting chair clinical health information forum
Free prize draw at 3.45 pm
Win an iPod, hamper or the mystery prize
Informatics: Future direction
Dr Graham Evans, chief information officer and
director of informatics, NHS North East
Clinical Health Informatics Forum
“Informatics: Future direction”
16th May 2012
Dr Graham Evans
Chief Information Officer/Director of Informatics
• Looking back…..
Agenda
• The future……………………..
• Created 64 years ago
• A long-held ideal that good healthcare should be available to all, regardless
of wealth or ability to pay
• One of the largest employers in the world; Chinese People’s Liberation
Army, the Indian railways and the Wal-Mart supermarket chain. Employs iro
1.3M people, approx. 1 in 23 of working population*.
• Men and women now live an average of 10 yr’s more than they did in 1948.
• Patients in England the right to choose between providers for non-emergency treatment.
Looking back – the NHS its origins and ideals
Whilst there have been significant NHS delivery improvements over recent years…
These factors have placed significant pressure on
the NHS “system”
Hence the need for……….
Reform and transformation!
Technology had (has) a part to play
* Expected to be less in 2012
• Back in 2002, the National Programme for IT (NPfIT) an ambitious multi
billion £ programme of investment designed to reform how the NHS in
England uses information to improve services and patient care.
• The aim was to create a fully integrated electronic care records system, for
the NHS in England.
• The original objective was to ensure every NHS patient had an individual
electronic care record which could be rapidly transmitted between different
parts of the NHS, in order to make accurate patient records available to
NHS staff at all times.
• The Programme (as we knew it) was officially terminated in 2010, although
some programmes continue.
Looking back – the NHS its challenges (NPfIT)
"Sometimes when you innovate, you make
mistakes. It is best to admit them quickly and
get on with improving your other innovations."
– Steve Jobs – Apple inc
Looking back – the NHS its challenges (NPfIT)
Looking back – Our Journey
“So what have Informatics done for us in the NE?”
Looking back – Journey continued…
Within an aligned informatics strategic framework -
implement ‘pathway based’ technologies that; supports
and informs clinical decision making; enables, care
closer to home, facilitates, flexible mobile working and
reduces demand on hospital services.
The North East Informatics “Vision”
Aligned
People
Process Technology
QIPP
Strategic programmes • Summary Care Record (SCR) • Electronic Prescription Service (EPS) • SystmOne • Image Exchange Portal (IEP) • Map of Medicine (MoM) • Pathways / ECS • 111 • Standard Templates to support care Pathways (Eol, LD etc.) • GPIT • PCT Commissioning systems and support
Collaborative programmes • Stroke data capture system • Videoconferencing • Telehealth solutions • WebEx • Information Governance campaigns
Plus Informatics Services • Professional Programme Management • Informatics Programme Governance with PCOs • Information Governance advice/guidance • Change and Benefits Management • Requirements, Design, Engagement and Service Management
The patient at the centre
Align to deliver QIPP
Joining the “system”
Looking back – North East “delivered”
Clinical Networks – OVOF
• Strategic networks, with Informatics enablement/support
• Business/Service focus
• Accelerated Solutions Events (ASE)
• Cross cutting solutions
Clinical Health Informatics Forum (CHIF)
• HI focused Clinicians who will act as a specialist resources
• Forum where Clinicians find out about current local/national initiatives
• Best practice sharing with each other/their networks
• Clinician involvement in IT enabled Transformational change programmes
• Develop governance structure / escalation route to DHID Clinical
division/alignment to other groups.
Looking back – CSF’s = Clinical engagement
Looking back – CSF’ = Patients…
• Patient Engagement and involvement
• Rich resource of Knowledge
• Eager to help shape the future
• Networks existed
Safer Care North East
Patient Carer Public Engagement
(PCPE)
• Patients our “ultimate customer".
• NPfIT had its challenges, the NE progressed on many fronts
• 100% Foundation Trust provider landscape (autonomy and choice)
• Excellent clinical engagement – Our customers
– Informatics involvement in service development and transformation
– Clinical Innovation Teams – Leadership, Sponsorship, Ownership
– Clinical Health Informatics Forum (CHIF)
• Patient engagement – Our customers
– Patient Safety - Safer Care North East
– Clinical Safety Management System (CSMS via CSO)
• Much of what we do fits with the future state direction
Looking back – Reflection of the journey
Looking forward
The Future - The NHS “its accountability”.
More localised
Less top down
Innovative
Outcomes Focused
Responsive
Clinicians leading
Open
Transparent
• Informatics services will be radically different from today:
– Some national (DHID/CfH) and regional (SHA) functions and
services will transition into receiving organisations where
appropriate
– not all current activities and services will continue
– some “must do’s” will be delivered, but differently
– new system design predicated on 9 key principals
The Future - the new “Informatics system”
1. Patients, the public and health and social care organisations will have access to information,
technology and services that meet their needs at the lowest possible cost.
2. There will be a clear policy owner (in the DH or the NHSCB) for all IT systems and services and they
will be formally appointed as the system or service SRO.
3. The NHS will build on the best of what it has, maximising investments made to date. Value for money
will underpin decision making and we will be open and transparent about costs and benefits.
4. Decisions will be taken as close as possible to the front line: action will only be taken centrally where it
will be more effective and there is a single, clear need across the NHS.
5. There will be a wide, varied and dynamic market of capable and engaged suppliers of healthcare
systems and services.
6. The NHS will be an informed customer of IT systems and services.
7. IT systems and services will be connected across business, technical and service boundaries.
Standards will ensure consistency and support clinical safety.
8. Non-informatics professionals and clinicians will see the connection between having a strong
informatics capability at an individual and organisational level and improving outcomes for patients
and the public.
9. There will be an active community of informatics specialists, clinical informaticians, leaders and
change managers to embed informatics into day to day work.
The Future - Informatics “design principals”
DH • Policy Ownership
• SRO Responsibility (social care & public health)
• ALB Sponsorship
• DH Portfolio Management
Health & Social
Care Policy
The Future - NHS informatics
NHS
Informatics
Strategy
NHSCB Information Strategy
IT Strategy
Strategic Delivery Model
Policy Liaison
Oversight of Information
Standards & IG
Strategic Supplier & Market
Development
Levers & Incentives
Business & Enterprise
Architecture
Informatics Leadership &
Professional Development
Portfolio Management
Global Leadership &
Exploitation
Best Practice & innovation
NHS Policy Policy Ownership and SRO Responsibility
(patients, commissioning, information, choice)
Patient
Engagement
Insight &
Informatics
(PEII)
Directorate
Customers
Patients
Local Authorities
Commissioners
Providers
Information Centre
for Health & Social
Care Programme
Delivery
Service
Delivery/
Operations
Assurance &
Accreditation
Finance &
Commercial
Delivery
Standards Delivery
Commissioning
Support Commissioning
Support Commissioning
Support
Smaller
Estate
Smaller Skilled
Workforce
The Future - the business context
Cost reduction
And improved
outcomes
through service
Transformation
Closing the loop
Outcomes, Quality
improvements &
Transparency enabled by
Information
“Choice” and
commissioning
intelligence enabled by
Information
QIPP
Creating
intelligence
as data is
analysed
and
interpreted
Care records
your records
form the
primary
source of
data
The
Information
revolution
Leading to
patient-centred
care
Improving
service quality
and outcomes
for you
Promoting
benchmarking of
outcomes
by clinicians
Allowing you to
share information
from your record
with others
Enabling
more direct
communication
between you &
your professional
Giving you greater
ownership & control
over your care
Encouraging
clinicians and care
professionals
to respond to your
needs and capture
data at the point
of care
Enabling you
to make properly
informed
choices
Leading to
easily understandable
Information
published by a range
of organisations to
meet your needs
Improving
data quality
as data is exposed
to professional scrutiny
and the quality of
data improves
Leading to
greater
transparency
through routine
publication of
core data
The main source for
aggregate data
for secondary uses
such as research
The
Information
Revolution
The Future - the “Information Revolution”
Are we connected?
• 77% households have access to internet
• 45% of internet users used mobile phone [23% 2009]
• 6 million accessed internet via mobile phone for first
time 2010-11
Reference : ONS 2011
The Future - the “Information Revolution”
Reference : ONS 2010
Steady increase in internet usage by
adults over recent years.
Mobile internet access growing fast
On-line, anywhere, anytime:
• SMART Phones
• Digital Services
The Future – the “Information Revolution”
“Information, combined with the right support, is the key to better
care, better outcomes and reduced costs. Patients need and should have far more information and data on all aspects of healthcare, to enable them to share in decisions made about their care ”
Reference: White paper DOH 2010
“Record access for patients is likely to improve their care and their safety”
Reference : Enabling Patients to Access Electronic Health Records:
Guidance for Health Professionals RCGP Sept 2010
We are connected!
So what about health and care?
The Future - the Opportunity
184
QIPP
Regional &
Local Team
Delivery QIPP National workstreams
Policy
Drivers
QIPP Right
Care
QIPP
Productive
Care
QIPP
Long Term
Conditions
QIPP Urgent
&
Emergency
Care
QIPP End
of Life
Digital Technology National Enablers
(e.g. standards, guidance, best practice)
Strategic
Initiatives
Adoption Support
(First of Types /
Case Studies)
Initia
tives
Regis
ter
Practical use of technology in supporting QIPP drivers and key outcome measures
Clinical
Dashboards
Sharing End of
Life
Preferences
Patient
Decision-Aids
Online Pre-Operative
Assessment
Risk Stratification
Personalised Care Planning
Online Meeting Services
• Informatics is a key “enabling part” of the wider service reform agenda,
including:
– Commissioning Intelligence
– Transformation and service reform (Clinical Networks/Senates)
– QIPP
– Organisational change
• It’s not just about IT…………but thinking, behaving and working
differently with; information, systems, services and resources
Aligned
People
Process Technology
The Future - Informatics, vision and enabling
The value proposition (Vision)
Drivers
Information will be key.
Clinical Networks/Senates
must be able to access
professional Informatics
services and knowledge to
deliver better outcomes.
Joining the system - Strategically
• We need to provide health and care services in different ways,
by:
– reducing hospital admissions
– delivering services closer to patients homes
– improving clinical decisions and enabling patient choice,
through, open/transparent data
– providing real time access to the clinical record at all points
of care (pathways), for health/care professionals, and
patients as they become more connected and in control
The Future - the NHS working differently
Courtesy of Orion Health Ltd
• Recorded once & share = integrated care
• Patient and professionals responsibility to record – shared
• Portal/signpost to information I need for my Health
Default – access online
• Data about me / care belongs to me
• No decision about me without me Information Revolution 2011
Patient
Care Coordination
Community
Nurses Allied
Health
Acute
Clinicians
Ambulance
Mental Health
Services
Social
Services
Housing
Services
Care Coordination
A Clear Strategic Vision
– Business/Patient centric (Benefits)
– Informatics enabled
Coordinated;
– Leadership and direction
– Locally implemented
Patient centred;
– Clinically owned
– Measurable, realistic and achievable
benefits
Informatics can “enable” transformational change,
but people make it happen…The Future
“Don’t do the same things better, do better things”
Informatics “transforming”
Th
e r
ole
of
Info
rma
tics
Thank you
The clinical network
Professor Sir John Burn, lead clinician, NHS North
East
Sir John Burn MD
Clinical Director
David Nicholson NHS Chief Executive
And Lord Darzi at Centre for Life 2008
Stephen Singleton
NHS NE Med Director
Invited JB to be lead
Clinician for OVOF
Summer 2008
• GP Palliative care registers
• Liverpool care pathway
• Care homes and advanced care planning
• “would you be surprised?”
• 24/7 community support
• Early engagement with 111
• Deciding right
End of Life Care
NHS Clinical Networks
Provide a route to shared decision making
Can help to standardise and simplify
Offer economy of scale
Policy on Clinical Networks
Equity and Excellence heralded a major cultural shift towards
focusing on outcomes of care
Future Forum recommended networks “should have a role
in supporting commissioners and providers” but “need to
define and review their function, form and effectiveness”
Government confirmed clinical networks retained and
strengthened in the new NHS
Objectives
Principles
Focused on quality improvement
single operating model
Regularly reviewed, remaining purposeful
Clinically led, member orgs actively engaged, duty of co-operation
Embedded, leading change, and co-ordinating systems of care
Dr Kathy McLean
Network Categories
•Informal clinical networks
•Formal clinical networks
•Formal clinical networks prescribed by NHS CB
“We propose that these networks are
entitled Strategic Clinical Networks (SCNs)”
Strategic Clinical Networks
• primary, secondary and tertiary care clinicians together, +/- social care and
the third sector, to support evidence based best practice
• lead a change process or co-ordinate care across complex pathways
maintaining and / or improving quality and outcomes
• made up of commissioners and providers, who will be the member
organisations.
• local non statutory org. models, pan England
• geographical patch, single overarching network structure & support team
• Overarching structures aligned with the footprint of clinical senates and linked
with research networks.
Effectiveness
“SCNs are established for five years. Where they remain
purposeful …should be renewed. Where the work
…concluded there should be a process for its
disestablishment
…regular review at the level of the geographical
overarching structures…
Chief Executive
Nurse Director Medical Director
Domain 3 Domain 1 Domain 4 Domain 5 Domain 2
Lead Nurse Medical Lead
CCGs, Providers, Patients and Clinicians
National Level
Sub national commissioning sector
Sub sector level
National Clinical Directors
Strategic Clinical Networks
Clinical
networks
and
Senates
Clinical Networks NorthEast
Themes
Acute Planned Long Term
Functions: team members might specialise and offer
support across networks in their area of special expertise
• Informatics
• Communications
• Transport
• Laboratory services
Themes: Acute, Planned and Long Term Conditions
embrace all of medicine and are too general to be “networks” but a clinical director can be assigned to each to integrate
activities
Existing Networks
Cancer Cardiovascular
Burns Care Neurosciences
Critical Care Chronic Fatigue
Diabetes Neonatal
Pathology Respiratory
Renal Trauma
Prospects for CITs
Maternity )
Child Health )probable SCN
Mental Health probable SCN
End of Life Care FCN
Learning Disability FCN
Acute Care workstreams-sepsis, rehab
Planned Care workstreams-enhanced recovery
Long Term Conditions workstreams-?
New Networks Should we pilot A dementia network? A primary care network?
Universities
•Durham
•Newcastle
•Northumbria
•Teesside
•Sunderland
NHS trusts
• City Hospitals Sunderland
•County Durham and Darlington
•Gateshead Health
•Newcastle upon Tyne
•North Tees and Hartlepool
•Northumbria Healthcare
•South Tees
•South Tyneside
•Northumberland Tyne and Wear
•Tees, Esk and Wear Valleys
CCGs
•Durham Dales, Easington and
Sedgefield Clinical
Commissioning Group
• North Durham Clinical
Commissioning Group • Darlington Clinical
Commissioning Group • Hartlepool and Stockton on
Tees Clinical Commissioning
Group • South of Tees Clinical
Commissioning Group • Newcastle - Tyne
Health Clinical Commissioning
Group • Newcastle Bridges Clinical
Commissioning Group • Northumberland Clinical
Commissioning Group
• North Tyneside Clinical
Commissioning Group
• Gateshead Clinical
Commissioning Group
• Sunderland Clinical
Commissioning Group
• South Tyneside Clinical
Commissioning Group
We also need to make links and join things up
•Ambulance Service
General plan • Work with NHS CB to clarify central support for SCNs
• Integrate and rationalise current funding streams
• Appoint Managing Director: Job Description needed
• Identify secondary/tertiary care delivery networks eg CCN, Neonatal, Trauma: request FT support
• Identify formal networks needing CCG support eg Learning Disability, EOL care
• Present an integrated business plan in September
Clinical Networks Northern England?
Provides a route to shared decision making
Can help to standardise and simplify
Offers economy of scale
Should we embrace N. Cumbria from the outset?
It’s getting very cheap!
Cost per Sequenced Human Genome
2001
2007
Functional classification of JDW SNPs
SNP Type Known SNPs Novel SNPs
Missense 8967 2421
Nonsense 44 5
Synonymous 9121 2261
UTR 18517 7102
Intron 922048 381924
Hereditary persistence of intestinal lactase Used to be called hereditary lactose intolerance(223100)
Europeans usually have haplotype A
Africans have lots of different haplotypes,
A, B, C, U etc Hollox et al Am J Hum Genet 2001;68:160-172
C -13910
T -13910
The lactase gene
The lactase gene
Ennatah et al 2002 found C allele with lactose
intolerance in 4 different populations and T
with tolerance Nature Genetics 30:233-37
A
Beyond the gene
People who can drink milk belong to 5 haplotype groups
Europeans
Kenyans
Tanzanians
Sudanese
Tishcoff et al Nature Genetics 2007;39:31-40
Where are the variants ?
Patrick Willems 01Sept11
Collaborative Curation of the Variome
Human Variome project will launch in June at UNESCO
a pilot programme of partnership between developing countries
and major Genetics centres to begin to create a worldwide
genomics network
Utility and cost
3.5M euros to develop a
Point of care test for
Malaria: Nanomal
Institute of Genetic Medicine
Newcastle University
Centre for Life, Newcastle UK
DNA genotyping and sequencing on nanowires – “while you wait”
Prof Sir John Burn MD FRCP FRCPE FRCPCH FRCOG FMedSci
Medical Director
International Congress of Human Genetics 2011
All authors are stockholders
Elaine Warburton CEO Sam Whitehouse COO
Jonathan O’Halloran Chief Scientist
The team
DNA Extraction We are extracting 20-50ng/ul
for each chip, from whole blood
samples.
Below are results from 3 blanks
and 3 blood cassettes. Buffer
gives “false positive” at 100ng
level
Automated extraction in 4 minutes
In a disposable cassette
2001
Cui, Y., Wei, Q.Q., Park, H.K. & Lieber, C.M.
Nanowire nanosensors for highly sensitive
and selective detection of biological and
chemical species. Science 293, 1289–1292
(2001).
“Devices based on nanowires are
emerging as a powerful platform
for the direct detection of
biological and chemical species,
including low concentrations of
proteins and viruses.” 1st July
2006 Analytic Chemistry
QMDx Sequencing principles
T
G
G
A
C
C
G
T
T
C
A
A
R
- ve - ve
- ve
- ve - ve
- ve
- ve C
Nanowire
QMDx Sequencing principles
C
T
G
G
A
C
C
G
T
T
C
A
A
- ve - ve
- ve
- ve - ve
- ve
- ve
R
100 Å
Debye Length
Nanowire
QMDx Sequencing principles
C
T
G
G
A
C
C
G
T
T
C
A
A
- ve - ve
- ve
- ve - ve
- ve
- ve
Wash
R
Nanowire
QuantuMDx technology: The QPoc
Prototype
design
Institute of Genetic Medicine, Newcastle upon Tyne, UK
Clinical Networks
• There will be central funding from NHS CB for 14/15
Clinical network teams to cover defined geographical patches
Networks and senates will share the same support team
We can create “local networks” within this structure
Informatics is important!
Institute of Genetic Medicine, Newcastle upon Tyne, UK
Genomics
• Whole genome sequencing is now cheap
• Understanding the outputs needs global partnership
• Delivering effective care needs better informatics
• Point of care genetic testing will offer answers
when and where needed
Free prize draw
iPod Nano – EMIS
Hamper – INPS
Kindle - Trisoft
Clinical health information
forum
Facing the future
3.45 pm
Concluding remarks and presentation
Dr Jonathan Richardson
North East Clinical Health
Informatics Forum
• A body of health informatics focused clinicians who
will act as a specialist resource for organisations,
present and future.
• Assistance in consultation and delivering
recommendations
• A forum of clinicians to share best practice.
• where clinicians can find out about current local
and national information initiatives.
• An opportunity to promote clinical involvement
in IT enabled transformational change.
• An open, supportive environment for clinicians
to discuss issues and concerns.
Future
Approach
Sociotechnical principles
• ‘moving away from a too-narrow focus on IT
• developing a better balance between national
requirements and local flexibility for grassroots
adaptability
• establishing the capacity and capability to support
effective handling of critical human and organisational
issues
• undertaking systematic reviews and evaluations’
Ref Peltu et al How a Sociotechnical approach can help NPfIT deliver better NHS patient care May 2008
RiO Mobile Pilot
• 2 Mobile Solutions / BlackBerry and PC laptop &
notebook devices
• RiO Store & Forward helps maintain existing assets
• Can work with RiO5 and later software releases
• Working with CSE to beta test RiO mobile for Blackberry
and RiO store and forward.
• Issues
• Standards e.g. content of the mental health electronic
patient record, national care plan.
• Clear recommendations on the functionality of systems
e.g. system usability scale.
• Payment by results in mental health e.g. meaningful
clinical outcomes.
• Opportunities
• Patient/Carer involvement.
• Facility to share information e.g. assessment documents,
care plans, procurements documents.
• Clinical Leadership e.g. Clinical Directors and Chief Clinical
Information Officer.
Informatics Committee
https://www.iwantgreatcare.org/
Social media
• ‘It took 100 years from invention of the telephone for it to reach 50% of UK households in the mid-1970s. Has the telephone radically changed medical practice?
• Facebook reached 50% of the UK population in 5 years. Will it be a more powerful disruptor?’
• http://www.gmc-uk.org/guidance/10900.aspDr Anne-Marie Cunningham (@amcunningham), a GP and Clinical Lecturer at Cardiff University
Chief Clinical Information Officer
Summary
• Information
• Communication
• Documentation
• Integration
• Continuous improvement
• Transparent
Acknowledgments
1. NE SHA informatics team
Clinical health information
forum
Facing the future
Thank you for coming
Book now for the next meeting
e-health Insider CCIO workshop on 19 June 2012