Katie SummersChief Information Officer

How CCGs can support whole system interoperability? 

2

CCG role in technology

Foster technology S-curve

Maturity DeclineGrowth

Effort

Per

form

ance

Introduction

Breakdown Information silos

Foster clinician engagement

Patient and public engagement

Shared information agreements

Whole system co –ordination

The story of technology in West Berkshire CCGS

Population: circa 600,0004 CCGs (54 practices)3 UA1 Acute Trust1 Community Trust1 Ambulance Trust

The Berkshire West 10 “Integrated Care programme”

Integration Approach

• Engaging clinicians, managers and voluntary sector in workshops, to develop a vision of “what good looks like” for an elderly frail person – a patient centred pathway across the health and social care economy

• Building on feedback received from service users, patients and carers to inform the new design

• Identifying key features and metrics enabling us to recognise and measure progress

Integration Approach

• Economic modelling, to assess system and organisational impact and inform further investment and savings

• BCF submissions , CCG QIPP Business cases and provider IBP include key elements of the pathway which have been developed locally and informed by the Workshops

• This means that a significant number of initiatives that contribute to the pathway are already underway or planned

Global research shows successful integrated care systems require three core building blocks 1

… by working in a multi-disciplinary system …

… supported by key enablers

Address specific patient needs …Patient cohorts

Clinical protocols and care packages

Care coordination and planning

Performancereview

Case management

1

2

3

4

Aligned incentives and

reimbursement models

Accountability

and joint

decision-making

Information

transparency and

decision support

Clinical leadership and

team working

Patient engagement

Low risk

Moderate risk

High risk

Very low risk

Very high risk

Success in integrated care

1. Source: AQuA/Tower Hamlets 2013

What does good look like at each stage…for Sam?

Objectives of our new pathway

• Our whole system shifts from reacting to anticipating

• Personalised, shared coordinated care planning – with Sam at the centre

• Common assessment and care planning process: no duplication by multiple agents

• Ensuring most effective and efficient use of resources and avoiding duplication

Sam tells his story once, has one assessment, one care plan, one key coordinator who pulls him through one integrated system

Information Enabler Through the Integration Programme a Berkshire West’s Digital Journey for the widespread exploitation of information and IT to achieve whole system goals, through:

• Enabling transformation of care pathways and services;• Improving whole-system care service efficiency, effectiveness and safety – right

information, right place, right time;• Supporting commissioning decision-making;• Empowering patients and the public to take greater responsibility for their health

and healthcare;• Ensuring confidential information is held securely and shared on a need to know

basis

Commencing our digital journey began with listening

“Adequate and timely information must be shared between services whenever there is a transfer of care between individuals or services.”

“Services in all settings including health and social care need to improve their communication and handover ”

“The information I have is limited and frequently is missing important elements…”

“I don’t have access to some important information electronically…”

“If I had better information then it would help me evaluate risks when deciding whether to admit a patient…”

“There are delays in getting hold of information that I need…and I spend a lot of time chasing it up…”

“There needs to be better communication between ‘in-hours’ and out of hours services.”

Clinicians told us that NOT having access to accurate, timely, shared information wastes time and is a ‘blocker’ to providing high-quality, effective, efficient care…

Connected Care is our response to the call from practitioners and clinicians across Berkshire West for better, more joined-up information to support local care and local pathways.

Connected Care will deliver • Single, secure, web-based clinical portal to view key information from

multiple systems• Patient-centred view – your information follows you, instead of being

trapped in ‘silos’ in different hospitals and different systems• Improving the quality, safety and efficiency of care and practice• Underpinning transformations in where and how services can be

provided

Berkshire West Connected Care – why?

• Demographics• Laboratory• Radiology• Encounters• Allergies• Diagnosis

Clinical Data RepositoryRhapsody Integration Engine

Orders and Results (ICE)

GPs

BHFT RiO Extracts

• Authentication• Authorization• Single Sign-On• Patient Privacy & Consent• Relationships• Audit Logs

• Patient Search• Patient Lists• Patient Summary• Timeline• Flowcharts• Secure Messaging• Orion Health Applications• Third Party Applications

E-Mail

Secure Inbox

Mobile

Notifications

Presentation

Integration

Source Systems

Security & Privacy Patient Record

• Medications• Problems • Procedures• Transcribed

Documents

Portal

Connected Care Clinical Portal

MiG

RBFT Cerner

PAS

Adastra End Of

LifeRAISE – West

Berkshire

Adastra Out Of Hours

Framework i Social Care –

Wokingham

Framework i Social Care – Reading

Based on learning from Bristol and Northern Ireland

Our Digital System

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What we have achieved over 6 months

• Collaborative ownership of the programme and challenge, developing alliance approach

• Proof of concept – testing clinical scenarios with industry providers

• Clinical movement for programme • Roll of MIG to primary care and out of hours • Moving to pilot and PQQ • Launched an information sharing agreement (53

or 54 practices sign up in 3 weeks)

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Question