sharing information to improve patient care in sussex adrian woolley head of strategic it nhs...
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Sharing information to improve patient care in
Sussex
Adrian WoolleyHead of Strategic IT
NHS Coastal West Sussex CCG
NHS Crawley CCG
NHS Horsham & Mid-Sussex CCG
November 2014
Sharing information between care settings
Photo: sparkle glowplug
particularly for use in unscheduled care
Reactive, not predictive services: failure to identify vulnerable people who might then be given extra help to avoid hospital admission or deterioration / complications of their condition…
Fragmented care: the healthcare system…not being considered in a whole system approach with social care…
Lack of informational continuity: care records which can’t be accessed between settings...
NHS England. Everyone Counts: Planning for patients 2014/5- 2018/9
NHS England describe the barriers to great care for people with long term conditions:
The phone…how we traditionally share information between health and social care
Somebody’s handbag…where to find latest home visit assessment
Serious case reviews – ‘familiar failings’
• Poor communication between and within agencies• "Professional over optimism"• A lack of "professional curiosity" in questioning information• A lack of confidence among professionals in challenging parents and
other professionals• A lack of analysis of information• Shortcomings in recording systems
Significant diagnosisDNACPR
Social Services visit daily
ECGDiabetes clinicIn-patient discharge letter
Specialist nurse record
Care providers can have ‘silos’ of information held within their organisational boundaries
Dementia nursing
GP practice system
Social Services
Hospitals
Community Nursing
Mental Health
Admission Avoidance DES Care Plan
MH Crisis Plan
Contingency Care Plan
Significant diagnosisDNACPR
Social Services visit daily
ECGDiabetes clinicIn-patient discharge letter
Specialist nurse record
Care providers can have ‘silos’ of information held within their organisational boundaries
Dementia nursing
GP practice system
Social Services
Hospitals
Community Nursing
Mental Health
Admission Avoidance DES Care Plan
MH Crisis Plan
Contingency Care Plan
A real time Read Only viewer for use in direct patient Care, with Information derived from both Health and Social Care
ROCI
A Virtual Integrated Digital Care Record
Live data (no data warehouse)Live data (no overnight updates)Consent to view at point of need
Real time messaging to multiple systems – ‘send pertinent information for unscheduled care’
GP
Social Services
NHS No, Name, DoB
Community Nursing
Mental Health
Integration Engine and VIPER360 portal
Hospital
Consent record for audit
RBAC
a patient summaryproblemsdiagnosesmedication (current, past and issues)risk and warningsproceduresinvestigationsblood pressure measurementsencounters, admissions and referralspatient demographics
What data could be available?From GP (via MIG):
current medsallergiesadverse reactions
From SCR:
Main AddressCurrent AddressPlacement AddressAllocated Worker, Open/Closed Agency Providing Care Package Funded? Emergency Next of Kin details Does the Subject Have a Carer? Is the Subject a Carer?
From Social Services:
recent admissions & dischargesEDD
From Acute Trusts:
open referrals
From Community Trust
LCanticipatory care plans
From care plan repository:
Mental health crisis plan
From Mental Health:
Patient detailsExaminationsEventsSummaryInvestigationsProblemsProceduresRisks & warnings
Live data from the GP clinical system
Recent testsBiochemistryECGHaematologyImagingMicrobiologyCytologyOthersPhysiologyUrinalysis
Potentially useful in admission avoidance
• Mrs W is a 91 y.o. woman who has dementia. She lives with her family but they are normally out during the
working day. Mrs W is quite deaf. She has a leaky heart valve and AF, she has oedema in legs; she has been
reviewed by a cardiology consultant. She is diabetic.
• Mrs W presses her emergency button when she feels a bit breathless and wants a hand getting out of her chair. An
ambulance is dispatched.
Scenario 1
• Ambulance crew have no background data but find a confused patient unable to remember what medication she is
on. They undertake ECG and find it abnormal, they decide to convey her to A&E.
• Mrs W waits on a trolley in A&E, confused and a bit frightened.
• A&E have no background data on patient. 4 hour target looming. Decide to admit to MAU for blood tests and ECG
Scenario 2
• Ambulance crew access anticipatory care plan and are reassured that her condition is not acute. They decide not to
convey but advise the district nurse.
Scenario 3
• Ambulance crew do convey, however A&E access the ROCI system to understand the medical history and admission
to hospital is avoided.
Case study
Admission AvoidancePeople, especially the frail elderly, can find hospital admission a frightening experience and would rather be treated in their own homes.
Avoiding tests and medication If unscheduled care has access to primary care and social care information then this information can sometimes avoid repeating test or medication that have already been prescribed. As well as a cost saving, it avoids subjecting patients to test or medication that does not benefit their care.
Qualitative benefits
• Information Sharing Agreement finalised
• Trust Interface Engine (messaging technology) installed and operational.
• Pull of MIG data through system tested and working.
• 30 day pilot run in hospital A&E; data from 8 local GP practices.
• Social Services record to include NHS numbers; monthly batch tracing to start.
• To Include social services, mental health and anticipatory care plans in next few
weeks.
ROCI: Where have we got to?
•Better Care: Proactive Care
•Primary / secondary care interface: One Team
•Duty social worker
•Hospital in-reach
•Discharge planning / Alerting
•Planned Care
Potential applications of ROCI
ROCI is supported by the 7 CCGs across both West and East Sussex
Population 1.6 million
(Population 159,311 in 1801)
•The classics – stakeholder engagement etc x n2.
•Information Governance, legal opinion
•Data access. Paternalism
•Commercial self interest of system suppliers
•Finding care plans
•Waiting to test against Spine 2
Challenges for this type of project
GP Admission Avoidance DES care plans
Proactive Care EoLC Plans
NHS mail – special
template
AmbulanceA&E (ROCI) OOH GPs
Sussex widecare plan database
Data readers
Data sources
One place to find care plans = reduced conveyance by ambulance.