EMR as a Platform for Clinical Transformation

Transcription

1 EMR as a Platform for Clinical Transformation Dr Vinod Patel MD for the Integrated Diabetes Team George Eliot NHS Hospital HIC16-26 July, 2016

2 Overview of Talk The Burden of Diabetes Care and National Health Services Alphabet Strategy for Diabetes Care: The What, Why and How The EMR Solution: Development and Implementation Lessons learnt Conclusions and What next? 26 July, 2016 Dr Vinod Patel 2

3 The Global Burden of Diabetes DIABETES IN AUSTRALIA 1,079, 600 (6.3% of the popn.) Cost per patient $7,652 USD; 6,342 deaths pa Fastest growing chronic condition DIABETES IN NEW ZEALAND 285,900 (9.1% of the popn.) Cost per patient $4,962 USD; 1,778 deaths pa Fastest growing chronic condition 26 July, 2016 Dr Vinod Patel 3

4 The Cost of Diabetes $14.6 billion Estimated total annual cost impact in Australia (AUD) 26 July, 2016 Dr Vinod Patel 4

5 Diabetes Care: The Complications Retinopathy Most common cause of blindness in people of working age Heart Disease and Stroke Increased risk of CHD and Stroke, 75% have hypertension Nephropathy 16%-30% of all new patients needing renal replacement therapy Foot problems Commonest cause of nontraumatic amputation NICE Diabetes Guidelines 2015 CG July, 2016 Dr Vinod Patel 5

6 Intensive Steno-2 targets achieved same as NICE targets Intensive Conventional Advice Standard Standard Blood Pressure 131 / /78 Cholesterol Diabetes Control : HbA1c% TC 3.5 mmol/l LDL 1.8 mmol/l 5mmol/l 7.9% 9% Eyes Annually Annually Feet Annually Annually Guardians : aspirin, ACEI / AIIA All on ACE-I Statins 85% 22% NEJM July, 2016 Dr Vinod Patel 6

7 Steno-2 : Conclusion A target driven, long-term, intensified intervention aimed at multiple risk factors in patients with type 2 diabetes and microalbuminuria reduces the risk of cardiovascular and microvascular events by about 50%. 26 July, 2016 Dr Vinod Patel 7

8 What we do in Healthcare? Evidence Base Healthcare Professional & Patient Education Better Outcomes Action Plan 26 July, 2016 Dr Vinod Patel 8

9 The Alphabet Strategy Diabetes Care Checklist An evidenced based approach for health care professionals and patients for reducing complications and facilitating cost efficiencies in health economies Advice: weight, smoking, exercise Blood pressure: target Cholesterol: target Diabetes control: target Eyes: annual check Feet: daily check. annually by Health Professional Guardian drugs: protective drugs e.g. aspirin

10 The GAIA Study: Global Alphabet Strategy Implementation Audit This study collected audit data on 4537 patients in 52 Diabetes Centres in 32 countries in all the main continents 71% of HCPs and over 80% of patients felt that the paper version of the Alphabet Strategy could be improved and improve patient care IDF July, 2016 Dr Vinod Patel 10

11 Diabetes Care Plan 26 July, 2016 Dr Vinod Patel 11

12 Diabetes Passport (1) 26 July, 2016 Dr Vinod Patel 12

13 Diabetes Passport (2) 26 July, 2016 Dr Vinod Patel 13

14 Patient Education Education and Prevention 26 July, 2016 Dr Vinod Patel 14

15 GP Guidelines

16 Effective communication to other HCPs 26 July, 2016 Dr Vinod Patel 16

17 A guide to delivering care in the NHS From Roger Boyle 26 July, 2016 Dr Vinod Patel 17

18 POETIC Vision for Effective, Safe and Efficient Healthcare POETIC framework for generic success factors in long term healthcare P O E T I C Patient-centred: Outcomes-clear: Evidence-based: Team orientated: Integrated: Cost-effective: Patient-centred, Public Health- Driven, Professionally inspired What is it that we desire to achieve and why? Audit-informed, research will be desirable Multidisciplinary, well-trained, validated Primary, secondary care, schools, community, councils, workplace Cost efficient, but clinically governed Source: Vinod Patel and John Morrissey, Warwick Medical School/George Eliot Hospital NHS Trust 26 July, 2016 Dr Vinod Patel 18

19 Challenges 1. Variable methods for capturing patient and service information Lorenzo, Paper, Review, Insignia 2. Medical records: service had its own medical records that were not shared with the rest of the Trust and vice versa 3. Data capture: non-standardised and duplicated across variety of paper forms 4. Administrative activities: labour intensive especially letters to GPs and patients 5. Clinical handover to internal and external staff was manual and labour intensive 6. Coding: attendances not always accurately coded with potential impact on revenue 7. National reporting data for was extracted manually e.g. referral to treatment time, audit 8. Research data recorded manually and difficult to manage and monitor 26 July, 2016 Dr Vinod Patel 19

20 Objectives of the Medical Pilot 1. Clinical information: capture electronically in Lorenzo to improve service efficiency, quality and patient safety 2. Standardise clinical practice: ways of working so that information is captured and can be reported on in a consistent manner 3. Diabetes as an exemplar service for demonstrating improvements in clinical processes through the use of Lorenzo and a template for rolling out clinical functionality in the Trust 4. Standardise data capture and access: reuse processes, solution, forms and assessments in all diabetes care clinical areas 5. Structured data to enable reuse, reporting, research, clinical audits and decision support in the future 6. Patient education: using the EMR platform to uniquely record care plans, patient education delivery and recording e.g. driving, pregnancy planning advice 26 July, 2016 Dr Vinod Patel 20

21 Approach 26 July, 2016 Dr Vinod Patel 5 month duration - October to March

22 Current and Future State Process Flows Developed by Tas Hind (Clinical Enablement, CSC) and the GEH Diabetes Care Team 26 July, 2016 Dr Vinod Patel 22

23 Diabetes Clinical Chart Assessment, Correspondence and Leaflets Tab Developed by Suki Sembi (IT analyst/form creator) and the GEH Diabetes Care Team Solution: CSC Lorenzo EMR 26 July, 2016 Dr Vinod Patel 23

24 idea Integrated Diabetes Education and Academic Research Form 26 July, 2016 Dr Vinod Patel Solution: CSC Lorenzo EMR 24

25 Diagnosis Section Solution: CSC Lorenzo EMR 26 July, 2016 Dr Vinod Patel 25

26 Form sections Diabetes Care Solution: CSC Lorenzo EMR 26 July, 2016 Dr Vinod Patel 26

27 Form sections Advice Blood Pressure Solution: CSC Lorenzo EMR 26 July, 2016 Dr Vinod Patel 27

28 Form sections Cholesterol Solution: CSC Lorenzo EMR 26 July, 2016 Dr Vinod Patel 28

29 Form sections Diabetes control Solution: CSC Lorenzo EMR 26 July, 2016 Dr Vinod Patel 29

30 Form sections Eyes Feet Solution: CSC Lorenzo EMR 26 July, 2016 Dr Vinod Patel 30

31 Form sections Guardian Current medication Solution: CSC Lorenzo EMR 26 July, 2016 Dr Vinod Patel 31

32 Form sections Investigation, Assessment & Management Plan Research Solution: CSC Lorenzo EMR 26 July, 2016 Dr Vinod Patel 32

33 Form sections Follow up Solution: CSC Lorenzo EMR 26 July, 2016 Dr Vinod Patel 33

34 Leaflets 26 July, 2016 Dr Vinod Patel Solution: CSC Lorenzo EMR 34

35 idea Letter 26 July, 2016 Dr Vinod Patel Solution: CSC Lorenzo EMR 35

36 National Diabetes Audit 2016 Report Largest diabetes audit in world: England and Wales,» records, 70% of the Diabetes population 8 Care processes (NICE): weight, BP, HbA1c, Urine Albumin Creatinine ratio (UACR), cholesterol, feet screening, smoking status and advice 2003: All 9 Care Bundle Processes: 8.1% in type 2, 6.8% in Type 1 Type 1 (10%) Type 2 (90%) All 8 Processes 38.7% 58.7% HbA1c% % 66.1% Cholesterol < 5 mmol/l 76.4% 74.2% BP 140/ % 77.5% All Targets 18.9% 41.0% On average only 1 in 5 are reaching targets 26 July, 2016 Dr Vinod Patel 36

37 National Diabetes Audit Able to create audit report and review the data daily at the press of a button Created manually once a year 26 July, 2016 Dr Vinod Patel 37

38 Benefits Clinical information is now captured electronically in clinic by the consultants. Information captured for each patient is closely aligned to the best practice alphabet strategy The electronic information is instantly available to nurses and any other clinician Medical secretaries no longer type letters and input data manually Letters to GPs and patients can be sent immediately following consultation Real time audit on why the patient attends the clinic Easy access to patients who express an interest in taking part in clinical research Ability to continuously improve the clinical form This implementation has proven to be an exemplar for the Trust 26 July, 2016 Dr Vinod Patel 38

39 Benefits in Numbers 85% Improved adherence to National Diabetes Audit parameters and Alphabet Strategy Clinical Pathway: from 60% to % 33% Less time to complete GP, patient other supporting documentation 75% 50% 50% Less time to collect data for clinical audits Less time to collect data for research Less time to collect data for national clinical statistics n = cases 26 July, 2016 Dr Vinod Patel 39

40 Any trust that has Lorenzo will have the ability to implement the same approach in their organisations. We are keen to share the learning, and trusts that already have Lorenzo, or trusts that are in process of implementing Lorenzo or thinking of deploying it, are very welcome to visit us and to view the pilot first hand. Dr Ponnusamy Saravanan Associate clinical professor and honorary consultant physician in diabetes, endocrinology and metabolism 26 July, 2016 Dr Vinod Patel 40

41 Lessons Learnt Keys to success: Senior level support and sponsorship Clinical support and engagement Leadership from both nursing and clinical staff Strong teamwork between CSC and Trust Observe how nurses and clinicians work First prototype and trial solution in the department Considerations: Don t underestimate time needed to define requirements and develop forms Focus on incremental improvement Clinician leadership and team engagement Strong project management is vital Effective staff training, communication and knowledge transfer Lorenzo know-how and access to technical support 26 July, 2016 Dr Vinod Patel 41

42 What next? Phase II Optimise referral management Telemedicine Endocrine and Chronic Fatigue Syndrome Clinics Diabetes in pregnancy, prepregnancy care, structured education programme Integration with dictation devices Real time clinical audit dashboard Main A&E Majors and Minors Phase III All Medical OP Departments (Cardio, Stroke ) Integration with GPs Phase IV All Women s and Children s All Community Phase V All Surgical End-to-End Pathways ED, AMU OP, Pre-Op, Surgery Medical OP and IP Medical? Accident and Emergency Audiology Cardiology Chronic fatigue Chronic pain Diabetes Endocrinology Gastroenterology Geriatric medicine Ophthalmology Respiratory care Women s and Children s OP and IP Medical? Gynaecology Obstetric Paediatrics Diagnostic and therapeutic Cardio respiratory unit Clinical psychology Occupational therapy Pharmacy Physiotherapy Surgical OP and IP Surgery Breast care Colorectal Maxillo facial Neurosurgery Oncology Orthopaedics Urology Vascular Community all OP? Blue Sky Sexual Assault Referral Centre Camp Hill Health Centre The Chaucers Surgery Coventry and Warwickshire TB Service Genitourinary Medicine (GUM) Leicester Road Surgery Leicester Urgent Care Centre Nuneaton and Bedworth Health and Wellbeing Service Satis House Surgery Warwickshire Community Dental Service Warwickshire Stop Smoking Service 26 July, 2016 Dr Vinod Patel 42

43 EMR as a Platform for Clinical Transformation Thank you Any Questions? 26 July, 2016 Dr Vinod Patel 43

44 Community Wide Impact Level 1: Community Prevention Entire Local Population Target Group 2: Pre-Diabetic Screening At risk groups within the local population 3: Early Diagnosis Pre-diabetic population, Known impaired glucose tolerance, newly diagnosed DM 4: Forging Foundations Newly diagnosed: excellent care from start focus on lifestyle, experience, outcomes, concordance, preventing complications 5: Rolling Review 5A: Well controlled with few risk factors to manage. Achieving high quality care parameters 5B: Complicated, higher risk or psychological or social issues affecting engagement with high quality care 6: Early Escalation Uncontrolled clinical and social factors at high risk of complications, admission or morbidity. e.g. hypertension, poor concordance, poor glycaemic control 7: Curbing Complications 7A: Patients with known complications/conditions: e.g. pregnancy, concurrent illness, planned surgery 7B: Patients with unpredictable complications: reaction s to medications, poly pharmacy 8: Avoidable Admissions Hypoglycaemia, DKA, Foot ulceration and infection, 9: Unavoidable Admissions Patients with advanced disease and complications: acute coronary syndromes, stroke, amputation, nephropathy, neuropathy 10: Rationalised Long Term Care Patients with co-morbidities not amenable to treatment: end-stage renal disease, review of medications, end-of-life care 26 July, 2016 Dr Vinod Patel 44