development and implementation strategies - roy harper
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Development and Implementation Strategies
A Clinician’s Perspective
Development and Implementation Strategies
A Clinician’s Perspective
Dr Roy HarperConsultant Physician & Endocrinologist
The Ulster Hospital
Visiting Professor, School of Mathematics and Computing
The University of Ulster
Heading to a place where?
ICT is used to support patients, healthcare personnel and healthcare delivery
- making it better- making it easier- making it safer
For me - potential is being realised
Timeline for Health Computing (Informatics) in Health and Social Care in Northern Ireland (1999 – Present) – A Personal View
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Diamond
Diabetes ECR
installed
HPSS ICT ‘Vision’ HPSS ICT
‘From Vision to Reality’
Emergency Care
Record Pilot Goes Live
ECCH set up
Start of H&C Number roll out
Wireless Carts
NI BCS
Health set up
First COM 723
at UUJ
Local PACS
Tablet PCs and
remote access
Regional EHR
Research Group
Established
2009
PatientCentre
Di@L-log
Appointed as Physician in
UCHT
RPA
Roll out of PCs in all OPD Consulting Rooms
Pilot ECR
NIPACS
• Disease specific EMR• Comprehensive • Based on Microsoft Access • Used by all HCP• Modified as required for NI • Used by almost all hospital diabetes
units
Diamond
Development and Implementation Strategies
Something about• Bottom up / peer-to-peer
Timeline for Health Computing (Informatics) in Health and Social Care in Northern Ireland (1999 – Present) – A Personal View
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Diamond
Diabetes ECR
installed
HPSS ICT ‘Vision’ HPSS ICT
‘From Vision to Reality’
Emergency Care
Record Pilot Goes Live
ECCH set up
Start of H&C Number roll out
Wireless Carts
NI BCS
Health set up
First COM 723
at UUJ
Local PACS
Tablet PCs and
remote access
Regional EHR
Research Group
Established
2009
PatientCentre
Di@L-log
Appointed as Physician in
UCHT
RPA
Roll out of PCs in all OPD Consulting Rooms
Pilot ECR
NIPACS
Development and Implementation Strategies
Something about• Bottom up / peer-to-peer• Good foundation (infrastructure)
“Information technology is no longer perceived as just a supporting tool,
but has become a strategic necessity for developing an integrated
healthcare IT infrastructure that can improve services and reduce medical
errors”
Source: Le Rouge, Mantzana & Wilson, European Journal of Information systems (2007) 16, 669-671
Systematic Review: Impact Of Health Information Technology on Quality,
Efficiency, and Costs of Medical Care. Chaudhry et al., Ann Intern Med 2006;144:742-52.
Improving Safety with Information Technology
Bates and Gawande. N Engl J Med 2003;348:2526-34.
Development and Implementation Strategies
Something about• Bottom up / peer-to-peer• Good foundation (infrastructure)• Disseminate and build ‘evidence’
Timeline for Health Computing (Informatics) in Health and Social Care in Northern Ireland (1999 – Present) – A Personal View
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Diamond
Diabetes EMR
installed
HPSS ICT ‘Vision’ HPSS ICT
‘From Vision to Reality’
Emergency Care
Record Pilot Goes Live
ECCH set up
Start of H&C Number roll out
Wireless Carts
NI BCS
Health set up
First COM 723
at UUJ
Local PACS
Tablet PCs and
remote access
Regional EHR
Research Group
Established
2009
PatientCentre
Di@L-log
Appointed as Physician in
UCHT
RPA
Roll out of PCs in all OPD Consulting Rooms
Pilot ECR
NIPACS
Ongoing Information & Support Regular Feedback on Progress
Patients increasingly need (and demand) ready access to feedback on their progress with advice from HCPs
Effective ‘Connected Health’ approaches
• Copy letters to patient• Use the telephone• Use SMS• E-mail• On-line contact ….via a web-portal
VoiceXMLInterpreter
Primary / SecondaryCare Provider
Intranet
Patient Enters InformationAt Home Or On The Move
Regular Health ReportPrint-Outs Sent To Patient
PSTN
Secure Firewall
Electronic PatientRecord (EPR)
Data Repository
• Data Management• Visualisation• Trend Analysis• Decision Support/• Evidence Based Medicine
PDA
Clinical Workstation
Doctor / NurseOn The Move
• Patient Details• Clinical Targets• Protocols
DI@L-log
• Weight • Blood Sugar• Blood Pressure
DI@L-log Architecture Schematic
• ECCH launched January 2008
• To promote health improvement through the use of new technologies
• First project is to establish a large-scale remote monitoring service
Remote telemonitoring • Patients record data on an agreed set of parameters at
a remote location
• Data is routinely communicated to a monitoring centre
• Data is analysed and feedback given as appropriate to support patient self-care
• Incoming data outside of ‘limits’ triggers an alert and ‘response’
• Data is used to support ongoing clinical decision making
Transformation from Industrial Age Medicine to Information Age Healthcare
Source: Adapted from Malaysian Telemedicine Blueprint
Industrial Age Medicine Information Age Medicine
TransformationThrough Cost-Effective
Use of Information & Communication Technologies
Person
Community
Primary
Secondary
Tertiary
Individual Self-Care
Friends and Family
Community Networks
Professionals as Facilitators
Professionals as Partners
Professionals as Authorities
Home (self) monitoring technologies can transform
episode driven health services into a relationship based continuum of care
E A Balas 1999
Does it work in diabetes care?
Before RTM (n=65) After RTM (n=65)
HbA1c Weight Systolic
BP
Diastolic
BP HbA1c Weight
Systolic
BP
Diastolic
BP
Mean 9.2 94.8 137 75 7.8 94.8 133 74
SD 1.6 23.6 19 11 1.3 21.7 16 10
Mean HbA1c (n=65) was 9.2 % before and 7.8 % after the period of remote
telemonitoring (RTM) and the difference was highly statistically significant (p <0.0001).
The median reduction in HbA1c from baseline after the period of RTM was 1.2%. Only 8% of
patients had an HbA1c at target (i.e. ≤ 7%) prior to RTM compared to 28% after RTM.
And so RTM may help those:
• With diabetes (and co-morbidities) experiencing repeated hospital admissions
• With type 2 diabetes starting on injection therapy
• Pregnant or preparing for a pregnancy
• With type 2 diabetes and suboptimal blood sugar or blood pressure control
• Preparing for major surgery
• With type 1 diabetes
Secure Server
PHR
ECG Monitor
Activity Monitor
Blood Pressure Monitor
Glucometer
Mobile Phone
Home PC
Care Support Team
GPRS
Di@L-log
Smart Clothing
Automated data transfer
Manual data transfer
Conclusions
• Home-based remote telemonitoring (RTM) can be used to support and motivate patients with diabetes improve their self-management skills and their diabetes.
• Clinically relevant improvements in HbA1c were seen in patients using RTM for 12 weeks.
• Patients readily accept RTM. Significant changes to working patterns and a redeployment of resources will be required for RTM to become widely used and accepted by clinicians.
And so ‘connected health’• Has little evidence in our health economy
• Limited potential
• Increases workload
• Lots of ancillary (superfluous) data which is hard to interpret and out of context
• Not another system!
• And so little clinical engagement
Development and Implementation Strategies
Something about• Bottom up / peer-to-peer• Good foundation (infrastructure)• Disseminate and build ‘evidence’• Careful if little clinical engagement
Timeline for Health Computing (Informatics) in Health and Social Care in Northern Ireland (1999 – Present) – A Personal View
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Diamond
Diabetes ECR
installed
HPSS ICT ‘Vision’ HPSS ICT
‘From Vision to Reality’
Emergency Care
Record Pilot Goes Live
ECCH set up
Start of H&C Number roll out
Wireless Carts
NI BCS
Health set up
First COM 723
at UUJ
Local PACS
Tablet PCs and
remote access
Regional EHR
Research Group
Established
2009
PatientCentre
Di@L-log
Appointed as Physician in
UCHT
RPA
Roll out of PCs in all OPD Consulting Rooms
Pilot ECR
NIPACS
Problems around the way we record and use clinical
information
Problems around the way we record and use clinical
information
Still very much a paper-based world
Before ECRBefore ECR
PAS A&EPACS
South Eastern
Labs Renal G P Comm
Others
H&C
Belfast Northern
Southern WesternWesternGP’s
• Valuable time and resources wasted every day searching and waiting for clinical information needed for effective, fast and safe decision making.
• Reliance on notes, fax, post, porters, phone calls, taxis to obtain relevant clinical information.
• Significant duplication of effort due to multiple unconnected information systems across the service – limited sharing of information.
• Personal experiences - lack of information increases clinical risk & reducing efficiency.
The answer – a NI-wide ECR
Key information from various disparate
legacy clinical information systems
brought together effectively and
collated within a secure regional
electronic care record (ECR)
Feasible ?
Here’s what’s happening Here’s what’s happening • Research group – learnt from othersResearch group – learnt from others
• HSC supported a proof of concept studyHSC supported a proof of concept study
• Pilot ECR is up and runningPilot ECR is up and running
• Running for >18 monthsRunning for >18 months
• Very positive evaluationVery positive evaluation
• Moving now to a regional ECRMoving now to a regional ECR
Before ECRBefore ECR
PAS A&EPACS
South Eastern
Labs Renal G P Comm
Others
H&C
Belfast Northern
Southern WesternWesternGP’s
With ECRWith ECR
Belfast
Western
Northern
Southern
Southeastern
Single sign-on, Security, Auditing, Business rules
Patient Access to Personal Health Records
GP’s
97% of users were very satisfied or satisfied with the ease of use
97% of clinicians surveyed found the PoC system useful and 100% would recommend the system to a colleague
74% of doctors surveyed reported that the ECR use helped them to make the right diagnosis quicker and 84% agreed ECR use had contributed to a better clinical outcome at least once during the evaluation period.
33% of clinicians had found at least one occasion where use of the ECR had prevented an adverse event, such as an allergic reaction.
In an outpatient audit the ECR avoided unnecessary review appointments in 6.8% of patients seen.
Development and Implementation Strategies
Something about• Bottom up / peer-to-peer• Good foundation (infrastructure)• Disseminate and build ‘evidence’• Careful if little clinical engagement• Clinical champions with something to
show
Timeline for Health Computing (Informatics) in Health and Social Care in Northern Ireland (1999 – Present) – A Personal View
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Diamond
Diabetes ECR
installed
HPSS ICT ‘Vision’ HPSS ICT
‘From Vision to Reality’
Emergency Care
Record Pilot Goes Live
ECCH set up
Start of H&C Number roll out
Wireless Carts
NI BCS
Health set up
First COM 723
at UUJ
Local PACS
Tablet PCs and
remote access
Regional EHR
Research Group
Established
2009
PatientCentre
Di@L-log
Appointed as Physician in
UCHT
RPA
Roll out of PCs in all OPD Consulting Rooms
Pilot ECR
NIPACS
Help clinicians to get Help clinicians to get involved?involved?
• EncouragementEncouragement
• A leadership role (CCIO campaign)A leadership role (CCIO campaign)
• Support (time, resources, peer, IT)Support (time, resources, peer, IT)
• Proper Structured TrainingProper Structured Training
Help clinicians to get Help clinicians to get involved?involved?
• EncouragementEncouragement
• A leadership role (CCIO campaign)A leadership role (CCIO campaign)
• Support (time, resources, peer, IT)Support (time, resources, peer, IT)
• Proper Structured TrainingProper Structured Training
eHealth Competency Framework
• Clinical Leadership and Management• IT Healthcare Projects• Working with Information• Clinical Care Records• Clinical IT Systems and Technologies• Knowledge Management• Clinical and Health IT Standards
• Glossary of Terms• Bibliography
eHealth Competency Framework
• Developed by Academy of Medical Royal Colleges and Scottish Government
• To define knowledge, skills and attitudes required to use healthcare IT to support the delivery of care
• Suggest a framework for training and education of postgraduate doctors (for all but especially those with an interest in eHealth)
eHealth training for clinicians in NI
• HSC ICT Programme Board supported (bursaries)
• Collaboration with local Universities (University of Ulster)
• Certificate, Diploma and MSc programme in Healthcare Informatics
• Ensure competencies are covered
Development and Implementation Strategies
Something about• Bottom up / peer-to-peer• Good foundation (infrastructure)• Disseminate and build ‘evidence’• Careful if little clinical engagement• Clinical champions with something to
show• Grow informed clinical champions
Timeline for Health Computing (Informatics) in Health and Social Care in Northern Ireland (1999 – Present) – A Personal View
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Diamond
Diabetes ECR
installed
HPSS ICT ‘Vision’ HPSS ICT
‘From Vision to Reality’
Emergency Care
Record Pilot Goes Live
ECCH set up
Start of H&C Number roll out
Wireless Carts
NI BCS
Health set up
First COM 723
at UUJ
Local PACS
Tablet PCs and
remote access
Regional EHR
Research Group
Established
2009
PatientCentre
Di@L-log
Appointed as Physician in
UCHT
RPA
Roll out of PCs in all OPD Consulting Rooms
Pilot ECR
NIPACS
• Recently CE approved Vitalsens VS100 patient monitor from Intelesens Ltd. (Northern Ireland)
• The product combines disposable electrodes, offering reduced motion artifact for high quality vital sign collection, with a reusable, miniaturized clip-on body-worn device for non-invasive vital signs monitoring.
• Data sent wirelessly to a web based tool developed by Intelesens Ltd, allowing patient data and medical trends to be viewed via a web browser.
Intelesens Device
Development and Implementation Strategies
Something about• Bottom up / peer-to-peer• Good foundation (infrastructure)• Disseminate and build ‘evidence’• Careful if little clinical engagement• Clinical champions with something to show• Grow informed clinical champions• Supporting Innovation – and taking a risk
Development and Implementation Strategies
A Clinician’s Perspective
Development and Implementation Strategies
A Clinician’s Perspective
Dr Roy HarperConsultant Physician & Endocrinologist
The Ulster Hospital
Visiting Professor, School of Mathematics and Computing
The University of Ulster