hl7 and care pathways colin gordon director, nhsia disease management systems programme health...
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HL7 and Care Pathways
Colin Gordon
Director, NHSIA Disease Management Systems Programme
Health Informatics Manager, Royal Brompton Hospital
Integrated Care Pathway
• An integrated care pathway determines locally agreed, multidisciplinary practice based on guidelines and evidence where available, for a specific patient/client group. It forms all or part of the clinical record, documents the care given and facilitates the evaluation of outcomes for continuous quality improvement.
National Pathways Association (UK) 2001
• An Integrated Care Pathway or ICP describes a process within health and Social Care, which maps out a pre-defined set of activities and records care delivered and the variations between planned and actual care. ICPs will be used to support "whole systems" processes spanning Primary Care and Secondary Care service boundaries.
ICRS OBS Part 2, 2003
Protocol
• detailed descriptions of the particular steps taken in the process of delivering care or treatment to a patient, sometimes referred to as the care pathway.
• designed at local level to implement national standards, or, by using the best available evidence, to determine care provision.
• developed on a multi-disciplinary basis, reflecting local services and staffing arrangements, and integrate the care provided by different groups or different organisations.
Protocol
• include specific information on who carries out key parts of the care or treatment, and where that should be delivered.
• Protocols also usually incorporate decision support systems that help the practitioner make decisions about the appropriate care for specific clinical circumstances.
Source: What is Protocol-Based Care? UK DoH 2002 www.modernnhs.nhs.uk/protocolbasedcare
Protocol / ICP
• A protocol is an ICP if it…– is local, agreed, mulidisciplinary– forms part of the care record– captures variances
Points about care pathways
• An actually existing, widely used mainly paper technology
• Basically a proforma/checklist with some embedded rules and exception recording
• Commonly focussed on one task in one place for one time period – e.g. day-case elective surgery
• Locally developed• NeLH has an RCN database of 2000+ locally
developed pathways with 200+ full-text examples at http://www.nelh.nhs.uk/carepathways/
• Useful listserver group http://www.smartgroups.com/groups/clinicalpathways
Care Pathways – an aspirational concept
Aspirations:• Patient-centredness• Joined-up interdisciplinary care• IT geared to service improvement• IT responsive to clinical requirement• • Advantages:• Attractive to diverse constituencies• Risks:• ’pathways’ can mean anything • Ambiguity, contradiction, multiple vague promises
Health informatics and guidelines/pathways/protocols
Mainly driven by decision support agendas• Oncocin - Musen/Shortliffe - Stanford c 1986• DILEMMA - EU - 1991-94• Prestige - EU - 1995-99• PRODIGY UK 1997->• GLIF - USA et al 1997->• EON, PROTÉGÉ, ASGAARD - Stanford 1995->• Prompt/ PROFORMA UK 1995->• NeLH-Guidelines UK 2000->• HL-7 working group on decision support 2000->• HL-7 SIG on Virtual HER – cf talk today by Peter Johnson
• Holy Grail – standardised clinical knowledge representation linked to health data/comms architecture standards 20??
ICRS Specification Elements for ICPs
• Proposed lifecycle model of pathway• Focus on care plan definition• Advanced goals – merging pathways• Plan monitoring and reporting objectives• ICPs deliverables in Phase 1 probably few and may be
still under negotiation• Current specification may not be the last word
The NHSIA Disease Management Systems Programme (DMSP)
• Commissioned by NHSIA Director of Development, in support of ICRS
• Linked to NPfIT DA• Role: develop and prove capability to specify IT support
for care pathways in NSFs• 4 examplar sites with national clinical leads:
– Newcastle – Breast Cancer – Clive Griffith– Salford – Diabetes – Bob Young– NW London – CHD – Mark Dancy– Walsall – Heart Failure – Martin Cowie
• Member of HL7-UK; working with local suppliers forum• Managed by Royal Brompton and Harefield NHS Trust• Lead technical consultant: Ramsey Systems Ltd (C
McCay)
DMSP Precursor project – Rapid Access Chest Pain Clinics
• Initiated by CHD NSF and NeLH, 2001-2• Commissioned by NHS IPU• Working with 5 Acute Trusts, 4 2ndary sector suppliers,
GP systems suppliers• Agreed and validated a national dataset/pathway
specification for RACPCs with XML message format and tools
http://www.nelh.nhs.uk/heart/racpcs/dataset/index.htm
DMSP - current NHS contexts
• CHD Collaborative Dr Mark Dancy• National Cancer Collaborative Mr Clive Griffith• Diabetes NSF Dr Bob Young• NICE Prof Martin Cowie• Protocol-Based Care Implementation Group
Chaired by NHS Modernisation Agency (Changing Workforce Programme)Forum for interested national players in NHSAims to pool knowledge and map and track related work
• National Programme for ITCommunications and Messaging ProgrammeICRS OBS Part II - LSP SERVICES
105 - Integrated Care Pathways and Care Planning
DMSP Approach to Pathway
• Shared dataset definition as basis of pathway definition• HL7 messages used to define dataset and functional subsets• Uses NPfIT approach to business modelling• W3 Business process• W5 Clinical statements• • Complementary to HL7 virtual EHR and decision support initiatives• Earlier feasibility study produced specification proposals on criteria
language for decision support• Not currently attempting to implement these
DMSP – Mapping the pathways
• Who / what / where /when• Key workflows• Key information flows• Varieties of service configuration
Referral proforma
Call/recall systems for
chronic disease management
Placed on heart
failure register
Stabilisation
Initiation of Beta blocker &/
spironolactone
Up-titration of drugs
Initiation of treatment
with ACE and diuretics
Requires further
investigations
Preliminary conclusions
Heart failure clinic
Primary care Either Secondary care
Further treatment
LV systolic dysfunction
Unclear
Transfer ofreferral data
Summary of conclusions
From heart failure clinic
Single message to put on register
a*
Sheet 1
Sheet 2
Sheet 4Sheet 3
a*: if continuing care to be in acute trustinitiates appropriate arrangements. If to be primary care initiates request message to 1y care to book patient into their clinic
a*
Working with suppliers
• HCIF – subgroup on shared care• DSMP Forum established following suspension on HCIF,
in consultation with NpfIT• Current active members:
– EMIS– IPS– ISoft – ISoft Revive– ORION– TomCat– DMSP Specifications will be made available for review via HL7-
UK
DMSP Pathway Specification Components
A. Pathway process map (NPfIT W3 format)B. Maximum Dataset (NPFiT W5 format)C. W5 subsets (to be provided, captured, communicated) mapped to
W3 process elementsD. Additional specification detail for data capture and message-
generation templates.E. Recommended minimum dataset for clinical management (subset
of B)F. Draft national audit dataset (subset of E)G. Clinical term mappings.H. Decision-support rules (not currently included).I. Transport protocol definition• DMSP Tools under development• Schema generation tool
Collaborations - Datasets, Codes, Audit
DMSP collaborates with NHSIA PHSMI work on:– NHSDatasets Programme
• datasets definition and term mapping– [e.g. Diabetes User Dataset]
– NCASP
• national audit datasets and message definition– [e.g. NCASP Diabetes Core Dataset]
Specific requirements encountered
• Data on information supplied to patient• Data on what the patient has been told• Data on education provided and advice given• Patient access to self-management record – web; ‘bank statement’• Sharing Multi-Disciplinary Team meeting results• Local disease management warehouse feeds• National audit message production• Combined care – functional requirements for virtually shared record• linkage of professional communications to data
communications
Technical issues / work in progress
• Data entry templates definition formalism• Transport protocol definition• Managing change in shared data items across message
templates• Capturing and supporting local process variance• Links to decision support / virtual EHR
DMSP Rationale and future role
• Helping to organize Clinical Participation in NPfIT
• Focus first on areas where professional consensus is
important and possible• Use existing consensus and redesign process – MA,
NSFs, professions• Link consensus process directly to pathway specification• Common tools, language and purpose• Specification supporting local professional
practice variation• Cooperate with suppliers witin standards process