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