integrated care record … integrated care geraldine fitzpatrick 11 dec 2003 icr worshop, edinburgh...
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Integrated care record … integrated careGeraldine Fitzpatrick11 Dec 2003
ICR Worshop, Edinburgh Dec 11-12 2003
Problems with paper & silos ...
NHS Care Record (formally ICRS)
• Deeper clinical info at local level• Access to info that supports integrated delivery• Provide clinicians with support and guidance• Support bookings• Support transfer of prescriptions between GPs
and pharmacies• Provide clinicians with ability to view summary
of national patient record• Provide patients with ability to view and
contribute to their records
(NHS ICRS Introduction to the Output Based Specification, p20)
NHS Care Record (formally ICRS)
• Deeper clinical info at local level• Access to info that supports integrated delivery• Provide clinicians with support and guidance• Support bookings• Support transfer of prescriptions between GPs
and pharmacies• Provide clinicians with ability to view summary
of national patient record• Provide patients with ability to view and
contribute to their records
(NHS ICRS Introduction to the Output Based Specification, p20)
ICR Conceptualisation
• Information repositorypassive,
decontextualised structured content issuesin-between data exchange
• Formal… bird’s eye view
• Practice support… care pathways, decision support
• Change management etcseparate from ICR spec
“Records as archive”
ICR Conceptualisation
• Information repositorypassive,
decontextualised structured content issuesin-between data exchange
• Formal… bird’s eye view
• Practice support… care pathways, decision support
• Change management etcseparate from ICR spec
“Records as archive”
Where is the local situated day-to-day doing of care
work?
Overview
• Case study 1 – ‘at work’– practical integration of paper chart into care
practices ‘on the ward’
• Case study 2 – ‘to work’– the work to put telehealth to work
Location:• hospital medical unit
Method:• qualitative
– observation – in-context interviews – artefact collection
Focus:• “Understanding paper in practice can direct and inspire
new technologies” (Sellen & Harper 97)• Implicit, taken-for-granted practices…
Case Study 1: (LPR) at work
Overview of the work setting• Medical unit across two wards
–Assessment and planning ward & medical ward
• Clinical team–Medical consultant, registrar, resident–Visiting consultants–Ward nurses–Allied health
• Pharmacy• Physiotherapist• Social worker
–Services• Stroke service team• Drug and alcohol service
• Healthcare work–Allocation of patients–Rounds
Firstly…
…no such thing as the record...
… a diverse distributed collection ...
Multiple views
Teams with views-concurrent -inter-related
Ward round
Ward meeting
Stroke service& others …
Pharmacist notes
Physio
ward-book
Case manager notes
Management plan
• Individuals with views•Integrating multiple working forms
•Transformations between forms
Ward overview
Nurses work sheet
Summary: The record as diverse distributed collection
• formal ... informal
• transient ... persistent
• different locations
• different owners & authors
• different intended audiences
• different purposes
…no such thing as the record in practice...
Summary (cont)
• Buff chart (LPR) as –pivot or anchor of the network–the collaboratively-rendered persistent archival trace
• Working record as–different views as putting information to work–local stores vs central stores–transformations & representations
• How could the ICR support working records?
ICR supporting working record?
• Role-specific views of patient– Parallel records– Core and local data– Formal (persistent) and informal (temporary) data
• Summary templates for ‘paper in the pocket’– Ward views– Patient allocation views– Basis for note-taking
Secondly …
paper is highly flexible & adaptable ...
supports local adaptation,
responsiveness, and
directed communication
…allows clinicians to respond
in a timely way to local needs
Tailorable - supports individual preferences
Flexibility & adaptability…
Supports local practice & rapid prototyping
Adaptable - supports local responsiveness
Directed communication
at the point of action
Contextualised embedded conversations
Eg: Drugs & prescription screen
(www.target4.com/hc/home)
90% Informal communication
• 90% of information transactions involve informal communication rather than interaction with formal information sources (Coiera 2002)
[http://www.mja.com.au/public/issues/176_09_060502/coi10481_fm.html]
Summary: paper-based artefact
• overlaid functionality
• annotations
• conversations at the point of care
• local practices
• local responsiveness
• individual preferences
ICR supporting adaptation & communication?
• End-user tailorability of screens/forms– Within constraints
• Context and person specific communication– Informal– At point of care– Asynchronous as well as synchronous
(LPR) at work…
Integrally & actively embedded in– the doing of ‘integrated care’– as part of total environment
spatial, organisational, professional, social, medico-legal, ...
Two themes
1. No such thing as the record … a diverse distributed collection
2. Flexibility and adaptability of paper supports adaptation, responsiveness, and directed communication
And many more … a role in communication and coordination, location as information, etc
Overview
• Case study 1 – ‘at work’– practical integration of paper chart into ‘on
the ward’ care practices
• Case study 2 – ‘to work’– the work to put telehealth to work– embedding videoconferencing and data
sharing as just another tool
Case Study 2 – ‘to work’
Intensive care telehealth project
ICRS: - telemedicine as new technology to support remote
diagnosis, near patient testing …- Video conferencing to improve communication and
share knowledge
The work to put telehealth to work
Getting the technology in place is only the first part of the process
In the corner or in use?
There is significant effort required to introduce ‘non critical path’ technology and evolve working practices so that it is familiar enough and easy enough to use to be just another tool like the telephone or stethoscope…
Clinician-driven ICU telehealth
Three ICUs
Experience with
remote monitors
Off the shelf technology
The work to put it to work
• Dedicated project officer• Training for ad hoc use• Role of serendipity, experimentation• Other activities to encourage use
Different ICR conceptualisation
as archive & at work
designing records … designing practice …
information focus … practice focus …
Moving forward
Integrated care record to be used in careor
Integrated care practice enabled/supported by ICR?
• Change management– not just macro but on the ground– proactive not reactive– training to evolve practice not just to use
• How to understand issues, needs– What are the small easy things that will make big
differences to care?
• Who to involve and how– What roles, Time and resource issues,
Acknowledgements
• Work undertaken while at University of Queensland, Distributed Systems Technology Centre and Centre for Online Health, Australia
• Partners from hospitals, Telstra and UQ involved in telehealth project