Transforming patient care through enhanced Digital Imaging

Peter RowlandsConsultant radiologist Royal Liverpool university hospital

My background

• Interventional radiologist

• Longstanding obsession with technology

• Two PACS procurements as clinical lead

• One Npfit One Consortium

• Trust Imaging /order comms lead for 3 trust EPR procurement

• partner selected… Implementation imminent

• Not part of a STP

Content

• Bringing all information about a patient together

• RIS and PACS in delivering goal of a paperless NHS

• Integration with Electronic Patient Records

• The role of STP in imaging

• Novel workflow management tools

RIS /PACS• National Programme for IT . originally not a core part

• Subsequently added, regarded as the biggest win

• Rolled out from 2006 onwards… replaced 2013 onwards

• Exists unchanged in some areas

• No cross site sharing

• Provision of RIS and PACS

• Paperless in radiology departments only

RIS/PACS

• An easy win. Standards based

• Paperless only within departments

• No order comms integration. Very hard to remove all papetrails

• No EPR integration

• No regional integration

Order comms

• The hardest part• Human interface is hard to manage

• EPR integrated or standalone

• Interface to hospital

• Other hospitals

• Primary care

• Other providers• Independent sector

• Other health systems, eg pet CT service

Our experience

• PACS since 2006

• RIS before that

• Despite this

• Many GPs not connected

• Main cancer centre uses paper requests

EPR/ EMR/ EHR

National Audit Office

• 2.7Bn spent by 2011

• 4.3Bn 2011 – 2015

• New Royal Liverpool Hospital will cost 0.43 Billion

• North Midlands East

• 4/97 systems in 7 years

Lost in Brexit

Framework

• Open standards

• Interoperability

• Secure Identity

• Modular systems

• Designed around user need

• Use modern browsers

• OS agnostic

• Internet /mobile first

• Public Cloud located

• Standard data layers

• Open API ( application programming interfaces)

Whats in an EPR?

Levels of EPR

What does an EPR do?

• PAS• tracking of patient movement

• Scheduling of activity - eg clinics

• Bed management

• Stats eg 18 week target

• Document management• Clinical notes

• Clinic and Discharge letters

Pathways

• Storage of physiological data

• Decision supportSmart pathways

‘Bundles’ of Investigations and treatment for a specific condition

What can an EPR do?

• Order communications

• Requests for tests or investigations

• Results management

• Critical Results Notification

Drugs prescribing and administration

decision support

avoiding interactions

Business intelligence

analysis of activity

Alerts for exceptions

Higher levels of EPR

• Multimedia

• PACS/ RIS

• Cardiology

• medical photography

• PACS/RIS can be regarded as easy gain

PACS integration with EPR

• Integrated viewer

• Open API

Trak

Open API

• Launch patient in context from patient page

• Launch from order comms

• Launch in context

• Viewer with rich functionality or client

• Proportion of EPR with working link??

Sustainability and Transformation Project

• Became apparent 2015

• Proposals published 2016

• Part of 5 year forward plan /Long term plan

• Mostly in draft structure

• Several abandoned

• Eg London A&E reorganization plan

• All should become integrated care systems by 2021

STP objectives

• Performance measures will include a new ‘integration index’ developed jointly with patient groups and the voluntary sector which will measure from patient’s, carer’s and the public’s point of view, the extent to which the local health service and its partners are genuinely providing joined up, personalised and anticipatory care

Radiology and STP

Radiology component

Enablers

• Cross site booking

• Using any areas of excess capacity

• Cross site reporting

• Seamless PACS/RIS/EPR access

• New breed of workflow management products

• Enable efficient control of work

• GIRFT

• Single specialist report avoid duplication

Disablers

• Multiple separate radiology departments

• Specialist and General

• Acute and Cold

• Individual trust contracts

• Much of the country no joined up image share/reporting

• Reluctance to have specialist reporting hub

• Clinical relationships

• Desire to retain wide reporting skills

• Many imaging exams are not easily categorised

Disablers

• Individual hard pressed departments

• Failing with own workload

• Suspicion regarding top down management

• Imposition without discussion

Other STPs –Greater Manchester

• Consolidated applications – creation of an infrastructure that allows for shared Picture Archiving and Communication System across GM and shared pathology results with central storage

No room for imaging/ PACS image sharing in 84 pages

Derby

Nottingham

Sheffield

STP headlines

• Increased image sharing

• Cross site reporting

• Standardisation of protocols

• Less reports and MDT reviews

• Better access for outside hospital agencies

• (integration of other providers)

New breed of workflow managers• Cross site

• Smart reporting

• Allocation to groups

• Rules based

• Can build in time targets

• Hide easy gain studies

• Push high priority studies

• Put in deadlines

Workflow managers

• https://collaboration.carestream.com/solutions/workflow-management/workflow-orchestrator

• Many other vendors are developing smart workflow tools

• Can live in RIS, in PACS or separately

• System live and working in SE Scotland

Workflow manager

• Minimal frontend

• Minimal number of worklists presented

• Reporting launched seamlessly from front end via normal client

• Images streamed rather than pushed / pulled

• Smart lists

• Configurability

Success story and good PR..

My team successfully implemented a commercial EPR (happened to be Epic) in a US health system with 9 million patients, 32 hospitals, and 12,000 physicians (plus 70,000 nurses and other health professionals). It happens to be Kaiser Permanente for those who are curious.It works really well...because the chief executive was the sponsor, clinicial leadership was committed, and the project was properly resourced by both clinical and IT staff who were trained to develop and deploy the system. One of the realities is that you WILL need to evolve the approach to the patient experience to get the right data - into and the value out of -your EPR investment.

Another success story

Sure we need the technical ability enabled by common standards-but that gets you no-where without sorting the politics, the clinical standards, the information governance, the transformational change agenda, the capacity of staff to learn IT systems, the cross organisational care planning, the sharing of clinical records and data standards, the governance process and the designing out of variability in clinical care. This process must be clinically lead with close IM&T support and quality project management to enable deployment. It can be done but not with a patchwork of software products from SME's- if no other reason than because your staff cannot attain the proficiency needed to operate multiple systems built with differing design concepts. We have the tools already-what we lack is the ability to link strategy, tactics and operational deployment in a coherent fashion.

Conclusions

• Easy wins have gone

• More and more behaviour change

• New exciting technology

• Don’t lose sight of your targets