EMR as a Platform for Clinical Transformation€¦ · in all diabetes care clinical areas 5....

EMR as a Platform for Clinical

Transformation

Dr Vinod Patel MD for the

Integrated Diabetes Team

George Eliot NHS Hospital

HIC16 - 26 July, 2016

Twitter: @vinodpatel12345

Overview of Talk

• The Burden of Diabetes Care and

National Health Services

• ‘Alphabet Strategy’ for Diabetes Care:

The What, Why and How

• The EMR Solution: Development and

Implementation

• Lessons learnt

• Conclusions and What next?

26 July, 2016 | Dr Vinod Patel 2

Twitter: @vinodpatel12345

The Global Burden of Diabetes

DIABETES IN AUSTRALIA

• 1,079, 600 (6.3% of the 20-79 popn.)

• Cost per patient $7,652 USD; 6,342 deaths pa

• Fastest growing chronic condition

DIABETES IN NEW ZEALAND

• 285,900 (9.1% of the 20-79 popn.)

• Cost per patient $4,962 USD; 1,778 deaths pa

• Fastest growing chronic condition


The Cost of Diabetes

$14.6

billionEstimated total annual cost

impact in Australia (AUD)


Diabetes Care: The Complications

Nephropathy16%-30% of all new patients

needing renal replacement

therapy

Heart Disease and StrokeIncreased risk of CHD and Stroke, 75% have

hypertension

Foot problemsCommonest cause of non-

traumatic amputation

NICE Diabetes Guidelines 2015 CG38 .

RetinopathyMost common cause of blindness

in people of working age


Intensive Conventional

Advice Standard Standard

Blood Pressure 131 / 73 146/78

Cholesterol TC 3.5 mmol/l

LDL 1.8 mmol/l

5mmol/l

Diabetes Control :

HbA1c%

7.9% 9%

Eyes Annually Annually

Feet Annually Annually

Guardians : aspirin,

ACEI / AIIA

All on ACE-I

Statins 85% 22%

NEJM 2008

Intensive Steno-2 targets achievedsame as NICE targets


Steno-2 : Conclusion

“ A target driven, long-term, intensified intervention aimed at

multiple risk factors in patients with type 2 diabetes and

microalbuminuria reduces the risk of cardiovascular and

microvascular events by about 50%.”


What we do in Healthcare?

Evidence Base

Action Plan

Healthcare Professional

& Patient Education Better Outcomes


The Alphabet Strategy

Diabetes Care ‘Checklist’

An evidenced based approach for health

care professionals and patients for reducing

complications and facilitating cost

efficiencies in health economies

• Advice: weight, smoking, exercise

• Blood pressure: target

• Cholesterol: target

• Diabetes control: target

• Eyes: annual check

• Feet: daily check. annually by Health Professional

• Guardian drugs: protective drugs e.g. aspirin

The GAIA Study: Global Alphabet Strategy Implementation Audit

• This study collected audit data on 4537 patients in 52 Diabetes

Centres in 32 countries in all the main continents

• 71% of HCPs and over 80% of patients felt that the paper version of

the Alphabet Strategy could be improved and improve patient care

IDF 200826 July, 2016 | Dr Vinod Patel 10

Diabetes Care Plan


Diabetes Passport (1)


Diabetes Passport (2)


Patient EducationEducation and Prevention


GP Guidelines

Effective communication to other HCPs


A guide to delivering care in the NHS

From Roger Boyle


POETIC Vision for Effective, Safe and Efficient Healthcare

Patient-centred, Public Health-Driven, Professionally inspired

Outcomes-clear: What is it that we desire to achieve and why?

Cost efficient, but clinically governed

Audit-informed, research will be desirable

Multidisciplinary, well-trained, validated

Primary, secondary care, schools, community, councils, workplace

Patient-centred:

Evidence-based:

Team orientated:

Integrated:

Cost-effective:

P

O

E

T

I

C

Source: Vinod Patel and John Morrissey, Warwick Medical School/George Eliot Hospital NHS Trust

‘POETIC’ framework for generic success factors in long term healthcare


Challenges

1. Variable methods for capturing patient and service information Lorenzo, Paper, Review, Insignia

2. Medical records: service had its own medical records that were not shared with the rest

of the Trust and vice versa

3. Data capture: non-standardised and duplicated across variety of paper forms

4. Administrative activities: labour intensive especially letters to GPs and patients

5. Clinical handover to internal and external staff was manual and labour intensive

6. Coding: attendances not always accurately coded with potential impact on revenue

7. National reporting data for was extracted manually e.g. referral to treatment time, audit

8. Research data recorded manually and difficult to manage and monitor


Objectives of the Medical Pilot

1. Clinical information: capture electronically in Lorenzo to improve service efficiency, quality

and patient safety

2. Standardise clinical practice: ways of working so that information is captured and can be

reported on in a consistent manner

3. Diabetes as an exemplar service for demonstrating improvements in clinical processes

through the use of Lorenzo and a template for rolling out clinical functionality in the Trust

4. Standardise data capture and access: reuse processes, solution, forms and assessments

in all diabetes care clinical areas

5. Structured data to enable reuse, reporting, research, clinical audits and decision support in

the future

6. Patient education: using the EMR platform to uniquely record care plans, patient education

delivery and recording e.g. driving, pregnancy planning advice


Approach

5 month duration - October to March 201526 July, 2016 | Dr Vinod Patel 21

Current and Future State Process Flows

Developed by

Tas Hind (Clinical

Enablement, CSC)

and the GEH Diabetes

Care Team


Diabetes Clinical ChartAssessment, Correspondence and Leaflets Tab

Developed by

Suki Sembi (IT

analyst/form

creator) and the

GEH Diabetes Care

Team

Solution: CSC Lorenzo EMR


iDEAIntegrated Diabetes Education and Academic Research Form

Solution: CSC Lorenzo EMR26 July, 2016 | Dr Vinod Patel 24

Diagnosis Section


Form sections

Diabetes Care



Form sections

Advice

Blood Pressure



Form sections

Cholesterol



Form sectionsDiabetes control



Form sections

Eyes

Feet



Form sections

Guardian

Current medication



Form sections

Investigation, Assessment & Management Plan

Research



Form sections

Follow up



Leaflets


iDEA Letter


National Diabetes Audit 2016 Report

• Largest diabetes audit in world:

England and Wales, »1 800 000

records, 70% of the Diabetes

population

• 8 Care processes (NICE): weight,

BP, HbA1c, Urine Albumin Creatinine

ratio (UACR), cholesterol, feet

screening, smoking status and advice

• 2003: All 9 Care Bundle Processes:

8.1% in type 2, 6.8% in Type 1

Type 1

(10%)

Type 2

(90%)

All 8 Processes 38.7% 58.7%

HbA1c% ≤ 7.5 29.9% 66.1%

Cholesterol < 5 mmol/l 76.4% 74.2%

BP ≤ 140/80 71.3% 77.5%

All Targets 18.9% 41.0%

On average only 1 in 5 are reaching targets


National Diabetes Audit

Created manually once a year

Able to create

audit report

and review

the data daily

at the press of

a button


Benefits

• Clinical information is now captured electronically in clinic by the consultants.

• Information captured for each patient is closely aligned to the best practice alphabet strategy

• The electronic information is instantly available to nurses and any other clinician

• Medical secretaries no longer type letters and input data manually

• Letters to GPs and patients can be sent immediately following consultation

• Real time audit on why the patient attends the clinic

• Easy access to patients who express an interest in taking part in clinical research

• Ability to continuously improve the clinical form

• This implementation has proven to be an exemplar for the Trust


Benefits in Numbers

Improved adherence to National Diabetes Audit parameters and

Alphabet Strategy Clinical Pathway: from 60% to 90-100%

Less time to complete GP, patient other supporting documentation

Less time to collect data for clinical audits

Less time to collect data for research

Less time to collect data for national clinical statistics

85%

33%

75%

50%

50%

n = 1000+ cases


Any trust that has Lorenzo will have the ability to

implement the same approach in their organisations. We

are keen to share the learning, and trusts that already

have Lorenzo, or trusts that are in process of

implementing Lorenzo or thinking of deploying it, are very

welcome to visit us and to view the pilot first hand.

Dr Ponnusamy Saravanan

Associate clinical professor and honorary consultant physician in diabetes,

endocrinology and metabolism


Lessons Learnt

Considerations:

• Don’t underestimate time needed to

define requirements and develop

forms

• Focus on incremental improvement

• Clinician leadership and team

engagement

• Strong project management is vital

Keys to success:

• Senior level support and sponsorship

• Clinical support and engagement

• Leadership from both nursing and clinical staff

• Strong teamwork between CSC and Trust

• Observe how nurses and clinicians work

• First prototype and trial solution in the department

• Effective staff training, communication and

knowledge transfer

• Lorenzo know-how and access to technical support


What next?

Medical OP and IP Medical?• Accident and Emergency

• Audiology

• Cardiology

• Chronic fatigue

• Chronic pain

• Diabetes

• Endocrinology

• Gastroenterology

• Geriatric medicine

• Ophthalmology

• Respiratory care

Surgical OP and IP Surgery• Breast care

• Colorectal

• Maxillo facial

• Neurosurgery

• Oncology

• Orthopaedics

• Urology

• Vascular

Women’s and

Children’s OP and IP Medical?

• Gynaecology

• Obstetric

• Paediatrics

• Diagnostic and therapeutic

• Cardio respiratory unit

• Clinical psychology

• Occupational therapy

• Pharmacy

• Physiotherapy

Community all OP?• Blue Sky Sexual Assault Referral

Centre

• Camp Hill Health Centre

• The Chaucers Surgery

• Coventry and Warwickshire TB

Service

• Genitourinary Medicine (GUM)

• Leicester Road Surgery

• Leicester Urgent Care Centre

• Nuneaton and Bedworth Health and

• Wellbeing Service

• Satis House Surgery

• Warwickshire Community Dental

Service

• Warwickshire Stop Smoking Service

Phase II

• Optimise referral management

• Telemedicine

• Endocrine and Chronic Fatigue

Syndrome Clinics

• Diabetes in pregnancy, pre-

pregnancy care, structured

education programme

• Integration with dictation devices

• Real time clinical audit dashboard

• Main A&E Majors and Minors

Phase III

• All Medical OP Departments

(Cardio, Stroke …)

• Integration with GPs

Phase IV

• All Women’s and Children’s

• All Community

Phase V

• All Surgical

• End-to-End Pathways

• ED, AMU

• OP, Pre-Op, Surgery


EMR as a Platform for Clinical TransformationThank you | Any Questions?

26 July, 2016 | Dr Vinod Patel 43Twitter: @vinodpatel12345

Community Wide Impact

Level Target Group

1: Community Prevention Entire Local Population

2: Pre-Diabetic Screening At risk groups within the local population

3: Early Diagnosis Pre-diabetic population, Known impaired glucose tolerance, newly diagnosed DM

4: Forging Foundations Newly diagnosed: excellent care from start focus on lifestyle, experience, outcomes,

concordance, preventing complications

5: Rolling Review 5A: Well controlled with few risk factors to manage. Achieving high quality care parameters

5B: Complicated, higher risk or psychological or social issues affecting engagement with high

quality care

6: Early Escalation Uncontrolled clinical and social factors at high risk of complications, admission or morbidity. e.g.

hypertension, poor concordance, poor glycaemic control

7: Curbing Complications 7A: Patients with known complications/conditions: e.g. pregnancy, concurrent illness, planned

surgery

7B: Patients with unpredictable complications: reaction s to medications, poly pharmacy

8: Avoidable Admissions Hypoglycaemia, DKA, Foot ulceration and infection,

9: Unavoidable Admissions Patients with advanced disease and complications: acute coronary syndromes, stroke,

amputation , nephropathy, neuropathy

10: Rationalised Long Term Care Patients with co-morbidities not amenable to treatment: end-stage renal disease, review of

medications, end-of-life care


EMR as a Platform for Clinical Transformation€¦ · in all diabetes care clinical areas 5....

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