Berkshire Connected Care Interoperability Solution

Medical Directorate Conference

Wednesday 7 June 2017

Nigel Foster Director of Finance & Performance

Berkshire East CCGs

Aligning a lot of organisations…

Aligning a lot of systems…

• 70 staff from across all organisations involved in the procurement supplier days

• Strong clinical engagement developed through patient stories which formed a key part of the procurement

• Funding through BCF and whole system programme boards have ensured all organisations “own” Connected Care and contribute to the success

Doing it together

2016 - Building the foundations

Patient facing Health and Social care facing

Patient Portal

Conn

ecte

d Ca

re

2016 2017 2018 2019 2020 2020 2019 2018 2017

Decision Support

Whole System

Intelligence Genomics

Integrated dynamic

care plans

Paper Free Patient Triage

Patient Portal

Apps

Wearables Support

Integrated Hubs

BI tools to support early identification

Technology to support behaviour

change

It’s live… Connected Care (Graphnet) Records Accessed From 27 February 2017 to 21 May 2017 (12weeks)

Number of Records Accessed - By Organisation Number of Users - By Organisation

Number of Different UsersNumber of Records Accessed

282258 267

298269

304

257241

287 279

319 328

0

50

100

150

200

250

300

350

745806

849 874 850

953890

846911 933 937

1133

0

200

400

600

800

1000

1200

9 6 5 11 23

554623 589

706802

38 6 5 14 14

275 274331

205292

2 1 20

100

200

300

400

500

600

700

800

900

Week 8 Week 9 Week10 Week11 Week12

BFCouncil BHFT Central Cluster RBFT WestCall WBCouncil

5 3 2 4 7

202

245 239

282 282

12 2 3 4 432 35 34 28 34

2 1 10

50

100

150

200

250

300

Week 8 Week 9 Week10 Week11 Week12

BFCouncil BHFT Central Cluster RBFT WestCall WBCouncil

“I feel very passionate about this excellent resource so excuse the rant!!” “ We are coming to understand that this excess mortality is not the result of suicides it is the result of neglecting physical health risk factors. I’m leading on this improvement of physical health monitoring for those with SMI. As part of this work we have been urging people to attend GP for PHC especially cholesterol and glucose monitoring – connected care means we can easily check if our request has been actioned, we can then use this information for the important cardio metabolic monitoring. We can also see if patients have had their annual health check and we can use this info to target interventions if required or we can put our efforts into encouraging the patient to go along to the surgery for this if not. “ “Previously we would have had to call up the GP to get this information and to be honest people were not doing this –connected care has made it much more accessible.” “I have recently investigated the unexpected deaths of 5 patients from physical causes. Findings have highlighted we request various physical health tests but we don’t always check if they have been actioned-connected care will enable us to do this easily.” “Last week I had a patient tell me that his GP had not prescribed his medications or the personal training sessions we had agreed I was able to go in to the system whilst the patient was with me and check-I was able to see that this had been done that morning so they could be collected on the patients way home. In the past I would have been trying to get hold of the GP, the patient wouldn’t be able to get reassurance as more often than not you can’t get through so you wait until patient has gone to chase. He was really pleased to hear an answer there and then.” “The system itself is really easy to use no additional passwords etc –very clear where things are from the front screen, nicely laid out and easy to read.” “In the future I can see this being so useful for sharing risk information, discharge information and just making communication so much easier. I think this is a really important step forward for us and it will improve our ability to provide physical and mental health care and improve patient experience.”

And making a difference

Rollout

• There is a staggered rollout split over three tranches

• By the end of Tranche 3, all participating organisations will be viewing data and all apart from OOH & SCAS will be providing data

Tranche 1

Tranche 2

Tranche 3

Jun Jul Aug Sept Oct Nov Dec Apr May

Q1 2017 Q2 2017 Q3 2017

Feb Mar

Q1 2017

Jan

• 95% GP Data • X2 Social Care

Feeds (WBC and BFC) • BHFT

Comm & MH Feed

• Social Care Data Enhancement

• X1 new Feed (RBWM)

• RBFT ADTs • 2 Yr Backload

• 100% GP Data

• RBFT Documents and embedded access

• RBH Lab Results

• FHFT ADTs • 2.5 Yr Backload

• BHFT Documents

• Remaining x3 Social Care Feeds

• Children's Social Care Feed (WBC and BFC)

Tranche 1, 2 and 3 indicative time-scales

• Patient Tracking Pilot

Stepwise Delivery of Increased Data and Functionality

Patient information available at point of care (June)

Care

Cent

ric

GP Practices 94 0f 99

Administration

Alcohol Exercise Diet

Allergies

Glucose / HbA1C

Blood Chemistry

Cervical Cytology

Blood Pressure

Child Health Data

Chronic Disease Data

Contraception & HRT

ECG Pulmonary

Family History

Heamatology

Height & Weight

Other Diagnostics

Medication Issues

Other Therapeutics

Pregnancies etc.

Smoking

Urinalysis

Immunisations

Active Problems

Encounters

Operations

Obstetric Procedures

Cytology

Other Pathology

Problems List

Social History

Physiology Function Tests

Investigation Admin

OTC Prophylactics

Referrals

Medication Admin

Admissions

Past Problems

Diabetes Diagnosis

Contraindications

Recent Tests

Active Problems

Encounters

Microbiology

Repeat Medications

Administration

Alcohol Exercise Diet

Allergies

Glucose / HbA1C

Blood Chemistry

Cervical Cytology

Blood Pressure

Child Health Data

Chronic Disease Data

Contraception & HRT

ECG Pulmonary

Family History

Heamatology

Height & Weight

Other Diagnostics

Medication Issues

Other Therapeutics

In SCR

Not in SCR

Demographics

Case Workers

Disability Type

Care Plans

Needs/ Outcomes

Risks Demographics

Admissions

Referrals

Appointments

A&E Attendances

Demographics

Discharges

Transfers

Inpatient activity

Outpatient activity

Waiting Lists

Admissions

Discharges

Transfers

Inpatient activity

Outpatient activity

Referrals

Allergies

Risks / Warnings

Diagnosis

Care Plans

Appointments

Referrals

Associated Carer

Disability Type

Lessons learned / challenges

It isn’t a digital project

• Embedded context launching has been imperative to high usage (Ease of use)

• Simple, clean, interfaces within core systems • Enhancements and developments are being worked

through by a whole system clinical group

User experience

Maximising the value of a shared digital ecosystem

Connected Care has been built using “LEGO”

Technology made of “MEGA BLOKS” will not link up and could cause issues with engagement or increased costs.

• IG framework that all organisations are bought into

• LMC chair the IG group • Every practice signed up within a few weeks • Start with provision of care and clearly defined

data sharing to build confidence

Getting the IG right

Exciting stuff coming soon!

Epilepsy use case

The information collected will be

analysed and reported on to

monitor the success of the

project

As part of the project NHS Staff will also be asked to pilot some

additional applications - an “all about me”

application, for example.

A wearable device that captures activity data and stores this data in the cloud

(Azure) A mobile application that helps

visualise activity and provides insights on progress (using cloud based

machine learning)

Staff pilot

400 NHS staff in Berkshire will

pilot an activity improvement programme

A patient portal (web and mobile?) that allows access to the Berkshire Record (GP data, results, hospital information,

etc.).

…and provides information, resources and signposting to services

1

2

3

4

5 6

7

They will use:

Alerting

Big data, machine leaning and all that…

The public face of Connected Care

https://www.shareyourcareberkshire.org

Any Questions?