Delivering Quality Through eHealth and Information Technology

Delivering Quality Through eHealth and

Information Technology

Session Overview

11:45 - 11:50 Opening: Derek Feeley

11:50 - 12:10 NHS Lanarkshire Quality Improvement Tool:Diane Campbell and Pamela Milliken

12:10 - 12:30 NHS Lothian/ Trakcare:Martin Egan/Tracey Gillies

12:30 - 12:50 NHS Lanarkshire/ ECSDr Gregor Smith

12:50 - 13:00 Questions

BETTER EQUIPPED: USING DATA TO DRIVE HEALTHCARE

IMPROVEMENT

Pamela Milliken, Head of Clinical Governance and Risk

ManagementNHS Lanarkshire

Diane Campbell, Head of Safety, NHS Lanarkshire

QUALITY IMPROVEMENT

Use of data in healthcare is changing………

Traditional• Audit and Research• Data collection staff• Time consuming• Whole data set• Biannual, annual,

quarterly reporting• Points in time

Quality Improvement• Data for improvement• Clinician collects,

reviews and acts = OWNERSHIP

• “Real time” collection• Regular small samples• “Real time” reporting• “Real time”

improvements

CHALLENGES…

• Data management using paper collection, spreadsheets or databases

• Common plea from clinical staff - needs to be consistent and simple

• As SPSP spread - databases became unstable

• Need for rapid reporting for rapid improvement in clinical processes and outcomes

Lanarkshire Quality Improvement Portal (LanQIP)• ‘User friendly’ - clinical staff use the

same mechanism and format to report and analyse a range of Quality Measures:– Scottish Patient Safety Programme– Healthcare Associated Infection– Clinical Quality Indicators– Better Together– HEI Environmental Cleaning Audit

DEVELOP LANARKSHIRE QUALITY IMPROVEMENT PORTAL

DATA ENTRY

USING DATA FOR IMPROVEMENT

Using data for

improvement

PVC

Hand Hygiene

WARD SAFETY BRIEF

USING DATA TO DRIVE IMPROVEMENT

QUALITY ASSURANCE

• Quality Measures Framework – L3• Timely data at levels of:

– Wards and Teams– Hospitals– Divisions– Board– Feed national reporting and scrutiny

• Early warning and decision making• Create Dashboards with other measures

(e.g. incidents, activity, staffing)

DASHBOARDS

BOARD DASHBOARD REPORT

BENEFITS

• Scottish Government funding to take LanQIP to other Boards

• System can be built upon to:– Enhance the reputation of NHS Scotland

accessing common data to improve quality and governance

– Support the development of local, accurate, meaningful indicators within the Quality Measure Framework

– Enable more in depth analysis and ongoing rapid improvement

– Ultimately, however, not about a system, but about a mechanism specified by clinical staff to support them to improve patient experience, patient care and patient outcomes.

Supporting Quality with Supporting Quality with TrakCare Business TrakCare Business

IntelligenceIntelligenceMartin J EganDirector eHealth, NHS Lothian

Agenda

• BI Overview

• TrakCare BI Overview

• Trakcare BI dashboards

• Integration with Real Time BI

• Summary

• True genius resides in the capacity for evaluation of uncertain, hazardous, and conflicting information.

- Winston Churchill

• Information is not knowledge.

- Albert Einstein

What is TrakCare BI

• Built on InterSystems DeepSee product embedded within Trakcare

• Data model of the Trakcare database • Queries and Pivots built using the Trakcare data • Library of preconfigured Dashboards• Options to create ad-hoc queries and build

dashboards• Ability to export data to MS Excel

On Screen Reporting

One of the key objectives of the BI is to reduce the reliance on paper and to optimise the available On Screen reporting.TrakCare supports a large number of On Screen reports, these provide real time access to the required data and can be used interactively to access and update the records that are reported on the screen, this reduces the time taken to process the data as well as working with the current state of the data.

Improving Efficiency

Assessing Workloads

Meeting Targets

A&E Snapshot

Waiting Times

TrakCare Embedded Business Intelligence provides another layer of reporting and data analysis, the ability to view the data in an alternative presentation formats, facility to refine searches by ‘Drilling Down’ into specific data and as well as the ability to export the data for subsequent analysis and review.Following are two examples where the Embedded BI facility is used to better manage and review

TrakCare Embedded BI

Example 1: Emergency Treatment ManagementIn Scotland the target for treatment for Emergency Departments is 4 hoursThe embedded BI facility allows management to quickly identify their current or periodic performance against the target times. This is used in real time to look for those episodes where there is a risk of breachThe ‘Drill down’ facility is used to examine those patients who breach the waiting time standards and to proactively manage these cases or investigate the reasons why the breaches have occurred.


Example 2: Waiting List ManagementIn Scotland there is close scrutiny of the time patients are waiting and the time from referral to treatment. Each Waiting List entry is managed to a Waiting Guarantee Date

The embedded BI facility allows management of the waiting times in real time to look at performance against targets and review the overall status of performance against guarantee times

The ‘Drill down’ facility is used to obtain detailed listings of those patients who are approaching their guarantee dates or whom have already breached waiting time standards so that these cases can be followed up.


Summary

• Flexible

• Relevant

• Timely

• Drill down detail

• Configurable presentation

• Drives Improved Efficiency & Quality

Using e health to support improving the quality

of care

Ms TE GilliesNHS Lothian

Stepwise development in the use of Trak over five years

• PAS

• Order comms

• Support quality of care• Pathway support• Alerts• Availability of information

•

Electronic ordering• Allows standard order sets• Reduces duplication- others can see outstanding

orders• Streamlines movement onto diagnostic waiting lists

for radiology• Saves time for radiology inpatient requests

• BUT• Increase in CRP 250%• “disputed” or discontinued orders- less visible• Not all tests are ordered this way

Handling results electronically

• Next step• Sign off- whose responsibility?• Change in behaviour• “Abnormal” means different things to different

people• Needs accurate care provider and clear

processes around responsibilities

Trak Maternity

• Stand alone module- entire electronic record• Reduce unnecessary variation with

embedded protocols• Use as an example to demonstrate balance

of mandatory and non mandatory fields• Aid to service management via standard

reports

Booking Questionnaire

Hyperlinks – linking to document for referral

Hyperlinks – linking to document linking to a protocol

Ethnicity

Non mandatory fields – language preferred & Ethnicity

Example of new code values for Ethnicity

Alcohol brief intervention information – HEAT Target requirement

Hyperlinks – linking to document linking to a protocol

Compliance Reports

Handling referrals

Time to process referral manually (days)

Time to process referral during e triage (days)

General Surgery 4.3 1.4

Vascular 4.2 1.2

Gastroenterology 3.1 1.9

Clinical Outcomes

Using clinical outcomes

• To improve information capture about what we do- procedures, multidisciplinary consultations

• To improve workflow- from outpatients to order to outcome to waiting list

• To start conversations about variation

Legitimate Clinical Variation? - General Surgery Hernia New Patients, Jul-Oct 2010

Add to WL to Treat

Diagnostic Discharge to GP

Follow up OPA

DNA Other Outcome

OutcomeRecorded

% Add to WL to Treat

Mr SK Kumar 62 8 11 9 12 1 103 60%

Mr SJ Nixon 40 6 2 7 0 1 56 71%

Ms TE Gillies 16 5 10 0 4 1 36 44%

Mr B Tulloh 11 6 10 0 1 1 29 38%

Others 83 24 27 6 7 4 151 55%

All Consultants 212 49 60 22 24 8 375 57%

Developments into clinical practice

• Questionnaires• Operation notes- mandatory field

for antibiotic and DVT prophylaxis

• Improved legibility• Estimated blood loss• Pathology specimens

Sharing information: A&E Discharge Child Protection Form

Next steps

• Increase use of developments and make standard practice

• Increase use of pathways and move into MDT/ cancer tracking

• Harness enthusiasm and speed of implementation

Medicines Reconciliation in Scheduled Care using the

Emergency Care Summary Dr Gregor Smith

Background•Medication errors have potential to be cause of harm to patients and are not infrequent

•Occur most commonly at interfaces of care

•Accurate medicines reconciliation a major component of safe hospital care

•ECS invaluable in helping achieve this goal

•Good experience of its safe and appropriate use in unscheduled environment

Medicines Reconciliation“Every time a patient is transferred from one healthcare setting to another it is essential that accurate and reliable information about the patient‟s medication is transferred at the same time. This enables healthcare professionals responsible for the care to be able to match-up the patient‟s previous medication list with their current medication list; thereby enabling timely, informed decisions about the next stage in the patient‟s medicines management journey. This process is called „Medicines Reconciliation‟ and it should be one of the basic principles of good medicines management.”

(Medicines Reconciliation: A Guide to Implementation. www.npci.org.uk )

Project Structure

Project Management

•Test ECS in four clinical areas of planned care

•Project end point 400 patients

•Evaluate

•Clinical benefits

•Acceptability (staff, patient)

•Assess impact on decisions and care

•75% (305 patients) ECS accessed

•100 records not accessed; range of reasons

Did you access ECS?

Answer Options Response Percent Response Count

Yes 75.3% 305

No 24.7% 100

answered question 405

skipped question 0

Please indicate below why you could not /did not access ECS for this patient

Answer Options Response Percent Response Count

Patient not on any medications 20% 20Patient refused access (Verbally) 1% 1Patient ECS details “Opted Out” 20% 20Other accurate source available 51% 51No access to computer. 0% 0ECS site down 4% 4Other (please state reason ) 4% 4

Not able to get consent X2

Transferred from another hospital

Had up to date cancer care plan available answered question 100

skipped question 305

Results – Accessing ECS

ResultsEnvironment Profession

Summary by Workgroup Total %

Elderly Day Care 77 19%

Pre Assessment 135 33%

Oncology 84 21%

Surgical Other 109 27%

405 100%

Who accessed ECS?

Answer Options

Response Percent Count

Medical0% 0

Nursing63% 193

Pharma37% 112

Clerical0.0% 0


skipped question

Did the ECS reflect the current treatment?

Answer Options

Nursing

% Pharmacy %Total

%Total Count

Yes122 65 76

66

65.5% 198

No65 35 39

34

34.5% 104

Total

187 100 116100


skipped question 3

ECS and Current Treatment

Results – Impact of ECS

Results- ManagementQ8: Did the ECS change your advice re clinical management of the patient?

Answer Options

Nursing

%Pharm

acy%

Response

Percent

Response

Count

Yes2 9% 5

11%

10% 7

No21 91% 39

88%

90% 60

Total 23

100.0

44100.0

100%


Answer Options NursePharmac

yRespon

se

Further Investigations0 0 0

Admission0 0 0

Referral1 0 1

Alternative Treatment1 3 4

Other (please state)0 2 2*

7

* Ensure that interacting drug not taken

* Confirmation that interacting drugs are discontinued

Acceptability•All patients asked for consent before access; 1 refusal

• 86% staff found ECS helped in medicines reconciliation process

•93% staff thought accessing ECS as part of reconciliation process would reduce time

•79% advocated use in all admissions and OPD appointments

•Excellent understanding of governance arrangements surrounding use

Retrospective Audit of E-ReferralNo of episodes of care 31

Age in years (range) 56 (21 – 79)

Male / Female 77% Female

Number of episodes with referral paperwork and ECS available

24

Average length of time between referral and pre-assessment in days (range)

110 (20-316)

Total number of discrepancies 119

Average Number of Discrepancies / Episode

5

Summary

•ECS accessed in 75% (300 patients) of the study group

•22% of accesses provided additional information

•Access resulted in:

•Prevention of harm to 23 patients

•Change of management plan for 7 patients

•ECS reflected current treatment in 2/3 of cases

•Main professionals who initiated access were nurses and pharmacists

•ECS provides additional information to that in electronic referral

Will this be available in other hospitals?

•Significant interest from other Boards and within QI community

•Great deal of discussion around access to data for this purpose

•Consultation now taking place on draft guidance issued by Scottish Government e-Health to form a basis for this

•Health Boards, GPs and representative bodies, patients by 16th September

Delivering Quality Through eHealth and Information Technology

Technology

Transcript of Delivering Quality Through eHealth and Information Technology