Post on 24-Jan-2016
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Difficult discussions at the end of life
SCIMP Nov 2010 Using the electronic Palliative Care Summary (ePCS)
& Key Information Summary (KIS) as Anticipatory Care Plans
Dr Peter KiehlmannGP, Aberdeen & National Clinical Lead Palliative Care eHealth
Dr Libby MorrisGP, Edinburgh & National Clinical Lead Primary Care eHealth
Questions?
What is ePCS? Who can use it? How does it help
Patients & carers Staff
In-hours Out of hours?
Developing an Anticipatory Care Plan Future developments – Key Information
Summary (KIS)
The maze of trees
“How we care for the dying must surely be an indicator of how we care for all our sick and vulnerable patients. Care of the dying is urgent care – with only one opportunity to get it right, to create a potential lasting memory for relatives and carers…”
Professor Mike Richards CBE
Living and Dying Well
• “ to ensure a comprehensive approach to palliative care based on clinical need and not diagnosis, age, post code, creed or ethnicity”
• Outputs from many expert groups• GMC Guidance on End of Life Treatment and care• How to help Clinical staff to have confidence to
deliver quality Pall & End of Life Care
ePCS - What is it?
An electronic Palliative Care Summary An extension to Emergency Care Summary (ECS) & Gold Standards Framework Scotland (GSFS) For use both In Hours & OOH ePCS replaces current faxed communications Allows GPs & Nurses to record in one place
Diagnosis, Rx, Pt Understanding & Wishes, Anticipatory Care Plans, review dates, lists for meetings
ECS
Patient info from GP computers -> ECS store twice daily
Medication & Allergies 97% of GP Practices >5 million patients
Explicit Consent to view ‘Read only’ available to… NHS24, A&E, AMAU, SAS
• Covers 99%+ of population• Used by 4500 NHS staff• 50,000 accesses per week• (3.5million to date)• EU-commissioned independent evaluation• Benefits found included:
• patient safety, time saving, faster treatment decisions
• financial value assigned to costs and benefits, over time….
Emergency Care Summary–benefits
Usage & progress of ECS
Pilot 2004, full rollout 2006Over 5.3 million patient records 1900 patient opt-outs (0.03%)5.5 million clinical accesses to ECS since
launchAverage 195,000 accesses per month
2.17 million ECS accesses were made from Jan – Dec 2009, an increase of 37% from 2008
Total Accesses
0
50000
100000
150000
200000
250000
Jan
Feb Mar Apr
May Ju
n Jul
AugSep
tOct
Nov Dec
Month
Acc
esse
s
2008
2009
Ongoing ECS Projects
Go live with Scottish Ambulance Service In Cab paramedic use
Integration with Clinical Portal North and West Portals in testing
Integration with National PMS InterSystems developing user interface
Integration with FairWarning Audit reporting linked to use of other eHealth systems
ePCS Overview
OOH clinician ePCS display
ePCS update 1. During
consultation
2. Due to prescription
3. Team meeting or other contact
Audit
trail
ECSStore
NHS 24
A&E
Ambulance
TBD…
Practice Admin. Staff
PracticeServer
GP /DN
consultation
ePCS Dataset Consent - Palliative care data transfer Carer details and key professionals Diagnosis – as agreed by patient by pt & GP Current Rx –Rpt, 30/7 Acute, Allergies; Patient wishes
Preferred Place of Care [PPoC] )DNA CPR decision ) Anticipatory
Patient’s & Carer’s understanding of ) Care diagnosis/prognosis ) Plan
Just in Case – Rx & equipment ) Advice for OOH care )
GP Mobile no., death expected? Cert. etc )
EMIS - Summary
ePCS no diagnosis added yet
Diagnosis agreed with pt & added
Patient/Carer Wishes
New ECS build screenshots
Access to PCS Information
Base ePCS –view in Adastra
Mobile ePCS - Adastra
Using ePCS in practice –a continuing process
Does this pt have Palliative Care Needs?Does this pt have Palliative Care Needs? Add to Pall Care Register, Add to Pall Care Register, Once Consents to send ePCS ->OOH,Once Consents to send ePCS ->OOH,
agree Medical History, set review dateagree Medical History, set review date Once consented any new info goes automaticallyOnce consented any new info goes automatically Not expected to complete in one go!Not expected to complete in one go! Complete pt wishes and Understanding, DNA CPR, record Complete pt wishes and Understanding, DNA CPR, record
“Just in case” Rx and Equipment as appropriate“Just in case” Rx and Equipment as appropriate Regular review at PHCTRegular review at PHCT Keep updating!Keep updating!
Profile of People who die
UK1900 /
Age at death
46 Top 3 causes
1. Infectious diseases
2. Accident
3. Childbirth
Disability before death Not much
UK 2000
Age at death
78 Top 3 causes
1. Cancer
2. Organ failure
3. Frailty/ dementia
Disability before death Months - many years
Death
High
LowMany years
Function
Death
High
LowMonths or years
Function
Organ failure
6
Acute2
Dementia, frailty and decline
7
Death
High
LowWeeks, months, years
Function
5
Cancer
GP has 20deaths perlist of 2000patients peryear
How to deliver End of Life care for all?
Palliative Care DES (1 of 26!)
1. Put pt on Palliative Care Register Clinical, Pt choice, Surprise Question From Prognostic Indicator Guidance
2. Send OOH form/ePCS within 2w 3. Make Anticipatory Care Plan – as ePCS inc. Preferred Place of Care/death 4. When dying use LCP /locally agreed pathway
Aim- encourage anticipatory care, for all diagnoses
Current ePCS Use – Aug 2010
Health Board Practices % of Total Lothian 74 54% Greater Glasgow & Clyde 42 15%Grampian 24 29% Dumfries and Galloway 10 28% Forth Valley 8 Ayrshire & Arran 5 Lanarkshire 5 Western Isles 2 Orkney 1
171 16% Total summaries 1281
ePCS – Benefits
Natural progression from GSFS & ECS Fits into day to day work of GPs & DNs Aims to identify patients “upstream” ie last 6-12 months, not just last days/weeks Encourages Anticipatory Care Planning Prompts to remind to ask about “difficult” issues
“Just in Case”, DNA CPR, PPoC Shares critical info. on vulnerable patients at important times. OOH & Secondary Care say it transforms care Patients & carers reassured Safer, better experience
Key Information Summary
Proposal / Early development stageAims to replace paper based faxing of
“Special Notes” from GP PracticesMore generic version of ePCSSupport for:
electronic Anticipatory Care Plans (eACP) Long Term Conditions Mental Health
Use existing infrastructure and process
Principles of KIS
Patient consent required to send informationExplicit Consent to view record Review date & consent only mandatory fieldsFlexible
Only send information required
Focused on Patient Wishes and SafetyKIS sent automatically to ECSFurther consultation with patients and
clinicians to be carried out
4 Sections on KIS
Section 1 – “Special Note” Free text field for information (usually to OOH) Review date and consent Patient and Carer details
Section 2 – Current Situation Main Diagnosis and Current Issues ACP / Self Management Plan agreement BP and Oxygen
4 Sections on KIS
Section 3 – Care and Support details Homecare support Incapacity / Guardianship Power of Attorney
Section 4 –Information and Action for OOH / A+E DNACPR Current and Preferred Place of Care
KIS Next Steps
Further consultation plannedDevelopment of specifications and planDiscussions with GP SuppliersDiscussions with End UsersAccelerate to support eACP timescalesLearn from ePCS rollout….Maintain patient focus
Summary
ePCS rollout well underway with increasing use and clinical benefit
Further projects underway on ECS to build upon existing infrastructure and process
Key Information Summary (KIS) expected to make significant difference to patient safety and care
Thank you
Dr Peter KiehlmannGP, Aberdeen & National Clinical Lead Palliative Care eHealth
Dr Libby MorrisGP, Edinburgh & National Clinical Lead Primary Care eHealth
peter.kiehlmann@scotland.gsi.gov.ukLibby.morris@scotland.gsi.gov.uk
http://www.scotland.gov.uk/epcshttp://www.ecs.scot.nhs.uk/epcs.html
ePCS Overview
OOH clinician ePCS display
ePCS update 1. During
consultation
2. Due to prescription
3. Team meeting or other contact
Audit
trail
ECSStore
NHS 24
A&E
Ambulance
TBD…
Practice Admin. Staff
PracticeServer
GP /DN
consultation