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
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.
TrakCare Embedded BI
TrakCare Embedded BI
TrakCare Embedded BI
TrakCare Embedded BI
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.
TrakCare Embedded BI
TrakCare Embedded BI
TrakCare Embedded BI
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
answered question 305
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
answered question 302
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%
answered question 67
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