ICR Worshop, Edinburgh Dec 11-12 2003
Integrated care record …
integrated care
Geraldine Fitzpatrick
11 Dec 2003
Problems with paper & silos ...
NHS Care Record (formally ICRS)
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Deeper clinical info at local level
Access to info that supports integrated delivery
Provide clinicians with support and guidance
Support bookings
Support transfer of prescriptions between GPs
and pharmacies
• Provide clinicians with ability to view summary
of national patient record
• Provide patients with ability to view and
contribute to their records
(NHS ICRS Introduction to the Output Based Specification, p20)
NHS Care Record (formally ICRS)
•
•
•
•
•
Deeper clinical info at local level
Access to info that supports integrated delivery
Provide clinicians with support and guidance
Support bookings
Support transfer of prescriptions between GPs
and pharmacies
• Provide clinicians with ability to view summary
of national patient record
• Provide patients with ability to view and
contribute to their records
(NHS ICRS Introduction to the Output Based Specification, p20)
ICR Conceptualisation
“Records as
archive”
• Information repository
passive, decontextualised
structured content issues
in-between data exchange
• Formal… bird’s eye view
• Practice support…
care pathways,
decision support
• Change management etc
separate from ICR spec
ICR Conceptualisation
“Records as
archive”
• Information repository
passive, decontextualised
structured content issues
in-between data exchange
• Formal… bird’s eye view
• Practice support…
care pathways,
decision support
• Change management etc
Where is the local
separate from ICR spec
situated day-to-day
doing of care work?
Overview
• Case study 1 – ‘at work’
– practical integration of paper chart into care
practices ‘on the ward’
• Case study 2 – ‘to work’
– the work to put telehealth to work
Case Study 1: (LPR) at work
Location:
•
hospital medical unit
Method:
• qualitative
– observation
– in-context interviews
– artefact collection
Focus:
• “Understanding paper in practice can direct and inspire
new technologies” (Sellen & Harper 97)
• Implicit, taken-for-granted practices…
Overview of the work setting
• Medical unit across two wards
–Assessment and planning ward & medical ward
• Clinical team
–Medical consultant, registrar, resident
–Visiting consultants
–Ward nurses
–Allied health
• Pharmacy
• Physiotherapist
• Social worker
–Services
• Stroke service team
• Drug and alcohol service
• Healthcare work
–Allocation of patients
–Rounds
Firstly…
…no such thing as the record...
… a diverse distributed collection ...
Multiple views
Teams with views
-concurrent
-inter-related
Ward round
Ward meeting
Stroke service
& others …
Pharmacist notes
Physio
ward-book
Management plan
Case manager notes
•
Individuals with views
•Integrating multiple working forms
•Transformations between forms
Ward overview
Nurses work sheet
Summary: The record as diverse
distributed collection
•
formal ... informal
• transient ... persistent
• different locations
• different owners & authors
• different intended audiences
• different purposes
…no such thing as the record in practice...
Summary (cont)
• Buff chart (LPR) as
–pivot or anchor of the network
–the collaboratively-rendered persistent archival trace
• Working record as
–different views as putting information to work
–local stores vs central stores
–transformations & representations
• How could the ICR support working records?
ICR supporting working record?
• Role-specific views of patient
– Parallel records
– Core and local data
– Formal (persistent) and informal (temporary) data
• Summary templates for ‘paper in the
pocket’
– Ward views
– Patient allocation views
– Basis for note-taking
Secondly …
paper is highly flexible & adaptable ...
supports local adaptation,
responsiveness, and
directed communication
…allows clinicians to respond
in a timely way to local needs
Flexibility & adaptability…
Tailorable - supports individual preferences
Supports local practice & rapid prototyping
Adaptable - supports local responsiveness
Directed communication
at the point of action
Contextualised embedded conversations
Eg: Drugs & prescription screen
(www.target4.com/hc/home)
90% Informal communication
• 90% of information transactions involve informal
communication rather than interaction with formal
information sources (Coiera 2002)
[http://www.mja.com.au/public/issues/176_09_060502/coi104
81_fm.html]
Summary: paper-based artefact
• overlaid functionality
• annotations
• conversations at the point of care
• local practices
• local responsiveness
• individual preferences
ICR supporting adaptation &
communication?
• End-user tailorability of screens/forms
– Within constraints
• Context and person specific communication
– Informal
– At point of care
– Asynchronous as well as synchronous
(LPR) at work…
Integrally & actively embedded in
– the doing of ‘integrated care’
– as part of total environment
spatial, organisational, professional, social, medico-legal, ...
Two themes
1. No such thing as the record … a diverse distributed
collection
2. Flexibility and adaptability of paper supports adaptation,
responsiveness, and directed communication
And many more … a role in communication and
coordination, location as information, etc
Overview
• Case study 1 – ‘at work’
– practical integration of paper chart into ‘on
the ward’ care practices
• Case study 2 – ‘to work’
– the work to put telehealth to work
– embedding videoconferencing and data
sharing as just another tool
Case Study 2 – ‘to work’
Intensive care telehealth project
ICRS:
- telemedicine as new technology to support remote
diagnosis, near patient testing …
- Video conferencing to improve communication and
share knowledge
The work to put telehealth to work
Getting the technology in place is only the
first part of the process
In the corner or in use?
There is significant effort required to
introduce ‘non critical path’ technology
and evolve working practices so that it is
familiar enough and easy enough to use
to be just another tool like the telephone
or stethoscope…
Clinician-driven ICU telehealth
Three ICUs
Experience with
remote monitors
Off the shelf technology
The work to put it to work
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Dedicated project officer
Training for ad hoc use
Role of serendipity, experimentation
Other activities to encourage use
Different ICR conceptualisation
as archive
designing records …
information focus …
&
at work
designing practice …
practice focus …
Moving forward
Integrated care record to be used in care
or
Integrated care practice enabled/supported
by ICR?
• Change management
– not just macro but on the ground
– proactive not reactive
– training to evolve practice not just to use
• How to understand issues, needs
– What are the small easy things that will make big
differences to care?
• Who to involve and how
– What roles, Time and resource issues,
Acknowledgements
• Work undertaken while at University of
Queensland, Distributed Systems
Technology Centre and Centre for
Online Health, Australia
• Partners from hospitals, Telstra and UQ
involved in telehealth project