“NHS change challenge” Clinical content work in the NHS Tony Shannon Consultant in Emergency Medicine, LTH Clinical Consultant, NHS CfH Travel to HL7 kindly funded by Ocean Informatics Tony Shannon M.B. B.Ch. B.A.O. Fellow of College of Emergency Medicine Ireland England Fellowship in Informatics MS in IT Management USA England Consultant in Emergency Medicine, Leeds Teaching Hospitals Clinical Consultant, NHS Connecting for Health Leeds, England Complex Systems • Many parts, Many interactions • Perpetual novelty • Difficult to describe/understand completely • Difficult to control/change • Identify simple rules – Self-organise • e.g. Weather, Economy, Internet, ED National Health Service in the UK • Established in 1948 by Labour Government • Huge – 3rd largest employer in world, largest in Europe, 1 million+ staff – 45+ million patients in England • Healthcare free to all at the point of care • Quality • Costly – Increasingly financially oriented – “Payment by Results” • “NHS Plan” = Service Reform (inc. IT) – e.g. Leeds Teaching Hospitals • City <1million population • 4 EDs; 110,000 + 90,000 census • 95%/98% “4 hour ED target”… • Biggest civil IT programme in world • 10 year; based in Leeds, England • $20+ billion with commercial suppliers • 5 Regions of England – North East Cluster • • • • • 7.5 million population 170,000 NHS staff 23 Acute Hospitals 12 Mental Health Trusts 1200+ Primary Care practices – Care Record Service • contract £1 billion • Hugely ambitious • Primary, Community, Hospitals, Mental Health – Contracts for several interim solutions – Aiming for a single strategic EHR solution • National Services – Single NHS patient identifier number – Service Directory – Choose and Book scheduling • Local Services – Care Record Service (Electronic Health Record) • Guideline based • Workflow integrated • Cross organisational working NHS + IT = Complex Change – Emergency Medicine Change - Management Drivers Benefits = Quality Risk↓ Cost↓ Time↓ Change - Software Engineering People+ Process + Technology in a “Model Community” Systems in Silos • People – Challenge siloed thinking • Process – Look for simplicity within the complexity – ? Core generic processes in healthcare • Technology – Evolutionary approach – Process related IT requirements • esp. at the complex front end. i.e. ED charting – free text/dictation versus forms (e.g. T-system) • Aim to reuse – Distributed process-oriented SOA? • Balance central control and local innovation Process - Urgent Care Study • • Identify top/core business processes in Urgent Care Identify and prioritise information/technology needs • Methodology – • Stakeholders/ core Processes / IT Requirements Site visits – – – – – NHS Direct Ambulance Services ED (4 in West Yorkshire) Walk in Centre GP Out of Hours A view of NHS process … cd Urgent Care Now - Top Lev el «Lane» «Lane» Urgent Care Now - Top Level Ian Herbert 1.0 09/04/2006 18:13:11 21/04/2006 10:08:26 This may also be done by contacting NHS Direct XOR fork know provider to use ? Identify concern(s) Patient has care concern XOR fork contact relevant provider Concern(s) may be identified by the patient, a carer, a bystander, an attendant (e.g. police at an RTA) or a care professional. So may the provider contacting & service requesting, e.g. if the patient is unconscious. no This overview of urgent care is compatible with the submodels provided for each urgent care provider. However it explicitly shows some of the detail which is within each of the submodels. The detail shown deals with assessing the appropriateness of the care request by each provider, and the passing of the patient to another provider if further urgent care is needed that is outside the scope of the current provider. Find out providers available now, and their contact details Decide which provider to use yes Go to walk-in centre patient / carer/ etc directed to more more urgent care appropriate provider. This may be to required - patient / a specialist ED, e.g. for obstetrics carer/ etc directed or eye care to another provider Go to emergency depatment more urgent care required - patient / carer/ etc directed to another provider patient / carer/ etc directed to more appropriate provider Patient, etc & WIC Patient, etc & ED «Lane» «Lane» «Lane» Patient, etc & OOHrs Patient ,etc & ambulance Patient, etc & NHSD «Lane» Patient & carer / bystander / care professional Name: Author: Version: Created: Updated: Request WIC care Walk-in centre provide care XOR fork more urgent care needed? no transfered to WIC Request ED care Emergency department assess appropriatness of request XOR fork appropriate provider End of urgent care episode May include 1 or more attendances at ED clinics after initial attendance Emergency department provide care End of urgent care episode patient delivered to emergency dept. e.g. if specialist ED service reqd Contact ambulance servce & request care Contact GMP OOHrs service & request care Contact NHS Direct & request care Ambulance service assess appropriatness of request Ambulance service handle request XOR fork appropriate provider transferred to OOHrs GMO OOHrs assess appriopriatness of request NHS Direct handle request transferred to ambulance service GMP OOHrs provide care transferred to OOHrs XOR fork more urgent care needed? transferred to OOHrs XOR fork patient disposition more urgent care required - patient / carer/ etc directed to another provider transferred to ambulance service transferred to ambulance service no I. e. self-care advice / information provision is sufficient End of urgent care episode End of urgent care episode A view of Generic Processes in Healthcare Strategic (++ patients) Performance management e.g. Audit Tactical ( > 1 patient) Resource Management e.g. staff, beds Operational (1 patient) Referral in Assessment Diagnostics Deliver Care Plan Care Sorting Referral Out A journey through the NHS … Self care GP Angina diagnosis & 1st care plan NHS Direct Suspected MI: self-care advice given & ambulance requested Ambulance Taken to A&E: given oxygen in transit Emergency Department Acute CCU Returns to self / primary care Diagnosis confirmed: & patient stabilised Transferred to CCU to complete post-MI care time Specific Patient Journeys IT Library Generic Generic Process IT Bricks A tale from Denmark … The Danish solution… OpenEHR • 15+ years of European & Australian R&D • Generic Process based EHR Architecture • Related to – European Standard (en13606) – ISO standard OpenEHR Templates (Toys) Specific Generic Archetypes (Bricks) Archetype • Reusable list of clinical statements • Useful for clinical documentation • Can be coded with terminologies e.g. Snomed CT Archetypes & Templates •Central control •Local flexibility Archetypes • North, Midlands and East – 60% of England • Supplier – Contract with CSC – Single strategic EHR solution – Requirement & Design Stage • NHS “Clinical Content” needed – To support charting • Big Opportunity Phases of Content Delivery NHS input… example.. NHS content – inputs via wiki • Collaborative • Evolvable • Version control • comments NHS input… e.g. Head & Neck examination Into Head & Neck exam archetype Archetypes can bind to codes… Archetypes available as XML/HTML etc… NHS Archetype library Archetypes configured in Templates solves central control + local need Template editor output as HTML/XML/Forms etc…. OpenEHR content Templates (Toys) • Can be used for application UI – e.g. forms • Can be transformed into messages – e.g. HL7 CDA • Can be used for querying +/- Terminology Archetypes (Bricks) NHS template library .. for use in any supplier system .. for use in any supplier system openEHR content cycle.. • Clinical content will continue to evolve • Archetypes and templates are version controlled • Content changes – don’t impact application – if fit with openEHR Benefits of Archetypes • Quality – Better documentation - for complexity of healthcare • Via Standard Archetype + Flexible Templates – Can evolve over time - as medicine changes • Via version control – Balances central control and local innovation • Risk – Solid foundation for Decision Support • Time – Save time • Build templates fast • Cost – Save NHS money • Standard methodology – all can share • Non proprietary NHS Clinical Content Service • NHS Requirements • E-Care Pathways • Archetypes & Templates – Archetype outputs 150+ – Template outputs 20+ • Clinical Coding – Via SNOMED CT • Resource • Governance NHS Tech Office.. today Logical View Messaging Realisation with templates Business Use Case Story board Clinical Use Case Interactions Clinical Content Model Message Clinical Templates HL7 Templates Clinical Archetypes HL7 Templates Reference Model, Types, Terminology RIM + Data Types + Terminology NHS Tech Office.. tomorrow Logical View Messaging Realisation with templates Business Use Case Story board Clinical Use Case Interactions Clinical Content Model Message Clinical Templates HL7 Templates Clinical Archetypes HL7 Templates Reference Model, Types, Terminology RIM + Data Types + Terminology International efforts… Key issues…. • NHS IT – Hugely ambitious – Learning valuable lessons • People issues – How to involve the right people • Think beyond current silos – Governance • Local versus National? • Process issues – look for the generic within • Technology issues – Evolutionary – Clinical process oriented approach i.e. archetypes – Ensures clinical content is reusable/evolvable NHS content library Templates (Toys) Archetypes (Bricks)