“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)