Sharing information to
improve patient care in
Sussex
Adrian Woolley
Head of Strategic IT
NHS Coastal West Sussex CCG
NHS Crawley CCG
NHS Horsham & Mid-Sussex CCG
November 2014
Sharing information between care settings
Photo: sparkle glowplug
particularly for use in unscheduled care
NHS England describe the barriers to great care for
people with long term conditions:
Reactive, not predictive services: failure to identify
vulnerable people who might then be given extra help to
avoid hospital admission or deterioration / complications
of their condition…
Fragmented care: the healthcare system…not being
considered in a whole system approach with social
care…
Lack of informational continuity: care records which
can’t be accessed between settings...
NHS England. Everyone Counts: Planning for patients 2014/5- 2018/9
The phone…how we traditionally share information
between health and social care
Somebody’s handbag…where to find latest home
visit assessment
Serious case reviews – ‘familiar failings’
• Poor communication between and within agencies
• "Professional over optimism"
• A lack of "professional curiosity" in questioning information
• A lack of confidence among professionals in challenging parents and
other professionals
• A lack of analysis of information
• Shortcomings in recording systems
Care providers can have ‘silos’ of information held
within their organisational boundaries
GP practice system
Hospitals
Community Nursing
Significant diagnosis
DNACPR
Admission Avoidance DES Care Plan
ECG
Diabetes clinic
In-patient discharge letter
Specialist nurse record
Contingency Care Plan
Mental Health
Dementia nursing
MH Crisis Plan
Social Services
Social Services visit daily
Care providers can have ‘silos’ of information held
within their organisational boundaries
GP practice system
Hospitals
Community Nursing
Significant diagnosis
DNACPR
Admission Avoidance DES Care Plan
ECG
Diabetes clinic
In-patient discharge letter
Specialist nurse record
Contingency Care Plan
Mental Health
Dementia nursing
MH Crisis Plan
Social Services
Social Services visit daily
A real time Read Only viewer for use in direct
patient Care, with Information derived from both
Health and Social Care
ROCI
A Virtual
Integrated Digital Care Record
Live data (no data warehouse)
Live data (no overnight updates)
Consent to view at point of need
Real time messaging to multiple systems –
‘send pertinent information for unscheduled care’
GP
NHS No, Name, DoB
Hospital
Community Nursing
Integration Engine and
VIPER360 portal
Mental Health
RBAC
Social Services
Consent record for audit
What data could be available?
From GP (via MIG):
a patient summary
problems
diagnoses
medication (current, past and issues)
risk and warnings
procedures
investigations
blood pressure measurements
encounters, admissions and referrals
patient demographics
From SCR:
current meds
allergies
adverse reactions
From Community Trust
open referrals
From Social Services:
Main Address
Current Address
Placement Address
Allocated Worker, Open/Closed Agency
Providing Care Package Funded?
Emergency Next of Kin details
Does the Subject Have a Carer?
Is the Subject a Carer?
From Acute Trusts:
recent admissions & discharges
EDD
From Mental Health:
Mental health crisis plan
From care plan repository:
anticipatory care plans
LC
Live data from the GP clinical system
Patient details
Examinations
Events
Summary
Investigations
Problems
Procedures
Risks & warnings
Potentially useful in admission avoidance
Recent tests
Biochemistry
ECG
Haematology
Imaging
Microbiology
Cytology
Others
Physiology
Urinalysis
Case study
• Mrs W is a 91 y.o. woman who has dementia. She lives with her family but they are normally out during the working
day. Mrs W is quite deaf. She has a leaky heart valve and AF, she has oedema in legs; she has been reviewed by a
cardiology consultant. She is diabetic.
• Mrs W presses her emergency button when she feels a bit breathless and wants a hand getting out of her chair. An
ambulance is dispatched.
Scenario 1
• Ambulance crew have no background data but find a confused patient unable to remember what medication she is
on. They undertake ECG and find it abnormal, they decide to convey her to A&E.
• Mrs W waits on a trolley in A&E, confused and a bit frightened.
• A&E have no background data on patient. 4 hour target looming. Decide to admit to MAU for blood tests and ECG
Scenario 2
• Ambulance crew access anticipatory care plan and are reassured that her condition is not acute. They decide not to
convey but advise the district nurse.
Scenario 3
• Ambulance crew do convey, however A&E access the ROCI system to understand the medical history and admission
to hospital is avoided.
Qualitative benefits
Admission Avoidance
People, especially the frail elderly, can find hospital admission a frightening
experience and would rather be treated in their own homes.
Avoiding tests and medication
If unscheduled care has access to primary care and social care information then
this information can sometimes avoid repeating test or medication that have
already been prescribed. As well as a cost saving, it avoids subjecting patients
to test or medication that does not benefit their care.
ROCI: Where have we got to?
• Information Sharing Agreement finalised
• Trust Interface Engine (messaging technology) installed and operational.
• Pull of MIG data through system tested and working.
• 30 day pilot run in hospital A&E; data from 8 local GP practices.
• Social Services record to include NHS numbers; monthly batch tracing to start.
• To Include social services, mental health and anticipatory care plans in next few
weeks.
Potential applications of ROCI
•Better Care: Proactive Care
•Primary / secondary care interface: One Team
•Duty social worker
•Hospital in-reach
•Discharge planning / Alerting
•Planned Care
ROCI is supported by the 7 CCGs across both West
and East Sussex
Population 1.6 million
(Population 159,311 in 1801)
Thank you
adrian.woolley@nhs.net
Photo: garryknight
Challenges for this type of project
•The classics – stakeholder engagement etc x n2.
•Information Governance, legal opinion
•Data access. Paternalism
•Commercial self interest of system suppliers
•Finding care plans
•Waiting to test against Spine 2
One place to find care plans = reduced conveyance by
ambulance.
A&E (ROCI)
Ambulance
OOH GPs
Data
readers
Sussex wide
care plan database
GP Admission Avoidance
DES care plans
Proactive
Care
Data sources
EoLC
Plans