Delivering Quality Through eHealth and Information Technology


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Using information to improve the quality of care is becoming increasingly important. This session will highlight how the new eHealth Strategy links to the quality agenda and the benefits and successes of three innovative eHealth tools.

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  • Order Item is displayed, enter username & password
  • Returned to the Ward, the Order Icon is displayed on Floor Plan, hovering over Icon shows which Order(s) have been placed
  • Click the Look-Up to display the Mannequin and Select the Category & Option
  • General Surgery Operation Note
  • Selecting Yes will access the Questionnaire
  • Delivering Quality Through eHealth and Information Technology

    1. 1. Delivering Quality Through eHealth and Information Technology
    2. 2. 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/ ECS Dr Gregor Smith 12:50 - 13:00 Questions
    4. 4. Pamela Milliken, Head of Clinical Governance and Risk Management NHS Lanarkshire Diane Campbell, Head of Safety, NHS Lanarkshire
    5. 5. QUALITY IMPROVEMENT Use of data in healthcare is changing ……… <ul><li>Traditional </li></ul><ul><li>Audit and Research </li></ul><ul><li>Data collection staff </li></ul><ul><li>Time consuming </li></ul><ul><li>Whole data set </li></ul><ul><li>Biannual, annual, quarterly reporting </li></ul><ul><li>Points in time </li></ul><ul><li>Quality Improvement </li></ul><ul><li>Data for improvement </li></ul><ul><li>Clinician collects, reviews and acts = OWNERSHIP </li></ul><ul><li>“ Real time” collection </li></ul><ul><li>Regular small samples </li></ul><ul><li>“ Real time” reporting </li></ul><ul><li>“ Real time” improvements </li></ul>
    6. 6. CHALLENGES … <ul><li>Data management using paper collection, spreadsheets or databases </li></ul><ul><li>Common plea from clinical staff - needs to be consistent and simple </li></ul><ul><li>As SPSP spread - databases became unstable </li></ul><ul><li>Need for rapid reporting for rapid improvement in clinical processes and outcomes </li></ul>
    7. 7. Lanarkshire Quality Improvement Portal (LanQIP) <ul><li>‘ User friendly’ - clinical staff use the same mechanism and format to report and analyse a range of Quality Measures: </li></ul><ul><ul><li>Scottish Patient Safety Programme </li></ul></ul><ul><ul><li>Healthcare Associated Infection </li></ul></ul><ul><ul><li>Clinical Quality Indicators </li></ul></ul><ul><ul><li>Better Together </li></ul></ul><ul><ul><li>HEI Environmental Cleaning Audit </li></ul></ul>
    9. 9. DATA ENTRY
    10. 10. DATA ENTRY
    12. 12. Using data for improvement PVC Hand Hygiene
    15. 15. QUALITY ASSURANCE <ul><li>Quality Measures Framework – L3 </li></ul><ul><li>Timely data at levels of: </li></ul><ul><ul><li>Wards and Teams </li></ul></ul><ul><ul><li>Hospitals </li></ul></ul><ul><ul><li>Divisions </li></ul></ul><ul><ul><li>Board </li></ul></ul><ul><ul><li>Feed national reporting and scrutiny </li></ul></ul><ul><li>Early warning and decision making </li></ul><ul><li>Create Dashboards with other measures (e.g. incidents, activity, staffing) </li></ul>
    16. 16. DASHBOARDS
    18. 18. BENEFITS <ul><li>Scottish Government funding to take LanQIP to other Boards </li></ul><ul><li>System can be built upon to: </li></ul><ul><ul><li>Enhance the reputation of NHS Scotland accessing common data to improve quality and governance </li></ul></ul><ul><ul><li>Support the development of local, accurate, meaningful indicators within the Quality Measure Framework </li></ul></ul><ul><ul><li>Enable more in depth analysis and ongoing rapid improvement </li></ul></ul><ul><ul><li>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. </li></ul></ul>
    19. 19. Supporting Quality with TrakCare Business Intelligence Martin J Egan Director eHealth, NHS Lothian
    20. 20. Agenda <ul><li>BI Overview </li></ul><ul><li>TrakCare BI Overview </li></ul><ul><li>Trakcare BI dashboards </li></ul><ul><li>Integration with Real Time BI </li></ul><ul><li>Summary </li></ul>
    21. 21. <ul><li>True genius resides in the capacity for evaluation of uncertain, hazardous, and conflicting information. </li></ul><ul><li>- Winston Churchill </li></ul><ul><li>Information is not knowledge. </li></ul><ul><li>- Albert Einstein </li></ul>
    22. 22. What is TrakCare BI <ul><li>Built on InterSystems DeepSee product embedded within Trakcare </li></ul><ul><li>Data model of the Trakcare database </li></ul><ul><li>Queries and Pivots built using the Trakcare data </li></ul><ul><li>Library of preconfigured Dashboards </li></ul><ul><li>Options to create ad-hoc queries and build dashboards </li></ul><ul><li>Ability to export data to MS Excel </li></ul>
    23. 23. On Screen Reporting <ul><li>One of the key objectives of the BI is to reduce the reliance on paper and to optimise the available On Screen reporting. </li></ul><ul><li>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. </li></ul>
    24. 24. Improving Efficiency
    25. 25. Assessing Workloads
    26. 26. Meeting Targets
    27. 27. A&E Snapshot
    28. 28. Waiting Times
    29. 29. <ul><li>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. </li></ul><ul><li>Following are two examples where the Embedded BI facility is used to better manage and review </li></ul>TrakCare Embedded BI
    30. 30. <ul><li>Example 1: Emergency Treatment Management </li></ul><ul><li>In Scotland the target for treatment for Emergency Departments is 4 hours </li></ul><ul><li>The 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 breach </li></ul><ul><li>The ‘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. </li></ul>TrakCare Embedded BI
    31. 31. TrakCare Embedded BI
    32. 32. TrakCare Embedded BI
    33. 33. TrakCare Embedded BI
    34. 34. <ul><li>Example 2: Waiting List Management </li></ul><ul><li>In 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 </li></ul><ul><li>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 </li></ul><ul><li>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. </li></ul>TrakCare Embedded BI
    35. 35. TrakCare Embedded BI
    36. 36. TrakCare Embedded BI
    37. 37. Summary <ul><li>Flexible </li></ul><ul><li>Relevant </li></ul><ul><li>Timely </li></ul><ul><li>Drill down detail </li></ul><ul><li>Configurable presentation </li></ul><ul><li>Drives Improved Efficiency & Quality </li></ul>
    38. 38. Using e health to support improving the quality of care Ms TE Gillies NHS Lothian
    39. 39. Stepwise development in the use of Trak over five years <ul><ul><li>PAS </li></ul></ul><ul><ul><li>Order comms </li></ul></ul><ul><ul><li>Support quality of care </li></ul></ul><ul><ul><ul><li>Pathway support </li></ul></ul></ul><ul><ul><ul><li>Alerts </li></ul></ul></ul><ul><ul><ul><li>Availability of information </li></ul></ul></ul>
    40. 40. Electronic ordering <ul><li>Allows standard order sets </li></ul><ul><li>Reduces duplication- others can see outstanding orders </li></ul><ul><li>Streamlines movement onto diagnostic waiting lists for radiology </li></ul><ul><li>Saves time for radiology inpatient requests </li></ul><ul><li>BUT </li></ul><ul><li>Increase in CRP 250% </li></ul><ul><li>“ disputed” or discontinued orders- less visible </li></ul><ul><li>Not all tests are ordered this way </li></ul>
    41. 43. Handling results electronically <ul><li>Next step </li></ul><ul><li>Sign off- whose responsibility? </li></ul><ul><li>Change in behaviour </li></ul><ul><li>“ Abnormal” means different things to different people </li></ul><ul><li>Needs accurate care provider and clear processes around responsibilities </li></ul>
    42. 44. Trak Maternity <ul><li>Stand alone module- entire electronic record </li></ul><ul><li>Reduce unnecessary variation with embedded protocols </li></ul><ul><li>Use as an example to demonstrate balance of mandatory and non mandatory fields </li></ul><ul><li>Aid to service management via standard reports </li></ul>
    43. 45. Booking Questionnaire Hyperlinks – linking to document for referral Hyperlinks – linking to document linking to a protocol
    44. 46. Ethnicity Non mandatory fields – language preferred & Ethnicity Example of new code values for Ethnicity
    45. 47. Alcohol brief intervention information – HEAT Target requirement Hyperlinks – linking to document linking to a protocol
    46. 48. Compliance Reports
    47. 49. Handling referrals
    48. 50. 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
    49. 53. Clinical Outcomes
    50. 54. Using clinical outcomes <ul><li>To improve information capture about what we do- procedures, multidisciplinary consultations </li></ul><ul><li>To improve workflow- from outpatients to order to outcome to waiting list </li></ul><ul><li>To start conversations about variation </li></ul>
    51. 55. 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%
    52. 56. Developments into clinical practice <ul><li>Questionnaires </li></ul><ul><li>Operation notes- mandatory field for antibiotic and DVT prophylaxis </li></ul><ul><li>Improved legibility </li></ul><ul><li>Estimated blood loss </li></ul><ul><li>Pathology specimens </li></ul>
    53. 59. Sharing information: A&E Discharge Child Protection Form
    54. 60. Next steps <ul><li>Increase use of developments and make standard practice </li></ul><ul><li>Increase use of pathways and move into MDT/ cancer tracking </li></ul><ul><li>Harness enthusiasm and speed of implementation </li></ul>
    55. 61. Medicines Reconciliation in Scheduled Care using the Emergency Care Summary Dr Gregor Smith
    56. 62. Background <ul><li>Medication errors have potential to be cause of harm to patients and are not infrequent </li></ul><ul><li>Occur most commonly at interfaces of care </li></ul><ul><li>Accurate medicines reconciliation a major component of safe hospital care </li></ul><ul><li>ECS invaluable in helping achieve this goal </li></ul><ul><li>Good experience of its safe and appropriate use in unscheduled environment </li></ul>
    57. 63. 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. )
    58. 64. Project Structure
    59. 65. Project Management <ul><li>Test ECS in four clinical areas of planned care </li></ul><ul><li>Project end point 400 patients </li></ul><ul><li>Evaluate </li></ul><ul><ul><li>Clinical benefits </li></ul></ul><ul><ul><li>Acceptability (staff, patient) </li></ul></ul><ul><ul><li>Assess impact on decisions and care </li></ul></ul><ul><li>75% (305 patients) ECS accessed </li></ul><ul><li>100 records not accessed; range of reasons </li></ul>
    60. 66. Results – Accessing ECS 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% 20 Patient refused access (Verbally) 1% 1 Patient ECS details “Opted Out” 20% 20 Other accurate source available 51% 51 No access to computer. 0% 0 ECS site down 4% 4 Other (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
    61. 67. Results Environment 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 Medical 0% 0 Nursing 63% 193 Pharma 37% 112 Clerical 0.0% 0 answered question 305 skipped question
    62. 68. ECS and Current Treatment Did the ECS reflect the current treatment?         Answer Options Nursing % Pharmacy % Total % Total Count Yes 122 65 76 66 65.5% 198 No 65 35 39 34 34.5% 104 Total   187 100 116 100     answered question 302 skipped question 3
    63. 69. Results – Impact of ECS
    64. 70. Results- Management Q8: Did the ECS change your advice re clinical management of the patient?       Answer Options Nursing % Pharmacy % Response Percent Response Count Yes 2 9% 5 11% 10% 7 No 21 91% 39 88% 90% 60 Total   23 100.0 44 100.0   100%   answered question 67 Answer Options Nurse Pharmacy Response Further Investigations 0 0 0 Admission 0 0 0 Referral 1 0 1 Alternative Treatment 1 3 4 Other (please state) 0 2 2* 7 * Ensure that interacting drug not taken       * Confirmation that interacting drugs are discontinued      
    65. 71. Acceptability <ul><li>All patients asked for consent before access; 1 refusal </li></ul><ul><li>86% staff found ECS helped in medicines reconciliation process </li></ul><ul><li>93% staff thought accessing ECS as part of reconciliation process would reduce time </li></ul><ul><li>79% advocated use in all admissions and OPD appointments </li></ul><ul><li>Excellent understanding of governance arrangements surrounding use </li></ul>
    66. 72. Retrospective Audit of E-Referral No 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
    67. 73. Summary <ul><li>ECS accessed in 75% (300 patients) of the study group </li></ul><ul><li>22% of accesses provided additional information </li></ul><ul><li>Access resulted in: </li></ul><ul><ul><li>Prevention of harm to 23 patients </li></ul></ul><ul><ul><li>Change of management plan for 7 patients </li></ul></ul><ul><li>ECS reflected current treatment in 2/3 of cases </li></ul><ul><li>Main professionals who initiated access were nurses and pharmacists </li></ul><ul><li>ECS provides additional information to that in electronic referral </li></ul>
    68. 74. Will this be available in other hospitals? <ul><li>Significant interest from other Boards and within QI community </li></ul><ul><li>Great deal of discussion around access to data for this purpose </li></ul><ul><li>Consultation now taking place on draft guidance issued by Scottish Government e-Health to form a basis for this </li></ul><ul><li>Health Boards, GPs and representative bodies, patients by 16 th September </li></ul>