Prof David Patterson, Consultant Cardiologist, Professor of Cardiovascular Medicine and CEO of Helicon Health, gave this presentation at Commissioning Live - November 2014. He covers a range of issues including better identification of patients with atrial fibrillation and better management of anticoagulation patients. Helicon Health's web-based integrated package - HeliconHeart - is compliant with National Institute for Health and Care Excellence (NICE) guidelines on anticoagulation and self-monitoring, and cited as a learning exemplar in NICE’s guidelines for atrial fibrillation.

1. STROKE
PREVENTION
SERVICES
QUALITY
AND
SAFETY
INDICATORS
IN
A
CHANGING
CONTEXT
• David
Pa;erson
MD
FRCP
FRSPH
• Professor
of
Cardiovascular
Medicine
• Consultant
Cardiologist
• Department
of
Cardiovascular
Medicine,
WhiMngton
Health
• CHIME,
University
College
London
• Helicon
Health,
Chief
ExecuPve

2. HeartBeat/HeliconHeart - Seamless anticoagulation and stroke prevention services across north London
building on 20 years of world-leading research on electronic health records
1992
Good European
Health Record
1996
2000
1998
1996
2002
2004 2006
2006
2012
2008
20 years of international research on
the requirements, design,
implementation, sharing and
protection of electronic health
records
Leading a global open
source EHR
Foundation
implementation of an ISO EN 13606
conformant EHR server with a suite of
cardiovascular web applications
Leading the development of
European and International
EHR standards
HeartBeat
Anticoagulation
management and
advisory system
2006
Set up and seed funded by UCL in 2012
Key partners CHIME and Whittington Health
1999
2011
HeliconHeart
is
a
unique
package
of
clinical
services
comprising:
-­‐
Web
soSware
-­‐
Clinically
useful
Electronic
Health
Record,
standards-­‐based
-­‐
Decision
support
–
which
drugs
to
use,
how
and
when
-­‐
CollaboraPon
tools
-­‐
EducaPon
-­‐
Governance
data
analyPcs

3. NICE
AF
GUIDELINES
2014
Key
prioriPes
for
implementaPon:
•
Personalised
package
of
care
and
informaPon
•
Referral
for
specialised
management
•
Assessment
of
stroke
and
bleeding
risks
•
IntervenPons
to
prevent
stroke
•
Rate
and
rhythm
control

4. 2014
ATRIAL
FIBRILLATION
AWARE
WEEK
24TH
NOVEMBER
-­‐
29TH
NOVEMBER
The
aims
of
the
AF
Aware
week
are
simple:
AF
-­‐
Detect,
Protect,
Correct:
! Detect:
OpportunisPc
Screening
has
been
shown
to
increase
detecPon
of
AF
! Protect:
IdenPficaPon
and
treaPng
paPents
with
AF
at
an
early
stage
will
deliver
significant
health
and
cost
benefits
! Correct:
Early
detecPon,
diagnosis
and
appropriate
medical
management
leads
to
fewer
appointments
admissions,
saving
individuals
long-­‐term
ill
health
The
All-­‐Party
Parliament
Group
on
AF
(APGAF)
has
played
a
key
role
in
helping
to
establish
that
AF
should,
in
both
policy
and
clinical
domains,
be
considered
a
discrete
enPty
within
“the
family
of
cardiovascular
disease”.
APGAF
meets
again
tomorrow
to
explore
the
sPll
exisPng
barriers
for
paPents
to
gain
access
to
the
opPmal
treatment.

5. WHAT
ARE
THE
REASONS
FOR
OFFERING
ANTICOAGULANT
AND
STROKE
PREVENTION
TREATMENT
TO
PATIENTS
?
“AnPcoagulaPon
therapy
is
required
for
people
with
different
condiPons,
who
are
idenPfied
in
a
range
of
seMngs
and,
in
the
case
of
deep
venous
thrombosis
and
pulmonary
embolism,
require
urgent
intervenPon.”
NICE
2013
Based
on
epidemiological
data
and
other
informaPon,
it
is
concluded
that
the
number
of
adults
aged
18
or
over
in
England
who
require
anPcoagulaPon
therapy
and
may
need
access
to
an
anPcoagulaPon
therapy
service
include:
CondiEon AnEcoagulaEon
therapy
service
Atrial
fibrillaEon
(CHADS2
score=1) 226,000
Atrial
fibrillaEon
(CHADS2
score1) 476,000
VTE
including
PE
and
DVT
125,000
Others 155,000
“Therefore,
it
is
suggested
that
the
indicaPve
rate
for
people
needing
anEcoagulaEon
therapy
is
up
to
2.4%
or
2400
per
100,000
of
the
populaPon
aged
18
years
or
over”
NICE
2013

6. ARE
WE
IDENTIFYING
ALL
THE
PATIENTS
WITH
AF
WHO
SHOULD
BE
ANTICOAGULATED?
ATRIAL
FIBRILLATION
IS
A
MAJOR
PREVENTABLE
CAUSE
OF
STROKE
NaPonal
data
obtained
from
GRASP-­‐AF
show
that
only
66%
of
high
risk
paPents
are
managed
using
oral
anPcoagulaPon
(May
2014
–
33%
of
all
pracPces
in
England)
This
is
in
spite
NaPonal
Guidelines
from
NaPonal
InsPtute
for
Health
and
Care
Excellence
and
the
European
Society
of
Cardiology
promoPng
their
use

7. RAISING
AWARENESS
–
IDENTIFYING
PATIENTS
WITH
AF
The
Atrial
FibrillaEon
AssociaEon
(AFA)
and
the
Stroke
AssociaEon
have
undertaken
awareness-­‐raising
events:
Know
your
pulse
EducaEonal
events
OpportunisEc
or
screening
programme?
OpportunisEc
is
cost-­‐effecEve
Flu
vaccinaEon
programme
Surgery
pre-­‐assessment
Eye
appointments
Pharmacy
visit
Supermarket
visit
Pub
visits?

8. NICE
(2013)
SUPPORT
FOR
COMMISSIONING:
ANTICOAGULATION
THERAPY
NICE
GUIDELINES
FOR
AF
(2014)
• There
is
such
an
inPmate
relaPonship
between
AF
and
other
manifestaPons
of
CV
Disease
(The
Family
of
Cardiovascular
Disease)
and
to
anPcoagulant
and
prevenPon
services
for
strokes
• It
is
an
essenPal
step
to
idenPfy
paPents
with
AF
and
direct
appropriate
paPents
to
anPcoagulant
and
stroke
prevenPon
therapy
in
order
to
reduce
the
incidence
of
stroke.
ATRIAL
FIBRILLATION
Hypertension
Raised
lipids
Coronary
artery
disease
HEART
FAILURE
Hypertension
Coronary
artery
disease
Raised
lipids
ANTICOAGULATION
Monitoring
Frequent
visits
PST
PSM
opPons

9. WHY
ARE
WE
HERE?
Cardiovascular disease
(CVD) is the biggest
killer in the UK
Costs of CVD are
massive
Strokes are avoidable
with preventive
treatment
11% £19b
Wide variations in
quality and safety
Strokes are very
costly to the patient
and society
153,000
Strokes/year UK
Poor clinician and
patient education
of UK population
have CVD
ONS 2011
BHF 2014
Stroke Association 2014
Not on
effective
therapy to
reduce
strokes
44% £23k Saving from
NICE UK
each stroke
prevented
NAO 2010
No. 1 risk
“Not all staff have
the required work
competencies”
NPSA Risk of
Anticoagulation, 2006

10. POPULATION
ATTRIBUTABLE
RISK
The
contribuPon
each
risk
factor
makes
to
overall
stroke
prevalence
can
be
calculated
as
a
populaPon
a;ributable
risk
(PAR).
In
England:
PAR
of
smoking
13.3%
PAR
of
hypertension
34.8%
50%
of
the
risk
of
stroke
can
be
“preventable”
by
controlling
these
2
risk
factors.
There
is
logic
in
managing
these
risk
factors
at
the
same
Pme
as
the
risks
a;ributable
to
atrial
fibrillaPon
(heart
rhythm
and
rate
control
and
oral
anPcoagulaPon)

11. IMPACT
OF
HELICON
AF
STROKE
PACKAGE
Strokes/year
101
64
37
strokes
saved
Before
EsPmated
cost
saving:
£592,000
With
Helicon’s
AF
Stroke
package
An
Urban
CCG
Total
populaPon:
320,000
60y:
57,290
“The
cost
of
stroke
could
be
cut
by
20%
with
beBer
management
of
atrial
fibrillaFon.”
NICE
2006

12. UNIQUE
ONLINE
SOLUTION
FOR
SHARED
CARE
Electronic
Health
Record
An online care record
shared across all
venues of care
Clinical
Decision
Support
Integrated tools for
better diagnosis, risk
assessment
treatment
Clinical
Governance
Analytics
Robust analytics
enables multi-site
comparison
Clinician
Patient
Education
Patients are
equipped for self-care
and clinicians
are kept up to date
with accredited
learning

13. EDUCATION
The patient The clinician
It
has
features
for
the
paEent,
together
with
their
carer
or
family
member
that
include:
! Only
comprehensive
on-­‐line
resource
to
support
the
self-­‐tesPng
paPent
! Assessment
tools
to
assess
competencies
! More
value
on
expansion
to
self-­‐
management
(inclusion
of
dosing
support)
! Retain
support
of
local
pracPPoner
for
skills-­‐based
training
! Resource
that
paPent
can
share
with
their
pracPPoner
to
facilitate
consultaPons
! User
can
select
different
levels
of
informaPon
based
on
learning
needs
! Produced
and
supported
by
experts
in
field
Part
of
the
course
for
the
clinician
is
to
study
the
course
for
the
paEent.
! Offer
both
skills
and
knowledge
based
educaPon
with
assessments
of
both
! In
addiPon
to
the
clinical
knowledge
base
we
offer
very
pracPcal
support
in
terms
of
service
delivery,
clinical
governance
and
paPent-­‐centred
consultaPons
! User
can
select
different
levels
of
informaPon
based
on
learning
needs
! Supported
by
experts
in
field
! UCL
branding
! Forum
to
allow
interacPon
with
fellow
students
and
mentors
/
tutors
! Not
a
stand-­‐alone
product.
! Forum
for
alumni
to
help
conPnue
their
educaPon
and
to
share
experiences

14. THE
INVOLVEMENT
OF
THE
PATIENT
AND
CARER

15. CASE
STUDY
COUNTY
DURHAM
AND
DARLINGTON
NHS
FOUNDATION
TRUST
(CDDFT)
• In
June
2013,
200
paPents
taking
warfarin
were
idenPfied
and
recruited
for
an
INR
self-­‐tesPng
study
• Within
6
months
of
the
study
starPng,
70%
of
paPents
had
increased
their
Pme
in
therapeuPc
range
(TTR)
by
over
20%.
The
average
increase
was
15%.
• Financially,
INR
self-­‐tesPng
was
cost
neutral
when
all
CCG
costs
were
included
such
as
the
reducPon
in
adverse
events.
Self-­‐tesPng
also
freed
up
clinic
capacity.
• PaPents
loved
the
service
-­‐
every
paPent
in
the
study
said
they
would
recommend
it
Average
TTR
across
all
200
paFents,
before
aMer
study
6
months
before
study
59.7%
3
months
before
study
59.0%
3
months
ader
study
71.9%
6
months
ader
study
74.7%

16. PATIENT
SELF-­‐TESTING
AND/OR
SELF-­‐MANAGING
THE
CONTROL
OF
THE
INR
! FINGER
PRICK
TESTING
WITH
COAGUCHEK
! COMMUNICATION
WITH
HCP:
Grace
concludes:
• “I
get
comfort
from
knowing
that,
thanks
to
HeliconHeart,
all
my
clinicians
have
access
to
a
single
electronic
health
record
for
me.
I
also
like
playing
an
acFve
role
in
my
treatment
and
I
find
I
worry
less
about
my
AF.”
ADDRESSING
THE
CO-­‐MORBIDITIES
OF
AF
! BLOOD
PRESSURE
PULSE/HEART
RATE
! SMOKING
! ACTIVITY/EXERCISE/DANCE
! WEIGHT
MEASUREMENT
(PARTICULARLY
FOR
HEART
FAILURE
MANAGEMENT)
SUPPORTED
BY
! ON-­‐LINE
EDUCATION
! LOCAL
HEALTH
CARE
PROFESSIONAL
WITH
ACCESS
TO
EHR
AND
ADVISORY
SYSTEMS
! STRONG
CLINICAL
GOVERNANCE
IVR
Web
App

19. STROKE
PREVENTION
SERVICES
WARFARIN
CLINIC
VISIT

21. COMMUNITY
BASED
STROKE
PREVENTION
SERVICES
IN
ROMIRE
STROKE
PREVENTION
IN
PATIENTS
WITH
ATRIAL
FIBRILLATION
PERIOD
01.01.2014
–
31.12.2014
TOTAL
NUMBER
OF
PATIENTS
SUSTAINING
A
STROKE
IN
ROMIRE
:
236
Data
from
NaEonal
SenEnel
Stroke
Audit
THOSE
THAT
HAD
AF
THOSE
THAT
NOW
HAVE
AF
AF
PREVIOUSLY
DIAGNOSED
PROPORTION
ON
AN
OAC
AT
TIME
OF
STROKE
PROPORTION
NOW
ON
AN
ORAL
ANTICOAGULANT
100
80%
100%
40%
QUALITY
OF
SERVICE
VKA
CONTROL
TTR
70
TTR
60
65%
81%
NUMBER
TAKING
A
NOAC
5
THOSE
THAT
HAD
AF
AND
SMOKED
PROPORTION
WHO
HAD
A
SMOKING
INTERVENTION
20
15%
THOSE
THAT
HAD
RECOGNISED
HYPERTENSION
PROPORTION
TAKING
HYPOTENSIVE
AGENTS
4
0
%
P
R
O
P
ORTION
WHOSE
BP
WAS
WELL
CONTROLLED
30
%
EXERCISE/ACTIVITY
PROPORTION
TAKING
EXERCISE
5
TIMES
PER
WEEK
20%
PROPORTION
WHO
ARE
SEDENTERY
45%

22. PREVENTION
OF
STROKE
NEW
OPPORTUNITIES
The
expanded
HeliconHeart
package
that
results
from
our
new
strategic
partnership
with
InHealthCare,
is
an
integrated,
web-­‐based
soluPon
for
stroke
prevenPon,
which
makes
it
easier
for
busy
healthcare
professionals
to
plan
and
manage
AF,
oral
anPcoagulaPon
and
stroke
prevenPon
services.
It
is
also
designed
for
paPents
who
wish
to
play
a
more
acPve
role
in
managing
their
condiPon.
THE
PACKAGE
FEATURES:
! Real-­‐Pme
electronic
health
record
(EHR)
shared
with
clinical
colleagues
and
paPent
! AnPcoagulant
AF
advisory
systems
! Interoperability
with
exisPng
GP
systems
and
other
clinical
systems
! Affordable
paPent
self-­‐monitoring,
using
BP
monitor
and
Roche’s
Coaguchek
! Hosted
on
NHS
spine
via
N3
! EducaPon
for
clinicians
! EducaPon
for
paPents

23. KEEP
IN
TOUCH
To
discuss
today’s
presentaPon
or
any
ma;ers
arising
please
email
me
at
d.pa;erson@ucl.ac.uk
I
will
be
on
the
Roche
stand
between
3
and
4
this
aSernoon
To
find
out
more
about
Helicon
Health’s
unique
package
of
stroke
prevenPon
services,
go
to
www.heliconhealth.co.uk