Making prudent healthcare happen

Enabling the delivery of prudent healthcare through information technology

  • Hamish Laing, Medical Director and Director of Informatics and Innovation, Abertawe Bro Morgannwg University Health Board

Summary

There are many ways in which Information Technology (IT) can be and will be an enabler of prudent healthcare. This article explores how IT will support the delivery and promise of prudent healthcare.

Information technology

Introduction

Information technology (IT) is the application of computers and telecommunications equipment to store, retrieve, transmit and manipulate data. When modern IT was first described in 1958 (1), the NHS was just 10 years old.

We all know about the pace of change of technology in our daily lives – we can do things now using computers and smartphones, which we couldn’t imagine would be possible even a few years ago when a tablet was something to be swallowed and not something on which to do the shopping. The iPad was only launched in 2010 but by this year it is estimated that 280 million tablets will be in use worldwide,  more than 24 million people in the UK already own or use one regularly (2) and this number is set to increase further (see Figure 1).

The medical profession have not let the technological revolution pass them by either – 72 per cent of doctors in the USA say they own a tablet device and recommend programmes – “apps” – to their patients (3). An incredible 93 per cent of UK citizens own or use a mobile phone and nearly two thirds UK citizens own a smartphone (4).

UK Tablet Users, 2012-7: where will be in three years?

UK Tablet Users, 2012-7: where will be in three years?

Figure 1: Individuals of any age who use a tablet at least once a month Source: eMarketer. October 2013

Can this technology, so pervasive in our daily lives, support the application of prudent healthcare in the NHS?  Three prudent healthcare principles are considered in this chapter:

  • Do no harm
  • Carry out the minimum appropriate intervention
  • Remodel the user and provider relationship with co-production.
Do no harm

Know your patient – an essential prerequisite for safe and effective care and for secure sharing and linking patient information is having confidence that the patient before you is the right one. This can be difficult when many people share the same name or when information is inaccurate or incomplete. Changes to systems in the NHS over time, resulting in the merging of hospitals and medical records, means most people now have multiple local record numbers and this introduces the very real risk of confusion and harm.

The creation of a unique identifier, issued shortly after birth, such as the individual NHS number in England and Wales (5), has been an important first step but it now requires IT to use it to make sure that NHS systems – X-rays, blood tests, GP and hospital attendances, for example – are correctly and accurately linked together. An enterprise master patient index (EMPI), such as the one in NHS Wales, with processes to match citizens to their records is a vital computer process, which works in the background and already help avoids harm in the NHS every day.

Safer information transfer – there are many opportunities to use IT to help reduce harm in healthcare. Systems and processes can support effective and timely sharing of information between health and social care professionals, helping avoid the potential for miscommunication and the omission of important information, such as test results. Electronic referrals between primary care physicians and hospital specialists speed up communication, reduce potentially harmful delays in urgent situations and reduce transcription errors. They also allow more relevant information to be shared: the use of standardised formats help to ensure completeness of information. E-referral using the Welsh Clinical Communication Gateway (WCCG) will be universal in NHS Wales in 2015. Common information systems between health and social care professionals are being developed and will be another way of reducing the risk of harm.  The sharing of a summary of the GP record (the “IHR”) with out-of-hours GP services means that patients seeking care when their usual GP is not available can be assured that the relevant information is available to the doctor or nurse they are speaking to. Sharing the IHR with hospital clinicians when a patient is admitted is the next phase and supported by strong information governance and audit tools is being tested on wards in the University Hospital of Wales for wider deployment in 2015.

Better information when care is delivered. IT can support clinical decision-making by bringing evidence of best practice to the clinic room or bedside. The prevalence of smartphones and tablets among clinicians means that ‘bringing your own device’ (BYOD) to work allows immediate access to online information apps such as electronic formularies and best practice guidance, for example NICE.org and BNF.com. Many hospitals now provide fast wireless broadband for patients, visitors and staff, which is a vital enabler for BYOD and for giving patients access to information such as use of short videos on YouTube to explain operations to patients before surgery or to teach them to do a procedure for themselves.

Improving safety – IT can also support safer practice and reduce cost in the process. For example, prescriptions in hospitals are still handwritten, introducing significant risk of two medicines with similar names being confused or a dosage misinterpreted. Transposing prescriptions for pharmacists or their robots to dispense is another risk-creating step which IT can make into a seamless and safer process. The complexity of medicines and the number of different medicines taken by individual patients now mean there are many potential interactions or contraindications to avoid.

Electronic medicines prescribing and administration (EMPA) systems –are used in primary care and avoid the need for transcription and can identify potential interactions while supporting clinicians to use best practice and to follow agreed formularies. These advantages are even greater in hospital settings where EMPA can allow safe onward transmission of discharge medication directly to the GP surgery and can also be shared with the patient who can be discharged from hospital faster on the day, using this technology. Seeing the benefits of EMPA in use at University Hospitals Birmingham NHS Foundation Trust, where it is at the heart of their electronic patient safety and improvement processes, inspired Abertawe Bro Morgannwg University Health Board to introduce EMPA: initially into its outpatient areas where a project to deployed it this year (2015) is underway and plans for in-patient deployment are being developed. In Birmingham they use powerful and accurate information from their EMPA to increase the timeliness of medicine administration, to understand which medicines have not been taken by patients and why and to link prescribing advice to clinical condition, such as a change in medication in response to a lab test result.

Early warning systems and patient deterioration –IT can also help identify patients who are becoming unwell and alert clinical staff. By using physiological information regularly collected at the bedside, IT can identify deteriorating patients and alert staff automatically. This takes the paper-based early warning scoring system (NEWS) and uses IT to improve its ease of use and effectiveness. Different automated phone or text alerts can be set up according to the severity of deterioration. Oxford University Hospitals NHS Trust ‘SEND’ project (6) uses iPads to collect these data and has been in place since 2013. Other NHS trusts have used software from ‘Nerve Centre’ (7) to do the same. Good results have been reported, particularly out-of-hours, when staffing is leaner and tasking of clinicians to the highest priorities is particularly important. For example, Nottingham University Hospitals NHS Trust saw a 70% reduction in out-of-hours incidents related to poor handover information, fewer cardiac arrests, better team satisfaction and the release of 70 hours of staff time a week when Nerve Centre was deployed (8) – this is an example of IT helping to improve safety and make best use of resources.

Prioritising care –IT can also help nurses and doctors focus on the most important things when there are many calls on their attention. Betsi Cadwaladr University Health Board is using funding from the Small Business Research Initiative (SBRI) to develop software and systems to reduce the cognitive load on frontline staff and remind them when time-critical tasks were due, allowing them to spend more time with patients and to organise their work appropriately. When the project is complete in 2016 the products and systems will be made available across NHS Wales to benefit staff and patients.

Supporting high reliability approaches – “Guidelines are typically forgotten half of the time, so we made these automated pathways the default way of doing things.” This observation comes from Dr Brent James, Chief Quality Officer at Intermountain Healthcare in the US (9) and demonstrates how using IT in routine processes can support busy clinicians to make the right decisions, permitting but also monitoring, justified variation that can be reviewed later.

The importance of planning for excellence cannot be over-emphasised and this requires good documentation and also measurement of outcomes, both of which can be made much easier using IT. As Professor Ronan Lyons of Swansea University observes: “We need to measure outcomes” to know if we are providing effective treatments for patients and meeting their need (10).

Carry out the minimum appropriate intervention

Good clinical decisions are informed by good quality evidence. This includes evidence of need at an individual or population basis, and making the best practice evidence about a condition available to clinicians and patients can help to them make sure the appropriate options for treatment and care are considered and at the minimum appropriate level of intervention. This can be difficult when there is so much published evidence to review. IT allows the most powerful and relevant information to be identified and presented to clinicians by searching through large databases of publications quickly and effectively using sophisticated search algorithms, which would previously have taken many hours by a librarian  or clinician. This “context-specific” evidence can then be retrieved and reviewed electronically by clinicians without needing to wait for journals or reprints to be obtained.

PROMs – the coding of procedures and other clinical activity allows them to be audited and correlated with outcomes; particularly the outcomes valued by the patient (PROMs). Validated PROMs for a number of the major elective procedure have now been developed (11): these can help to inform the advice given to other patients with similar needs. The analysis of these data is greatly facilitated by IT which can capture, interpret and present the information as well as share it with other centres to use for benchmarking.

Eliminating duplication – one way of avoiding over-treatment is to avoid duplication of tests. This remains a problem in healthcare because a test may have been done in one GP practice or hospital and it may then be repeated in another. Sometimes a test result is not expected to change rapidly and there is no sense in repeating it soon after a previous test; even deliberately. Recording all of the results on computer systems and matching them together using the EMPI (see above) allows duplication to be spotted and messages to be sent to requesting clinicians to tell them that there is a recent similar test in the system. Not only does this avoid the patient having to go through the test again but it can allow clinicians to reach a decision more quickly and at lower cost. NHS Wales is adopting this approach, combining EMPI with the deployment of a common Laboratory Information Management System (LIMS) that allows results to be viewed across the whole NHS by a patient’s GP or hospital clinician, wherever the test was done or requested.

Decision support tools – IT systems can also help direct clinicians to the most appropriate test using decision-support tools built into electronic clinical systems. These tools are now very sophisticated and can be of great help, particularly for clinicians early in their careers. Similar decision-support is intrinsic to ‘e-ITU’, where patients who need critical care can be supported in a hospital away from the main critical care centre (12). Through careful analysis of millions of items of patient physiological data matched with outcomes, it is possible to anticipate a patient’s likely needs earlier and alert specialists in the main centre who can then support local staff to look after the patient using remote monitoring and telemedicine. Already widespread in the USA, where travel distances to specialist centres can be great, e-ITU is being evaluated in the UK at Guy’s and St. Thomas’ Hospitals in London (12).

Remodel the user and provider relationship with co-production 

As we have moved away from paper-based to digital systems in the NHS, there are now great opportunities to share information of all kinds, from outcomes to waiting times, with patients and the public. The work of Professor Sir Brian Jarman and Dr Foster Intelligence® to promote the publication of mortality and other outcomes has now extended into speciality-specific outcome reports developed by clinicians for the public, particularly in surgery (13). The recent Palmer review in Wales encourages such approaches as well as careful individual scrutiny of the care records of all patients who die in hospital to learn if anything could have been done better. Information systems to help document these “Mortality Reviews” are now being tested in Abertawe Bro Morgannwg University Health Board.

As care records increasingly become digital then text analytical systems can be used to “read” the records looking for triggers of potential harm. Such systems have been developed in Denmark and are undergoing research evaluation (14).  Access to this aggregated information on health services will empower people to manage their health better, promote equity of user group and community engagement with health and social care professionals and it will also provide useful feedback to the health and social care systems to support improvement processes and allow them to do their job better. The advent of cheap digital “cloud” storage and broadband are great enablers for this information sharing.

It is also possible to allow patients to conduct transactions with the NHS such as requesting prescriptions or making appointments, through “myHealthOnline”. This platform has potential to have much greater use as a vehicle for patient empowerment in the future: for example as a place to store and share healthcare related correspondence about them.

One-way information sharing: service-to-patient – initial steps have been to share information from health professional to patient. This one-direction transfer has meant that patients can see some of their own test results – for example the PSA test for a man with prostate cancer under surveillance or the HbA1C for the long-term monitoring of diabetes mellitus – and know how they are doing and when to make contact with their GP or specialist. Similar sharing takes place with the monitoring of blood anticoagulation or cholesterol or kidney function tests. This is an important start in engaging the public in their own health and care.

One-way information sharing: patient-to-service – IT solutions have allowed patients to be monitored remotely and to use technology to inform the service of their status rather than having regular hospital or GP check-ups. The widespread use of Telehealth and assistive home technologies have allowed many thousands of people – often frail and elderly – to continue to live independently in their own homes, secure in the knowledge that if they need assistance then they can quickly get help and if they fall or become confused that this will be detected and acted upon. In Bridgend, there are over 1400 users of assistive technology.  Each service user referred to the intermediate care service is assessed and a suitable package of technology is put in place depending on need.   An innovative aspect of the Bridgend service lies in the support model, which includes a mobile response service provided by trained and registered domiciliary care workers, which responds to calls within 30 minutes.  This means that the team can respond to calls (for example, to someone who has fallen) and quickly provide any necessary personal care as well as staying with the individual until other support arrives.  This reduces the need for hospitalisation and is also reassuring for family members who may live at a distance.

Devices can monitor many aspects of patient’s health from their blood pressure, fluid balance for heart and kidney failure to their heart rhythm, blood sugar and breathing tests. These devices can be connected to a remote monitoring service using the internet so that a large number of patients can be looked after by a small clinical team. There is considerable development in such devices and they can be connected through existing technologies. Abertawe Bro Morgannwg University Health Board is conducting a large-scale trial of heart monitoring in the community to detect atrial fibrillation, which untreated can lead to stroke, using monitors connected to an iPod touch. These remote-monitoring approaches help people with long term conditions to have a better understanding and control of their own health and empower them with information which they can share with their clinicians. (15).

More recently the development of apps and health/lifestyle devices which connect to smartphones are allowing people to monitor various health-related data themselves, such as their body mass index, sleep patterns, heart rate and daily activity. There is an intention to provide some clinical validation for these apps and devices in the future (a ‘kite-mark’ for example) to enable healthcare staff to make recommendations and encourage more self-management and better, health protecting, lifestyle choices.

Two-way information sharing – a number of health organisations have created patient portals for two-way sharing of information. This two way sharing might use teleconferencing for a consultation in order to make access to a specialist or GP easier, for example. The portals can use non-specialist technologies such as Skype or FaceTime. These approaches can be empowering for patients and allow them to make contact at a time that is appropriate for them. The Vitality GP Partnership (16) in England has reported using Skype successfully for large numbers of urgent consultations. ABMU and Betsi Cadwaladr Health Boards in Wales have also secured funding to evaluate a successful service model used in Airedale NHS Trust that uses video consultations between the GP out-of-hours service and Care Homes based on to minimise the need for conveyance to hospital.

Some organisations have created secure data-sharing portals where results from the healthcare provider can be placed for patients to see. In return the patient can upload their own information, such as blood results done elsewhere or pictures of a wound, for example. This helps to involve patients in their care, improve efficiency and provide a more equal partnership for their care. Queen Elizabeth Hospital Birmingham have developed “MyHealth@QEHB” which is popular with patients and clinicians.  However, all of these approaches require tight information governance and security which can be perceived to be a barrier to take-up but if planned for well can be managed safely (17).

Collaborative sharing – the most comprehensive information sharing between citizens and health, social care and other stakeholders is seen in approaches such as those taken by “My Health Locker” (18) and “Patients Know Best® (19). Here the person is given, by mutual agreement, a copy of their health and social care information and any plans from third sector organisations and they add to it any information they also wish to share. They are then in control of that information and choose who they would wish to share it with. For example, this might allow a patient to let the GP, hospital specialist and community nurse all have sight of their social care and end-of-life plans (see figure 2, below).

Sharing information in this way gives an individual control of it, removing some of the information governance barriers. Some such systems then allow the person to contact a health or social care professional using email, Skype or phone to discuss anything unexpected or to arrange a face-to-face review. The British social enterprise, “Patients Know Best®” has developed an electronic personal health record (PHR) and worked with gastroenterologists at Luton and Dunstable Hospital to use it to empower patients with inflammatory bowel disease to self-manage, with expert advice on hand when required. This resulted in a dramatic fall in outpatient attendances, financial savings and greater satisfaction (20). Such approaches are very supportive of this principle of prudent healthcare.

Opportunities for information sharing by and with patients through Patients Know Best

Figure 2: Opportunities for information sharing by and with patients through Patients Know Best® (used with permission) www.patientsknowbest.com

Conclusion

Prudent healthcare promises a transformation of our health service, putting patients at the centre and in control of their own health and healthcare, while services will deliver what’s needed and with the lightest touch, to maintain good health for individuals and for the population as a whole. IT is not optional but must be at the heart of this transformation process. It offers access to information, systems to protect patients from harm, opportunities for better governance, better integration of services and remote contact with patients to facilitate co-production processes and patient partnerships.

Patients and service users are often surprised that some things they can do easily at home are not available to them when accessing healthcare. Opening up information held about citizens for them to have and share is a vital part of transparency and empowerment and is long overdue. The public is impatient for the NHS to catch up and by considering its impact on delivering healthcare more prudently, the case for investment and deployment of information technology can no longer be denied.

With thanks to

Andrew Phillips, Ian Phillips, Abertawe Bro Morgannwg University Health Board.

Dylan Williams and Matt Makin, Betsi Cadwaladr University Health Board.


 References

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  15. Steventon A, Bardsley M, Billings J, Dixon J, Doll H, Hirani S et al. Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. BMJ. [Online] 21 June 2012. [Cited: 19 October 2014.] http://dx.doi.org/10.1136/bmj.e3874.
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  18. My Health Locker. South London and Maudsley NHS Foundation Trust. [Online] [Cited: 12 December 2014.] http://www.slam.nhs.uk/patients-and-carers/patient-information/myhealthlocker.
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Watch Hamish Laing talk more about this article, click the video.

Information technology infographic

Innovation is one of the key drivers for prudent Healthcare. #ConnectNHS

Prudent Healthcare - collaboration leads to increased sustainability in patient care. #ConnectNHS pic.twitter.com/C33lMtboqH