Transcript Continuing Professional Development

Sometimes you have to be the worst
to become the best?
 2006: My Region was
highlighted as having
significantly high
admissions for diabetes.
 Our performance data
was terrible.
 They sent me to Chicago.
 I decided to create an IT
solution
The Initial Aims of the System
1. Accurate Benchmarking.
2. Automated Risk Stratification
with Identification of High Risk
Patients.
3. Integrated Care with improved
access for Remote Specialist
Evaluation.
4. Summary & Self Management
Reports for the Patients
5. Improve Safety of Prescribing .
6. Ability to Implement Patient
orientated projects.
7. Prevent events like foot ulcers!
Benchmarking
 Accurate Benchmarking of
how the surgery and PCT is
performing on clinical
markers.
 NICE
 QOF
 How we were performing in
terms of outcome data.
 How we were performing in
terms of cost.
Benchmarking (2)
2. Identification of High Risk Patients
Six types of High Risk Patients
 1. Those that have poor end-point
data.
 2. Those that have deteriorating
end point data.
 3. Those that fail to have screening
 4. Those who are not on or not
collecting appropriate medications
 5. Those that are on inappropriate
medications.
2.High Risk Patients:
b. Deteriorating Scores
 Looking
at flux of
endpoint
data helps
identify
patients
earlier.
Every Patient has their
own eHealthcard
 Secure online for ease of
access by:
 GPs
 Other HCPs
 Patients
3. Summary Reports
 Allows quick
overview of patient
 Allows pre-diabetes
clinics
 Allows remote clinics
 Allows compliance
issues to be
identified.
3. Patient Self Management Plan
7 essential steps for diabetes perfection.
 Blood Pressure
Control
 Blood Sugar Control
 Cholesterol Control
 Weight Control
 Healthy Lifestyle
 Medication
Compliance
 Regular Screening
4) Self-management plans
 Encourage Patients.
 Educate Patients.
 Essential in achieving longterm diabetes control.
 Reduce complications.
 Reduce costs.
Diabetes Management Reports
•
There are a number of variations
in the way the self-management
report can be created and the
language in which they are
presented.
•
We use these at our weekly
Diabetes Clinic to help with the
creation of action plans.
•
15 essential parameters to
outline the patients’ condition
•
Colour coding again provides
quick and easy referencing
Ability for the Patient to Feedback
Data
6. Track Overall Cost-effectiveness at
surgery level
Or at PBC or PCT level
 Analyse by surgery
or at PBC or PCT
level.
 Calculate cost per
patient for each
region.
 Calculate savings
generated by
alterations in
performance.
7. Liaising With Specialists
7. Liaising with Specialists
But Does it work!
 1 year analysis
 Diabetes & Primary Care
Journal
 PCDS
Graph of glycaemic control
achieved from 2009 QOF
data.
Table of Hypoglycaemic Agents being used by
Patients at 04/2008, 04/2009 and 01/2010
Results of Secondary Parameters
Blood Pressure
Cholesterol / Body Mass Index
The Result
 Better outcome for patients
 Better education of patients
(autotranslation etc)
 Increasing Self-management
 Reduced need for
medications.
 Easy patient alerts
 Easy patient tracking
 Reduced Emergencies.
 Reduced Admissions
 Better project and formulary
compliance.
 Better access for Healthcare
Professionals.
 Better education for
Patients.
 Better outcomes for
Patients.
But It was Not Good Enough!
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Better integration
Easier Extracts
Too GP based
Community Services
Ambulances
Patient Access
Hospital OPAs.
Other Chronic Conditions
 Primary Care Diabetes
Society
 RCGP
 Diabetes UK
 NHS Diabetes
Commissioning
www.nhspatient.org was realised.
 The NHS had wasted £20 billion
on a project that would never
work.
 Way of extracting data from all
GP systems into secure
centralised portal.
 Allowing a central portal to be
accessed by all individuals
involved in the Patients Journey.
 Need the ability to allow that
portal to achieve the objectives.
“Putting Patients First”
 Giving them the
information needed in
an orderly manner.
 Risk Stratification
 True Integrated Care
 Personalised Plans
 Centralised
Management
Presenting the Information
 Only what is needed
 Easy to read
 Intuitive
 Reliable
 Automatic
 Alerts
Suddenly There Could Be Complete Integration of
Data
Allowing complete integration of patient care
The Patient Portal
 Must be Cost-effective
 Must be Patient Friendly
 Must be secure
 Must be Confidential
 Must be able to be
accessed anywhere.
Secondary Objectives
 QIPP
 Long Term Conditions
 Local Projects
 National Projects
 NICE
 SMC
Traditionally the NHS has been
Hopeless In Communicating
 Confusion.
 Conflicting Treatment Plans.
 Referral Pathway is mad.
 Patients Lives put at risk.
 Sanity of Healthcare Workers put at risk.
Healthcare Access to One Another
 Reliable
 Educational
 Saves Admissions
 Saves Referrals
 Saves Lives
Patient Access to their Team
 Telehealth
 Expensive
 Not been integrated
 Routine
 Improves
communication
 Reduces Workload
 Saves Lives
Integrated Self Management Plans
 We have
developed a
number of
Long term
condition
interfaces for
the Patients.
But does it work?
 Too often we Collect data and don’t do anything with
it.
 When we do something with it we spend lots of
money.
 And then we forget to see if it actually works!
Cardiovascular
 2006
 +21%

Cardiovascular 2
 2011
 -80%

Diabetes
 2006
 +201%

Diabetes 2011
 2011
 -71.4%

Stokes
 2006
 -7%

Strokes
 2011
 -73%

What About Total Overall Cost?
 Total Spend on Seconday
Care Services in My CCG
per Head of Population
2011/12 (Norfolk CCG
SAR Dash)
 Reduction of over 30% in
surgeries using the
system. (My surgery the
cheapest by over £60 per
patient.)
25
23
21
19
17
15
13
Series1
11
9
7
5
3
1
300
400
500
600
700
The Future
 There is the Possibility to
radically change patient
care in a way never been
seen before.
 Central Integration and
working in partnership
with forward thinking
regions.
 Allowing Patients to
become the centre of their
Healthcare.
 Using IT where
appropriate.