Transcript Do we know what we need?

What do we expect
and require from IMT?
Digitised citizen – join up systems and services
that contribute to a 21st century health service
Dr Sunil Bhandari
Consultant Nephrologist/Honorary Clinical Reader
 Do we know what we need?
 Do we know what we want?
Patient
Information
Clinician
Quality Care
Government
“Big Brother
Manager
Targets
 Do we understand what may
be available?
 Do we know what patients
want or even do they know?
 Fears – are we misguided?
Do we know what we need?
Competencies set by GMC for Doctors
 Diagnosis and Decision making
 Treatment – electronic prescribing/ TOXBASE
 Teaching and training - Evidence base - Up to date -
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

databases
Audit
Keeping accurate records
Team working
Time management
Education – e-portfolios, e-induction,
Risk – Datix
IMT CAN ENHANCE THESE
How reliable are NHS Staff at
following recommendations
Keeping accurate records
All medical entries require
 Name- printed
 Grade/Title
 Date
 Time
 Signature
 All of above
NHS Trust Audit 2009
What percentage achieved this?
Doctors
Nurses
12%
30%
80%
6%
95%
12%
10%
35%
96%
9%
97%
17%
What is the job of a Doctor?
“are we really that important”
 What skills do we possess and can they be replaced?
 Diagnostic reasoning skills - making a diagnosis
 Information Provider
 Interactions – Support and Reassurance
 After Care
 Education and Teaching
 Research
 Management
It can in part be digitalized
An “evidence based” decision
Evidence From
Research
Clinical
Expertise
EVIDENCE
BASED DECISION
Available
Resources
Patient
Preferences
Aksentivevic D, Bhandari S et al Kidney International 2009
Available Resources
Clinical Expertise
Is there a place for clinical expertise?
Decision support tools which apply clinical logic
 ? Interpretation of data
 ? Rare cases
 Only as good as the information imputed
Improve clinical decisions
Avoid preventable errors
Patient Preferences
Patient and service users being active
participants in their care
Life’s Priority
What
interests
patients
•Alcohol
•Cigarettes
•Family
•Sex
•TV – what’s on tonight
•Money
•Work
•Dress and style
•Football
•What my neighbour thinks of me
•Health
Do we know what we Need
?
Do we know
what we want?
The current issues?
 Qualified but not
necessarily IT savvy

simple and user friendly
 Haphazard and random
training

needs structure
 Varied systems in different
hospitals

streamline
A Quality Framework to Enable
Quality Improvement
Bring
clarity to
quality –
standards
Measure
quality
Publish
quality
performance
• NICE
• Metrics –
• NHS
local,
accounts
national,
• NHS Choices
international
• International
• Clinical
measures
dashboards
Evidence
• Quality
Recognise
& reward
quality
• CQUIN
Clinical
leadership
Safeguard
quality
Stay
ahead
• SHAs –
• Care Quality
• SHA - duty to
Medical
Directors;
clinical
advisory
boards
Commission
• National
Quality
Board
Maximise Quality & Safety
in Health Care
From Donal O’Donoghue Tsar for Renal Medicine UK
innovate
• Academic
Health
Science
Centres
• Health
Innovation
and
Education
Clusters
Universal Recording
E -Drug
Chart
Clinical
Observ.
Voice
Recorded
Notes
Clinicians
Automatic
IDL
generation
Order
Tests
Review
Notes
Do we understand what will be available?
The NHS Challenge:
Quality, Innovation, Productivity & Prevention
Public Sector Net Debt
90
80
70
50
40
30
20
10
2010-11
2006-07
2002-03
1998-99
1994-95
1990-91
1986-87
1982-83
1978-79
0
1974-75
% of GDP
60
From Donal O’Donoghue Tsar for Renal Medicine UK
The NHS needs to plan for making huge
efficiency savings
NHS expenditure by year
130,000
120,000
£15-20bn
productivity
challenge
100,000
90,000
demand, pay & price
pressures
80,000
scenario with "flat cash"
from 2011/12
actual and planned spend
/1
4
13
/1
3
20
12
/1
2
20
11
/1
1
20
10
/1
0
20
09
/0
9
20
08
/0
8
20
07
20
06
/0
7
70,000
20
£millions
110,000
From Donal O’Donoghue Tsar for Renal Medicine UK
Operating Framework 2010/11
“To put into effect changes that will deliver the most benefits to patients
we need to focus on three things:
Improving quality whilst improving productivity
Local clinicians & managers working together to spot opportunities &
manage change
To act now and for the long term
“If we are successful, the NHS in 5 years time will have more
services closer to home & therefore less investment & activity in
the acute sector.”
“The quality and productivity gains we need to make lie at the interfaces
between primary and secondary care, health and social care and
empowered patients and the NHS.”
Sir David Nicholson CBE:
19 Colchr
40 Sheff
48 L Guys
28 Glasgw
33 Airdrie
6 Edinb
44 Ports
31 Bristol
8 Redng
41 Hull
4 Leeds
49 Nottm
6 Middlbr
10 B Heart
15 Liv RI
34 Carsh
13 Sund
37 Cardff
24 Belfast
39 Stevng
13 Antrim
5 Abrdn
34 Plymth
15 Prestn
13 York
39 Bradfd
15 Dudley
21 Norwch
8 Leic
13 Basldn
12 Covnt
49 Exeter
46 Swanse
53 England
17 N Ireland
34 Scotland
43 Wales
50 UK
Urea reduction ratio (%)
Registries – Comparing Data
Figure 8.6: Median URR in the first quarter after starting RRT in patients who started haemodialysis in
2008
85
N=2,278
80
75
Centre
UK Renal Registry 9th Annual Report 2006
Lower quartile
Median
Upper quartile
70
65
60
55
50
45
Do we know what we need?
Do we know what we want?
Do we understand what is available?
Do we know what patients want?
Fears – are we misguided?
Patient
View
Decision
aids
User
groups
Information
Sites
Patient
power
View notes
at discharge
Treatment
Algorithm
Healthy
Life style
Contract
with NHS
“No decision about me without me”
Patient View – UK Renal system
 14,000 Registrants in the UK
 Does not Increase Patient Anxiety
 Increases Quality of Consultation
 Increases Trust
 Encourages Patients to take Control
Fears – Are we Misguided?
Small changes can have big Effects
MOLECULE
MAN
C2 H5 OH
C H3 OH
ETHANOL
METHANOL
Drunk
Drunk
Blind
Dead
Its time for a change?
Intuitive ? Correct
Disasters among babies
 Routine practice in 40s & 50s to give
premature infants pure oxygen
 It was noted that there was an ‘epidemic’ of
blindness among premature babies

 RCT - Linked to oxygen use.
A Culture change for Clinicians
 No excuse to make mistakes
 Results instantaneously available – yet we do not look at
them until we see the paper results, then we cannot
remember who it is and need the notes rather than
interrogate the computer
 Paper results not robust – a scribbled signature
 No audit trial – IT’S A NO BRAINER
What are things like
today and is all
what it seems?
Lets talk about Cows
Slow
INFECTION
No
Cumbersome
Control
Medications
inconsistent
User
Friendly?
Fails to
deliver
Cows-The Good the Bad & the Ugly
Cows-The Good the Bad & the Ugly
Ordering tests – still have 2 renal
consultants on system – one retired
and one left – 7 years ago
Computers cannot cope with data
Cows-The Good the Bad & the Ugly
Too simplistic graphs
Data trends required
Multiple crashes
How safe is IMT
 Once summary case record system comes fully online
 every item of interest available digitally will find its way into
the public domain
T Delamothe BMJ 2010
 “news is what somebody somewhere wants to suppress; all
the rest is advertising”
Downsides for
the clinician?
 Immediate access to doctor
 Information overload
 Discourages deep critical thinking
 Less able to think & reason out problems
 ? Are computer making us smarter
Time for a Break
Clinical Practical Situations
Lessons from Australia
A great place to live
What am I doing here?
Lessons from Australia
 The good aspects of IT in Australia leading to
 more clinical effectiveness
 better communication with patients e.g. clinics
 GP interactions – virtual consult
A Single Unique Identifier
 HEY numbers
MEDICARE
 NHS Number
CARD NUMBER
 Case record Number
CARRIED BY PATIENT
The paperless system
 Dictation
 Results
 Consults – reduced text
 Real time data with patients
 PDA based practice
 Reduced writing clinical records
 Reduced duplication
 More time to deliver clinical care
 Flexible system
The Emergency Admissions
Doctor
Patient
Service
• All data should be on a system anywhere in the
UK - Access to info at the point of care to
support patient transition between care
settings
• No phone calls No requests for notes
• Reduced RISK
• Do I want a copy of my case records to carry
around with me
• only 30% want a copy of clinic letters
• Reduced duplication of investigations
• Timely service
The Ideal Clinical Ward Round
Clinical
Team
E-prescribing
Display patient images
Viewing results – trends/graphs
Summarising notes
Automatic generation of discharge
summaries with all investigations,
problems and medications
Teaching trainees
Transparency
Patients see action
The Clinic Visit
 Patient – sitting nervous
 Patient agenda V doctors agenda
 Solution
 communication and information
 One stop visit in 24 hours
 the Australian model
 NOT THE AMU model
What does the user want?
 Not the “best clinician” – how is this measured
 Figures tell I have high mortality – but I take on more
complex cases –
 Patients want convenience and time
The DNA
 No show in clinic – what to do?
 Wrong address
 Patient died
 Patient moved
 UTA
 Wrong GP – weekly letter from GP - NOP
Does the Future
hold any surprises
The problems today to resolve
28%
72%
Does one size fit all
The problems today to resolve
 Politicians – short term fixes
 Managers - bean counters
ACTIVITY versus QUALITY versus RISK
IT Driving Greener Healthcare
 Meetings – video conferencing
 Home view – aids in informative patient assessment - SAFETY
 Endocscopy – patient send back because results not printed out –
13/07/2010
 Theatres- all results must be printed pre –op prior to transfer to theatre
 Cannot send email during weekend or after 5 pm to primary care
 issues of confidentiality
 Wrong email address
 No one to look at
So is it too late to change?
Hopefully we won’t slip up in our decisions?
Future
Gandhi once said after being asked
What do you think
About Western Civilization?
I think it would be a very
good idea
IMT development is a
good idea
How will we measure Success
Gross National product (GNP) counts air pollution &
cigarette advertising, & ambulances to clear out highways
of carnage. It counts the destruction of the redwood & the
loss of our natural wonder in chaotic sprawl... Yet the
GNP does not allow for the health of our children, the
quality of their education or the joy of their play. It does
not include the beauty of our poetry or the strength of
our marriages, the intelligence of our public debate or the
integrity of our public officials....it measures everything, in
short, except that which makes life worthwhile.
Senator Robert F Kennedy 1968