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“NHS change challenge”
Clinical content work in the NHS
Tony ShannonConsultant in Emergency Medicine, LTHClinical Consultant, NHS CfH
Travel to HL7 kindly funded by Ocean Informatics
Tony Shannon
M.B. B.Ch. B.A.O. IrelandFellow of College of Emergency Medicine England
Fellowship in Informatics USAMS in IT Management England
Consultant in Emergency Medicine, Leeds Teaching HospitalsClinical Consultant, NHS Connecting for Health
Leeds, England
Complex Systems
• Many parts, Many interactions• Perpetual novelty
• Difficult to describe/understand completely• Difficult to control/change
• Identify simple rules– Self-organise
• e.g. Weather, Economy, Internet, ED
National Health Service in the UK
• Established in 1948 by Labour Government
• Huge– 3rd largest employer in world, largest in Europe, 1 million+ staff– 45+ million patients in England
• Healthcare free to all at the point of care
• Quality
• Costly– Increasingly financially oriented– “Payment by Results”
• “NHS Plan” = Service Reform (inc. IT)– e.g. Leeds Teaching Hospitals
• City <1million population• 4 EDs; 110,000 + 90,000 census• 95%/98% “4 hour ED target”…
• Biggest civil IT programme in world• 10 year; based in Leeds, England• $20+ billion with commercial suppliers
• 5 Regions of England– North East Cluster
• 7.5 million population• 170,000 NHS staff• 23 Acute Hospitals• 12 Mental Health Trusts• 1200+ Primary Care practices
– Care Record Service • contract £1 billion
• Hugely ambitious
• Primary, Community, Hospitals, Mental Health– Contracts for several interim solutions– Aiming for a single strategic EHR solution
• National Services– Single NHS patient identifier number– Service Directory– Choose and Book scheduling
• Local Services– Care Record Service (Electronic Health Record)
• Guideline based • Workflow integrated • Cross organisational working
NHS + IT = Complex
Change – Emergency Medicine
Change - Management
Benefits = Quality
Risk↓ Cost↓ Time↓
Drivers
Change - Software Engineering
People+ Process + Technology in a “Model Community”
Systems in Silos
• People– Challenge siloed thinking
• Process– Look for simplicity within the complexity– ? Core generic processes in healthcare
• Technology– Evolutionary approach– Process related IT requirements
• esp. at the complex front end. i.e. ED charting– free text/dictation versus forms (e.g. T-system)
• Aim to reuse– Distributed process-oriented SOA?
• Balance central control and local innovation
Process - Urgent Care Study • Identify top/core business processes in Urgent Care• Identify and prioritise information/technology needs
• Methodology– Stakeholders/ core Processes / IT Requirements
• Site visits– NHS Direct– Ambulance Services – ED (4 in West Yorkshire)– Walk in Centre– GP Out of Hours
A view of NHS process …A view of NHS process …cd Urgent Care Now - Top Lev el
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Name: Urgent Care Now - Top LevelAuthor: Ian HerbertVersion: 1.0Created: 09/04/2006 18:13:11Updated: 21/04/2006 10:08:26
Patient has care concern
Identifyconcern(s)
XOR fork -know providerto use ? Find out providers available now,
and their contact detailsDecide which
provider to use
Contact ambulanceservce & request care
Contact GMP OOHrsservice & request care
Contact NHS Direct &request care
Go to walk-in centre
Go to emergencydepatment
Ambulance servicehandle request
GMP OOHrsprovide care
NHS Direct handlerequest
Request WIC care
Emergency departmentassess appropriatness
of request
Ambulance serviceassess appropriatness of
request XOR fork -appropriateprovider
Walk-in centreprovide care
RequestED care
XOR fork -appropriateprovider Emergency department
provide care
GMO OOHrs assessappriopriatness of
request
XOR fork -patientdisposition
End of urgent care episode
XOR fork -contactrelevantprovider
XOR fork -more urgentcare needed?
XOR fork -more urgentcare needed?
End of urgent care episode
End of urgent care episode
End of urgent care episode
I. e. self-care advice / information provision issufficient
This may also be done by contacting NHS Direct
Concern(s) may be identified by the patient, a carer, a bystander, an attendant (e.g. police at an RTA) or a care professional. So may the provider contacting & service requesting, e.g. if the patient is unconscious.
This overview of urgent care is compatible with the submodels provided for each urgent care provider. However it explicitly shows some of the detail which is within each of the submodels . The detail shown deals with assessing the appropriateness of the care request by each provider, and the passing of the patient to another provider if further urgent care is needed that is outside the scope of the current provider.
May include 1 or more attendances atED clinics after initial attendance
patient delivered toemergency dept.
transferedto WIC
no
no
no
transferredto OOHrs
transferred toambulanceservicetransferred toambulanceservice
more urgent carerequired - patient /carer/ etc directedto another provider
patient / carer/ etc directed to moreappropriate provider. This may be toa specialist ED, e.g. for obstetrics
or eye care
more urgent carerequired - patient /carer/ etc directedto another provider
yes
transferredto OOHrs
patient / carer/ etcdirected to more
appropriate provider
transferredto OOHrs
transferred toambulanceservice
e.g. ifspecialist EDservice reqd
more urgent carerequired - patient /carer/ etc directedto another provider
Referral in
Assessment
Plan CareDeliver Care
Referral Out
Operational (1 patient)
Strategic (++ patients)
Tactical ( > 1 patient) Resource Management e.g. staff, beds
Performance management e.g. Audit
Diagnostics
Sorting
A view of Generic Processes in Healthcare
A journey through the NHS …A journey through the NHS …
GP
timetime
NHS Direct
Emergency Department
Acute CCU
Taken to A&E: given oxygen in transit
Transferred to CCU to complete post-MI care
Self care
Returns to self / primary care
Angina diagnosis & 1st care plan
Ambulance
Diagnosis confirmed: & patient stabilised
Suspected MI: self-care advice given & ambulance requested
Generic Generic Process IT Bricks
Specific Patient Journeys IT Library
A tale from Denmark …
The Danish solution…
• 15+ years of European & Australian R&D
• Generic Process based EHR Architecture
• Related to – European Standard
(en13606)– ISO standard
OpenEHR
Archetypes
(Bricks)
Templates (Toys)OpenEHR
Generic
Specific
Archetype
• Reusable list of clinical statements
• Useful for clinical documentation
• Can be coded with terminologiese.g. Snomed CT
Archetypes & Templates
•Central control
•Local flexibility
Archetypes
• North, Midlands and East– 60% of England
• Supplier– Contract with CSC– Single strategic EHR solution– Requirement & Design Stage
• NHS “Clinical Content” needed– To support charting
• Big Opportunity
Phases of Content Delivery
NHS input… example..
NHS content – inputs via wiki
• Collaborative• Evolvable
• Version control
• comments
NHS input… e.g. Head & Neck examination
Into Head & Neck exam archetype
Archetypes can bind to codes…
Archetypes available as XML/HTML etc…
NHS Archetype library
Archetypes configured in Templates solves central control + local need
Template editor output as HTML/XML/Forms etc….
Archetypes
(Bricks)
Templates (Toys)OpenEHR content
• Can be used for application UI – e.g. forms
• Can be transformed into messages– e.g. HL7 CDA
• Can be used for querying +/- Terminology
NHS template library
.. for use in any supplier system
.. for use in any supplier system
openEHR content cycle..
• Clinical content will continue to evolve
• Archetypes and templates are version controlled
• Content changes – don’t impact application – if fit with openEHR
Benefits of Archetypes• Quality
– Better documentation - for complexity of healthcare • Via Standard Archetype + Flexible Templates
– Can evolve over time - as medicine changes• Via version control
– Balances central control and local innovation• Risk
– Solid foundation for Decision Support• Time
– Save time• Build templates fast
• Cost– Save NHS money
• Standard methodology – all can share• Non proprietary
NHS Clinical Content Service
• NHS Requirements• E-Care Pathways • Archetypes & Templates
– Archetype outputs 150+– Template outputs 20+
• Clinical Coding– Via SNOMED CT
• Resource• Governance
NHS Tech Office.. today
Clinical Use Case
Clinical Content Model
Clinical Templates
Clinical Archetypes
Reference Model, Types, Terminology
Logical View Messaging Realisation with templates
Story board
Message
HL7 Templates
HL7 Templates
RIM + Data Types + Terminology
Business Use Case
Interactions
NHS Tech Office.. tomorrow
Clinical Use Case
Clinical Content Model
Clinical Templates
Clinical Archetypes
Reference Model, Types, Terminology
Logical View Messaging Realisation with templates
Story board
Message
HL7 Templates
HL7 Templates
RIM + Data Types + Terminology
Business Use Case
Interactions
Auto
Generated
International efforts…
Key issues….• NHS IT
– Hugely ambitious– Learning valuable lessons
• People issues– How to involve the right people
• Think beyond current silos– Governance
• Local versus National?
• Process issues– look for the generic within
• Technology issues– Evolutionary – Clinical process oriented approach i.e. archetypes– Ensures clinical content is reusable/evolvable
Archetypes
(Bricks)
Templates
(Toys)NHS content library
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