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Sharing information to improve patient care in West
Sussex
Adrian WoolleyHead of Strategic IT
NHS Coastal West Sussex CCG
NHS Crawley CCG
NHS Horsham & Mid-Sussex CCG
June 2014
Sharing information to improve communication & inform patient care
Photo: sparkle glowplug
The 15 million people in England with long term conditions… their treatment and care
absorbs 70% of acute and primary care budgets in England.
Fragmented care: the healthcare system…not being considered in a whole system approach with social care…
Lack of informational continuity: care records which can’t be accessed between settings...
Reactive services, not predictive services: failure to identify vulnerable people who might then be given extra help to avoid hospital admission or deterioration / complications of their condition…
The issue…failure to provide integrated care
LTCsAdmission Avoidance
Proactive care planningJoint working between health and social care
End of Life care
Significant diagnosisDNACPR
Social Services visit daily
ECGDiabetes clinicIn-patient discharge letter
Specialist nurse record
Care providers can have ‘silos’ of information held within their organisational boundaries
Dementia nursing
GP practice system
Social Services
Hospitals
Community Nursing
Mental Health
Admission Avoidance DES Care Plan
MH Crisis Plan
Contingency Care Plan
Significant diagnosisDNACPR
Social Services visit daily
ECGDiabetes clinicIn-patient discharge letter
Specialist nurse record
Care providers can have ‘silos’ of information held within their organisational boundaries
Dementia nursing
GP practice system
Social Services
Hospitals
Community Nursing
Mental Health
Admission Avoidance DES Care Plan
MH Crisis Plan
Contingency Care Plan
A real time Read Only viewer for use in direct patient Care, with Information derived from both Health and Social Care
ROCI
•The classics – stakeholder engagement etc x n2.
•Information Governance, legal opinion
•Data access. Paternalism
•Commercial self interest of system suppliers
•Finding care plans
•Waiting for Spine 2
Challenges for this type of project
A Virtual IDCR
Live data (no data warehouse)Live data (no overnight updates)Consent to view at point of need
Real time messaging to multiple systems – ‘send pertinent information for unscheduled care’
GP
Social Services
NHS No, Name, DoB
Community Nursing
Mental Health
Integration Engine and VIPER360 portal
Hospital
Consent record for audit
RBAC
a patient summaryproblemsdiagnosesmedication (current, past and issues)risk and warningsproceduresinvestigationsblood pressure measurementsencounters, admissions and referralspatient demographics
What data could be available?From GP (via MIG):
current medsallergiesadverse reactions
From SCR:
Main AddressCurrent AddressPlacement AddressAllocated Worker, Open/Closed Agency Providing Care Package Funded? Emergency Next of Kin details Does the Subject Have a Carer? Is the Subject a Carer?
From Social Services:
recent admissions & dischargesEDD
From Acute Trusts:
open referrals
From Community Trust
LCanticipatory care plans
From care plan repository:
GP Admission Avoidance DES care plans
Proactive Care EoLC Plans
NHS mail – special
template
AmbulanceA&E (ROCI) OOH GPs
Sussex widecare plan database
Data readers
Data sources
One place to find care plans = reduced conveyance by ambulance.
Patient detailsExaminationsEventsSummaryInvestigationsProblemsProceduresRisks & warnings
Live data from the GP clinical system
Recent testsBiochemistryECGHaematologyImagingMicrobiologyCytologyOthersPhysiologyUrinalysis
Potentially useful in admission avoidance
• PIA and Information Sharing Agreement signed by relevant parties
• Trust Interface Engine (messaging technology) installed and operational.
• Several practices signed up to supplying data (MIG).
• Pull of MIG data through system tested and working.
• Social Services record to include NHS numbers
Next steps• Turn on integration to Social Services data
• Turn on integration to Care Plan repository
• Clinical safety sign off
• Pilot go-live at A&E
So where have we got to?
•Discharge planning / Alerting
•Hospital in-reach
•Planned Care
Potential other applications of the technology
