What do we expect and require from

IMT?

Dr Sunil BhandariConsultant Nephrologist/Honorary Clinical

Reader

Digitised citizen – join up systems and services that contribute to a 21st

century health service

Do we know what we need?

Do we know what we want?

Do we understand what may be available?

Do we know what patients want or even do they know?

Fears – are we misguided?

ClinicianQuality Care

ManagerTargets

PatientInformation

Government“Big Brother

Do we know what we need?

Competencies set by GMC for Doctors

Diagnosis and Decision makingTreatment – electronic prescribing/ TOXBASETeaching and training - Evidence base - Up to date

- databasesAuditKeeping accurate recordsTeam working Time managementEducation – e-portfolios, e-induction, Risk – Datix

IMT CAN ENHANCE THESE

How reliable are NHS Staff at following recommendationsKeeping accurate records

All medical entries require

Name- printedGrade/TitleDateTimeSignatureAll of above

What percentage achieved this?

Doctors Nurses12% 10%30% 35%80% 96%6% 9%95% 97%12% 17%

NHS Trust Audit 2009

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 ReassuranceAfter CareEducation and TeachingResearchManagement

It can in part be digitalized

An “evidence based” decision

Evidence From Research

Clinical Expertise

Available Resources

Patient Preferences EVIDENCE

BASED DECISION

Aksentivevic D, Bhandari S et al Kidney International 2009

Available Resources

Clinical ExpertiseIs there a place for clinical expertise?

Decision support tools which apply clinical logic? Interpretation of data ? Rare casesOnly as good as the information imputed

Improve clinical decisions

Avoid preventable errors

Patient PreferencesPatient and service users being active

participants in their care

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

Life’s Priority

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 hospitalsstreamline

A Quality Framework to Enable Quality Improvement

Bring clarity to quality – standards

Measure quality

Publish quality performance

Recognise & reward quality

Clinical leadership

Safeguard quality

Stay ahead

•NICE

•NHS Evidence

•Metrics – local, national, international

•Clinical dashboards

•Quality accounts

•NHS Choices

•International measures

•CQUIN •SHAs – Medical Directors; clinical advisory boards

•National Quality Board

•Care Quality Commission

•SHA - duty to innovate

•Academic Health Science Centres

•Health Innovation and Education Clusters

Maximise Quality & Safetyin Health Care

From Donal O’Donoghue Tsar for Renal Medicine UK

Universal Recording

Do we understand what will be available?

The NHS Challenge:Quality, Innovation, Productivity & Prevention

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Public Sector Net Debt

From Donal O’Donoghue Tsar for Renal Medicine UK

The NHS needs to plan for making huge efficiency savings

NHS expenditure by year

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demand, pay & pricepressuresscenario with "flat cash"from 2011/12actual and planned spend

£15-20bn productivity challenge

Illustrative figures only

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 productivityLocal 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:

Registries – Comparing Data

UK Renal Registry 9th Annual Report 2006

Figure 8.6: Median URR in the first quarter after starting RRT in patients who started haemodialysis in 2008

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Lower quartileMedianUpper quartile

N=2,278

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?

“No decision about me without me”

Patient View – UK Renal system14,000 Registrants in the UK

Does not Increase Patient Anxiety

Increases Quality of ConsultationIncreases TrustEncourages Patients to take Control

Fears – Are we Misguided?

Small changes can have big Effects

Drunk

DrunkBlindDead

ETHANOL METHANOL

MOLECULE MAN

C2 H5 OH C H3 OH

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 CliniciansNo 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 signatureNo audit trial – IT’S A NO BRAINER

What are things like today and is all what it seems?

Lets talk about Cows

INFECTIONControl

No Medications

SlowCumbersomeinconsistent

User Friendly?

Fails to deliver

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 graphsData trends required

Cows-The Good the Bad & the Ugly

Multiple crashes

How safe is IMTOnce summary case record system comes

fully onlineevery item of interest available digitally will find

its way into the public domain

“news is what somebody somewhere wants to suppress; all the rest is advertising”

T Delamothe BMJ 2010

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 BreakTime for a Break

Clinical Practical Situations

Lessons from AustraliaA great place to live

What am I doing here?

Lessons from Australia

The good aspects of IT in Australia leading to

more clinical effectivenessbetter communication with patients e.g. clinicsGP interactions – virtual consult

A Single Unique Identifier

HEY numbersNHS NumberCase record Number

MEDICARE

CARD NUMBER

CARRIED BY PATIENT

The paperless systemDictationResultsConsults – reduced textReal time data with patientsPDA based practiceReduced writing clinical recordsReduced duplicationMore time to deliver clinical careFlexible system

The Emergency Admissions

The Ideal Clinical Ward Round

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 VisitPatient – sitting nervous

Patient agenda V doctors agenda

Solutioncommunication 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 DNANo show in clinic – what to do?

Wrong addressPatient diedPatient movedUTAWrong GP – weekly letter from GP - NOP

Does the Future

hold any surprises

The problems today to resolve

Does one size fit all

28%

72%

The problems today to resolve

Politicians – short term fixesManagers - bean counters

ACTIVITY versus QUALITY versus RISK

IT Driving Greener HealthcareMeetings – video conferencingHome view – aids in informative patient assessment - SAFETYEndocscopy – patient send back because results not printed

out – 13/07/2010Theatres- all results must be printed pre –op prior to transfer

to theatreCannot 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?

What do you thinkAbout Western Civilization?

I think it would be a very good idea

Gandhi once said after being asked

Future

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