A new approach to wound care –improving outcomes, improving
efficiency
Jonkoping Microsystems Festival February 2015Lisa Hilder
Assistant Director for Strategic Planning
N.E. Lincolnshire Clinical Commissioning Group
Roger Young
Managing Director
Longhand Data Ltd
The Commissioning challenge
• Elevated level of problems with tissue viability resulting in serious untoward incidents across care environments
• Limited specialist tissue viability resource
• Ageing population – increased and increasing demand
• N.E Lincolnshire is big – population density low
• Distributed rural community
• 60 residential care homes
• Flat allocation of cash to commissioners for the foreseeable future
Purpose of the project
• To deliver better outcome woundcare to an increasing population of older people within a smaller budget.
• To introduce better measurement of woundcare outcomes
The solution part one:Integration of remote clinical expertise, robust data and local practice
• Healogics – third party tissue viability expertise with national/global
credibility
• Experience in working remotely
• Strong training component
• Ability and willingness to work with range of clinical expertise.
• Able to respond to referrals with
o Corrected diagnosis
o Amended/additional treatments
o Expert tissue viability intervention if necessary
AND
• Local Community Nursing team open to improving outcomes by
working differently
The solution part two:connecting everybody
• A wound referral application that is easy to use
• Exactly meets the agreed demands of the project
• Hosted online and compliant with ISO 27001
• Mobile technology so nurses can refer + take photos
• Strong tiered permissions of access and edit
• Patients grouped by location
• A development team to evolve the care pathway
• Clear care plan listing
• TELER Patient Measured Outcomes
• Robust evidence of the effectiveness of treatment
Developing the project
• Working with local clinicians, Healogics and TELER to
develop the pathway tailored to local needs
• Dealing with Information governance requirements
• Rollout of ipads to support mobile working and
woundcare pathway
• Training on TELER
• Project Launch
The challenges of delivery
• Generating engagement
• Hardware
• Software
• Training
• Change management
• politics with a small “p”
• Patience with a large “P”!
Initial feedback
• Nurses and patients love the application and find it easy
to use
• Remote clinical advice praised
• New treatments advised and adopted locally
• Already opportunities for knowledge transfer have
arisen and been used
• Desire to expand scope of the project to include a wider
range of wounds
Care pathway
Care pathway - continued
• Patient referred into the system
• Triage patient priority
• Schedule appointment
• Clinician confirms/corrects
original diagnosis
• TELER Grid used to specify
treatments and indicators to
measure results
• Grid can even be completed by
a patient!
Use the TELER Grid for:
• Remote monitoring
• Decision making
• Intervention
System features
• Permission-based access
• Referral system
• Patient history
• Current medical information
• Clinical notes
TELER Grid – the patient narrative
• Referral – possible from multiple locations
• Online triage - remote oversight and management
• Easy recording of important steps within referral pathway
• Scheduling of TVN/community nurse visits
• Onward-referral for acute cases
• Monitoring of non-critical patients by acute care teams
• Visibility of all associated files and images (pdf, scans, jpeg, etc..)
• Acute care monitoring of care-plans delivered in the community
• Oversight case-reviews for chronic conditions
• Reporting at discharge
The patient narrative - continued
Thank you
A valid measurement scale of unambiguous clinical statements, in which
each step is clinically defined from the problem to a treatment goal
Indicator title
Recovery from pain induced at dressing changesIndicator library No.WC0048
Code5 Able to do I want to do without pain – Treatment goal4 Able to do what want to do, with pain, but pain does not interrupt3 Able to do what I want to do with pain, pain interrupts, but able to resume2 Pain interrupts what I want to do - not able to resume1 Pain prevents me doing what I want to do0 Unable to even plan what I want to do due to pain - Problem
So what is a TELER Indicator?
• Wound care
• Stroke rehab
• General Physiotherapy
• Paediatrics
• Occupational therapy
• Speech therapy
• COPD
• Mental health
• Palliative care
Over 1,200 in total
TELER library of clinical indicators
• Patient measured outcomes
• Using TELER Indicators
• To deliver TELER indexes via TELER algorithms
• deficit Index
• Improvement index
• Variability index
• Disparity index
• Cost effectiveness index
• In research – clinical and statistical evidence of
change. n-of-1 within an RCT
• In every-day clinical care – tracks treatment
narrative. Strong evidence to back-up clinical
decisions.
The TELER engine
Data collection
Records are more than measurement
• Patient ID methodologies
• Biographic detail
• Co-morbidities
• Referrals
• Triage
• Care Plans
• Contemporaneous notes
• Over-sight notes
• Associated images
• Assessment forms
• Treatment formularies
• Reports
The patient narrative: tele-health via TELER
• Referral – possible from multiple locations
• Online triage - remote oversight and management
• Easy recording of important steps within referral pathway
• Scheduling of TVN/community nurse visits
• Onward-referral for acute cases
• Monitoring of non-critical patients by acute care teams
• Visibility of all associated files and images (pdf, scans, jpeg, etc..)
• Acute care monitoring of care-plans delivered in the community
• Oversight case-reviews for chronic conditions
• Reporting at discharge
• Date of contact
• Duration of contact (mins/units)
• Time-codes vs. actual time
• Wound photos
• Form submissions
• Indicator measurements
• Treatments performed & by whom
• Other measurements – e.g. ABPI, pH, wound
depth
All in chronological order
The patient contact
Indicator descriptions
First form and image
Access notes
Last image
Summary – the TELER grid
• Deficit Index – where 0 is no deficit and 100 is total deficit
against Indicators in use
• Improvement Index – % deficit recovered
• Effectiveness Index – a measure of the loss of function
while under treatment. Relates to quality of care and
therefore a measure of delivery of treatment
• Variability Index – the amplitude of variation of
improvement and deterioration.
• Disparity Index – a measure of comparison between two
runs of TELER Indicators; used in n-of-1 research projects
TELER Indexes
Global Wound reports
• Wound on admission
• New wounds after admission
• Wounds healed
• Average wounds/patient
• Wound aetiology
• Common indicators
Initial Assessment
reports
• Wound details
• Wound durations
• Measurements taken
• Medical history
• Previous treatments
used
Daily Treatment reports
• Indicator scores
• Treatments used
• Index values
Management reports
• Patients seen
• Admitted/Discharged
patients
• Referrals received
• Referrals declined
• Referrals
correct/incorrect
• Average
appointments
We can report on any of the data the system is customised to collect
Clinical reporting
Cost of Treatment Reports
• Cost per wound
• Total patient cost
• Average cost per contact
• Average cost per contact for a specific wound
• Average cost to heal specific wound
• Cost effectiveness – cost per clinically significant change
Bespoke cost reports can be created on request
With the right information collected in our system, we can report on more
than simple ‘estimated’ costs.
Linking Cost to Indicator Scores, compare the clinical results of using different treatments
Identify treatment cost impact against clinically significant improvements in patient care
Health economics - reporting
We found out what patients’ needed – an alternative to
bandages
We involved a fashion designer to design garments to
‘clothe the wounded body’
We involved a knitwear manufacturer with computerised
knitting Research Assistant & Designer acted as
‘surrogates’ and tested the garments, refined by the
designer and manufacturer
N-of-1 design: Patients tested the garments and collected
their own outcomes data
King’s granted a licence to the manufacturer to
commercialise and sell
The data supported an application to Prescription and Pricing
Authority
Drug Tariff Listing May 1st 2013 (adults) May 1st 2014
(children)
http://www.skinniesuk.com/category/web
WEB Summary
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