Continuing development of the community based anticoagulant and stroke

prevention services

Progressing towards

A STROKE PREVENTION SERVICE (AF AND AC)

Transition from successful pilot services towards more robust and expanding services

21 November 2011 Professor David Patterson, Professor Dipak Kalra,

Department of Cardiovascular Medicine and Pharmacy, Whittington Health

Centre for Health Informatics and Multiprofessional Education, University College London

Electronic Health Record (EHR) Supporting clinical shared care across organisations Building on ~20 years of European research Conforms to the latest international standards Robust medico-legal and confidentiality features Standards for clinical knowledge capture enable meaningful clinician developer interaction and rapid development Implemented as a web based system Incorporates decision support and alerts

Cardiovascular modules •HeartBeat AC: anticoagulation - in live use

• HeartBeat HF: heart failure - ready for live use

• HeartBeat AF: atrial fibrillation - clinical engagement commencing

Clinical Governance report

Derived automatically from the EHR Each site can run its own report at any time

All reports include anonymous service-wide comparisons Reviewed at quarterly Clinical Governance Board meetings

North Central London Community Based Anticoagulant and Stroke Prevention Services

PROGRESSING TOWARDS A STROKE PREVENTION SERVICE (AF AND AC)

• Enhancing our ability to prevent patients developing strokes • Progressed from a doctor delivered service in hospital toward an

increasingly community based service • Delivered by practice nurses, community pharmacists and GPs,

supported by a state of the art information and advisory system which uses an Electronic Health Record

• A strong focus on education and on clinical governance • Our services have been shown to be safe and very well received

by the patients, by the commissioners of health services and by the community staff

• Multiple chronic conditions • Multiprofessional care • Shared information needs - across boundaries • Interface with other organisations:

– Social services – Housing – Voluntary sector – Ambulance/car services – Primary/secondary/tertiary care

Forgetful, elderly person with diabetes, atrial fibrillation, heart failure and mild aortic valve

stenosis, who lives alone in poor housing and requires anticoagulation

Development of advisory systems for warfarin dose and follow-up interval guidance

• CONTEXT - 1

• In latter part of 20th Century – warfarin management was a doctor delivered service in hospital environment

• Regarded as dull and unchallenging • Often performed by the most junior doctor with little

experience of anticoagulation

Development of advisory systems for warfarin dose and follow-up interval guidance

• CONTEXT - 2

• And yet

• Developing realisation that warfarin was potentially a dangerous drug influenced in its effects by many factors such as diet and use of other drugs

• Increasing evidence that there was an unacceptably high morbidity and death directly related to warfarin

• Very poor communication between health professionals when introducing a new drug or starting new treatment for a patient

[1] Evaluation of a decision support system for initiation and control of oral anticoagulation in a randomised trial

[2] Validation of an algorithm for oral anticoagulant dosing

and appointment scheduling

• [1] The computerised decision support system was safe and effective • It improved the quality of initiation and control of warfarin by trainee

doctors

• [2] The algorithm performs better than inexperienced clinicians and as well as experienced clinicians for the non-difficult patients

• Algorithm better at recognising the more difficult case than the non-expert (ie to see doctor)

• Analysis of combination of dose and interval recommendation showed remarkable similarity between experts and algorithm

3

2

1

0.5

0

-0.5

-1

-2

-3

INR -Target INR

2.0 - 3.0 2.5 - 3.5 3.0 - 4.0 3.0 - 4.5

Therapeutic range

95%

75% 90%

50%

10% 5%

25%

5.50 5.00 4.55 4.00 3.50 3.00 2.50 2.00 1.50

4000

3000

2000

1000

0

INR value - patients with therapeutic range 2.0 - 3.0

Total 18881 (full tail at high values not shown)

therapeutic

range

1 00

100

80

60

40

20

0

Above range

In therapeutic range

Below range

0 36

Months into anticoagulation therapy

Percentage

of INR results

All therapeutic ranges

North Central London Sector

ANTICOAGULANT AND STROKE PREVENTION SERVICES at

HOSPITALS AT: WHITTINGTON AND NORTH MIDDLESEX HOSPITALS PHARMACIES AT: HIGHBURY BARN, N5 BOOTS (WOOD GREEN), N17 POLYCLINIC AT: ENFIELD (1 GP CENTRE/POLYCLINIC), N9 GP PRACTICES AT: HIGHGATE GROUP PRACTICE, N6 DUKES AVENUE, N8 SOMERSET GARDENS, N15 TYNEMOUTH ROAD, N17 MORRIS HOUSE, N22 GOWER STREET, WC1 HAMPSTEAD GROUP PRACTICE, NW3 JAMES WIGG PRACTICE NW5 MUSEUM PRACTICE WC1B KEATS GROUP PRACICE NW3 PARK END SURGERY NW3 PARLIAMENT HILL SURGERY NW5 REGENTS PARK MEDICAL CENTRE NW1 ROSSLYN HILL SURGERY NW3 BRONDESBURY MEDICAL CENTRE NW6 AMPTHILL SQUARE NW1 ADELAIDE ROAD, NW5 ROMAN WAY MEDICAL CENTRE, N7 RITCHIE STREE GROUP PRACTICE, N AMWELL GROUP PRCTICE, WC1 ELIZABETH AVENUE, N1 RISE HEALTH CENTRE, N19 KILLICK STREET, N1 HOSPITAL OUTREACH SERVICES TO:

GOODINGE HEALTH CENTRE, N7 RIVER PLACE HEALTH CENTRES, N1 TORRINGTON SPEEDWELL HEALTH CENTRE, N12 EDGWARE COMMUNITY HOSPITAL, HA8

STANDARD CLINICAL OPERATING PROCEDURE

CLINICAL GOVERNANCE BOARD Anticoagulation & Stroke Prevention Service

• MEMBERSHIP

• PATIENTS

• HOSPITAL CONSULTANTS – CARDIOLOGY AND HAEMATOLOGY

• ANTICOAGULANT PRACTITIONER FROM EACH OF THE 5 PCTS (GP OR PRACTICE NURSE)

• ANTICOAGULANT PRACTITIONERS FROM HOSPITAL(S) OUTPATIENT SERVICE

• SENIOR PHARMACIST WITH EDUCATIONAL REMIT

• SENIOR PHARMACISTS WITH CLINICAL GOVERNANCE REMIT

• COMMISSIONER FROM EACH PCT

• CLINICAL LEAD FROM EACH PCT

• ACADEMIC HEALTH INFORMATIST

• ACADEMIC BEHAVIOURAL SCIENTIST AND STATISTICIAN

• ACADEMIC LEGAL AND EDUCATIONAL ADVISOR

• IM&T REPRESENTATIVE FROM WHITTINGTON HOSPITAL

Generic Ingredients of our integrated services

together with Our package of support

• Education and training for practitioners – Formally defined syllabus

– Training sessions including practical skills and use of the information system

– Formal assessment, required certification, periodic reassessment

• Clinical information system – Electronic Health Record supporting clinical shared care across different organisations

– Disease management system - anticoagulation; heart failure; atrial fibrillation etc etc

– Clinical management advisory system

• Clinical support – Direct contact with senior clinicians, able to access the same EHR from different sites

• Clinical governance – Clinical standard operating procedures and site specific operating procedures

– Quality assurance processes and monitoring

– Review and comparison of outcomes

– Multidisciplinary clinical governance board

Comments from Patients

• Site 1 –Very satisfied with everything –Always on time and always most helpful –I can not fault anything. I only wish I did not have to come –Nothing at this time –Very very good –Appointments always on time treatment well explained –All your staff are excellent –Very competent

• Site 2 –To continue this same way as at present –I am very happy with the service given here, many people take up

this choice –No Complaints at all –All very satisfied –I am very satisfied with the anticoagulant service –Delighted with the service, I got to compliment you on your lovely

polite staff –Couldn’t be better

Quality and safety principles of our integrated care

service

• the patient will receive monitoring care in the most convenient and safe place for them

• the practitioner will be demonstrably well trained, up to date and able to offer a high quality service

• the EHR of the patient will be available in a timely manner to all of the practitioners caring for the patient, wherever located

• clinical governance arrangements will be implemented and learning processes enhanced

• hospitals will continue to play key roles in clinical support, education of staff, clinical governance and service development

• the patient or customer is central to the planning and delivery of services

CLINICAL GOVERNANCE BOARD Anticoagulation & Stroke Prevention Service

• MEASURES OF SATISFACTORY QUALITY AND SAFE PERFORMANCE • PATIENT FEEDBACK/QUESTIONNAIRES FROM EACH PCT

• TRAINING, EDUCATION AND PERFORMANCE OF ANTICOAGULANT PRACTITIONERS

(OSCE AND RE-ACCREDITATION) FOR ALL PRACTITIONERS

• ANTICOAGULANT CONTROL (BY SITE -- BY WHOLE SERVICE – BY PCT --- BY PRACTITIONER -- BY TIME - BY THERAPEUTIC RANGE ETC)

• INFORMATION GOVERNANCE (ACCESS CONTROL; SECURITY; BACKUP POLICIES)

• QUALITY CONTROL OF CLINICAL PREMISES - ANNUAL VISITS –

• QUALITY CONTROL OF EQUIPMENT – POCT EQUIPMENT AND NEW REGULATIONS – SEEKING CPA ACCREDITATION FOR COMMUNITY SERVICE

• THE ANNUAL REVIEW OF PATIENT – NOW BEING PILOTED

• USE OF ROOT CAUSE ANALYSIS (RCA) AND COGNITIVE WORK ANALYSIS (CWA) IN “NEAR MISSES” OR UNTOWARD INCIDENTS

• REAL TIME ANALYSIS OF PERFORMANCE

Link with secure mobile device

Make solutions simple and intuitive

North Central London Integrated Care Model

Whittington Hospital and its collaborating

Hospitals

CHIME (UCL)

Consultant-led Community Cardiology

Service

GP Practices

and Pharmacies

Collaborative development

of EHR systems

The Consultant-led Community Cardiology Services provides protocol-led and formally-evaluated

collaborative care, initially for anticoagulant and cardiovascular diseases.