Northwest Herts diabetic management system

Computer Methods and Programs in Biomedicine 62 (2000) 177–189

Northwest Herts diabetic management system

Colin Johnston a,*, Elizabeth Ponsonby b,1

a St Albans and Hemel Hempstead NHS Trust, Hillfield Road, Hemel Hempstead, Herts HP2 4AD, UKb The Manor Street Surgery, Berkhamsted, Herts HP4 2DL, UK

Received 5 January 1999; received in revised form 8 September 1999; accepted 28 January 2000

Abstract

The Diabetic Management System was set up in Hemel Hempstead within the Dacorum district (population119 515 with 2176 registered patients with diabetes). The objective was to create a clinical management system for allpatients with diabetes in a district using a computerised clinical base. To achieve this a database of agreed clinicalinformation was collected from all general practitioners within the district. From the computerised data we canidentify those patients who do not have data recorded and can recall them for review. Consultant advice can be givenon patients with special or multiple risks identified from interrogation of the database. The outcome has been a higherpercentage of patients with diabetes receiving clinical review and achieving optimal clinical targets within the reviews.We already have recorded data on 85% for retinal screening and 75% for comprehensive annual reviews. Conclusionsdrawn from the Dacorum Diabetic Management System are that effective diabetic care to a population can beprovided by a combination of hospital and primary care. Primary care needs to be supported by adequate consultantadvice with continued monitoring of the whole population to ensure standards are met. This system achieves thiswithout increased hospital referrals. © 2000 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Computerised clinical management system; Diabetes

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1. Introduction

Diabetes is a common and complex disorderaffecting over 2% of the population. It is associ-ated with a significant increase in mortality andmorbidity for both men and women and con-sumes a high proportion of the UK health budget[1,2]. Recent research has shown that with earlyidentification and appropriate management, manyof the complications of diabetes can be prevented

or delayed [3–17]. The challenge is how to trans-late the knowledge we have to the clinical man-agement of all diabetic patients. We believe thatthis can only be achieved by using a computerisedpopulation database and a clinical managementsystem.

2. Background

There are published recommendations for thedata needed to advise individual diabetic patientson their medical care [18,19]. Advances in infor-

* Corresponding author. Tel.: +44-442-213141, ext. 2083.1 Tel.: +44-442-875935; fax: +44-442-875936.

0169-2607/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved.

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C. Johnston, E. Ponsonby / Computer Methods and Programs in Biomedicine 62 (2000) 177–189178

mation technology have made it possible to cap-ture the data at source and use it for both individ-ual and population management. This has been atarget for the DOIT study group of the EuropeanAssociation for the Study of Diabetes (EASD) [20].

A number of individual systems have been de-scribed, but primarily these have been based inhospital clinics dealing with a selective populationand a limited number of professionals [21,22].Expanding such a system to collect data on adistrict level is a daunting prospect [23]. A numberof projects have been set up but published resultssuggest that data collection is still only availablefor just over half of a district population [24–26].There is a balance between the amount of data tocollect and the impact on clinical activity. Oneapproach has been to suggest hierarchical datacollection, with primary care collecting less datathan specialist clinics. We reject this approach andbelieve that our published minimal data set (Ap-pendices B and C) is necessary for patient manage-ment in any setting [27].

Our district had a population of approximately119 000. All the general practitioners providedpatient details to compile a database of knowndiabetic patients and they agreed to use a standard-ised form for the data collection which included atreatment plan. They were prepared to send theseto the consultant for data entry and appraisal. Aninitial pilot study indicated that the data collectioncould be easily managed, it also revealed thatgeneral practitioners were receptive to the consul-tant’s advice given in this way. After discussionswhich were held in the form of bi-monthly meet-ings, it was agreed that all diabetic patients wouldhave this standard annual review either by thegeneral practitioner or at the hospital clinic.

3. Design considerations

The design considerations had to include thedefinition of the population, the data requirementof the record, for use in both general practice andthe hospital clinic, and to allow for updating fromboth sources. There needed to be regard for thesupporting services such as Mobile Retinal Pho-tography Screening (a separate service available to

all general practitioners without charge), chi-ropody and dietetics, and provision for variedoutput forms for clinical communication. Confi-dentiality of the record had to be maintained.Finally, and most important, were the audit facil-ities for the process and content of care withmultiple parameters allowing targeting of individ-ual patients at risk and creation of populationstatistics.

4. Requirement of the system

There was a need to provide a database ofpatients that could be regularly updated andprovide a miscellany of outputs which would varyaccording to use and development. The databasehad to contain all the relevant clinical material anddata input had to be easy and quick enough to usein the hospital clinic.

5. Selection criteria for the computer system

The system needed to be large enough for cur-rent needs and future expansion. It needed to beflexible enough to receive, process and provide arange of outputs and to include direct access fromremote stations. It required the inclusion of acomprehensive drug database and to use theREAD coding system that had recently been ac-cepted as standard for primary and secondary carein the UK [28]. However, we recognised the limita-tions of READ codes and wanted the facility tocreate additional customised codes where READdid not meet specific requirement and to haveprovision for free text to be integrated in themedical record and outputs. Other fundamentalissues were the maintenance of the confidentialityof the patient’s record and comprehensive searchfacilities for all parameters in it. Finally, it neededto be reasonably easy to set up and subsequentlyuser-friendly for use in the clinic by multi-disci-plines, including changing junior medical staff.

We initially looked at the possibility of using aPC with some local in-house software and then atMicrosoft Access. These were rejected as it wasimpractical to incorporate the drug database intothem. The setting up of the files and the main-

C. Johnston, E. Ponsonby / Computer Methods and Programs in Biomedicine 62 (2000) 177–189 179

tenance would be slow and complex, althoughAccess did provide attractive easy-to-read cus-tomised outputs. During this consideration stagewe were gaining considerable experience with ageneral practitioner patient management system,EMIS (Egton Medical Information Services), andfelt this could meet the requirement.

Appendix A illustrates the overall design of thesystem. There is a central computer containing allrecords with provision for updating following pa-tient reviews and providing pertinent informationfor interested parties.

The central structure of the system is the patientrecord. Additional structures are the drug databasewhich links into the record and templates andprotocols for use within the record. Templates arean easy way of organising quick entry of data.Protocols are a powerful tool which can prompt,search the record, provide decision support andcarry out administrative tasks.

The sources of data are the patient details fromthe register, the Annual Review (Appendix B)paper returns from the general practitioners, Reti-nal Screening forms (Appendix C) and directscreen input from hospital clinic. The host practicealso enters data directly. The facility exists forother practices to do the same by modem if theywish. The system is registered under the DataProtection Act and confidentiality is maintained byrestricting access to discreet personal passwordholders. These are personnel who need to use therecord for medical and administrative reasons.Passwords are changed when required and revokedwhen a staff member leaves.

Control mechanisms are the audit reports whichfirst list patients seen and not seen. For the at-tendees there are detailed reports on the adequacyof data collection with identification of patientswith specific characteristics.

6. Hardware

The original EMIS system to the surgery was a486/33 with a 700 megabyte hard disk, 16megabytes RAM with 32 ports allowing terminalsfor the doctors, secretaries, nurses and other pro-fessional staff who require access to the patient

record. It has been upgraded to a Pentium 133 with2.2 gigabyte×3 RAID hard disk system×RAMand 64 ports. A dedicated kilo stream land line andmultiplexors link the computer with the dumbterminals and PCs at the hospital. The system isavailable 24 h a day except during back-up timewhich is run between 02:00 and 06:00 h. Back-upsare run every day on a sequence of seven tapes andthe spare tapes are kept off the premises. Thesoftware is the Egton Medical Information Ser-vices (EMIS).

7. Cost

Initial set up and running costs for the first year:

RevenueCapital (£) Total (£)(£)

75002500 10 000Staff costs5364IT costs 12 52271581250750 2000Other

14 114Total 24 52210 408

Ongoing costs:

Computer services including £20 800provision of computer,updating/upgrading, software supportmaintenance and project leader’stimeKilo stream rental £2800

£3000Data input£26 600Total

8. Status report

The system is operational for the Dacorumdistrict population of 119 000 with 2450 diabeticpatients and now 17 surgeries.

Statistics: comparison between groups from1994 to 1997 is made using X2 with Yate’scorrection.


9. The Process of Care (comparison between 1994 and 1997)

% 1997 %1994

–Population of Dacorum 119 000119 000 –Diabetics 1690 – 2511 –Annual reviews 741243 1896 76

Examples of co6erage rate of different parameters :Blood pressure 1001244 1885 99

32 1782 94HbA1c 39296 18291189 96Urine dipstick (for protein)

1179Retinal screening 95 1800 95Fasting cholesterol 259 21 1317 69

Multiple risk factors :32 27 12 (PB0.001)Proteinuria in patientsB70 with systolic BP\160 287 334 37 (PB0.001)ProteinuriaB70, systolic BP\141 on ACE inhibitors

PatientsB70 with fasting cholesterol\6.0 with 15 65 45 29 (PB0.001)ischasmic heart disease

2Total patients with all three multiple risk factors 2025 1 (PB0.001)

Examples of coverage rate of differentparameters:

The following charts demonstrate the improve-ment in outcome for patients over the period:

The following chart demonstrates an areawhere there has been a lack of improvement inoutcome:


10. Data analysis

1. General practitioners — an annual report iscreated which is the basis of a meeting be-tween general practitioners and the consul-tant. Reports provide a list of registeredpatients, the numbers not seen and numbersexceeding agreed targets — single (e.g. hy-pertension) and multiple (e.g. hypertension,hyperlipidaemia and smoking). Individual pa-tients can be identified to aid GP interven-tion.

2. Hospital clinic — similar data can be ob-tained to demonstrate that all patients whohave attended have an annual review, fulldata collection and appropriate management.

3. District — finally, overall statistics areavailable for the whole population and wehave demonstrated by comparing the popu-lations between 1994 and 1997 that therehave been significant improvements, both inthe process of care and in outcomes.The Annual Review Audit has been in pro-

gress for 3 years from 1994 to 1997. It pro-vides for a reconciliation of practice andcomputer patient records, encourages compre-hensive coverage and allows identification ofdefaulters. The reasons for default are providedby the practices and are then discussed at thereview meeting held at each practice with avisiting consultant.

11. Lessons learned

People issues and implementation of change:It is essential that all clinicians appreciate theneed for an overall management system, willco-operate and are disposed to use the infor-mation it provides. It is necessary to explainthe system and gain acceptance by the generalpractitioners, particularly of the involvement ofthe consultant. The ways to approach this de-pend on local circumstances. Persuading peopleof the need to change requires agreement anddemonstration of benefit.

Sharing the reason for change and involvingpeople in its process results in shared owner-ship. This takes time, requires considerable pa-tience and determination to keep the systemgoing. Some general practitioners maintainedthat the control of diabetes was a matter forthe hospital clinic and would have to be per-suaded of their role. Others felt that they werealready providing a good service, though with-out any adequate audit figures to prove it. Themedical profession in general is now requiredto be more openly accountable and factualdemonstration of good practice will be neces-sary in the future.

We had anticipated some difficulty overconfidentiality but none arose. We believe thiswas because we gained the confidence of thegeneral practitioners at the outset and the cen-tral register and database are held on a GPsystem with a natural regard for protection ofboth patients’ and doctors’ confidentiality. Thesystem was essentially seen to promote goodcommunication between practice and hospitalfor the benefit of patient management. The pa-tients themselves seemed pleased to see theirgeneral practice consultation on the hospitalscreen and only complained when data hadNOT been shared or was unavailable.

There was, and still is, resistance to the useof computers by some hospital and ancillarystaff. This is mainly attributable to inadequatetraining, unfamiliarity and lack of confidence.In our case it is due not only to financial andtime constraints, but a lack of appreciation ofthe need for structured training. Use of anynew system requires time for training and al-lowance must be made for it in both adminis-trative and clinical settings. There should becareful appraisal of the impact of the systemon current working practices and organisationof the change. In the clinical setting this meansan initial increase in consulting time scheduledfor patients’ consultations and requires a re-duction in clinic size. In our case this has beenmanageable.

The design of data input forms is very im-portant. They must be easy to fill in by hand


and be suitable for data entry onto the com-puter. There can be conflict where these require-ments are seen to differ.

The illegibility of doctors’ handwriting regar-ding drugs was an initial problem but solved bygeneral practitioners attaching the patients owncomputerised prescription printouts to the An-nual Review forms completed in the surgeries.

Great care is required to maintain the confi-dence of everyone involved and to present re-ports that are seen to be contributory andsympathetic. Enthusiasm is essential, it takestime to establish and maintain, and is easilylost.

Throughout this experience we saw the needto create local templates for dietary advice, in-sulin management and clinical protocols for pa-tient management.

12. Technical issues

The installation and maintenance of the sys-tem presents major problems. The staff operat-ing the system are not design specialists,communication experts or computer engineersand provision of the appropriate support as andwhen required is a continuing problem. Devel-oping the system and software difficulties createproblems which require support that is not al-ways readily available. Repeated electricalbreakdowns, which are thought to be due tosurges in the hospital electrical supply, especiallyover the weekends and during a lighteningstorm, caused malfunction of individual portson the multiplexors. Inserting an optical cablesolved this.

Although in the long term it would be benefi-cial to be linked to the hospital PMS system, wehave derived considerable benefit from being astand-alone system. Whilst having had little ex-perience we got the system up and working inless than a year. The shortage of skilled IT re-sources and the lack of experience in clinicalsystems precluded any significant contributionfrom the hospital IT department. This extendedeven to the extent of safeguarding and maintain-ing the terminals on the hospital premises.

Our initial funding was from pharmaceuticalcompanies, Eli Lilly and Merck Sharp andDohme followed by a regional research grant.Later the Health Authority provided contingencyfunding but as the system cuts across primaryand secondary care there is no existing financialmodel and this has yet to be established.

13. Success

Comprehensive care is delivered and audited.There was an improvement in surrogate endpoints, e.g. the numbers of patients receivingscreening procedures and measurements such asblood pressure, HbA1C etc.

Care is targeted to those most in need. Theseinclude patients at high risk, e.g. those with hy-pertension and nephropathy, hyperlipidaemiaand ischaemic heart disease. Resources are usedwhere most needed, e.g. chiropody for those pa-tients with callous formation and neuropathy forthose who are at particular risk of foot ulcera-tion. We can advise on the appropriate andcost-effective use of drugs. For example, costscan be reduced by identifying patients who maybe using inappropriate blood sugar testing tech-niques and by encouraging cheaper prescribingof satisfactory equivalent drugs and the use of adistrict formulary.

The most radical change is the reduction innumbers of patients needing formal referral tohospital. A consultant can often advise on a pa-tient’s clinical management by inspecting theirmedical record without the need to see the pa-tient in person. This is only possible where thereis easy access and clear presentation of historicaldata. The advice can be entered directly into therecord and dispatched back to the referring doc-tor and/or patient.

14. Future

Within the current system we would want toincrease and refine the use of clinical protocols


to aid with patient disease management; to ex-tend the use of laboratory links to include allpathology results; increase personnel input to di-abetic specialist nurses and clinic nurses; usecomputer-generated patient information leafletsand initiate treatment orientated medical recordsfor patients to hold; formalise and develop tele-consultation links between professionals and pa-tients. This will be essential to develop the ‘keyfeatures of a good diabetic service’ [30].

As the medical profession slowly moves to-wards computerised medical records there willbe less use of paper. We will need to developdifferent approaches and systems for the deliv-ery and monitoring of medical care and thesewill need to integrate across existing careboundaries and be independent of the computerplatform [29].

15. Direct access

We believe that direct access to the patient’selectronic medical record by care professionalsshould be used to effect appropriate clinical

management. Either the patient’s details may bemade available on a hospital database for aconsultant opinion or the consultant may accessa patient’s medical record held on a generalpractitioner’s surgery system.

We believe this is a model for disease man-agement that can be used for other conditionsand, combined with increased clinical supportsystems at the point of care, will be an efficientand cost effective method of health/disease man-agement in the future.

Acknowledgements

We are grateful for all the support from ourlocal general practitioner colleagues, DonaldMoore MBE, FBCS, FIMC for assistance withsystem design and to the secretarial/data inputstaff for their help with this project. Our thanksalso to Eli Lilly for their considerable supportand funding. Additional funding was also ob-tained from the North West Thames RegionalAudit monies and latterly from the Hertford-shire Health Agency.


Appendix A


Appendix B


Appendix C

Appendix D. Table 1

Table 1Targeting of care

Risk factors Number of patients with more than one risk factor

369 – –(1) Systolic BP\160(1)+(2) 93(2) Fasting cholesterol\6.0 349(1)+(2)+(3)353 24(3) Smoker

(4) Proteinuria (1)+(2)+(3)+(4)340 5(5) HbA1c\8.0 (1)+(2)+(3)+(4)+(5)773 4


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