“NHS change challenge”

Clinical content work in the NHS

Tony ShannonConsultant in Emergency Medicine, LTHClinical Consultant, NHS CfH

Travel to HL7 kindly funded by Ocean Informatics

Tony Shannon

M.B. B.Ch. B.A.O. IrelandFellow of College of Emergency Medicine England

Fellowship in Informatics USAMS in IT Management England

Consultant in Emergency Medicine, Leeds Teaching HospitalsClinical Consultant, NHS Connecting for Health

Leeds, England

Complex Systems

• Many parts, Many interactions• Perpetual novelty

• Difficult to describe/understand completely• Difficult to control/change

• Identify simple rules– Self-organise

• e.g. Weather, Economy, Internet, ED

National Health Service in the UK

• Established in 1948 by Labour Government

• Huge– 3rd largest employer in world, largest in Europe, 1 million+ staff– 45+ million patients in England

• Healthcare free to all at the point of care

• Quality

• Costly– Increasingly financially oriented– “Payment by Results”

• “NHS Plan” = Service Reform (inc. IT)– e.g. Leeds Teaching Hospitals

• City <1million population• 4 EDs; 110,000 + 90,000 census• 95%/98% “4 hour ED target”…

• Biggest civil IT programme in world• 10 year; based in Leeds, England• $20+ billion with commercial suppliers

• 5 Regions of England– North East Cluster

• 7.5 million population• 170,000 NHS staff• 23 Acute Hospitals• 12 Mental Health Trusts• 1200+ Primary Care practices

– Care Record Service • contract £1 billion

• Hugely ambitious

• Primary, Community, Hospitals, Mental Health– Contracts for several interim solutions– Aiming for a single strategic EHR solution

• National Services– Single NHS patient identifier number– Service Directory– Choose and Book scheduling

• Local Services– Care Record Service (Electronic Health Record)

• Guideline based • Workflow integrated • Cross organisational working

NHS + IT = Complex

Change – Emergency Medicine

Change - Management

Benefits = Quality

Risk↓ Cost↓ Time↓

Drivers

Change - Software Engineering

People+ Process + Technology in a “Model Community”

Systems in Silos

• People– Challenge siloed thinking

• Process– Look for simplicity within the complexity– ? Core generic processes in healthcare

• Technology– Evolutionary approach– Process related IT requirements

• esp. at the complex front end. i.e. ED charting– free text/dictation versus forms (e.g. T-system)

• Aim to reuse– Distributed process-oriented SOA?

• Balance central control and local innovation

Process - Urgent Care Study • Identify top/core business processes in Urgent Care• Identify and prioritise information/technology needs

• Methodology– Stakeholders/ core Processes / IT Requirements

• Site visits– NHS Direct– Ambulance Services – ED (4 in West Yorkshire)– Walk in Centre– GP Out of Hours

A view of NHS process …A view of NHS process …cd Urgent Care Now - Top Lev el

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Name: Urgent Care Now - Top LevelAuthor: Ian HerbertVersion: 1.0Created: 09/04/2006 18:13:11Updated: 21/04/2006 10:08:26

Patient has care concern

Identifyconcern(s)

XOR fork -know providerto use ? Find out providers available now,

and their contact detailsDecide which

provider to use

Contact ambulanceservce & request care

Contact GMP OOHrsservice & request care

Contact NHS Direct &request care

Go to walk-in centre

Go to emergencydepatment

Ambulance servicehandle request

GMP OOHrsprovide care

NHS Direct handlerequest

Request WIC care

Emergency departmentassess appropriatness

of request

Ambulance serviceassess appropriatness of

request XOR fork -appropriateprovider

Walk-in centreprovide care

RequestED care

XOR fork -appropriateprovider Emergency department

provide care

GMO OOHrs assessappriopriatness of

request

XOR fork -patientdisposition

End of urgent care episode

XOR fork -contactrelevantprovider

XOR fork -more urgentcare needed?

XOR fork -more urgentcare needed?

End of urgent care episode

End of urgent care episode

End of urgent care episode

I. e. self-care advice / information provision issufficient

This may also be done by contacting NHS Direct

Concern(s) may be identified by the patient, a carer, a bystander, an attendant (e.g. police at an RTA) or a care professional. So may the provider contacting & service requesting, e.g. if the patient is unconscious.

This overview of urgent care is compatible with the submodels provided for each urgent care provider. However it explicitly shows some of the detail which is within each of the submodels . The detail shown deals with assessing the appropriateness of the care request by each provider, and the passing of the patient to another provider if further urgent care is needed that is outside the scope of the current provider.

May include 1 or more attendances atED clinics after initial attendance

patient delivered toemergency dept.

transferedto WIC

no

no

no

transferredto OOHrs

transferred toambulanceservicetransferred toambulanceservice

more urgent carerequired - patient /carer/ etc directedto another provider

patient / carer/ etc directed to moreappropriate provider. This may be toa specialist ED, e.g. for obstetrics

or eye care

more urgent carerequired - patient /carer/ etc directedto another provider

yes

transferredto OOHrs

patient / carer/ etcdirected to more

appropriate provider

transferredto OOHrs

transferred toambulanceservice

e.g. ifspecialist EDservice reqd

more urgent carerequired - patient /carer/ etc directedto another provider

Referral in

Assessment

Plan CareDeliver Care

Referral Out

Operational (1 patient)

Strategic (++ patients)

Tactical ( > 1 patient) Resource Management e.g. staff, beds

Performance management e.g. Audit

Diagnostics

Sorting

A view of Generic Processes in Healthcare

A journey through the NHS …A journey through the NHS …

GP

timetime

NHS Direct

Emergency Department

Acute CCU

Taken to A&E: given oxygen in transit

Transferred to CCU to complete post-MI care

Self care

Returns to self / primary care

Angina diagnosis & 1st care plan

Ambulance

Diagnosis confirmed: & patient stabilised

Suspected MI: self-care advice given & ambulance requested

Generic Generic Process IT Bricks

Specific Patient Journeys IT Library

A tale from Denmark …

The Danish solution…

• 15+ years of European & Australian R&D

• Generic Process based EHR Architecture

• Related to – European Standard

(en13606)– ISO standard

OpenEHR

Archetypes

(Bricks)

Templates (Toys)OpenEHR

Generic

Specific

Archetype

• Reusable list of clinical statements

• Useful for clinical documentation

• Can be coded with terminologiese.g. Snomed CT

Archetypes & Templates

•Central control

•Local flexibility

Archetypes

• North, Midlands and East– 60% of England

• Supplier– Contract with CSC– Single strategic EHR solution– Requirement & Design Stage

• NHS “Clinical Content” needed– To support charting

• Big Opportunity

Phases of Content Delivery

NHS input… example..

NHS content – inputs via wiki

• Collaborative• Evolvable

• Version control

• comments

NHS input… e.g. Head & Neck examination

Into Head & Neck exam archetype

Archetypes can bind to codes…

Archetypes available as XML/HTML etc…

NHS Archetype library

Archetypes configured in Templates solves central control + local need

Template editor output as HTML/XML/Forms etc….

Archetypes

(Bricks)

Templates (Toys)OpenEHR content

• Can be used for application UI – e.g. forms

• Can be transformed into messages– e.g. HL7 CDA

• Can be used for querying +/- Terminology

NHS template library

.. for use in any supplier system

.. for use in any supplier system

openEHR content cycle..

• Clinical content will continue to evolve

• Archetypes and templates are version controlled

• Content changes – don’t impact application – if fit with openEHR

Benefits of Archetypes• Quality

– Better documentation - for complexity of healthcare • Via Standard Archetype + Flexible Templates

– Can evolve over time - as medicine changes• Via version control

– Balances central control and local innovation• Risk

– Solid foundation for Decision Support• Time

– Save time• Build templates fast

• Cost– Save NHS money

• Standard methodology – all can share• Non proprietary

NHS Clinical Content Service

• NHS Requirements• E-Care Pathways • Archetypes & Templates

– Archetype outputs 150+– Template outputs 20+

• Clinical Coding– Via SNOMED CT

• Resource• Governance

NHS Tech Office.. today

Clinical Use Case

Clinical Content Model

Clinical Templates

Clinical Archetypes

Reference Model, Types, Terminology

Logical View Messaging Realisation with templates

Story board

Message

HL7 Templates

HL7 Templates

RIM + Data Types + Terminology

Business Use Case

Interactions

NHS Tech Office.. tomorrow

Clinical Use Case

Clinical Content Model

Clinical Templates

Clinical Archetypes

Reference Model, Types, Terminology

Logical View Messaging Realisation with templates

Story board

Message

HL7 Templates

HL7 Templates

RIM + Data Types + Terminology

Business Use Case

Interactions

Auto

Generated

International efforts…

Key issues….• NHS IT

– Hugely ambitious– Learning valuable lessons

• People issues– How to involve the right people

• Think beyond current silos– Governance

• Local versus National?

• Process issues– look for the generic within

• Technology issues– Evolutionary – Clinical process oriented approach i.e. archetypes– Ensures clinical content is reusable/evolvable

Archetypes

(Bricks)

Templates

(Toys)NHS content library