Health informatics: Improving patient care

by BCS, The Chartered Institute for IT (Editor)

Overview

Health informatics (HI) and technology play a major role in health care including empowering patients, shortening waiting lists and improving treatment efficiency. This ebook contains a range of material by HI experts on the latest developments. It includes articles on robotic surgery, on how technology can support people in their own homes, and on how electronic systems can help reduce risk of medical error. Readers do not require a detailed understanding of health care or health informatics.

Product Details

ISBN-13:	9781780171449
Publisher:	BCS, The Chartered Institute for IT
Publication date:	06/29/2012
Sold by:	Barnes & Noble
Format:	eBook
Pages:	68
File size:	866 KB

Read an Excerpt

CHAPTER 1

USING IT TO IMPROVE POPULATION HEALTH MANAGEMENT

At the annual conference of the Primary Health Care Specialist Group, Matthew Swindells, Chair, BCS Health, talked about the changes that have been brought in by the recent Health and Social Care Act 2012 and the implications this has for informatics.

The Health and Social Care Act 2012 hands commissioning of health services over to 'clinical commissioning groups' largely run by GPs. As the Chair of the NHS Commission Board, Malcolm Grant, said: 'The best clinical commissioning groups will be those with the best information systems.' There is, therefore, an obligation on those who work in the area of health informatics in general and those in primary care informatics in particular to step up to this challenge.

Traditionally health care has stood out as the one industry where the perceived wisdom is that spending and quality are inextricably linked. It is held by many to be self-evident that, if you reduce cost, you must by default increase how long people wait for care and reduce the quality of the service.

No other industry can get away with this simplistic view, and the evidence shows that in health care the perceived wisdom isn't true either. There are innumerable studies around the world to show that variations in quality are frequently nothing to do with the amount of money spent. Whether you look at the Dartmouth Health Atlas showing the failure of higher spending to correlate with better outcomes in the USA or at the fact that many of England's hospitals with the best clinical outcomes also have the lowest reference costs, you see that money can be spent wisely to get great outcomes at lower costs or badly to get poor outcomes at high cost.

The challenge for informaticians is to show that they can break the perceived wisdom, that they can reliably and repeatedly reduce cost while improving access, quality and outcomes through the application of information and technology.

There are only two ways to drive cost reductions and quality improvement:

• One is to make individual health care institutions and services such as hospitals, community clinics and home nursing more productive.

• The other is to make the whole health and care system more productive.

The former is critically important and the NHS should not be distracted from the important task of driving waste and inefficiency out of its services. I have previously written a number of papers and given several talks on the potential for productivity improvement in hospitals through process redesign and the application of evidence-based care, supported by information and technology. In my talk I focused on the whole system and opportunity to transform the economics of health and care by placing the patient at the centre of system design and using information and technology to improve their health and reduce their cost demand on the health care system.

The challenge is to IT-enable the whole system, not just the silos: stepping out of our narrow institutional interests and finding a way to deliver benefits for the population, the patient, the NHS and its staff. This needs to be based on five pillars:

1. Strong electronic health record (EHR) foundations in hospital care, primary care, community care and homecare: without good, real-time clinical information, very little else is possible.

There is a question about whether the purchaser or commissioner of care should worry about the EHR systems being used by their providers or even whether they have a right to have an opinion. I would argue that if they are serious about managing quality and developing benefits through system integration, they should insist that their providers have a digitised health record and are able to share this data in real time.

The next generation of health care information technology will apply knowledge algorithms, such as prompts on the appropriateness of admission or the identification of patients at risk of being readmitted as an emergency, as the data is collected so that, for instance, preparation for managing their discharge can start as they come into hospital.

These, and the hundreds of other intelligent support algorithms that it would be possible to build and run to support staff and protect patients, are dependent on comprehensive EHRs, gathering data on patients as it is known, not two days after discharge.

Furthermore, commissioners should insist on the digitisation of the whole care pathway because it will support the elimination of 'memory-based care' and the distribution of clinical decision support to propagate the application of best practice. It is well known that one of the keys to better, safer, lower cost care is the application of evidence, but it is also understood that the adoption of new knowledge into routine practice is painfully slow: one study showing that it takes 17 years for a new piece of knowledge to be adopted into practice by half the physicians.

This is not because doctors are difficult and refuse to use the evidence in front of them. It reflects the fact that the volume of new evidence being produced, the complexity of care pathways and the number of professionals involved in providing care makes 'memory-based care' a defunct approach to modern medicine. Einstein did not clutter his mind with 'facts' he could find in a book. He devoted his efforts to interpretation. The average clinic appointment doesn't provide the time for a doctor to refer to a pile of clinical text books, so we expect them to provide care based on what they can remember.

The consequences are seen in the waste and harm that is caused by prescribing errors: three to five per cent of all hospital admissions, £500 million unnecessary costs; and the myriad of examples of where best practice care can deliver low cost, higher quality, but is patchily adopted.

This is why, when commissioners think about redesigning a health system, they need to require their providers to use EHR technology effectively, and then apply the 'closed loop' principle to quality management beyond the hospital and integrated care pathway processes.

2. Using a health information exchange (HIE) to link the care system together, so that we don't have silos of information, but clinicians can have access to all the relevant information at the moment of decision. Digitising the health care silos is not enough to transform health care as a whole. HIEs allow organisations to connect and exchange information across an entire health system. In Oklahoma, for example, a publicly managed health information exchange called SMRTNET (Secure Medical Records Transfer Network) captures data on more than 2.6 million people or 72 per cent of the state's population.

There are a growing number of published studies that support the clinical and economic benefits of this integration. One recent study showed that HIE access achieved a 230 per cent return on investment by reducing admissions through A & E; another showed increased efficiency in primary care from improved access to test results and less staff time handling referrals; and a third showed that 70 per cent of outpatient doctors forecast that an HIE would reduce costs, 86 per cent that it would improve quality and 76 per cent that it would save time.

The technology exists to allow hospital doctors to see relevant patient data directly from the GP system and the GP to see data directly from the hospital electronic medical record (EMR), allowing clinicians to share their knowledge about a patient in real time.

3. Gathering data together, outside of individual systems and organisations, to give a comprehensive view of the health of a population.

Clinical integration through an HIE will improve quality and productivity in operational practice, but designing the health system of the future requires more than this. Advances in technology mean that system-wide information design, which is the legitimate interest of commissioners, can move beyond retrospective reporting into real-time patient and quality management. This requires us to lift data out of the institutions and bring it together at a higher level, in the cloud, to enable:

• pain-free health system reporting and benchmarking to drive process improvement, reduce bureaucracy and insurance income retrieval;

• real-time patient and system tracking to optimise the patient experience;

• predictive modelling to plan future interventions;

• whole pathway decision support that is not encumbered by organisational boundaries.

This liberation of data allows the health system to maximise value by addressing the needs of the whole population and, within that: to identify patients with long-term conditions and ensure that they receive locally agreed pathways of care, personalised to their own needs; to ensure that episodic care is applied according to best-practice evidence and that quality and cost are monitored; to ensure that specialist care is supported by the appropriate experts and advanced decision-support tools.

4. Support the direct management of patient care, so that community services address the correct patients, in a timely way, supported by the information and evidence that they need.

In an EHR-enabled health system, population level information analysis isn't simply for information and reporting: it needs to be integrated directly into front-line patient care to drive changes in population health.

The data from risk stratification and tracking the clinical data collected in hospital, community, primary and home care, as well as by patients themselves, can be used to prioritise cases for a case manager, telephone-based health coach or home nurse's schedule. It can then guide the conversation that they have and the vital signs that they need to collect, applying decision-support algorithms in the background to prompt advice to the patient or decisions to refer to another professional. It can alert the hospital or primary care clinician if a patient is deviating from their expected recovery or disease management pathway to provoke an intervention. It can ensure that patients, their carers and the clinical team are kept informed about decisions made in other parts of the care pathways.

5. Use technology to support the patient in being a partner in maintaining their own health.

There is considerable experience around the world to suggest that simply giving patients access to their clinical record adds little value. Some highly motivated patients are interested and access it frequently, but most look once and then very rarely. To make a personal health record (PHR) compelling it needs to be interactive and supportive.

The PHR should provide a simple and user-friendly record of the patient's notes in different organisations for them to view. Most patients have GP records and several hospital records. The PHR should bring these together in one place, not being tethered to a single institution or software vendor.

It should prompt the health maintenance activities that patients should be undertaking, such as exercise or taking their own measurements. It should integrate to home monitoring devices such as scales, pedometers and blood pressure cuffs.

Through its interface to the cloud-based population health platform it should link with data captured at home and with data captured in primary care or the hospital, and provide real-time alerts with advice on what to do next (such as an online, evisit questionnaire) and share this data with the GP, case manager or practice nurse.

IN CONCLUSION

Population health improvement requires more than retrospective public health analysis. It requires:

• Platforms of EHRs in all parts of the health system so that data can be accurately captured, shared and used to provide decision-support prompts that encourage application of best practice. These platforms need to be integrated through an HIE to allow clinicians to share information and gather the data to support analytical tools.

• An information infrastructure that allows:

* automated retrospective reporting and submissions;

* real-time patient tracking;

* predictive modelling, risk assessment and population segmentation;

* patient prioritisation;

* the application of evidence-based decision-support algorithms.

• Care management tools that support the management of patients in all settings and proactive intervention to support health.

• Tools to assist patients in managing their own health and engage them in decision making.

The NHS will not deliver 20 per cent productivity savings without this investment in information and technology. The challenge is whether we have the skills and the courage to change the way medicine is practised, with the help of information and technology.

CHAPTER 2

SAFETY FIRST

While IT is transforming health care practices and procedures throughout the UK, a significant proportion of the NHS relies on outdated paper-based processes. These are not just wasteful and inefficient; they are putting lives at risk. Dr Paul Shannon FRCA MBA, Consultant Anaesthetist, Doncaster and Bassetlaw Hospitals NHS Foundation Trust and Medical Director, CSC UK Healthcare, examines a flawed approach to patient safety and the solutions that should be adopted.

'Staggering numbers of people are harmed and killed by medical errors,' the World Health Organisation (WHO) said recently, with mistakes having an impact on 1 in 10 patients. Little wonder that the organisation is warning that patient safety is an 'endemic concern'. This is not new.

In 2004, the National Patient Safety Agency described the risks that arise from our complex health care system, warning that 'evidence shows that things will and do go wrong in the NHS; that patients are sometimes harmed no matter how dedicated and professional the staff.'

But while individual errors might be found to be due to the mistakes of one or more person (e.g. the tired doctor, the overworked nurse), it's invidious to blame health care staff for the WHO's 'endemic concern'. Why blame humans when we deny them the tools that can help cut the risks of error and improve patient safety?

Why tell staff they have to pull their socks up when there are solutions already out there that can improve their working lives and make the care they provide that bit better? Electronic systems, wisely designed and implemented, can help reduce risks in a variety of ways. Here's how.

CONSTRAINING HUMAN ERROR

'To err is human,' as the poet and essayist Alexander Pope said almost exactly three centuries ago. We can see examples of this every single day in every single health care setting.

The common types of individual human error are lapses and slips; that is, errors of omission (I forgot to do something I should have done) and commission (I did something I didn't mean to do). The root causes are many, including such contributing factors as fatigue, distraction, lack of knowledge, poor communication and even deliberate wrongdoing.

Electronic systems don't suffer from many of the frailties of humans. Where they can replace tedious, repetitive, high-speed and complex tasks currently performed by people, they can improve safety. Electronic systems are logical. Steps can be made compulsory: no cutting corners or skipping items by mistake. Think of buying an airline ticket; you must follow the prescribed sequence or else you can't complete the task.

There are many examples where there is evidence to show improvement in patient safety. Here are just a few: electronic cross-match of blood; electronic monitoring and voice prompts to enhance hand-washing, thereby reducing nosocomial infections; prompts and pauses.

A prompt reminds the user to do something, for example vital signs monitoring. A pause introduces time for reflection or confirmation: 'Do you really want to do this?' Cutting out that human element, or even prompting us to think a moment, can and does save lives.

HARDWIRING QUALITY

With the best will in the world no doctor or nurse can know everything. They'll have strong and weak points in their knowledge and skills. They have good days and bad days, like the rest of us.

Health IT can help direct care and ensure that the patient stays on the right track, that they receive all the appropriate care in a timely manner: right thing, right way, right time. Again, illustrations are plentiful. Enhanced communication across care boundaries, for example, can provide integrated care (vital for things like safeguarding) and also helps to overcome the fragmentation of care delivery.

Formal clinical decision support is also hugely useful, for example, with systems such as ePrescribing improving the quality and safety of patient care. Informal support, such as Medline and even Google, is also proving its worth.

Electronic systems are great for tracking patients along pathways of care, improving hospital care planning from well before admission to long after they return home. They can also help to implement care bundles (groups of interventions that, when implemented together, have a synergistic effect on a disease pathway or patient outcome).

(Continues…)

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Excerpted from "Health Informatics"
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Copyright © 2012 British Informatics Society Limited.
Excerpted by permission of BCS The Chartered Institute for IT.
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Table of Contents

Introduction Using IT to improve population health management Safety first Valuable lessons in validation The internet and patient information Health in the cloud Telehealth - for better patient care Robotic surgery Radiotherapy targeting Smart textiles Design for ageing well Speech recognition and digital dictation Shorter waiting lists and raised productivity Growing up A real rollercoaster ride

Preface

Health care is very much an information business. Administering health care was the subject of many early systems. It was not long after the first computers appeared that they were being used to support the finance function at the London Hospital. Things have come a long way since those days and still have far to go. Use of computers to support the clinical care of patients is a more recent phenomenon, but one that is obvious if you think about it. Much of health care deals with the collection of symptoms and results of tests to form a diagnosis. The formulation of a plan and its implementation involves the collection and recording of much information. The recent Health and Social Care Act 2012 initiates major changes to the NHS, giving responsibility for commissioning health services for local populations largely to groups GPs in Commissioning Care Groups. These changes aim to create productivity improvements in the health and care of populations by ensuring more integrated care across a range of settings from home to hospital care, where different providers contribute to the overall integrated pathway of care for a patient. This can only be achieved satisfactorily by using information and information systems to transform the productivity and economics of the NHS; improving the quality of care, its outcomes and the health of the population. This book is aimed at presenting just a few of the many innovative ways in which information systems and technology are being used to support health care. As Matthew Swindells, Chair of BCS Health, points out in the first article that ‘the challenge is to IT enable the whole system, not just the silos – stepping out of our narrow institutional interests and finding a way to deliver benefits for the population, the patient, the NHS and its staff’. He describes the five pillars on which this should be based to achieve success. You will find articles on robotic surgery and radiotherapy targeting showing how informatics is being applied in leading-edge clinical treatment of patients. ‘Telehealth for better patient care’ (Dr Nicholas Robinson), ‘Design for ageing well’ (Liam Burns and Ian Cleland) and ‘Smart textiles’ (Professor Tilak Dias) focus on how technology can support people in their own homes and avoid the need for expensive hospital care. It is well documented that patients are harmed and killed by medical errors with about 1 in 10 patients being affected in some way. In ‘Safety first’, Dr Paul Shannon explains how ‘electronic systems, wisely designed and implemented, can help reduce risks in a variety of ways’. As the number of different providers of health care to individual patients increases, the need to integrate care and information from different sources also increases. This risks greater fragmentation, potentially leading to more rather than less medical errors. Researchers William Buchanan and Christoph Thuemmler of Edinburgh Napier University talk about their approach to this complex problem using the latest innovations in cloud computing. Janet Sampson from the Welsh Blood Service describes how other areas of health care computing can learn from the strict validation procedures they must apply for new computing systems. This becomes increasingly important where information is crossing organisational boundaries in order to provide a complete picture for a patient. If you need any convincing of how exciting health informatics can be and want to be inspired, read Justin Richards interview with Dr Julie Greensmith – ‘A real rollercoaster ride’. Part of the Intelligent Modelling and Analysis Group in the School of Computer Science at the University of Nottingham, she describes how she got into this domain and what she is working on. The line-up is completed by Andy Savvides describing the NHS Infrastructure Maturity Model; Margaret Cosens and Keith Richardson on the application of speech recognition and digital dictation; Paul Chapman on how the implementation of an electronic patient record at NHS Rotherham has led to shorter waiting lists and productivity; and Carol Bond on how the internet has transformed information for patients, the public and health care professionals. While we cannot hope to cover the sheer variety of areas in health care where information technology is already making an impact or the complex and exciting areas still to be tackled, we hope that these articles give you some insight into the domain. They are aimed at an audience that does not require detailed understanding of health care or health informatics. Sheila Bullas, Vice Chair Publications, BCS Health