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NaSH: A national sexual health clinical management system

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Title: NaSH: A national sexual health clinical management system


1
NaSH A national sexual health clinical
management system
  • Dr Andrew WinterConsultant GUM Physician NHSGGC
  • Chair, NaSH Reference Group

2
Vision
  • Fully electronic clinical record and booking
    system to support integrated sexual health
    services (including GUM, FPRH, specialist
    services, counselling)

3
Vision the lab part
  • Common lab request printed
  • Epidemiology eg. For HPS HIV forms derived from
    EPR
  • All lab test results imported
  • All results processed electronically with logic
  • Results interpreted according to preset rules
  • Patients collect results (in understandable
    terms) e.g. with Telephonetics
  • All positives actioned without delay in
    workstreams
  • Results viewable by GPs where pts consent

4
NaSH
  • Single instance application, web deployed
  • Used by all Health Boards
  • Aimed at Specialist Sexual Health Services
  • 400,000 attendances
  • 100-200 sites
  • 1200 staff

5
NaSH Benefits
6
Some benefits of EPR for sexual health
  • Access to records across multiple sites
  • Centralized booking process possible
  • Automated import of lab test results
  • Asynchronous / remote STI results access
  • Management data gathered as part of clinical
    process

7
Multiple site working
  • Integration of sexual health services at Board
    level
  • Managed Clinical Networks across Boards

8
Security and confidentiality
  • Sexual Health even more sensitive
  • Patient choice for CHI or non-CHI
  • Three levels
  • Fully CHI identifiable
  • CHI confirmed but anonymous testing by AN
    number
  • Assumed identity, anonymous testing
  • Role-based access

9
Clinical safety
  • Availability of case records / results
  • Failsafe systems for abnormal results
  • Case management eg lt16 reporting, syphilis
  • Allergy alerts for prescribing
  • Partner notification

10
Service modernization
  • Utilisation of clinic space flow patients where
    service can fit
  • Remote results access
  • Workflow referrals (eg from SCI gateway) to most
    appropriate provider
  • Integration with other e-systems Gateway,
    SCIstore.

11
Integrated sexual health
  • Flow of clinical forms depends on main reason for
    presentation
  • Full sexual and social health history available
  • Internal referrals by messaging

12
Reporting and coding
  • Minimal additional effort for individual boards
  • Quality Improvement Scotland / Key Clinical
    Indicators
  • e.g. Proportion Clients with Gonorrhoea
    Undergoing PN within 7 Days (QIS 5.6)
  • STI coding (STISS) output
  • Audit at Board , Unit , Practitioner level
  • e.g. clinician-specific HIV uptake rates

13
Case 1
  • 25 year old lady attended Sandyford North
  • Request HIV test
  • Failed to return for ve result
  • Case management by consultant / senior HA in
    Sandyford Central
  • Result given in GP practice
  • Sandyford notes / results available on-line at
    first attendance at Brownlee for HIV care
  • Partner notification outcome recorded

14
Case 2
  • 19 year old man attended Sandyford SE with
    dysuria
  • Slide read at Sandyford Central results onto
    system ve gonorrhoea
  • Antibiotic prescribed
  • Contact attends Sandyford Inverclyde the next
    week
  • Partner records and treatment reviewed
  • Sensitivity testing guides epidemiological
    treatment
  • Partner notification outcome completed
  • Coding completed

15
NaSH Development Clinical involvement
16
NaSH Principles
  • Governance
  • Stakeholder involvement
  • National technical / developmental standards
  • National Data standards
  • Single product is only option
  • Implementation challenge / planning addressed

17
Development of NaSH
Design
Instigation
Clinician
Implementation
OngoingDevelopment
18
Clinician-led design
  • Reference group
  • Clinical specialists from GUM, FPRH with range of
    IT expertise
  • Key input into
  • Statement of Requirements
  • Functional Specification
  • Workflow
  • Interpretation of data definitions

19
Statement of Requirements headings
20
NaSH clinical process analysis
  • Detailed process analysis
  • Administration
  • Clinical GUM / FPRH including social health
  • Prescribing
  • Lab testing
  • Partner notification
  • Procedures
  • Coding

21
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22
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23
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24
Process redesign
  • Agree common methods of working
  • Confidentiality
  • Clinical process
  • eg automated results recovery
  • Interim process
  • Old records / results systems
  • Change
  • What can you now do?

25
NaSH labs
26
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27
NaSH and CHI
  • Explicit consent to use CHI
  • Three options
  • Fully identified Name/CHI on request CHI
    demographics
  • CHI check / anonymous testing CHI demographics
    downloaded tests labelled with AN number
  • Assumed identity No link to CHI tests labelled
    with AN number

28
NaSH and CHI
  • NaSH anonymous number
  • CHI-type number with check digit
  • Labs used to handing anonymous GUM numbers
  • Need to agree methods for entering name eg. Some
    labs prefix the anon number with a V
  • Labs will get EITHER the CHI-identifier OR NaSH
    number. CHI and NaSH cannot be linked on
    third-party systems

AN09879862
29
Top tests
  • Bacteriology
  • Gonococcal Culture (U / R / T / Cx)
  • Syphilis serology
  • HVS
  • Virology / PCR
  • NAAT Chlamydia Hep B serology
  • NAAT GC Hep C / HCV PCR
  • HIV HSV PCR / culture

30
Typical test set for STI exclusion in
asymptomatic man having sex with men
  • Gonorrhoea
  • Urethral
  • Throat
  • Rectal
  • Chlamydia
  • Urine
  • Rectal
  • Serology for
  • HIV
  • HepB cAb
  • Syphilis

31
Structured lab results
  • Bulk testing of key STIs
  • Sandyford 05/06
  • 20,000 chlamydia
  • 19,000 gonorrhoea swabs
  • 10,000 HIV
  • 11,000 syphilis

32
Problems
  • Anatomical sites
  • Antibiotic sensitivity
  • Multiple tests off one sample
  • Handling anonymous identifiers
  • Structured result format
  • SCI store

33
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34
Results
Lab and radiology results can be imported
electronically from lab systems and are available
for review by a single click. Manual input is
also supported.
35
SCI store issues
  • SCI store primarily conceived to allow viewing of
    results
  • Microbiology test results simply free text
    imported rather than structured
  • Slightest change in automatic wording derived
    from lab code will prevent successful reading of
    the result

36
SCI store / lab issues
  • No agreed coding for top STI tests
  • SNOMED-CT
  • Read codes
  • Lab system internal codes
  • Board-specific rules
  • Which tests get sent to SCI store
  • How unmatched results are handled

37
Apex(RAH)
STI tests
Hapless Patient
CLYSCIstore
HSV test
Telepath (SVC Gartnavel)
GGSCIstore
Masterlabs(Lanarkshire)
STI tests
LASCIstore
Hapless Patient
GC PCR 1
?
GC isolateTreponemal PCR
Telepath (STIBRL ERI)
LOSCIstore
GC PCR 2
38
More SCI-store issues.
  • Store-to-Store
  • Significant proportion of clients cross Board
    areas
  • Out-of-board tests eg reference syphilis / GC
    sensitivity now NOT reentered (HDL rule)
  • Provisional vs Final results

39
Test requested answer expected
Lab request (paper) sample sent
Lab result returned
Imported and mapped
80
NORMAL
ABNORMAL
Text / phone collection
Client contacted
40
What the clinician wants.
Lab tests / NaSH interface
Positive
Additional info type of test / lab no
Chlamydia endocervical
Negative
41
Clinic asks for..
Lab calls it
Lab test
Lab result
Endocervical sw
Chlamydia SDA
DNA detected
Chlamydia endocervical
C. trachomatis PCR
Swab endocervix
Positive
C. trachomatis Real Time PCR
Detected
Endocervix
Internal lab system codeTEST / SAMPLE SITEmay
stay same even if assay changes
42
Clinic asks for..
Lab calls it
Lab test
Lab result
Endocervical sw
No growth
N.gonorrhoeae isolated
GC endocervical
Swab endocervix
CULTURE
Heavy growth of N gonorrhoeae
Endocervix
Light growth of Streptococcus(Gp B)
Internal lab system codeTEST / SAMPLE SITEmay
stay same even if assay changes
43
List of anatomical sites for sexual health
44
Interpreted results
45
Syphilis EIA
Positive
Negative
VDRL or RPR
TPPA or TPHA
InnoLIA
IgM
Normal
46
Conclusion
  • NaSH designed to automate majority of STI test
    handling process
  • Improve clinical safety
  • Improve access to results by patients
  • Increase staff effectiveness
  • NaSH is going live near you soon..!!
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