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Integrated care pathways

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Integrated care pathways. Dr Jeremy Rogers MD MRCGP. Senior ... 60 in use at Gloucester NHS Trust (ERDIP), in urology. No. in use per trust. The Future: ... – PowerPoint PPT presentation

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Title: Integrated care pathways


1
Integrated care pathways
Dr Jeremy Rogers MD MRCGPSenior Clinical Fellow
in Health InformaticsNorthwest Institute of
Bio-Health Informatics
2
Talk Outline
  • ICPs
  • eICPs
  • Challenges

3
History of ICPs
  • Industrial process management tool from 1950s
  • Healthcare in US from 1980s
  • UK from 1990s
  • 12 NHS pilots 1991-2
  • UK user group 1994, but folded in 2002
  • Resurgent interest
  • BMiS Workshop May 2003
  • NELH database (Colin Gordon)
  • International Web Portal (Jenny Gray,Venture TC,
    UK)
  • National Pathways Association (Northgate)
  • NPfIT

4
Where we are nowWhats an ICP ?
  • Document
  • Describing idealised process
  • within health and social care
  • Collects variations
  • between planned and actual care
  • Iteratively developed
  • Develop implement review revise

5
Whats an ICP ?
  • Embed guidelines protocols
  • Locally agreed
  • Evidence based
  • Patient centred
  • Best practice
  • Everyday use
  • Individualised
  • Best use of resources
  • Record variances
  • Compare plan against reality
  • Tool for (Clinical) Business Process
    Re-engineering

6
Management of Newly Diagnosed Type 1 Diabetes
Diagnosis in Primary Care
Referral to and assessment by secondary care
within 24 hours
Dehydration/vomiting/at weekend Admit to
RBH Diabetes Clinical Nurse Advisor to see
No dehydration or vomiting DNS to commence
insulin within 24 hours
gt60 years twice daily pre-mix
lt60 years Basal/bolus
IV insulin as per protocol
Data collection HbA1c Weight/BMI Islet cell
antibodies
Unless patient and lifestyle dictate otherwise
Ongoing education Support/Assessment by DNS
Referral to dietitian, podiatrist and
psychologist
Group education at 3-6 months
T\type1.ppt\Julia\Feb99
7
(No Transcript)
8
(No Transcript)
9
Current UK Status
  • 2401 in NELH database
  • 1214 subjects
  • predominantly surgical
  • Often admission pro-formas
  • 170 Trusts writing, 179 using
  • 10 PCTs writing, 21 users
  • Not many available online
  • (lt10 ?)
  • Airdale, Battle
  • eICP rare
  • 60 in use at Gloucester NHS Trust (ERDIP), in
    urology

No. in use per trust
10
The FutureWhats an eICP ?
Model pathway
Instantiated pathway
  • Versioned
  • Iteratively developed
  • Links to guidelines, protocols, evidence
  • Activity specs
  • Valid state changes
  • Role specification
  • Explicit overall objective
  • Patient demographics
  • Patient characteristics at start
  • Care plan
  • Individualised
  • Activities carried out or not carried out
  • Outcome
  • Reasons for variance

11
Whats an eICP ?
Ended pathway
Whats an epathway?
  • Includes abandoned, rejected, completed
  • Record of variances
  • Patient characteristics
  • Activities or activity states
  • Performers
  • Timings
  • MLMs
  • GLIF
  • CLIPS
  • Protocols
  • PRESTIGE
  • Protégé
  • Proforma
  • SOPHIE

12
eICP in NPfIT
  • Phase I (2004/5)
  • Ability to construct and use ICPs
  • Migrate paper ICPs to eICPs
  • Record total journey times
  • Phase II (2006)
  • Model care pathway
  • Instantiated care pathway
  • Ended care pathway
  • By 2010
  • All singing all dancing

13
Automated eICPs ?
  • Evidence-based action at the point of care
    instantaneously triggers follow on actions
    elsewhere in the system Tackaberry, iSoft (2000)
  • Automatic identification and invoking of
    workflow, alerts, review and guideline
    activation NPfIT OBS 2003

14
ImplementationBarriers to the Future
  • Human Factors
  • Cultural
  • Organisational
  • Cognitive
  • Time
  • Patients
  • Commercial
  • Technical Factors
  • Time Scale
  • Too many critical dependencies
  • Not yet invented
  • Lack of EBM
  • Political
  • Cost
  • Expectations

15
Human FactorsLikely Hazard Warning
  • The usual
  • No buy-in, time, skills, training, leader,
    benefit
  • Sabotage, fizzling out
  • ICP from on high (ie written by consultant)
  • Attempt perfection at first draft rather than
    iterate
  • Or, alternatively, less enthusiasm for necessary
    iteration
  • Biting off more than can chew
  • Medicine is complex eat it a bit at a time
  • Interdisciplinary friction
  • Terminology, working practices, culture etc.

16
Technical Barriers Specific Informatics Problems
  • Authoring
  • EPR Data Quality
  • Indexing
  • Act management
  • Clinical Terminology
  • Consent
  • Visualisation
  • Automation
  • Pace of change

17
BarriersTechnical eICP Authoring
PROS
CONS
  • Automation requires strict logic
  • Specialist activity
  • Limits ownership participation
  • Edge-of-protocol effects
  • Can be very complex to view
  • Re-use at risk of curly bracket problem
  • Chaotic co-behaviour
  • Not done yet
  • Software supported
  • Re-use of modules
  • Standard Components
  • timeframes, interventions, evidence, references,
    and goals/outcomes
  • Geographically distributed authoring
  • Increase accessibility of process, buy-in ?

18
BarriersPolitical Commercial
POLITICAL
COMMERCIAL
  • Unrealistic expectations
  • Bad press
  • War of authorities
  • NICE, BNF, Colleges, BMA, Clinical Evidence,
    NELH, NHSIA, Pharmas etc.
  • Covert agendas
  • Manage docs, not patients
  • Cold feet
  • Pharmas
  • Snake Oil Distractors
  • Apathy in face of
  • Low user demand
  • More pressing problems
  • True development cost
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