Tuesday 28 November Welcome Professor Joe McDonald Director, - - PowerPoint PPT Presentation
Welcome to the Great North Care Record Network Tuesday 28 November Welcome Professor Joe McDonald Director, Connected Health Cities North East and North Cumbria Consultant Psychiatrist and Chief Clinical Information Officer, Northumberland
Welcome to the Great North Care Record Network
Tuesday 28 November
Welcome
Professor Joe McDonald Director, Connected Health Cities – North East and North Cumbria Consultant Psychiatrist and Chief Clinical Information Officer, Northumberland Tyne and Wear NHS Foundation Trust Chair, Chief Clinical Information Officers Leaders Network
The Great North Care Record. Our future shared
Professor Joe McDonald
About me
The Dawn of the Age of Precision Medicine
Build a Trusted Brand and Clear Vision
The Best Place In The World To Get Care The Best Place In The World To Do Research
A Perfect Storm? Or An Opportunity
How?
Engagement
Engagement
The Wall of Love
Digital Transformation of Regional Care
On GP Waiting Room Screens
Game Changing Citizen
Game Changing Clinical Engagement 1) Clinical Network Led 2) Embedded in secondary Care System (Hampshire usability) 3) Information Sharing Gateway
Digital Region – Inspired by Hampshire
MIG Usage
The Secret of Consent? Get Consent.
Phase 2 – Citizen Produced Consent
preferences
to be contacted
wearables etc
Consent-Rich Research Environment Consent
Model
Filed in the too difficult box?
https://blu3id.github.io/gncr- consent/preference.html
Imagine Phase 3
If the IG nightmare went away because we gave the citizen control of the “diameter of trust” = cure cancer/schizophrenia/everything else Learning Health System Too expensive, right? If you were setting up the NHS today……
NHS?
settings and preferences?
Show Me the Money
The Most Connected AND Consented Research Environment in the World
The Best Place In The World To Get Care The Best Place In The World To Do Research
Using clinical data to save lives and save money: The Warfarin story
Professor Sir John Burn MD, Professor of Clinical Genetics at Newcastle University Chair, Newcastle upon Tyne Hospitals NHS Foundation Trust
Using clinical data to save lives and save money: the warfarin story
Professor Sir John Burn MD
FRCP FRCPE FRCPCH FRCOG FMedSci Professor of Clinical Genetics, Newcastle University
Dr Harsh Sheth PhD
Post doctoral Research Fellow Institute of Genetic Medicine
Institute of Genetic Medicine Newcastle University, UK
in the 1990’s
choose the warfarin dose by 2103
would revolutionise healthcare
biotech company with a point of care genotyping
to be blamed when the NHS runs out of money…..
Aithal GP1, Day CP, Kesteven PJ, Daly AK Association of polymorphisms in the cytochrome P450 CYP2C9 with warfarin dose requirement and risk of bleeding complications. Lancet. 1999 Feb 27;353(9154):717-9.
The odds ratio for individuals with a low warfarin dose requirement having one or more CYP2C9 variant alleles compared with the normal population was 6.21 (95% CI 2.48-15.6). Patients in the low-dose group were more likely to have difficulties at the time of induction of warfarin therapy (5.97 [2.26-15.82]) and have increased risk of major bleeding complications (rate ratio 3.68 [1.43-9.50]) when compared with randomly selected clinic controls.
Our Inheritance, Our Future Realising the potential of genetics in the NHS White Paper presented to Parliament June 2003
A Patient now
Mary, 58, AF, GP prescribes warfarin, misses apts., collapse, severe internal bleeding, lucky to survive…
“In the future …..Mary is one of the 4-5% who metabolise warfarin
slowly…..Mary’s GP does a quick pharmacogenetic test using special equipment in the surgery……starts on lower, safer dose of warfarin… suited to personal genetic makeup”
Clotting factors
Vit K VKOR C1
VKORC1
S-Warfarin CYP2C9 *1
S-Warfarin
CYP2C9 *2 CYP2C9 *3 Clotting factors Vit K
1 in 30 N Europeans have all 3 variants & are v. sensitive to warfarin
Pirmohamed M et al, New England Journal of Medicine 2013
In a multi centre trial involving Newcastle, genotype guided dosing resulted in participants reaching the therapeutic window earlier and with fewer episodes of over dosing
Genotype guided warfarin dosing in NHS
Harsh Sheth Farhad Kamali Ann Daly Liz Kendrick John Hanley
Direct acting Oral Anti Coagulants
Personalised Warfarin use
Over the last 10 years, a new class of drugs called Non-vitamin K inhibitor Oral Anticoagulants
Abraham et al. BMJ 2015
Trend for a increase in bleeding risk with increase in age for DOACs compared to warfarin
British Medical Journal, 26th July 2014 British Medical Journal 26th Sept 2016 In the clinical trials,
was lower than in routine care
BUT
If the people on warfarin were In the therapeutic range more Than 66% of the time, then Warfarin was superior In Newcastle the INR clinic has over 70% in the normal range
People who take drugs that aren’t monitored are more likely to forget
Adherence data for oral anticoagulants in 380 Nationally-distributed General Practices (2,143 GPs) in Sept 2016 using selected InPS Vision clinical systems. warfarin dabigotran
CCGs that spend more on anticoagulation don’t get lower stroke rates
Number of prescriptions (n)
Prescription trend by GP practices in Newcastle area 2014-15
GPs spending 25x per patient more on NOACs prescription compared to warfarin
£400,000 WARFARIN 20,000 6000 RIVAROXABAN
Telephone apps already exist to calculate optimal dose. All that is needed is the bedside device
Nanowire chip PCR
Born April 2014 QuantuMDx disposable gene test lyse,extract,amplify and analyse in under 20 minutes DNA
extraction
Working Prototype
Lyse and extract Amplify by thermal PCR Genotype biosensor Drug sensitivity: warfarin Human Papilloma Virus Drug resistant Tb STIs BRAF Sample to result in 15 minutes for under £20
Expenditure on anti-coagulants rose by £400 million across England in the year to March 2016 for limited health gain
Routing of patients to warfarin/ DOAC based on genotype
Reduced bleeding with edoxaban in sensitive and highly sensitive responders compared to warfarin (low dose P=0.0036; high dose P=0.0066)
Mega et al. Lancet 2015
6mg, 24% 5mg, 7% 4mg, 31% 4mg, 4% 4mg, 1% 3mg, 0.5% 4mg, 8% 3mg, 6% 3mg, 1% 3mg, 13% 2mg, 3% 2mg, 0.1% 1mg, 0.2% 1mg, 0.1% 2mg, 1% 1mg, 0.3% 2mg, 0.2% 2mg, 2%
Norway prescription database and cancer registry
Cohort 1,256,725 Cancer 132,687 Warfarin users 92,942 (7.4%)
IRR 0.84 95% CI 0.82-0.86 Lung 0.80 prostate 0.69 breast 0.90 Sub group AF patients IRR 0.62 (0.59-0.65)
Lung 0.39, prostate 0.60, breast 0.72 colon 0.71
Summary
most people with good monitoring
a major part of warfarin sensitivity
make warfarin the better option for most people
the clinic
Newcastle pilot across the region, reduce stroke rates and save money
Ensuring quality clinical information at the point of care
Anne Cooper, Deputy Clinical Director and Chief Nurse, NHS Digital
Ensuring quality clinical information at the point of care
Anne Cooper, Chief Nurse, NHS Digital
@anniecoops #datasaveslives
1984
@anniecoops #ehilive
Today
49
@anniecoops #datasaveslives
On the front line
50
@anniecoops #datasaveslives
Supporting safer care
51
@anniecoops #datasaveslives
The half-life of data and Data Quality
52
‘Digital data does not decay like the information we record on paper. In a digital world data maintains its value and potentially has value beyond an individual person’s care’
@anniecoops #datasaveslives
Getting to grips with data and consent
53
Nursing Terminology and Standards
54
‘We need national nursing information standards that we can apply across professional practice that will enable us to; examine nursing outcomes, share safely and support accurate artificial intelligence’
The Future?
55
@anniecoops #datasaveslives
Questions? @anniecoops Anne.cooper@nhs.net
Refreshments
Sharing for caring: The MIG Story - the past, present and potential
Dr Mark Westwood, Dr Mark Dornan Dr Phil Stamp,
Mark Westwood
mark.westwood @gncr.info
Chronology of IT Wall of Cool
“super highway
theatre
week
but unfunded
North Tyneside CCG Northumberland CCG
co founder/founder ) CHC emerging as a possible project
/Great North Care Record
cross platform appt booking and get to alpha stage for a shared care record EOL POC
October 2015 Tyne2tweed I tyneside Great North Citizens record Great North Care Record
Dr Mark Dornan GP, NGCCG, SRO for the Digital Care Program
https:/learning.necsu.nhs.uk/ elearning/mark-dornan/story.html
Brian’s story- Why
The MIG story
Challenges
Recap - What is MIG & ISG?
Ambulance & NHS111 service.
Investigations, Encounters, Admissions and Referrals.
Agreements) –
To Share or Not
– The majority of those which have not activated sharing are from TPP SystmOne practices. – Some have responded saying that the ICO’s concerns re SystmOne EDSM sharing model are the reason they haven’t activated.
records held by GPs on TPP SystmOne–
centred on the fair and lawful processing of patient data on the system and ensuring adequate security of the patient data on the system. We continue to work closely with TPP...’ [Mar-17]
– TPP has confirmed it is piloting new functionality in its SystmOne electronic patient record, with a view to addressing data protection concerns raised by the Information Commissioner’s Office (ICO). [www.digitalhealth.net Aug-17]
GP Practices- 92%Signed up 88% Active 16145 records shared in Sept
GNCR Website
www.greatnorthcarerecord.org.uk/?article=resource s-for-gp-practices www.greatnorthcarerecord.org.uk/about/information- for-care-professionals/
Includes: Video piece on the benefits/use of MIG Feedback from clinicians using the MIG Example Privacy Notice content Statistics, by CCG area, detailing where patients go for Emergency, inpatient or outpatient care FAQs IG Governance & Security info Latest on EDSM / ICO concerns (or other emerging issues) Surgery screen ads, patient leaflets & posters Glossary
The Future
Organisation Region Local Area
We can’t afford.. … not to do this
Dr Phil Stamp A&E Consultant CCIO
Approximately 300 ED patients per day, around half arriving by ambulance
How it was before January 2016 ….
limited, stand-alone, no single sign on)
to lead to costly, unnecessary interventions and poor or inefficient patient care.
Worst case scenario:
and inaccurate record based on patient recollections and out of date information and makes decisions based on this.
training to be good at making the right decision based on the above with a strong emphasis on being cautious.
January 2016
reassurance about the consent model, The MIG went live and was available in Northumbria Healthcare’s clinical portal through single-sign-on.
effect:
(for illustration purposes only, not MIG)
Accessing the MIG in ED
Consent
MIG
Benefits of the information sharing
faxing).
information – supports <4 hour target.
we had already! – avoids repetition.
easily available.
How MIG actually helps clinically
1.Elderly confused lady – when Head Injury commented on in MIG. 2.Low BP in ED – confirmed to be normal for patient by reviewing MIG 3.Presence or absence of PMH helps steer management in multiple cases especially when the patient can’t speak for themselves (eg drug or alcohol dependency, diabetes, dementia).
My ED wish-list for next phases of info sharing
the information to be incorporated into a digital ED record rather than just displayed on a monitor– this would save even more time – would just need to check the accuracy rather than copy it – could save perhaps 15-20 minutes per patient!
care information
directional flow of information – still too many silos!
Antibiotics started by GP but not yet on SCR: Hydroxocobalamin - dates last given (not even on the SCR record). Temporal arteritis diagnosis – so saves phoning the GP to check why on steroids. recent weight - dosing if not able to weigh on admission, past weights guiding on wt loss. Useful particularly within
backtrack through all past issues to determine if/when patient on bisphosphonates and if had treatment breaks (particularly useful on a weekend when GP surgery closed) On one occasion the patent had been started on Memantine by the memory clinic it was on the MIG but not SCR Yes - patient with some cognitive impairment/ family not readily accessible/ OOH therefore unable to contact GP surgery - able to establish that abn CXR had already been addressed, etc Much easier in the A&E to confirm regular medications and past medical history, which has been really useful for older confused patients where important things would otherwise be missed Just amazing - reduces guesswork, reduces risk, improves safety, improves effectiveness. We’ve seen the benefits of record sharing with S1 (diabetes), but were missing out on EMIS people; this has been hugely helpful to them and their care
Questions?
When was this written ?
“my healthspace” secure web site.
Older People.
available, and receive a confirmed booking.
Accident and Emergency, or completion of an encounter with NHS Direct, a Walk-In Centre, or an out-of-hours primary care service), information will be available electronically to all clinicians within four hours of the transfer of care. The information will include details of advice given, procedures performed, and medication prescribed.
unstructured recording, and including a variety of input methods such as voice, pen, barcode reading, and keyboards.
planned use of all the above features.
Nought is free
Which = 11.5 p patient @2.5M =£287,500 pa
MIG Use
1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000
Grand Total
July August September
Perils of Cost centre
Context to our challenge https://www.jmir.org/2017/11/e367
Conclusions Implementing new technologies as part of changes to health and social care services is inherently challenging. While policy makers are calling for technology to be implemented rapidly and at scale, the reality is that when dealing with the multiple complexities of health and care, it is extremely difficult to go beyond small-scale demonstration projects. We hope that the NASSS framework will help implementation teams—and, at an earlier stage, technology and service designers—to identify, understand, and address the interacting challenges to achieving sustained adoption, local scale-up, distant spread, and long-term sustainability of their programs
https://twitter.com/trishgreen halgh/status/9267083223042 25280?s=09
Think Do “How do we win” 28
North East Sharing Map on ISG
Social care: A digital perspective
Ann Workman, ADASS Regional Chair (North East) and Director
Health, Stockton Borough Council
What if…….
Social Care - Five Year Forward View
resilient when facing health or care needs.
well at home.
meaningful things during the day or to look for work.
home in their own community.
The Digital Revolution
fully realised in social care.
patchy.
conditions can use devices to help them perform tasks.
Transforming Social Care through the use of information technology
channels.
independent, support Well Being and prevent escalation of crises.
Social Care Workforce
Shared Care Record
Ann Workman
Ann.workman@stockton.gov.uk
Ask the Chief Executive panel
Facilitated discussion
1.) What are the top three things you want the Network to support you on? 2.) How could being a network member support you to work more collaboratively?
Closing remarks and next steps
Professor Joe McDonald
Enabling Collaboration to Lead the World
Enabling Collaboration to Lead the World
Enabling Collaboration to Lead the World
The Collaboration Challenge
Trusts
Your Region Needs You
done
The Budget
The Chancellor, Philip Hammond has made investment in research the centrepiece of his budget. Mr Hammond said extra money for research announced last year would continue to be gradually increased. He also said that the government’s target is to increase public and private research investment from 1.6%
………..But We Are Going To Do This Anyway
Lunch and afternoon workshops Remember to sign up to Discourse
@GreatNorthCare www.greatnorthcarerecord.org.uk https://forum.greatnorthcarerecord.org.uk