Feature / Getting connected

01 July 2013

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A recent round-table event explored the potential for IT to help local health economies deliver a transformed health service. Seamus Ward reports

Integration of services is one of the key challenges facing the NHS as local commissioners and providers look to deliver transformational change. Integrated services should mean they are delivered closer to the patient, clinically effective and are better value for money. But the NHS must first put in place systems that will support the delivery of integrated care, with perhaps IT being the most important.

That much was agreed at a recent round-table event organised by HFMA commercial arm HCS and Net.Orange, and attended by clinicians and senior finance and IT staff.

No one was suggesting truly integrated care was just a flick of a switch or a click of a programmer’s mouse away. But it was accepted that technology was needed to ensure information about patient care was collected, analysed and shared.

A number of messages emerged from the discussion. These included the need to align financial incentives to promote integration, care coordination and greater self-care. IT had to come out of the back office and be regarded as a critical support function. Healthcare professionals and managers had to engage in decisions about IT procurement. They should also ensure that IT procurements eventually lead to seamless delivery across organisations to produce better patient care and cost improvements.

Participants said technology could help the NHS support patients after they have been discharged from hospital – for example, by providing reminders to take medicines or by monitoring information on their care plans and health status. Care coordination services should be targeted by analysing available data to focus on patients at risk of readmission. This, in turn, should take pressure off A&E and hospital capacity.

Barriers to integration

However, in a wide-ranging discussion, a number of practical, financial and cultural barriers to integration of services were identified. Net.Orange programme manager Bill Morrison – a former NHS director of informatics – said financial incentives were often in the wrong place, while organisational boundaries also limited integration. 'Healthcare IT is generally focused within organisational silos, rather than integrated services,' he said.

Traditionally, IT spending has been driven by the IT department and not linked with a healthcare body's clinical needs. This remains the case in many NHS organisations. Today, it is focused on ‘non-transformational’ areas, such as legacy patient administration systems and upgrading the operating systems in desktop computers (many trusts still use Windows XP), he said.

But there has been a change in industry over the past 10 years  and IT policy is now synchronised with the needs of the organisation. This has meant moving IT out of the back office and recognising it as a vital function in an organisation’s success.

This is beginning to be the case in some health service organisations. 'The IT department in some organisations now report directly to a clinical director. This is the right thing to do as it is positioning the IT function to deliver and is key to leveraging the value of IT to the organisation,' Mr Morrison said.

Care responsibilities

There was a discussion about care responsibilities in an integrated health economy. Around the table. there was a feeling from both those with a clinical and a finance background that patients would have to do more to manage their health. Again, IT could help.

Participants also examined the responsibilities of the healthcare providers – for example, if a patient with heart failure has not had self-care education and support, who should be responsible for ensuring that this is delivered?

Many of those present believed an integrated IT system should raise the alarm. ‘Rather than thinking in terms of primary, secondary, community and social care, think about chronic disease management,’ Mr Morrison said. ‘You can use patient information to focus resources on the right patients to make a difference. This would be based on evidence-based pathways augmented with professional judgement as necessary.

‘To ensure an integrated care programme is effective, you need a care management tool, as all the carers – in the community, social care, GP and acute setting – must be able to see the care plan. It should give clarity about who should be doing what at particular times and drive quality using medically proven pathways and real-time decision support.'

One doctor expressed frustration that integration was still at the discussion stage rather than being a reality. The lack of available useful information was a barrier, he said. 'The NHS is awash with information but very little of it is of practical use.'

Doctors would like to have information about the costs associated with individual patients across different care settings and for particular interventions and treatment options, he added. 'Give us information rather than data. If you have this, you will deliver care in the right way; you will deliver economic care.’

Net.Orange executive vice president and chief medical officer Rob Beardall said clinical engagement in using the IT was vital. And he added that identifying the right patients was crucial to success. In general, the NHS did not have the tools to achieve this.

‘An electronic patient record does not help manage the data across organisations – you need help to see which information is important, to contextualise the data,’ said Dr Beardall.

‘Also, EPRs are designed to help organisations meet the financial environment they are in – for example, in general practice they help doctors get quality and outcome framework points, but they have substantial limitations in terms of how to proactively improve the health of the population.

‘Ideally, you should be able to pull data from different systems to create a pathway for a patient with all the things that should happen over time. If something hasn't been done, the system should flag that up.’

Information technology could bridge existing IT silos and underpin integrated healthcare, ensuring up-to-date information and the care plan is shared between professionals and different organisations. This could facilitate proactive care and ongoing monitoring with a focus on those most at risk. However, cultural, financial and practical barriers must be overcome if the NHS is to realise its full potential.

Decision support

Macmillan Cancer Support is piloting a decision support tool to help GPs spot patients at risk of developing tumours. The software is based on algorithms developed by academics and is integrated into the GP’s IT system. It can operate with any GP system.

Macmillan early diagnosis programme manager James Austin says the software works in three ways. Its first role is during a consultation. When a patient comes to the surgery and their notes are opened, the tool assesses the notes for the past 12 months and calculates their cancer risk. The GP then decides whether to refer them for more tests.

‘It can be a powerful tool. If someone has been to the GP a few times and seen different doctors each time, the computer will piece together the story,’ says Mr Austin.

Second, if, given a patient’s symptoms, a GP suspects a particular type of cancer, they can use the tool to call up information

on that cancer, add in symptoms and check the risk level. The tool’s third function is for risk stratification. It examines a practice’s registered list, looking at the past year’s records and identifying patients with a higher risk of developing cancer.

The pilot, which is being held in more than 500 practices in England and Wales, is focusing on five tumour sites:

  • Pancreas
  • Upper gastro-intestine
  • Lung
  • Colorectal
  • Ovarian.

Mr Austin says these were chosen as it is often difficult to know when to refer in these cases, and they offer good opportunities for improved outcomes if diagnosed early. The pilot will end in autumn and is partly funded by the Department of Health.

‘The software is very scalable and if the findings are positive, there is no reason why we can’t have it in every GP surgery in the country,’ says Mr Austin.

IT strategy drivers

The UK is not alone in the challenge of IT silos, writes Net.Orange’s Rob Beardall (below). There is good evidence from the US that current commercial electronic patient records have been driven by historical clinical documentation needs, with a heavy emphasis on supporting the administrative processes and revenue generation rather than clinical management and patient needs. 

Both countries – in fact, probably all international health systems – are looking to evolve their models of care toward more integrated, proactive health management, managing the health of whole populations and particularly those with chronic disease.

The narrow focus on becoming ‘paperless’ without explicitly defined procurement requirements to support population health management risks achieving this critical ambition.

Recent research published in the Journal of General Internal Medicine (O’Malley 2010) evaluating existing electronic patient records’ ability to support care coordination identified six key findings:

  • EPRs facilitate within-office care coordination, chiefly by providing access to data during patient encounters and through electronic messaging.
  • EPRs are less able to support coordination between clinicians and settings, in part due to their design and a lack of standardisation of key data elements required for information exchange and a reluctance by many system vendors to facilitate interoperability.
  • Managing information overload from EPRs is a challenge for clinicians.
  • Clinicians believe current EPRs cannot adequately capture the medical decision-making process and future care plans to support coordination.
  • Realising EPRs’ potential for facilitating coordination requires evolution of clinical operational processes.
  • Current reimbursement encourages EPR use for documentation of revenue-generating events (office visits, procedures) and not of care coordination.

Designers of health information technology (HIT) systems to support transformation must keep these findings in mind. The HIT landscape is undergoing rapid change as computing power expands, HIT platforms change and the expectations of providers, patients and payers shift. The starting point must be an explicit statement of strategic clinical goals. These goals, unlike typical HIT goals, include sharing information and creating performance reports.