NHS ScotlandeHealth Strategy

NHS for Scotland’s 5.2m citizens

• NHS devolved to Scottish Parliament

• Scottish Government Health Directorate

• 14 Health Boards

– all care within a geographical area

• 1030 GP Practices

• ‘special’ Health Boards, eg. national ambulance service

Four things…

1. Do things of use to all

2. Convince that convergence and collaboration is in theinterests of all

3. Incentivise that collaborative activity

4. Put in place appropriate governance

sub title: How do you do strategy in a federated health system?

Scotland’s approach to eHealth

All about the right information to the right people at the right time

• Incremental• Pragmatic• Partnerships • Focus on benefits and governance, not

technology

4

1. Doing things of use to all –how far did this get us up to c. 2008?

• unique patient ID number, national Wide Area Network

• all Health Boards with local instance of national product for online test results, letters etc (both for hospital and GPs)

• truly national PACS service

• national e-communications service (SCI Gateway): 97% GP referrals electronic and structured (but only 3% of discharge letters)

• mature GP EPRs, eg. 98% practices paperless, e-prescribing and transmission

• home telecare installed for 17,000 people, at cost of £7.4m

- evaluation: over 60% of patients feel their quality of life has improved, and 90% felt saver

- £23m efficiencies, eg. avoided unscheduled admissions

• telehealth strategy to focus on ‘mainstreaming’: -

telestroke- paediatrics- COPD- psychiatry- eye care

1. Doing things of use to all –how far did this get us up to c. 2008?

Emergency Care Summary

covering 99.9% of population

1. Doing things of use to all –how far did this get us up to c. 2008?

What’s ECS?

National database containing….

• Patient identity (address, telephone, CHI number, GP)

• Allergies and Adverse Reactions to medications

• Medication

- Repeat prescriptions in past 12 months

- One-off prescriptions in past 30 days

• Patient safety = key driver

• Too much unknown when patient comes to unscheduled care

• Efficient use of clinical time also important

Why did we do this difficult thing?

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System Overview

ECSSyste

m

Request & display

NHS 24

A&E

Ambulance

TBD…

PracticeServer

GP consultation

Check audit log

HealthBoard

GP Practiceadmin

Progress to Date

• 5.4 Million Patient Records available

• 1900 patients have ‘opted out’ of practices connected (represents 0.03% of all patients)

• 6 million accesses to date and increasing trend in use (currently > 50,000 per month)

• Over 11,000 users across different clinical areas

• Expected increase in use as new developments are available

Implementation Approach

• leadership by clinicians and patient reps

• incremental rollout in each Health Board

• national and local communication

• full technical integration where possible

• Assume consent to create an ECS record, but patients can opt out

• Explicit consent from patient for their record to be viewed at point of care

(these provisions go further than the law requires in Scotland/ UK)

• all ‘the usual’ technical security - encryption etc

Confidentiality protections

15

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Costs and financing

• Total investment = £25.3m over 9 years

• IT cost: £3.3m = 13% of total (excludes broadband)

• annual costs now c. £0.6m (mainly 24x7 high specification data centre support)

Emergency Care Summary– benefits

0

1.000.000

2.000.000

3.000.000

4.000.000

5.000.000

6.000.000

7.000.000

2002 2003 2004 2005 2006 2007 2008 2009 2010

₤

Present value of total annual costs Present value of annual benefits

Patient Views

• Patients are very accepting of ECS with over 99.3% giving permission to access

• Patients in hospital or emergency situations (e.g. A/E Department) find it very useful when can’t remember their medication details

• Consumer Focus Scotland reported continued support for ECS

Clinicians Quotes

• “One of the best tools we have got for improving patient safety”

• “ECS has been a godsend, I can’t imagine how we managed without it”

• “It can take ages if we need to phone GP surgery”

• “Before ECS we often had to ‘work blind’ with no information at all.”

• “ECS information can help the most vulnerable patients, e.g. those who are admitted over the weekend who have no one to bring in their meds”

Lessons Learned…

• Incremental approach works for Scotland

• Careful consideration of patient groups and clinical need

• Patient Communication is key

• Clinical Leadership and Championship

Keep it simple

New Developments - ePCS

• electronic Palliative Care Summary

• Moving from paper based forms to shared electronic information for vulnerable group of patients

• Contains significant and sensitive information– Resuscitation Status, Preferred Place of Care– Diagnosis and Current Treatment– Carer Details and Advice for OOH

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New Developments

Key Information Summary (KIS)

Patient name, Address, Patient mobile number

Next of kin details: Emergency contact phone numbers

Usual GP name, Nurse, Care Manager, Specialist Nurse or other contacts, involved in care

Carer Details

Access information

KIS – section 1 – Basic details

KIS – section 2 – Current SituationMain Diagnoses, Current problems

Patient and family understanding and wishes, including goals and expectations

Patient has

- self management plan Yes □ No □

- Anticipatory care plan Yes □ No □

- Shared Assessment Yes □ No □

Home Oxygen, Normal Oxygen saturation

Usual BP Additional drugs available at home

KIS – section 3 – Carer/ Support details

Power of attorney in place?

Adults with Incapacity form Yes □ No □

Compulsory treatment order in the community?

Mental Health Act detention? Yes □ No □

Homecare support in place?

Moving and handling information and equipment in place

Agreed actions

KIS – section 4 – care suggestions

Current place of care

Preferred Place of Care

Special instructions for OOHs

DNA form Yes □ No □

2. Convince that convergence andcollaboration is in the interests of all

relationships relationships relationships

(+ putting financial and delivery responsibilitywhere it should be)

Where common cause exists,national contribution to collaboration

(Hospital Patient Management Systemand

GP system procurements)

3. Incentivise that collaborative activity

Agree aims that have business relevance

Offer funds to support achievement

Health Boards to set outcomes and show 4 year plans for each aim

(acknowledges that Boards at different placesand have different local priorities)

3. Incentivise that collaborative activity

5 strategic eHealth aims

1. Maximise efficient working practices, minimise wasteful variation, bring about savings and value for money

2. Support people to communicate with NHSS, manage their own health and wellbeing, and to become more active participants in the care and services they receive

To use information and technology in a coordinated way to:

1970 – 2000

2000 - 2011

2012 +

patient

£ andeffort

£ &£ &

adminadmin

clinical

clinical

patient

• Online administrative processes, eg. appointment booking, prescription renewal

• Trusted online information advice

• Online clinical services and support, eg. access to test results and e-consultation

• Patient self management

• Tele-monitoring

• Mobile telemetry

Patient eHealth - lots of possibilities

Solutions looking for problems?

yes but with what outcome?

• Improve patient’s health knowledge and ability to manage aspects of their health

• Improve access to services for citizens and patients

• Reduce admin costs

e-correspondence service?

how many paper letters does NHS Scotland send to its 5m citizens a year?

c. 25 million

compare that to banks and energy companies

opportunity to save costs, carbon and give a better service for patients who sign up for e-

correspondence?

Wha

t I w

ant

to do

My care

What I want

to know

My r

ecord

Citizen eHealth Strategy

5 strategic eHealth aims

To use information and technology in a coordinated way to:

1. Maximise efficient working practices, minimise wasteful variation, bring about savings and value for money

2. Support people to communicate with NHSS, manage their own health and wellbeing, and to become more active participants in the care and services they receive

3. Contribute to care integration and to support people with long term conditions

identifying at-risk patients, anticipatory care,supporting virtual wards/ joined-up patient pathways…

5 strategic eHealth aims

To use information and technology in a coordinated way to:

1. Maximise efficient working practices, minimise wasteful variation, bring about savings and value for money

2. Support people to communicate with NHSS, manage their own health and wellbeing, and to become more active participants in the care and services they receive

3. Contribute to care integration and to support people with long term conditions

4. Improve the availability of appropriate information for healthcare workers and the tools to use and communicate that information effectively to improve quality

what information? survey said…

• Past medical history

• Current problem list

• Current medications

• Allergies and Alerts

• Letters – Referral, Outpatient, Discharge

• Tests – Laboratory, Radiology, etc

• Clinical Observations (pulse, BP etc.)

• Local and national clinical guidelines

• Drug reference information (British National Formulary)

clinical portal

‘virtual’ electronic patient record – not about large national database

electronic window to information held in different places, fetched and viewed by

clinician on an as-required basis

Greater Glasgow & Clyde

In a given week some 5500 active users,

accessing 250,000 documents (test results,

correspondence, operation notes, pre-op assessments,

clinic lists, scanned paper records, theatre lists, etc)

+ range of e-forms to replace standard assessments, notes etc

In a given week some 5500 active users,

accessing 250,000 documents (test results,

correspondence, operation notes, pre-op assessments,

clinic lists, scanned paper records, theatre lists, etc)

+ range of e-forms to replace standard assessments, notes etc

the right IT – necessary…

…but on its own not sufficient without that there’s trust in the

safeguards

the right safeguards

through training & awareness, authentication of users, role-based access, single sign-on, audit

log analysis etc

very necessary, but still not sufficient

agreement to share in the first place

5 strategic eHealth aims

To use information and technology in a coordinated way to:

1. Maximise efficient working practices, minimise wasteful variation, bring about savings and value for money

2. Support people to communicate with NHSS, manage their own health and wellbeing, and to become more active participants in the care and services they receive

3. Contribute to care integration and to support people with long term conditions

4. Improve the availability of appropriate information for healthcare workers and the tools to use and communicate that information effectively to improve quality

5. Improve the safety of people taking medicines and their effective use

medicines reconciliation…

NHS Lanarkshire trial

• ECS accessed for 405 admissions

• for 67 patients (22%) ECS contained additional info

for 23 (35%) of those patients potential harm was avoided courtesy of ECS access

+ a separate comparison of 30 referral letters - drugs vs. actual current prescription - found 119 discrepancies

4. Put in place appropriate governance

(with acknowledgements to Accenture)