Specifying clinical IT requirements for pathways: a national perspective

Dr Mark Dancy

Consultant Cardiologist

National Clinical Lead CHD Collaborative

Potential benefits from NPfIT

• Readily available information• Patients

• Clinicians looking after them

• Ease of communication

• Combined care

• Audit

• Health economics & Public Health

Current position

• Numerous systems

• All different• Software

• Field definitions

• Architectures

• Not designed to communicate• Need paper

Current position

• Many databases designed for audit• Not designed around patient pathway• ‘Minimum dataset’• Implies majority of mandatory fields• Not suitable for EPR• High cost of data gathering – audit clerks

• Integrated care pathways• Within hospitals mostly paper-based• Within primary care – templates

Datasets: different according to purpose

•Clinical processes• history, exam, tests, diagnosis, treatment

•Audit and clinical governance• local and national - NSF targets

• Information for patients •general and personal

• Public health

• Service planning: •demand and capacity

•Finance

Clinical datasets (EPR)

• Needs a lot of data – medicine is complex

• Choice between free text and defined data items (auditable)

• Needs a lot of data items

• Many/most will not be mandatory

• How much of the requirements for other uses will be met by a good clinical dataset?

The ideal system design for clinical input

• Intuitive, fast• Follows predicted workflows• Accommodates the majority of clinical needs

with minimal need for free text• Data entered at point of care• Supports workforce developments (PwSI)• Platform independent• Organisation independent

Potentially difficult areas

• Inpatient care• Complex• Changing differential diagnoses• Changing firms• Logistics of the bedside

• Multiple pathologies• Systems often arranged around single diagnosis

Best test-bed is single disease managed out of hospital

RAPCP Pilot

Dataset development

Clinical systemsmanufacturers

Local developmentNational system

Provisional national datasetFunctional specification

Pilot sites

Maximum choice for end-users

Understanding workflows

Disease management system project: DMSP

• Common principles• Based on patient pathway• Translated into workflows• Platform and organisation independent• Electronic communications

• Three conditions• Heart Failure• Breast Cancer• Diabetes

Referral proforma

Call/recall systems for

chronic disease management

Placed on heart

failure register

Stabilisation

Initiation of Beta blocker &/

spironolactone

Up-titration of drugs

Initiation of treatment with

ACE and diuretics

Requires further

investigations

Preliminary conclusions

? LVSD

Heart failure clinic

Primary care Either Secondary care

Further treatment

LV systolic

dysfunction

Transfer ofreferral data and e-booking

Summary of conclusions

from heart failure clinic

Single message to put on register

a*

Sheet 1

Sheet 2

Sheet 4

Sheet 3

a*: if continuing care to be in acute trustinitiates appropriate arrangements. If to be primary care initiates request message to 1y care to book patient into their clinic

IP admission

Yes

No

Discovered tohave heart failure

in OPD

Heart failure suspected

Where to go from here?

• DMSP is proof of concept• Direct communication between local systems may

be unnecessary in NPfIT (via spine)• Recognition that the interface between the

clinician and the system is the most important element of design

• Extend into other more difficult areas• Major task in ‘information out’