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Integrated care pathways

Integrated care pathways. Dr Jeremy Rogers MD MRCGP Senior Clinical Fellow in Health Informatics Northwest Institute of Bio-Health Informatics. Talk Outline. ICPs e ICPs Challenges. History of ICPs. Industrial process management tool from 1950s Healthcare in US from 1980s UK from 1990s

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Integrated care pathways

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  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 T&C, UK) • National Pathways Association (Northgate) • NPfIT

  4. Where we are now:What’s 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. What’s 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 >60 years twice daily pre-mix* <60 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. 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 • (<10% ?) • Airdale, Battle • eICP rare • ~60 in use at Gloucester NHS Trust (ERDIP), in urology No. in use per trust

  8. The Future:What’s an eICP ? • Versioned • Iteratively developed • Links to guidelines, protocols, evidence • Activity specs • Valid state changes • Role specification • Explicit overall objective Model pathway Instantiated pathway • Patient demographics • Patient characteristics at start • Care plan • Individualised • Activities carried out or not carried out • Outcome • Reasons for variance

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

  10. 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

  11. 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

  12. 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 Implementation:Barriers to the Future

  13. Human Factors:Likely 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.

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

  15. Barriers:Technical eICP Authoring PROS CONS • Software supported • Re-use of modules • Standard Components • timeframes, interventions, evidence, references, and goals/outcomes • Geographically distributed authoring • Increase accessibility of process, buy-in ? • 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

  16. 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 Barriers:Political & Commercial POLITICAL COMMERCIAL

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