What do we expect and require from IMT?

1. What do we expect and require from IMT? Dr Sunil Bhandari Consultant Nephrologist/Honorary Clinical Reader Digitised citizen – join up systems and services that contribute to a 21st century health service

3. Do we know what we need? Do we know what we want? Do we understand what may be available? Do we know what patients want or even do they know? Fears – are we misguided?

4. Do we know what we need?

5. Competencies set by GMC for Doctors Diagnosis and Decision making Treatment – electronic prescribing/ TOXBASE Teaching and training - Evidence base - Up to date - databases Audit Keeping accurate records Team working Time management Education – e-portfolios, e-induction, Risk – Datix IMT CAN ENHANCE THESE

6. How reliable are NHS Staff at following recommendationsKeeping accurate records • What percentage achieved this? • Doctors Nurses • 12% 10% • 30% 35% • 80% 96% • 6% 9% • 95% 97% • 12% 17% All medical entries require • Name- printed • Grade/Title • Date • Time • Signature • All of above NHS Trust Audit 2009

7. What is the job of a Doctor? “are we really that important” • What skills do we possess and can they be replaced? • Diagnostic reasoning skills - making a diagnosis • Information Provider • Interactions – Support and Reassurance • After Care • Education and Teaching • Research • Management It can in part be digitalized

8. An “evidence based” decision Evidence From Research Patient Preferences Clinical Expertise EVIDENCE BASED DECISION Available Resources

9. Evidence from Research Aksentivevic D, Bhandari S et al Kidney International 2009

10. Available Resources

11. Clinical Expertise Is there a place for clinical expertise? Decision support tools which apply clinical logic ? Interpretation of data ? Rare cases Only as good as the information imputed Improve clinical decisions Avoid preventable errors

12. Patient Preferences Patient and service users being active participants in their care • Alcohol • Cigarettes • Family • Sex • TV – what’s on tonight • Money • Work • Dress and style • Football • What my neighbour thinks of me • Health Life’s Priority What interests patients

13. Do we know what we Need?

14. Do we know what we want?

15. The current issues? Qualified but not necessarily IT savvy simple and user friendly Haphazard and random training needs structure Varied systems in different hospitals streamline

16. A Quality Framework to Enable Quality Improvement Bring clarity to quality – standards Measure quality Publish quality performance Recognise & reward quality Clinical leadership Safeguard quality Stay ahead • NICE • NHS Evidence • Metrics – local, national, international • Clinical dashboards • Quality accounts • NHS Choices • International measures • CQUIN • SHAs – Medical Directors; clinical advisory boards • National Quality Board • Care Quality Commission • SHA - duty to innovate • Academic Health Science Centres • Health Innovation and Education Clusters Maximise Quality & Safety in Health Care From Donal O’Donoghue Tsar for Renal Medicine UK

17. Universal Recording

18. Do we understand what will be available?

19. The NHS Challenge:Quality, Innovation, Productivity & Prevention Public Sector Net Debt From Donal O’Donoghue Tsar for Renal Medicine UK

20. The NHS needs to plan for making huge efficiency savings £15-20bn productivity challenge Illustrative figures only From Donal O’Donoghue Tsar for Renal Medicine UK

22. Operating Framework 2010/11 “To put into effect changes that will deliver the most benefits to patients we need to focus on three things: Improving quality whilst improving productivity Local clinicians & managers working together to spot opportunities & manage change To act now and for the long term “If we are successful, the NHS in 5 years time will have more services closer to home & therefore less investment & activity in the acute sector.” “The quality and productivity gains we need to make lie at the interfaces between primary and secondary care, health and social care and empowered patients and the NHS.” Sir David Nicholson CBE:

23. UK Renal Registry 9th Annual Report 2006 Registries – Comparing Data

24. Do we know what we need? Do we know what we want? Do we understand what is available? Do we know what patients want? Fears – are we misguided?

26. “No decision about me without me”

29. Patient View – UK Renal system 14,000 Registrants in the UK Does not Increase Patient Anxiety Increases Quality of Consultation Increases Trust Encourages Patients to take Control

30. Fears – Are we Misguided?

31. Small changes can have big Effects MOLECULE MAN C2 H5 OH C H3 OH ETHANOL METHANOL Drunk Blind Dead Drunk

32. Its time for a change?

33. Intuitive ? CorrectDisasters among babies • Routine practice in 40s & 50s to give premature infants pure oxygen • It was noted that there was an ‘epidemic’ of blindness among premature babies • RCT - Linked to oxygen use.

34. A Culture change for Clinicians • No excuse to make mistakes • Results instantaneously available – yet we do not look at them until we see the paper results, then we cannot remember who it is and need the notes rather than interrogate the computer • Paper results not robust – a scribbled signature • No audit trial – IT’S A NO BRAINER

35. What are things like today and is all what it seems?

36. Lets talk about Cows INFECTION Control No Medications Slow Cumbersome inconsistent User Friendly? Fails to deliver

37. Cows-The Good the Bad & the Ugly

38. Cows-The Good the Bad & the Ugly • Ordering tests – still have 2 renal consultants on system – one retired and one left – 7 years ago • Computers cannot cope with data

39. Cows-The Good the Bad & the Ugly • Too simplistic graphs • Data trends required Multiple crashes

40. How safe is IMT Once summary case record system comes fully online every item of interest available digitally will find its way into the public domain “news is what somebody somewhere wants to suppress; all the rest is advertising” T Delamothe BMJ 2010

41. Downsides for the clinician? Immediate access to doctor Information overload Discourages deep critical thinking Less able to think & reason out problems ? Are computer making us smarter

42. Time for a Break

43. Clinical Practical Situations

44. Lessons from Australia What am I doing here? A great place to live

45. Lessons from Australia • The good aspects of IT in Australia leading to • more clinical effectiveness • better communication with patients e.g. clinics • GP interactions – virtual consult

46. A Single Unique Identifier • HEY numbers • NHS Number • Case record Number MEDICARE CARD NUMBER CARRIED BY PATIENT

47. The paperless system Dictation Results Consults – reduced text Real time data with patients PDA based practice Reduced writing clinical records Reduced duplication More time to deliver clinical care Flexible system

48. The Emergency Admissions

49. The Ideal Clinical Ward Round E-prescribing Display patient images Viewing results – trends/graphs Summarising notes Automatic generation of discharge summaries with all investigations, problems and medications Teaching trainees Transparency Patients see action

50. The Clinic Visit • Patient – sitting nervous • Patient agenda V doctors agenda • Solution • communication and information • One stop visit in 24 hours • the Australian model • NOT THE AMU model