Are our roadmaps going in the right direction?

A Physician’s PerspectiveDr Roy Harper

Consultant Physician & EndocrinologistThe Ulster Hospital

Visiting Professor, School of Mathematics and Computing The University of Ulster

What about heading to a place where?

Use ICT to support patients, healthcare delivery and healthcare personnel

- making it easier- making it better- making it safer

Systematic Review: Impact Of Health Information Technology on Quality,

Efficiency, and Costs of Medical Care. Chaudhry et al., Ann Intern Med 2006;144:742-52.

Improving Safety with Information Technology

Bates and Gawande. N Engl J Med 2003;348:2526-34.

Timeline for Health Computing (Informatics) in Health and Social Care in Northern Ireland (1999 – Present) – A Personal View

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Diamond

Diabetes ECR

installed

HPSS ICT ‘Vision’ HPSS ICT

‘From Vision to Reality’

Emergency Care

Record Pilot Goes Live

ECCH set up

Start of H&C Number roll out

Wireless Carts

NI BCS HIF

set up

First COM 723

at UUJ

Local PACS

Tablet PCs and

remote access

Regional EHR

Research Group

Established

2009

PatientCentre

Di@L-log

Appointed as Physician in

UCHT

RPA

Roll out of PCs in all OPD Consulting Rooms

Pilot ECR

NIPACS

“Information technology is no longer perceived as just a

supporting tool, but has become a strategic necessity for developing

an integrated healthcare IT infrastructure that can improve

services and reduce medical errors”

Source: Le Rouge, Mantzana & Wilson, European Journal of Information systems (2007) 16, 669-671

What about?

Using ICT to support patients, healthcare delivery and healthcare personnel

- making it easier- making it better- making it safer

• ECCH launched January 2008

• To promote health improvement through the use of new technologies

• First project is to establish a large-scale remote monitoring service

Remote telemonitoring • Patients record data on an agreed set of parameters at

a remote location

• Data is routinely communicated to a monitoring centre

• Data is analysed and feedback given as appropriate to support patient self-care

• Incoming data outside of ‘limits’ triggers an alert and ‘response’

• Data is used to support ongoing clinical decision making

Home (self) monitoring technologies can transform

episode driven health services into a relationship based continuum of care

E A Balas 1999

Does it work in diabetes care?

Transformation from Industrial Age Medicine to Information Age Healthcare

Source: Adapted from Malaysian Telemedicine Blueprint

Industrial Age Medicine Information Age Medicine

TransformationThrough Cost-Effective

Use of Information & Communication Technologies

Person

Community

Primary

Secondary

Tertiary

Individual Self-Care

Friends and Family

Community Networks

Professionals as Facilitators

Professionals as Partners

Professionals as Authorities

Ongoing Information & Support Regular Feedback on Progress

Patients increasingly need (and demand) ready access to feedback on their progress with advice from HCPs

Before RTM (n=65) After RTM (n=65)

HbA1c Weight Systolic

BP

Diastolic

BP HbA1c Weight

Systolic

BP

Diastolic

BP

Mean 9.2 94.8 137 75 7.8 94.8 133 74

SD 1.6 23.6 19 11 1.3 21.7 16 10

Mean HbA1c (n=65) was 9.2 % before and 7.8 % after the period of remote telemonitoring (RTM) and the difference was highly statistically significant (p <0.0001).

The median reduction in HbA1c from baseline after the period of RTM was 1.2%. Only 8% of

patients had an HbA1c at target (i.e. ≤ 7%) prior to RTM compared to 28% after RTM.

4 - 5 5 - 6 6 - 7 7 - 8 8 - 9 9 - 10 10 - 11 11 - 12 12 - 13 >130

5

10

15

20

25

HbA1c frequency distribution

Before RTM After RTM

HbA1c (%)

Num

ber o

f pat

ient

s

Remote telemonitoring

JB

JMcM

And so RTM may help those:• With diabetes (and co-morbidities) experiencing

repeated hospital admissions

• With type 2 diabetes starting on insulin / GLP-1 agonists

• Pregnant or preparing for a pregnancy

• With type 2 diabetes and suboptimal blood sugar or blood pressure control

• Preparing for major surgery

• With type 1 diabetes

Remote home-based telemonitoring – what have we

learn’t• Useful for a wide range of patients• Patients like it• Amazing amount of incoming data• Positive outcomes• Initial triage by someone else is helpful • Safety limits (4-16) are not always relevant• Software could be better• Requires a dedicated weekly virtual clinic session • Permits frequent treatment adjustments• Promising in terms of improving blood sugar control

Conclusions• Home-based remote telemonitoring (RTM) can be

used to support and motivate patients with diabetes improve their self-management skills and their diabetes.

• Clinically relevant improvements in HbA1c were seen in patients using RTM for 12 weeks.

• Patients readily accept RTM. Significant changes to working patterns and a redeployment of resources will be required for RTM to become widely used and accepted by clinicians.

Sort of solutions available

• Patient web portals

• Call centre type approach

• Mobile phone-based support solutions

• Remote home-based telemonitoring

• Voice activated RTM solutions (e.g. Di@L-log)

Secure Server

PHR

ECG Monitor

Activity Monitor

Blood Pressure Monitor

Glucometer

Mobile Phone

Home PC

Care Support Team

GPRS

Di@L-log

Smart Clothing

Automated data transfer

Manual data transfer

Demonstrate the advantages (NHS context)

Can it work? to Will it work?• Patients

– Safe– Acceptable (and used)– Better Outcomes

• HCPs– As above– Improves Efficiency

• Healthcare System– As above– Cost-effective

Self-monitoring technologies with regular feedback and

support can transform episode driven health

services into a relationship based continuum of care

supporting self-care

E A Balas 1999

Innovation

And so ‘connected health’• Has little evidence in our health economy

• Limited potential

• Increases workload

• Lots of ancillary (superfluous) data which is hard to interpret and out of context

• Not another system!

• ….And so little clinical engagement

What about?

Using ICT to support patients, healthcare delivery and healthcare personnel

- making it easier- making it better- making it safer

Problems around the way we record and use clinical

information

Very much a paper-based world

The problem is in accessing key information

• Many disparate clinical systems• Multiple log-on’s to lots of different password

protected systems• Only access to a single clinical domain or

service• Ever increasing amounts of clinical time

devoted to locating information• Preventing effective and timely decision-

making

The answer – a NI-wide ECR

Key information from various disparate legacy clinical information systems

brought together effectively and collated within a secure regional

electronic care record (ECR)

Quite feasible

Here’s what’s happening • HSC supported a proof of concept study

• Pilot ECR is up and running

• Running for >12 months

• Very positive evaluation

• Case made now for regional ECR

Before ECR

PAS A&EPACS

South Eastern

Labs Renal G P Comm

Others

H&C

Belfast Northern

Southern WesternWesternGP’s

With ECR

Belfast

Western

Northern

Southern

Southeastern

Virtual Patient Record

Single sign-on, Security, Auditing, Business rules

Patient Access to Personal Health Records

GP’s

What do we need • Continued investment in HSC ICT

infrastructure

• Support and long-term investment to deliver a Regional ECR for the population of Northern Ireland

• Support healthcare workers with the information tools they need

• Quantum leap in efficiency, quality and patient safety

Effective ‘Connected health’ approaches

• Copy letters to patient• Use the telephone• Use SMS• E-mail• On-line contact ….via a web-portal

Purpose built

Innovative

Need to find the right interface device

Summary• Current and emerging technologies will transform

healthcare• Demand new ways of working• Connected health is about enhanced communication• Solutions must support patients and healthcare

personnel• Use our data and information optimally• Integrate data from RTM solutions into ECR

• Opportunities here

Are our roadmaps going in the right direction?

A Physician’s PerspectiveDr Roy Harper

Consultant Physician & EndocrinologistThe Ulster Hospital

Visiting Professor, School of Mathematics and Computing The University of Ulster