Integrated care pathways
Dr Jeremy Rogers MD MRCGP
Senior Clinical Fellow in Health Informatics
Northwest Institute of Bio-Health Informatics
Talk Outline
ICPs
eICPs
Challenges
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
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
What’s an ICP ?
► Embed guidelines & ► Best use of resources
protocols ► Record variances
► Locally agreed ► Compare plan against
► Evidence based reality
► Patient centred ► Tool for (Clinical)
► Best practice Business Process Re-
engineering
► Everyday use
► Individualised
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
No dehydration or vomiting Admit to RBH
DNS to commence insulin Diabetes Clinical Nurse Advisor
within 24 hours to see
>60 years
<60 years IV insulin
twice daily Data collection
Basal/bolus* as per protocol
pre-mix* 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
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Current UK Status
160 ► 2401 in NELH database
140 ► 1214 subjects
►predominantly surgical
120
► Often admission pro-formas
100
► 170 Trusts writing, 179 using
80
► 10 PCTs writing, 21 users
60
► Not many available online
40
► (<10% ?)
20
► Airdale, Battle
► eICP rare
0
1 51 101 151
► ~60 in use at Gloucester NHS
No. in use per trust Trust (ERDIP), in urology
The Future:
What’s an eICP ?
Model pathway Instantiated pathway
► Versioned ► Patient demographics
► Iteratively developed ► Patient characteristics at start
► Links to guidelines, protocols, ► Care plan
evidence ► Individualised
► Activity specs ► Activities carried out or not carried
out
► Valid state changes
► Outcome
► Role specification
► Reasons for variance
► Explicit overall objective
What’s an eICP ?
Ended pathway What’s an epathway?
► Includes abandoned, rejected, ► MLMs
completed
► GLIF
► Record of variances
► CLIPS
► Patient characteristics
► Activities or activity states ► Protocols
► Performers ► PRESTIGE
► Timings ► Protégé
► Proforma
► SOPHIE
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
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
Implementation:
Barriers to the Future
► Human Factors ► Technical Factors
► Cultural ► Time & Scale
► Organisational ► Too many critical
dependencies
► Cognitive
► Not yet invented
► Time ► Lack of EBM
► Patients
► Commercial ► Political
► Cost
► Expectations
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.
Technical Barriers :
Specific Informatics Problems
► Authoring ► Clinical Terminology
► EPR Data Quality ► Consent
► Indexing ► Visualisation
► Act management ► Automation
► Pace of change
Barriers:
Technical eICP Authoring
PROS CONS
► Software supported ► Automation requires strict logic
► Re-use of modules ► Specialist activity
► Standard Components ► Limits ownership &
participation
► timeframes,
interventions, evidence, ► Edge-of-protocol effects
references, and ► Can be very complex to view
goals/outcomes
► Re-use at risk of ‘curly bracket’
► Geographically distributed problem
authoring
► Chaotic co-behaviour
► Increase accessibility of
process, buy-in ? ► Not done yet
Barriers:
Political & Commercial
POLITICAL COMMERCIAL
► Unrealistic expectations ► Pharmas
► Bad press ► Snake Oil Distractors
► War of authorities ► Apathy in face of
► NICE, BNF, Colleges, BMA, ► Low user demand
Clinical Evidence, NELH,
► More pressing problems
NHSIA, Pharmas etc.
► True development cost
► Covert agendas
► Manage docs, not patients
► Cold feet