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					The Map of Medicine in the
North West Update August 2009


James Walker
Map of Medicine Programme Lead NW SHA
Chief Information & Knowledge Office
The Map is a Core Component of NPfIT:




                          The Map of
                           Medicine
 NHS Care Record                              Choose and Book
     Service




                                                                New National
                        Picture Archiving &      GP2GP
                                                                  Network
                         Communications
Electronic Transmission
                             Systems
    of Prescriptions
    The Case for Change in Healthcare!
• The requirement to deliver World Class Commissioning
• NHS Operating Framework - working in a „cash
  constrained‟ environment PCTs judged by results
• Developing patient centric services, more personalised
  care - services closer to home, money following the patient
• More choice of providers including independent sector
• More information / knowledge about what choices to make
• Greater emphasis on quality of services and outcomes –
  PROMS – Commissioning for Quality (CQINS)
• Reconfiguration & Modernisation of Healthcare
• Patient Safety issues – Need to reduce medico-litigation
Closing the Gap
                  US data collated by Professor
                  Bill Runciman, President,
                  Australian Patient Safety
                  Foundation from McGlynn et al;
                  NEJM 2006 Vol 348; p2635-45
    Semmelweis, Vienna 1847
•   High rates of death due to puerperal fever (childbed fever)
•   Women delivered by physicians
  or students mortality rate
 (13–18%)
• Women delivered by midwives
  or trainees (2%)

Prof. Klein:
   Inadequate hospital ventilation

Prof. Semmelweis:
   Handling cadavers prior to delivery
     Instituted mandatory hand washing
     Mortality plummeted to 2%
                                Best, M et al. Qual Saf Health Care 2004;13:233-234
150 years later...Marshall and
Warren – Helicobacter pylori
•   Published seminal paper in the Lancet in 1983
•   NICE guidance 2000; Regimens to eradicate Helicobacter pylori
•   17 years to become standard best-practice
•   How many unnecessary gastrectomies and selective vagotomies?

     c10,000

Drugs like Thalidomide, Cox-2 inhibitors
Overuse of antibiotics - MRSA and antibiotic resistance
Drug-drug interactions
Others yet to be identified
 Highest rates for heart        Nearly a quarter of
  disease and stroke          children live in poverty

          16% people                   23% of adults
          on benefits                  binge drinkers

 The Case for Change in the NW
                            Average life expectancy 3
   Highest rate for        years less than the UK best
  long term mental
   health problems
                                         60% of adults
                                         overweight or
   2nd highest rates - deaths from
                                            obese
cancer and smoking related illnesses
The Problem
                                 Diabetes Guidelines                        Chronic Heart
                                                                             Disease NSF




 SUS Data


                        Draft Service                                                 Population profile
                           Review


                                              Prescribing data


      Internal
                                                                      My Documents
    memorandum


                                    Business Objects
                                        Reports

            Public Health Team                             Trust Board Report
NWSHA Map of Medicine RAG
Status January 2008 Map Views
    Ashton, Leigh & Wigan       A
    Blackburn With Darwen       B           H
          Blackpool             C
           Bolton               D
             Bury               E
 Central and Eastern Cheshire   F
      Central Lancashire        G
          Cumbria               H
       East Lancashire          I
     Halton & St Helens         J
                                                 O
Heywood, Middleton & Rochdale   K
          Knowsley              L
           Liverpool            M       C                     I

         Manchester             N
                                                G         B
       North Lancashire         O
                                                                    K
          Oldham                P       R                 D    E
                                                      A                 P
          Salford               Q                             Q             T
           Sefton               R               L J           U N
                                            M         V             S
         Stockport              S   X
     Tameside & Glossop         T
           Trafford             U                             F
        Warrington              V               W
      Western Cheshire          W
           Wirral               X
NWSHA Map of Medicine RAG
Status April 2008 Map Views
    Ashton, Leigh & Wigan       A
    Blackburn With Darwen       B           H
          Blackpool             C
           Bolton               D
             Bury               E
 Central and Eastern Cheshire   F
      Central Lancashire        G
          Cumbria               H
       East Lancashire          I
     Halton & St Helens         J
                                                 O
Heywood, Middleton & Rochdale   K
          Knowsley              L
           Liverpool            M       C                     I

         Manchester             N
                                                G         B
       North Lancashire         O
                                                                    K
          Oldham                P       R                 D    E
                                                      A                 P
          Salford               Q                             Q             T
           Sefton               R               L J           U N
                                            M         V             S
         Stockport              S   X
     Tameside & Glossop         T
           Trafford             U                             F
        Warrington              V               W
      Western Cheshire          W
           Wirral               X
NWSHA Map of Medicine RAG
Status September 2008
    Ashton, Leigh & Wigan       A
    Blackburn With Darwen       B                                  H
          Blackpool             C
           Bolton               D
             Bury               E
 Central and Eastern Cheshire   F
      Central Lancashire        G
          Cumbria               H
       East Lancashire          I
     Halton & St Helens         J
                                                                        O
Heywood, Middleton & Rochdale   K     = LHCs with Live
          Knowsley              L
           Liverpool            M   view on CSC instance       C                     I

         Manchester             N
                                                                       G         B
       North Lancashire         O
                                                                                           K
          Oldham                P                              R                 D    E
                                                                             A                 P
          Salford               Q                                                    Q             T
           Sefton               R                                      L J           U N
                                                                   M         V             S
         Stockport              S                          X
     Tameside & Glossop         T
           Trafford             U                                                    F
        Warrington              V                                      W
      Western Cheshire          W
           Wirral               X
NHS NW Map of Medicine RAG
Status July 2009
    Ashton, Leigh & Wigan       A
    Blackburn With Darwen       B                                      H
          Blackpool             C
           Bolton               D
             Bury               E
 Central and Eastern Cheshire   F
      Central Lancashire        G
          Cumbria               H
       East Lancashire          I
     Halton & St Helens         J
                                                                            O
Heywood, Middleton & Rochdale   K     = LHCs with Live
          Knowsley              L
           Liverpool            M   view on CSC instance           C                     I

         Manchester             N
       North Lancashire         O   All 24 PCT Led Local                   G         B
                                                                                               K
          Oldham                P   Health Communities             R                 D    E
                                                                                 A                 P
          Salford               Q
           Sefton               R
                                    have their own „view‟ of               L J
                                                                                         Q
                                                                                         U N
                                                                                                       T
                                                                       M         V             S
         Stockport              S   the Map of Medicine        X
     Tameside & Glossop         T
           Trafford             U                                                        F
        Warrington              V                                          W
      Western Cheshire          W
           Wirral               X
NHS NW Objectives for the Map
• To make the Map of Medicine available to all NHS &
  Social Care organisations
• To inculcate Clinical Ownership & uptake of MoM
• To exploit the potential of the Map to support improved
  care outcomes to support WCC & Healthy Horizons
• To facilitate improved Clinical Governance
• To implement an „evidence based‟ knowledge tool
• To implement a sustainable MoM Programme
• To make the Map of Medicine a single point of
  reference for patient-centric care, regardless of where
  care is delivered: Primary, Secondary or Tertiary Care
• Developing a vision for the Map to support improved
  care outcomes in NHS NW
Context - Current Status
• Sponsor - Alan Spours the NHS NW Chief Information &
  Knowledge Officer (CIO) is driving the national NHS CIO
  network for MoM adoption
• SRO Dr Andy Coley‟s NHS NW Chief Clinical Officer & Co-
  Founder of Clinical Leads Network www.cln.nhs.uk
• SHA resources in place to implement MoM & raise awareness
• 100% Technical enablement of MoM in the NW
• Utilisation of MoM in 22/24 PCT Led Local Health Communities
• Strong clinical engagement
• Utilising MoM to improve & standardise health care provision
• Utilising the Map to support enhanced quality of care in NW
• Striving to win „hearts & minds‟ of clinicians
• At the early stage of a move towards BAU for MoM
Objectives of Map Roll Out in NHS NW -
What Are We Aiming to Achieve ?
 Facilitate Redesign & Delivery of Health Services:
    Delivering Patient Centred Services

    Empowering Patients & Clinicians

    Improving Quality of Health Care

    Delivering Seamless Services

    Making Better Use of Resources
The Map of Medicine is developed In
partnership with clinicians and….
What is the Map of Medicine?
                   Localisable
                   benchmark for
Framework for      clinical
sharing clinical   processes
knowledge across
care settings
                         Evidence
                         based care
                         pathways
                         available in
                         any setting
Saves re-inventing the content
wheel locally
   How do I access the Map?


Access is via Smartcard and from within N3



 Patient Access via NHS Choices website
 http://healthguides.mapofmedicine.com
Registration Authority – Process
 •    Registration Authority – process by which
      users will gain access to NHS Spine
      applications:e.g. MoM, Choose & Book,
      ETP & Summary Care Record Service etc
 •    Access to services by smart card
 •    Single sign-on process described during
      procurement


                                       Local
                                      Network   NASP and LSP
                                       / N3      applications
     Users    Smart Card   Trust PC
               Plus PIN
SmartCards – Will Look Like This..
Chip & PIN - Only a lot better looking!



              James Walker
              Modernisation
              Programme Manager
              E&N Herts NHS Acute
              Trust
    There is a clear need for improving
    knowledge management
•     “The application of what we know already will have a bigger impact on health and
       disease than any drug or technology likely to be introduced in the next decade.”
•    J A Muir Gray, Director of Clinical Knowledge, Process and Safety - Connecting for
                                          Health, NHS



Improved knowledge management can help prevent and minimise:

•    Errors and mistakes
•    Poor quality healthcare
•    Waste
•    Variations in policy and practice
•    Poor patient experience
•    Overenthusiastic adoption of interventions of low value
•    Failure to get new evidence into practice
Localising the Map of Medicine
     Localising the Map
Local Administrative Information              Clinical Localisation
    – Adding administrative detail                 – Changes to the national care
        • e.g. contact details, clinic                pathways
           information, opening times etc.              • adding, changing or deleting
        • links to websites or intranet sites              information
    – Simple process                               – More complex involving stringent
                                                      local clinical governance
  Rationale for localising the Map
•Improve communication of local information and local patient pathways

•Increase relevance as a knowledge, governance and communication tool

•Gain local ownership, adoption and support

•Knowledge sharing of international evidence & best practice

•Opportunity to map current practice

•Undertaking service redesign to:
    meet government targets e.g. 18 week RTT
    support Practice-Based Commissioning

•Improve transparency and communication across:
care settings (community/primary care/secondary care)
     related departments
     sectors
Supporting the Independent Sector
• „IS CATS Provider Care UK Provide Clinical Services to 10 Greater
  Manchester PCTs
   – The use of the Map will improve the quality of referrals into GM NHS
     CATS as well as secondary care AND improve the quality of discharge
     summaries
   – IS CATS manages patients in the top 6 specialties: musco-skeletal
     medicine including orthopaedics & rheumatology, ENT, Urology,
     General Surgery and Gynaecology for 30% of these referrals for the 3rd
     largest city in the UK
   – IS CATS Provide services for part of the Pt journey
   – The Map Pathways are visible across the GM Region in Primary & Acute
     Sector
   – Provides transparency for referral criteria & the Pt journey
   – Clinicians from primary and secondary care clinicians agreed that the
     management of such patients on 50 Pathways should be based on the
     pathways in the Map of Medicine to ensure quality
Commissioning – Modernisation Developments
communicated via Map of Medicine in the Wirral
AMD Pathway Modernisation
Quantitative Benefits

Qualitative Benefits
Patients were waiting 10 weeks for appointments, this has been
reduced to 3 weeks. A real risk of patients losing their sight has been
addressed.

Data from 2008 is showing a saving of around £500 per patient for
30 patients per month


This single pathway development will save approximately £180,000

There are 100 pathways in development on the Wirral. Potential
savings can be assessed from all of these:
Map Supporting Reconfiguration
Cumbria PCT reconfiguration programme „Closer To Home‟

•Referral Management based on the Map of Medicine Care Pathways.
•Referral Criteria reviewed with clinicians and published on the Map

In 2007/08, Cumbria PCT spent £12.5M on first referrals which was £406k
above expected (based on the England average). Potential savings can be
assessed:
         £1M could have been saved if the 22 most extreme performing
         practices reduced their referrals to match the England average.

          £624k could have been saved if 10 practices reduced their referrals
          to match the England average.

If this benefits work were applied to other workstreams the return could be
huge, they need to be quantified and realised in one or two areas and then
cascaded across the organisation and quantified.
Date source NHS Comparators data, https://nww.nhscomparators.nhs.uk/NHSComparators/Login.aspx
Map Supports World Class Commissioning
  – World class commissioning will deliver better health
    and well-being for all:
  – People will live healthier and longer lives
  – Health inequalities will be dramatically reduced.
  – It will deliver better care for all:
  – Services will be evidence-based and of the best
    quality
  – People will have choice and control over the
    services that they use, so they become more
    personalised.
  – It will deliver better value for all:
  – Investment decisions will be made in an informed
    and considered way, ensuring that improvements are
    delivered within available resources
  – PCTs will work with others to optimise effective
    care.
  – The Map supports WCC Objective 5 – Provide
    „evidenced based care‟
The Operating Framework signalled that
incentives and interventions will be directly linked
with Commissioning Assurance


      “PCTs …be held to account for, and rewarded for, their
      development towards world-class commissioning through one
      national assurance system that will focus on commissioning
      outcomes, competencies and governance”


      Operating Framework 2008/09, page 46
 Map Supports Advancing Quality

• Supporting „Advancing Quality‟ (AQ)
  – AQ a NW SHA World Class Quality Programme
  – AQ incentivises Acute Trusts to consistently deliver
    Quality
  – AQ Indicators to be embedded in the Map of Medicine
  – Primary Care see Referral Criteria
  – Acute Trusts are rewarded to „Quality Care‟
       Advancing Quality Focus
• 5 Clinical Conditions
  -    Acute myocardial infarction (AMI)
  -    Heart failure
  -    Community Acquired pneumonia
  -    Coronary artery by-pass graft (CABG)
  -    Hip/Knee replacement surgery

• 105 Clinical measures

• 3 year project evaluated Oct 2003 - Sept 2006
• Hospitals in top 2 deciles rewarded for quality scores
   Advancing Quality Indicators to
be embedded in the Map of Medicine
• Evidence based consensus clinical measures
• Examples –

   Aspirin at arrival (AMI)
   Prophylactic antibiotic 1 hour prior to surgical incision (H&K)
   Smoking cessation advice /counselling (CHF)
   Blood culture collected prior to 1st antibiotic administration (P)
   In patient mortality rate (CABG)
Map Pathways are end to end

Acute Hospital            Diagnostic & Treatment
                           Centre              
Community Hospital 
                           Community Pharmacy
Mental Health Trust 
                           Social Service          
Primary Care Trust   
                           NHS Direct           
GP Practice          
                           Integrated Working   
Ambulance Trust      

     Patients cross organisational boundaries 
407 Pathways Available to patients via NHS
Choices website




http://healthguides.mapofmedicine.com
The Map supports Quality Measures




•Supports PROMS
•Supports CQUINS
•Supports PALS
•Supports Darzi Quality Indicators
  Culture v
  Technology

“The significant
problems we
have cannot be
solved at the
same level of
thinking with
which we created
them! –
Albert Einstein
Increasing Clinical Workload!
Programme Impact Summary – Map of Medicine

Programme overview / objectives

 • The Map of Medicine offers high quality clinical information visualised in over 400 patient pathways. It serves as a single healthcare
   knowledge source that will speed the delivery of evidence based best practice across healthcare organisations; this evidence is
   continually monitored, reviewed and updated. The Map of Medicine is endorsed by the NHS and the NHS National Library for Health
   (NLH) and is developing initiatives in partnership with the NHS Institute they work closely with the Royal Colleges, including the Royal
   College of Physicians & the Royal College of GPs . The Map also work with NICE and the National Patient Safety Agency
 • The Map of Medicine is working with EMIS & TPP to develop integration, they are also working with InPS and iSoft, and engaging with
   Out of Hours plus Acute suppliers i.e.Lorenzo & Cerner, it is anticipated that integration will be incremental from 2009 onwards.

Benefit summary                                                          Primary impact on                 Key dependencies
Patients                                                                 GP practices: Awareness of         Internal
• 407 Pathways available to patients on www.nhs.uk or                      changes to core business        •Clinical ownership
   http://healthguides.mapofmedicine.com Patient pathways online.          processes.                      •CEO ownership across LHC
• Increased patient confidence as pathways are evidence based            • Information Governance          •LHC Governance arrangements
• Improved communication across organisational boundaries                • Clinical Governance             •LHC resources
• Increased patient safety through access to information                   Communication NICE, NSF         •Practice based Commissioning
NHS staff                                                                  Data Set Change Notice          •Advancing Quality Programme
• Easier access to up-to-date information, 24 hours/day                    changes                         •Smartcard access
• Supports healthcare planning, PbC reconfiguration, modernisation       • Integral to Modernisation       •Stakeholder engagement
• Enables demand management – Appropriate referral information           • Supports PBC                    •World Class Commissioning
• Facilitates coordination between Health & Social Care                  Acute Care
• Supports 18 Week RTT targets                                           • Improved communication          External
• Provides knowledge support                                             • Improved Pt safety              •Map of Medicine
• Supports Clinical Governance                                           • End to End Pt pathways          •Acute ownership/engagement
GP practices                                                             Unscheduled care settings:        •GP practice sign up
• Timely access to information to support patient care                     A&E, OOH awareness of           •Urgent and emergency care
• Clinical Governance updates                                              local business process          resources
• Improved communication (Information Governance)                          redesign.                       •Local Service Provider – Key
                                                                         PCTs: Reconfiguration,            Supplier of NHS systems as
• Improved Pt safety, online access to BNF/NLH specialist libraries
                                                                           Planning resources;             hosts for HW
• Supports Continuous Professional Development (CPD)                       Management of clinical &        •Integration in strategic clinical
• Out-of-Hours patient care will be based on up to date pathways           patient information             solutions: GPSoC, CaB,
                                                                           Supports PBC                    Lorenzo, Cerner, Out of Hours
       NHS NW Vision for the Map
What                                                                                         By Whom   By When
Optimise the delivery of Quality Healthcare in the most appropriate setting by technically   JW        April 2009
     enabling access to the Map across the NHS NW - Completed
Embed the use of the Map of Medicine as a key strategic tool for                             JW        October 2009
    reconfiguration/modernisation
All 24 PCT Led Local Health Communities to use the Map of Medicine as a core tool for        JW        March 2010
      Commissioning of Services
Embed the Map as a core tool for providing clarity and transparency for who does what in     JW        March 2010
    the clinical process
Embed the Map of Medicine as a core tool to support World Class Commissioning                JW        March 2010
Embed the Map as a Core tool to support the delivery of Transforming Community Services      JW        March 2010
Embed the Map as a core tool to support ‘High Quality Care for All’ Include the Map as a     JW        March 2010
    reference tool in the ‘quality metrics’ process
Include the Map as part of the NHS NW SHA response to ‘Measuring for Quality                 JW        March 2010
      Improvement’,
Include the Map as a core tool to support the NHS North West Quality strategy                JW        March 2010
Inculcate the Map as a tool to support the SHA Quality Boards, Quality Accounts and          JW        March 2010
      Quality Observatories.
Raise awareness and adoption of the Map of Medicine by patients and carers across the        JW        March 2010
     NHS NW http://healthguides.mapofmedicine.com on the NHS Choices Website
Include Pathways and the Map of Medicine in GPSoC & Choose and Book contract                 JW        September
      renegotiations                                                                                        2009
To embed the Map of Medicine as part of the NHS North West Deanery agenda                    JW        March 2010
Darzi &

the Map

in the NW
Map Logins 2007/08
      Map Logins 2008/09
                             Logins by Week


700


600


500
                        12.5%          12.5 %
400


300
               12.5 %                            12.5 %

200


100
               12.5 %                           12.5 %

  0

                        12.5 %         12.5 %




                        Total Logins    Unique Logins
 The Map of Medicine
 in the North West a significant
 Change Management Programme
A programme that will only succeed with
clinical ownership www.cln.nhs.uk
Thanks…..
NW SHA Map of Medicine lead
James.walker@northwest.nhs.uk

				
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