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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

Integrated care pathways

Dr Jeremy Rogers MD MRCGPSenior Clinical Fellow in Health InformaticsNorthwest Institute of Bio-Health Informatics

talk outline
Talk Outline

ICPs

eICPs

Challenges

history of icps
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
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
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
management of newly diagnosed type 1 diabetes
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

current uk status
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

the future what s an e icp
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
what s an e icp
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
e icp in np f it
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
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

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
human factors likely hazard warning
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
Technical Barriers :Specific Informatics Problems
  • Authoring
  • EPR Data Quality
  • Indexing
  • Act management
  • Clinical Terminology
  • Consent
  • Visualisation
  • Automation
  • Pace of change
barriers technical eicp authoring
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
barriers political commercial
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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