Although the pursuit of digital excellence in the NHS continues, the adoption of technology across the health service remains, at best, patchy. Progress is undermined by a lack of both investment and, in some cases, clinical leadership to champion change. As we enter 2017, where sustainability and transformation are national watchwords, the NHS’ ability to optimise technology will become crucial. Our challenge is to deliver sustainable and affordable high-quality services, and underpin them with effcient processes that drive health outcomes. On its own, technology is not the answer; but it’s undoubtedly part of the solution. That’s certainly the case at Southport & Ormskirk Hospital NHS Trust, where technology has played – and indeed continues to play – a central role in the improvement of paediatric diabetes services.
In 2011/12, Southport & Ormskirk’s Paediatric Diabetes Unit (PDU) began an incremental programme of what’s now widely called ‘digital transformation’. Back then, our approach wasn’t influenced by a national movement to adopt innovative tech, it was a common-sense response to an under-performing service in need of an overhaul. From a technology perspective, the transformation began with the introduction of Twinkle, an information management system designed to support paediatric diabetes care and capture data required for mandatory audit submission. Its deployment has provided a catalyst for year-on-year performance improvements against all the national quality standards for paediatric diabetes.
Today, Twinkle remains at the centre of an award-winning service that has since been bolstered by Diasend, a system that monitors patients’ blood glucose in outpatient clinics, and a social media presence that’s improving engagement between patients, parents and the multidisciplinary team (MDT). In the future, we hope to increase engagement further with Skype clinics for children and parents. Because for us, digital transformation is an ongoing pursuit; a journey not a destination. We literally go nowhere by standing still.
Our metamorphosis into a highly-regarded service has not been easy – and there are still obstacles in our path as we strive for further improvements. However, through perseverance, leadership and a fundamental belief that technology can make a major contribution to patient-centred care, we’re redesigning our services in line with modern needs and modern communications – and using digital tools to help drive better patient outcomes.
Paediatric diabetes: context
Paediatric diabetes remains a major challenge in the UK. It has the fourth highest number of children and young people (CYP) with diabetes in Europe, and though the most recent National Paediatric Diabetes Audit (NPDA) shows steady improvement in the number of CYP achieving excellent diabetes control, it’s still one of Europe’s worst-performing countries in terms of blood glucose control. Nationally in 2014/15, less than a third of CYP with type 1 diabetes achieved the old HbA1c target of 7.5%. During 2015/16, Southport and Ormskirk NHS Trust improved its HbA1c outcome to 7.8% median and 34.2% of its patients had HbA1c of less than 7.5%.
Glucose control is just one of many NICE metrics to benchmark performance in paediatric diabetes. Paediatric Day Units (PDUs) are required to record and report patient progress against seven health checks; HbA1c BMI, blood pressure, urinary albumin, cholesterol, eye screening and foot examination. The theory is that if we can identify problems at an early stage, we’re better-placed to prompt immediate action and improve patient management. In practice, the realities of clinical practice, and the complexities of managing paediatric patients, make completing all seven health checks difficult. Non-attendance rates are particularly high in young adult clinics, whilst ensuring patients maintain accurate diaries for clinical review is a perennial challenge. These complexities naturally impede the optimal completion of care processes. The latest audit figures for Southport & Ormskirk reveal that from April 2015 – March 2016, the number of young people aged 12 years and older shown to have undergone all seven health checks has increased to 45.6% compared to 35.5% across England and Wales.
However, completing the care processes is just one part of the problem. For many trusts, recording and accessing the data to enable optimal patient care is an additional challenge. A high number of PDUs still use paper-based systems to manage patient information. With much diabetes care carried out in community settings, this not only impacts the speed, continuity and quality of care, it makes mandatory audit processes expensive and inefficient. It’s one area where technology can make a significant difference.
Technology in action
The holistic challenges of paediatric diabetes care are familiar to Southport and Ormskirk. In 2011, the trust was audited by the CCG and found to be an outlier in terms of overall HbA1c outcomes. Furthermore, it had the highest DKA admission rates and hospital admissions due to diabetes. To compound it, with NPDA data submissions dependent on manual data entry, our 2011/12 submission had excluded 49 out of 117 patients because of incomplete data, while the MDT noted 43% incomplete record of care processes due to manual data entry procedures. We knew that if we were to meet national standards and maintain the ICO’s reputation for high-quality children’s services, we needed to improve communications by harnessing technology.
In 2012, to coincide with the introduction of a mandatory NPDA and the Best Practice Tariff (BPT), we deployed Twinkle, a specialist electronic health record system for paediatric diabetes patients. The web-based system, which is provided on a software-as-a-service basis and requires no on-site installation, gives our diabetes teams – whether they’re in the hospital or the community – instant access to patient records. This allows us to undertake monthly audits to identify patients where intervention may be beneficial. Twinkle helps us highlight patients with poor metabolic control, frequent DNAs or those who have been admitted as inpatients. These patients are subsequently targeted for more intensive contact, education, specialist support or, where necessary, increased frequency in outpatient appointments.
Fundamentally, Twinkle has empowered the full composite of the multidisciplinary team – specialists, nurses, dieticians and psychologists – with greater visibility of what’s happening with our patients and given us the insight to make proactive and informed responses to their needs. We no longer have to go through clinical records manually to find the patients with poor HbA1c control, who are due for their annual structured education session, or who frequently DNA. It’s frightening to think that we ever did. We can now identify them at the click of a button – and accelerate care accordingly. The monthly audit has become a 10-second job. Twinkle is a continuous intervention and a great example of how technology can be used to help provide better patient-centred services. We could never go back to the old way.
What’s more, the system provides a real-world health check on our own performance – allowing us to review PDU performance against core care processes. Twinkle has transformed our annual audit procedures, eliminating labour-intensive manual processes, freeing up resources and driving effciencies. Better still, our ability to demonstrate that we’re meeting national standards has helped us unlock funding through the BPT.
It would be misleading to suggest that technology has been the single driver of improvement at Southport and Ormskirk – it’s just one piece of a complex jigsaw. But evidence shows that we’re heading in the right direction. National audits reveal year-on-year improvements in the core areas. In 2013, HbA1c levels showed marked improvement, whilst hospital admissions and length of stay were signicantly reduced. In 2015/16, 33.2% of our CYP with Type 1 diabetes had an HbA1c of less than 58 mmol/mol, compared to the national gure for England and Wales (26.6%). Similarly, the PDU’s completion rate of all seven key care processes was 15% higher than the national gure. These results are borne out in patient satisfaction surveys, which consistently highlight that both CYP and parents recognise and value the PDU’s use of technology in supporting their needs. The introduction of Diasend, allowing patients to download data from their devices both in outpatient clinics and from home, and our careful use of social media, have played a valuable part.
Footprints for the future
Today’s paediatric care means engaging the millennial generation. We cannot afford to run away from it – we must instead learn to communicate in their language using their tools. It will not be easy. When we first introduced it, Southport and Ormskirk was the only paediatric diabetes team with its own Facebook page – and we needed to satisfy a range of Information Governance requirements to get the green light. The response has been overwhelmingly positive. It’s been worth the hard yards.
And that’s the ultimate message. Digital transformation is not a quick fix for the NHS – and there are many barriers in its way. But it’s too easy to fall at the first hurdle. Digital technology, whether that’s information management systems, mobile tools or social media, can transform healthcare services in the UK. The most successful organisations will be those that show the clinical leadership and determination to drive change, and develop compelling business cases that prove how digital technology can improve patient care. It’s what we strive to do at Southport and Ormskirk. We did it with Twinkle. Now Skype is next.
This case study/article is by Pediatric endocrinologist May Ng, MBBS (Hons), FHEA, FRCPCH, LLM, PhD, of Southport and Ormskirk Hospital National Health Service (NHS) Trust and Hicom. Twinkle is our paediatric diabetes management solution