Introduction

The complexity of patient care often requires involvement from a number of different clinical teams and departments. In particular, in the area of diabetes, over two hundred thousand people are diagnosed with Type 2 diabetes every year, so with diagnosis rates rising rapidly integration between core and specialist systems across the NHS is vital to ensure effective resource management and improved patient care. But until relatively recently the NHS had relied on paper based systems to record and store information. It was a method that made information sharing challenging. The introduction of Electronic Medical Records (EMR) aimed to improve the way that information was held and made available between specialist clinical teams. However, the need for joined up systems and care across multiple departments has also grown and trusts are now implementing technology to allow systems to send and receive disparate information via interfaces. With advances in technology, communication and working processes have evolved to reduce manual processes of record keeping, and the introduction of EMRs has delivered operational efficiencies, accuracy and interoperability to drive better patient care – as well as helping the NHS to meet its aim of becoming fully digitised by 2024.

Motivations for integration

In 2016, the Carter Report cited interoperability between data systems as a key component in eliminating ‘unwarranted variation’. The report also highlighted the need for the introduction of data dashboards that integrate data from different sources and deliver real-time intelligence to support operational decision-making. NHS England is aiming to encourage a culture of data sharing, imploring trusts to ‘bring together the data necessary for quality improvement and cost reduction’ and create a ‘single source of the truth’ that facilitates complex analytics to inform patient care planning. It’s clear that trusts have taken this messaging on board, hospitals are increasingly deploying ICT strategies that integrate data from multiple clinical systems into one single view.

While a single view provides an overview of trust performance, the value and importance of specialist systems must not be underestimated. With services facing calls to drive productivity and efficiency, specialist systems undoubtedly have a role to play in providing valuable departmental insight. In the case of chronic diseases, there are significant gains to be made. Patients with long-term conditions (LTCs) currently account  for 50% of all GP appointments, 70% of all bed days and around 70% of acute and primary care budgets in England, trusts are facing huge pressure to reduce costs. Technology and innovations can play a valuable role. However, it is down to trusts to embrace this innovation to drive productivity and efficiency in LTC services.

Interoperability and diabetes care

In diabetes care, where many patients come into contact with a number of clinical and support teams, the need to drive this kind of integration and efficiencies is stark. The ability to interface and share information between departments has an enormous positive impact on patient care.

Diabetes is a huge priority for the NHS, both in terms of reducing the number of people with the condition and the cost of treating them – NHS England cites diabetes as “one of the major clinical challenges of the 21st century.” The condition accounts for 10% of all NHS expenditure and the number of newly diagnosed Type 2 diabetes patients is growing at an alarming rate – almost doubling in the past 20 years. It’s estimated that over 4.7 million people in the UK have a form of the condition, with older people being more at risk. If levels of diagnoses continue to rise at the same rate, by 2030 there will be 5.5 million people in the UK living with the condition. In terms of the treatment of Type 2 diabetes – the form of the condition that is rising – education and establishing systems that enable self-management are seen as key to tackling rising levels and associated costs. It’s also a condition associated with high levels of complications, with the prevalence of comorbidity also high. Having one shared patient record that can be accessed by multiple clinical teams across primary and acute care allows for better and easier management of the growing numbers of patients by health care providers. 

Electronic information management systems have been successfully adopted by diabetes teams and have helped trusts reduce both HbA1c levels and the proportion of CYP in DKA at diagnosis in both adult and paediatric care. They are now routinely used to record a range of clinical datasets to monitor patient performance against Quality Standards and NICE guidelines. EMRs are also used to conduct monthly audits, allowing diabetes teams to identify high-risk patients that may not be managing their insulin levels, have been admitted to hospital or have low levels of clinic attendance. By providing a way to monitor these patients, EMRs have led to improvements in the management of the condition though more effective, targeted education. In turn, this has led to the reduction in emergency admissions, minimised hospital stays and decreased diabetes-related complications. This is vital to reducing diabetes related expenditure and providing services which are cost-effective. The real-time visibility enabled by digital solutions makes this possible.

Some diabetes management systems go further, enabling trusts to capture the data required for mandatory national audits and the Best Practice Tariff (BPT). This has digitised what was previously  onerous manual processes, reducing the risk of human error,  improving efficiency and accuracy of audit submissions and helping trusts unlock vital funding through the BPT.  

Integration with other clinical systems

While specialist systems will undoubtedly continue to have an important role to play, greater gains can be made in combining data from other clinical systems. These gains go beyond the departmental level and allow for information to be combined with other clinical systems, such as retinopothy or ophthalmology, for example, to provide a holistic view. In the context of the current NHS focus on collaboration and integration, specialist EMRs must have the capability to allow for bidirectional data to be shared between other systems and data warehouses. This allows for more sophisticated analytics to be developed, enabling clinical teams to better understand trends and improve decision-making.

As trusts look at new ways to reduce costs and enhance quality, solutions that facilitate data integration in a holistic approach should be at the fore. For technology partners, the best approach is to work closely with clinicians to develop solutions that take into account the realities of real-world understanding of pathways – and truly understand the value of sharing data interdepartmentally.

NHS Long Term Plan

The Long Term Plan (LTP), published earlier this year, sets out a phased approach to support trusts in achieving industry-wide goals around improving performance, value and healthcare across the NHS. In addition to integration, the LTP focuses on collaboration and sets out a vision for a fully digitised NHS by 2024 that will require a cultural sea change. It’s helping all stakeholders keep focus and encouraging them to work together to unlock operational efficiencies and opportunities for better patient care.

Culturally, staff are seeing the impact different technology is having on transforming day-to-day practices. Acceptance of the need to digitalise and the adoption of technology continues to increase, which is creating a virtuous circle. Nurses and clinicians’ time is being saved by removing the need to manually enter data into systems from paper-based records. The better allocation and management of resources is leading to more meaningful time being spent with patients and is allowing for the delivery of improved patient care. Whereas in the past, patients’ time with clinicians would be partly spent going over notes from appointments with other departments, now the introduction of EMRs is reducing the amount of valuable clinical time spent on that overlap. Instead, patients have a greater opportunity to ask questions and clinicians have more time to advise them on their individual needs. The positive impact on patient care is clear to see and the importance of such collaboration will continue to grow with the rising number of diabetes patients in the UK.

These efficiencies are also generating valuable cost savings, which is helping to drive implementation of digitised solutions from the top, to support the clinicians who are making a difference in delivering patient care.

There is also a big culture shift in how specialist suppliers are working together to provide advanced technology and systems to the NHS and ensure these are able to integrate with one another. The LTP is a continuation in the shift in NHS thinking away from competition and towards collaboration. Suppliers, trusts and policymakers are becoming more closely aligned in their approach, putting their commercial differences aside, to come together to improve integrated care by enabling GPs and consultants to see the same patient data. InterOpen, for example, is leading the way in forging these alliances.

Whilst it may seem that there is a lot still to do in order to reach the goals laid out in the LTP, there is much progress being made and this needs to continue and expand. Trusts should ensure they share their successes, learn from each other, and work closely with trusted partners to join up IT systems and continue the growth of interoperability, from interfacing within hospital systems, through to GP practices and even national programmes.

So how does this work in practice?

Through its partnership with software and consultancy provider Hicom, the University Hospitals of North Midlands (UHNM), is providing multidisciplinary teams with instant access to patient medical history, whenever there is patient interaction.

Implemented in 2014, Hicom’s paediatric diabetes management system, Twinkle, links with the hospital’s PAS and pathology system to provide nurses, clinicians and dieticians with the ability to quickly access up to date patient data, appointments and test results. Twinkle also delivers a single view of all medical notes and as a result has improved operational efficiencies and interoperability, which has led to considerable time savings for staff and better care for patients within the hospital’s three clinics and in their homes.

Efficiency

Twinkle enables nurses to review vital patient data such as what insulin regimen a patient is on, previous appointment notes, historical HbA1c in graphical form and any ongoing issues that need to be evaluated.  They can also view any alerts that are on patient records that indicate additional tests are required.

Dr Parakkal Raffeeq, Consultant Paediatrician comments: “The process of planning each day of appointments has not only become less time intensive with using Twinkle but we’ve also been able to better manage resources.

“Previously, data was just being stored, however Twinkle is more than a database, it’s a live clinical information system. For example, if a nurse in the community visits a patient in the morning and a note is added to the system to state additional insulin was given, both us and our patients have the reassurance that a nurse on call later that evening will have access to up to date and accurate information and will know the next course of care needed to be given to the patient. This has led to the team feeling more prepared heading into an appointment and they know what the outcome of the appointment needs to be.”

Auditability

With the requirement to regularly submit information for the National Paediatric Diabetes Audit (NPDA), one of the initial main drivers for the Trust to use Twinkle was having the use of data indicators that immediately identify any gaps in information. Similarly, when reporting for the Best Practice Tariff (BPT), clinicians are able to click on individual patients and see how they are performing, how many appointments they have left in the fiscal year and whether they are likely to meet targets that have been set. These features are key to enabling clinicians to proactively manage long term care planning and ensure accuracy of data as part of their day to day patient interactions.

Dr Raffeeq continues: “The functionality of being able to access individual patient data, whether recent or historic, and at any time, is proving to be extremely useful for when we review patient care and for the NPDA.”

Paperless-approach

In support of the Government target for the NHS to become paperless by 2024, the Trust is committed to moving away from paper-based records and migrating to a digital working environment.

“Working with paper records has been challenging. If notes don’t arrive at the clinics in time or are misplaced, it can have an immediate knock on effect to not only our team but also our patients. Now, if a note is added to a patient record, regardless of when it was added or if it was added in a clinic or at the patient’s home, we are all able to view what care is needed on any given day.

“Additionally, we are delighted that having Twinkle and digitising our processes has meant that the aim to achieving paperless records throughout the entire Trust is well and truly in sight,” concludes Dr Raffeeq.

The implementation of Twinkle has proved to be an invaluable data resource for the diabetes team at UHNM and the day to day operation of the hospital. It is enabling staff to input changes to patient records in real time and giving them access to accurate and up to date information, whilst cutting down the amount of time spent on administrative tasks. Additionally, it is helping them to better prepare for and manage appointments and has freed them up to spend more time with patients.

Ultimately, the combination of all of the benefits being seen from using the technology has led to the diabetes team being able to make better informed decisions about the care they provide to each of their patients.

Looking to the future

There is already a great deal of progress being made by the NHS and its providers and it is vital that this good work continues. Integration must be a primary consideration when selecting and implementing new digital solutions, not an afterthought. The investment at an early stage of projects will deliver considerable rewards in terms of data accuracy, clinical time saving, patient satisfaction with how they are treated and ultimately better outcomes in the long term. This will allow targeting variation in the achievement of diabetes management, treatment and care processes, in line with the Long Term Plan commitments.