The third presentation at InterSystems Joined-Up Health & Care 2020 was from Liz Jones, digital project manager, Lincolnshire Sustainability and Transformation Partnership and David Smith, digital programme lead, Lincolnshire Sustainability and Transformation Partnership.
Background to the project
Liz: “Lincolnshire is the fourth largest county in the country. We have quite poor infrastructure. We have an aging population, much of which lives in the east of the county, with significant areas of deprivation. And we are financially challenged. Back in 2012, we had a sustainable services review that came up with a blueprint, that in 2014 became the Lincolnshire Health and Care Programme, that morphed into the sustainability and transformation partnership. The LHCP looked at what we needed to do for the future: and what came out of it was an ambition to move care closer to home, and to have closer working with some of our charitable and voluntary organisations.
“We looked at what finance and commissioning needed to look like, and buildings, and technology. And the biggest thing that came out of that programme was staff saying ‘it is terrible, none of the systems talk to each other’ and ‘why do we need so many systems anyway’. A single system is a step too far, but we looked at some interoperability… and in 2015 and 2016 we moved forward with a business case.”
Working with InterSystems, getting the architecture right
David: “We did a lot of market research. We talked to suppliers and we ran a proof of concept. That was quite significant for us, because we needed to make sure that our senior management and our clinicians could be confident that technology could do what we wanted to do; and it was a big success. We had the ear of NHS England, which was very keen on portals at the time, and we talked to them about securing funding. We have also been supported by our commissioners, and we have been able to buy a module a year so far. So, in year one we started with a care portal. Year two was a patient portal. Year three was going to be analytics, but instead we are focusing on care plans, and we will get back to that.
“What really attracted us to InterSystems was that their solution set supported a distributed model. We didn’t have to funnel everything into a central database, which could raise security and consent concerns. Instead, when somebody does a search, the system goes out and interrogates the edge gateways and returns information from hospital and other systems, and when the session closes none of the data is persisted. That is something the organisations that we are working with liked, and the information governance teams liked.”
Role based access
David: “It was very important for us that this went right across the county. We put in a Active Directory, which supports smartcard access, and we wanted to be in line with industry best-practice, so we have role-based access control. We have four roles set up, although we are only using two at the moment. When clinicians log in, they claim a relationship. As part of the design, that persists for 365 days and then it is aged off unless they reclaim it.
“We also have sealed-off data. So, if we are talking to an organisation like a mental health trust, we will look at the data they want to share with us. There might be some they are not comfortable about, but instead of removing it, we hide it behind a sealed-off data function. InterSystems also provided us with really good level auditing.”
Hearing some very familiar issues in the origin story of @LincsNHS STP:
•patients tired of retelling their story
•systems are siloed
•can't access the right data at the right time
— InterSystems UK (@InterSystemsUK) October 10, 2019
The Care Portal and its benefits
Liz: “The Care Portal is our integrated record. When users login, they see information from different systems. We also have some alerts set up. So a user can say that they would like to know that a patient has been admitted, discharged. And we plan to add more. David: “Some of the tipping points for us have been including hospital letters, and also discharge summaries. That has made a big difference to GPs and community teams, and there is some evidence that length of stay is being reduced. We hope that is because community services can see the discharge letters and rally round to help them.
“Other services that we have in there include the NHS Summary Care Record and CP-IS: the Child Protection-Information Sharing System. This is where local authorities maintain records of vulnerable children, so that when our clinicians are on the portal, they can get an alert by inbox and text message if there is an issue. We saw the value of that on the day it went live, when we had an alert triggered; so that was a win for us.
“In progress, we are hoping to add information from Lincolnshire County Council, which uses Mosaic, and we are ‘first of type’ for NHS Digital for GP Connect for structured data. We are in the final stages of testing for that. It is challenging in terms of due diligence, because we need information sharing agreements in place with all our GPs. We are also working with maternity and with the ambulance service to surface their electronic record. So there is lots going on. We are also talking to some of our neighbour trusts, to try and pull in some of their patient administration system information.”
A regional record?
David: “This has got the opportunity to scale up and scale out as the basis for a regional record. Given the modular nature of the system, we can push the patient management index element into the cloud and just reach out to the gateways and the systems of organisations around our border. Or we could be an exchange of exchanges and play in the local health and care record exemplar space. For the moment, we have 3,000 users, but when mental health comes on board we will add another 1,000 and community should be another 500.”
Liz: “I do not want to dwell on challenges, but there have been some. One is pace. Once the portal went in, everybody wanted more, and that is great, but it means resource. The other challenge we sometimes have is suppliers. Some are great and want to work with us. Some are less mature. Some have money to do this work. A lot don’t. And sometimes we can be seen as a threat to what they are doing. So that can slow things down significantly.
“Also, when you are first of type, it is easy to underestimate how much work there will be and how much effort it is going to take. We can’t just look at an organisation that has done it, we have to do it. That also makes it difficult to fully realise benefits. What we have in there at the moment might be good for one organisation but not another, so we need to build the volume of information in there, and then also get people working differently. Because if people just look at the information and do not act differently, you will not get the benefits.
“However, we have got great user feedback from the people on it. We have got better decision making, better patient management, and also significant patient experience, because people are sick of repeating their story over and over again, and they want to get the right care first time. We are seeing some savings, but the big ones will come from things like reducing duplicate tests and scans, and the big difference there is not just having that information on the system, but staff trusting they don’t need to do it again. It is when we get to that point we will see big financial savings.”
Liz: “One of the areas we have looked at is frailty. One of our areas, Gainsborough, was doing the 100 day frailty challenge. And what they wanted to know was whether their patients were going into hospital. We were able to set up a notification to say a patient over 75 from a specific set of GP practices had been admitted or discharged. They found lots more people were being admitted than expected. It has been really well received and we are looking to roll this out to different areas.”
Overview of the @LincsNHS Patient Portal:
• smart forms
• linked to the NHS App directory
• patients can access and add to their records
— InterSystems UK (@InterSystemsUK) October 10, 2019
The Patient Portal
Liz: “I also want to talk about the Patient Portal. That has forms, a message centre, and will be a way for patients to contribute their own information. We have delegated access as well. At the moment, all of the information is maternity focused, because we did a scoping exercise and maternity ‘won’ because it already has a transformation programme. We have created a library of information on there, split into different themes. In the future, we expect more libraries of information.
“A key requirement was to let patients self-refer. They have not had that before, so we have built a smart form for maternity to enable that to happen. We expect to use smart forms for lots of other services, so we can do things like pre-op forms and reduce demand for outpatients. It’s a smart form, because depending on how you answer we can show you different things. We have also added some algorithms, such as a due date calculator, so people get care in a timely manner.
“This has been live since Mid June. There have been 40 referrals so far. Maternity are seeing women self-refer much earlier. They can capture information about smoking and lifestyle much sooner. It also means staff are thinking differently about the information they need from ladies coming into the service.
“Where we get to is patients being able to login using NHS Login so they can self-authenticate. We are also starting to scope other services. We are also looking at wearables and remote monitoring devices. The portal can connect to a variety of medical devices. We have staff scoping out cardiac and renal failure services, with staff trying devices to see what they need.”
"We're focusing on delivering a #joinedupcare system based on what matters to our #patients, not just one based on what's the matter with them" – David Smith of @LincsNHS #JUHC19 #buildsomethingthatmatters pic.twitter.com/a4o8iQBSOS
— InterSystems UK (@InterSystemsUK) October 10, 2019
Pathways and analytics
David: “I mentioned we were going to do some analytics, but we decided to do some work on care plans. So this is early days, but we are using the InterSystems Care Community module, to achieve this goal. The care and support plan is the outcome of some co-production work we have done to look at people’s assessed needs and what matters to them. We are looking to capture that and move from paper to electronic capture. That will be available via the patient portal and surfaced in the clinical portal, so clinicians know what patient wishes are.
“At the moment, we are trialling this with some of our neighbourhood teams, with a focus on frailty. We will use learning from the first version to fine-tune it going forward, because there has already been a lot of interest from other services. We are using Care Community in its basic form. The idea at this stage is a patient will sit down with a clinician and fill in a form. But we think it can do a lot more: treatment plans, clever alerting.
“Finally, analytics. We purchased it at the end of last year, and we are struggling a little bit with capacity but we have lots of ideas for what we want it to do. There are lots of things that analytics can support. At its core, its main functions are smart alerting, risk stratification and population health management. We want to start with smart alerting, so it handles information coming in from smart devices and alerts a clinician is above a certain parameter. Now we have the care portal in place, we are seeing it make a huge difference, and we just want to do more and more with it.”