Technology case studies: Prescribing made easier

Birmingham CrossCity CCG

Birmingham CrossCity CCG was developing its own in-house interoperability solution when it heard about INPS’s work on Vision Outcomes Manager. It decided not to reinvent the wheel.

Ciaron Hoye, the group’s manager for information, says Vision is unique: “It is the only decision support tool that will let the CCG directly design new rules, publish templates into clinical systems to get the practice to capture clinical data, publish documents like patient leaflets into the clinical system, and then monitor progress centrally.”

He adds: “INPS has grasped what interoperability should be and made it a reality. They’ve jumped in with both feet whereas others are just playing round the edges.”

‘INPS has grasped what interoperability should be and made it a reality’

Birmingham is now piloting modules for diabetes and colorectal cancer among others. The city has one of the country’s highest rates of prescribing for diabetes. The diabetes module targets nurse practitioners and GPs, supporting them to prescribe correctly according to NICE guidance CG87 on type 2 diabetes. Mr Hoye explains: “CG87 has got a giant, really complex flowchart of how you should prescribe diabetic medication, and 95 per cent of people don’t understand flow charts. We’ve reduced that to a rule set that runs in the background.”

The rule looks at patients’ blood tests and medications and flags up any need to change their prescription.

Mr Hoye stresses that the programme supports clinical decision making rather than replacing it.

“The clinician still has to make a clinical decision but we try to prompt them down that path. It’s about noticing the patient earlier on. The background creepers of blood tests often get missed, but if you do it through a computer it draws your attention to it. People spend ages trying to figure it out - you could spend that time much better with the patient.”

Powerful trigger

Similarly, the colorectal cancer module waves a flag when the NICE scoring methodology has been triggered. This is powerful because one trigger for an investigation is repeated spells of diarrhoea, which are often reported to different clinicians. Vision puts those symptoms together, then prompts the GP to question the patient. If a referral is indicated it will take the clinician straight to a form.

The pilots started in April and will be evaluated in October. Metrics include comparing the behaviour of practices that are using Vision to a control group which is not. In the case of diabetes, Birmingham will measure compliance with the NICE prescribing guidelines, and appropriate fast track referrals.

So far the pilots are performing well, with clinicians capturing data during consultations as hoped. The next step is to make the prompts specific, for example a mental health flag which only a GP or specialist nurse would see.

‘Now I do a piece of work once, and all the practices have to do is say “yes, give that to me”’

At CCG level, Outcomes Manager provides a significant efficiency gain, by allowing Birmingham to distribute material such as a redefined pathway or a new model of healthcare to all its practices.

Mr Hoye says: “We have 118 practices with different clinical systems and we are getting new approaches out to all of them, rather than asking them to go through the job themselves 118 times or sending someone physically out to install it for them. Now I do a piece of work once, and all the practices have to do is say ‘yes, give that to me’.”

The programme permits finer tuning of commissioning. Mr Hoye explains: “We can only have informed commissioning if we start from a position which has data with which to inform our position. Outcomes Manager allows us to start from that informed position and formulate a change in process or pathway that we wish to implement.

“Once done, we can ask for a change in behaviour from our members. You can look at any given rule and the number of patients that have been actioned. This allows them to review their own compliance and the CCG to proactively contact them before there is an issue. We can support them through a change rather than retrospectively penalise them for failure to deliver.

“Finally, it allows us to look at the outcomes. We can then validate the commissioning pathway if appropriate, or return to the start of the audit cycle if not.”

Greenwich CCG

“If you think about asthma or hypertension, there is uniformity across the settings in how you manage them,” says Rena Amin, joint associate director of medicines management at Greenwich CCG.

“Whereas in wound management there is variability. The district nurse says ‘we have a beautifully healed leg’, they transfer it back to primary care, and because of variability of skills it does sometimes deteriorate.”

This is why she asked INPS to use Vision Outcomes Manager to develop an electronic wound management template. She explains: “We wanted something to guide nurses through the process systematically. We were looking for a cost-effective, evidence-based approach which was user friendly to the clinician.”

The interoperability of Vision was a plus point. It is compatible with both INPS and EMIS clinical systems, making it an attractive proposition for Greenwich commissioners.

Wound management is shared by GP nursing teams and community nursing teams. The template helps primary care teams treat wounds consistently and to a high standard, and spot when they are complex. First, it analyses the nature of the wound and suggests treatment. Then, if this first line of treatment is not working after six weeks, it advises the practice that the wound might be more difficult to treat and may require input from a tissue viability nurse.

‘We are getting new approaches out to all 118 GP practices, rather than asking them to do the job themselves 118 times’

It also encourages proactive management - for example requesting a pressure-relieving mattress for prevention of pressure ulcers in high risk patients -and a holistic approach which takes into account the patient’s quality of life, nutrition, mood and levels of pain.

This helps prevent chronic wounds, which have a huge impact on a patient’s quality of life and on their family, and are very costly.

“The template allows us to set up a comprehensive care plan and treatment strategy. It is a whole systems approach with the patient at the middle,” says Ms Amin.

Large quantities of inappropriate dressings are often given to patients which they may never use, and the template tackles this via an electronic formulary which is integrated into GP clinical systems. The formulary is embedded into the template, and set up in such a way that it defaults to minimum quantity of dressings. This lowers pharmaceutical wastage and boosts appropriate use of dressings.

Consistency

The full template is currently confined to practice nurses, as evidence of variability is greatest in primary care, so they need the most support to make consistent, timely interventions. However, district nurses in Greenwich use the same formulary. Because of this, prescribing is consistent across primary and community care.

In time, Greenwich hopes to roll the full template out to district nurses, tissue viability nurses and care homes. “The technology is already there, but needs wider stakeholder engagement,” says Ms Amin.

She adds: “We are exploring the idea of GPs visiting care homes with the template integrated into an iPad. That’s the direction of travel. If we can make wound care seamless at the point of assessing and prescribing, whether in primary care, community care or a care home, it should reduce variability in the care clinicians provide.”

‘The technology is already there, but needs wider stakeholder engagement’

The pilots, being set up in six GP practices, are due to go live this month and will be evaluated in August.

Greenwich is also piloting a referral pathway for lower urinary tract symptoms to reduce inappropriate referrals, and increase appropriate ones. Service design and procurement manager Jan Matthews says: “The result will be a really good referral which will ensure the patient is seen in secondary care having had all the appropriate tests and treatments…, allowing secondary care to do what it does best.”

Once the LUTS pilot is evaluated, it will be rolled out to all 42 practices and expanded to all pathways, with a goal of raising the quality of referrals across the board.

Both Ms Amin and Ms Matthews value the degree to which they have been able to collaborate with INPS. Ms Amin says: “They have been supportive - I went to them and said ‘I have this problem and I think this is the solution’. From then on they have been very useful, they have come up with the goods.”

She adds: “If we want to improve efficiency and productivity, we have to be innovative, which means doing things differently with the resources we have. That means technology and interoperability.”