NaSH: A national sexual health clinical management system

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NaSH A national sexual health clinical
management system

• Dr Andrew WinterConsultant GUM Physician NHSGGC
• Chair, NaSH Reference Group

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Vision

• Fully electronic clinical record and booking
  system to support integrated sexual health
  services (including GUM, FPRH, specialist
  services, counselling)

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Vision the lab part

• Common lab request printed
• Epidemiology eg. For HPS HIV forms derived from
  EPR
• All lab test results imported
• All results processed electronically with logic
• Results interpreted according to preset rules
• Patients collect results (in understandable
  terms) e.g. with Telephonetics
• All positives actioned without delay in
  workstreams
• Results viewable by GPs where pts consent

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NaSH

• Single instance application, web deployed
• Used by all Health Boards
• Aimed at Specialist Sexual Health Services
• 400,000 attendances
• 100-200 sites
• 1200 staff

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NaSH Benefits
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Some benefits of EPR for sexual health

• Access to records across multiple sites
• Centralized booking process possible
• Automated import of lab test results
• Asynchronous / remote STI results access
• Management data gathered as part of clinical
  process

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Multiple site working

• Integration of sexual health services at Board
  level
• Managed Clinical Networks across Boards

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Security and confidentiality

• Sexual Health even more sensitive
• Patient choice for CHI or non-CHI
• Three levels
• Fully CHI identifiable
• CHI confirmed but anonymous testing by AN
  number
• Assumed identity, anonymous testing
• Role-based access

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Clinical safety

• Availability of case records / results
• Failsafe systems for abnormal results
• Case management eg lt16 reporting, syphilis
• Allergy alerts for prescribing
• Partner notification

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Service modernization

• Utilisation of clinic space flow patients where
  service can fit
• Remote results access
• Workflow referrals (eg from SCI gateway) to most
  appropriate provider
• Integration with other e-systems Gateway,
  SCIstore.

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Integrated sexual health

• Flow of clinical forms depends on main reason for
  presentation
• Full sexual and social health history available
• Internal referrals by messaging

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Reporting and coding

• Minimal additional effort for individual boards
• Quality Improvement Scotland / Key Clinical
  Indicators
• e.g. Proportion Clients with Gonorrhoea
  Undergoing PN within 7 Days (QIS 5.6)
• STI coding (STISS) output
• Audit at Board , Unit , Practitioner level
• e.g. clinician-specific HIV uptake rates

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Case 1

• 25 year old lady attended Sandyford North
• Request HIV test
• Failed to return for ve result
• Case management by consultant / senior HA in
  Sandyford Central
• Result given in GP practice
• Sandyford notes / results available on-line at
  first attendance at Brownlee for HIV care
• Partner notification outcome recorded

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Case 2

• 19 year old man attended Sandyford SE with
  dysuria
• Slide read at Sandyford Central results onto
  system ve gonorrhoea
• Antibiotic prescribed
• Contact attends Sandyford Inverclyde the next
  week
• Partner records and treatment reviewed
• Sensitivity testing guides epidemiological
  treatment
• Partner notification outcome completed
• Coding completed

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NaSH Development Clinical involvement
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NaSH Principles

• Governance
• Stakeholder involvement
• National technical / developmental standards
• National Data standards
• Single product is only option
• Implementation challenge / planning addressed

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Development of NaSH
Design
Instigation
Clinician
Implementation
OngoingDevelopment
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Clinician-led design

• Reference group
• Clinical specialists from GUM, FPRH with range of
  IT expertise
• Key input into
• Statement of Requirements
• Functional Specification
• Workflow
• Interpretation of data definitions

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Statement of Requirements headings
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NaSH clinical process analysis

• Detailed process analysis
• Administration
• Clinical GUM / FPRH including social health
• Prescribing
• Lab testing
• Partner notification
• Procedures
• Coding

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Process redesign

• Agree common methods of working
• Confidentiality
• Clinical process
• eg automated results recovery
• Interim process
• Old records / results systems
• Change
• What can you now do?

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NaSH labs
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NaSH and CHI

• Explicit consent to use CHI
• Three options
• Fully identified Name/CHI on request CHI
  demographics
• CHI check / anonymous testing CHI demographics
  downloaded tests labelled with AN number
• Assumed identity No link to CHI tests labelled
  with AN number

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NaSH and CHI

• NaSH anonymous number
• CHI-type number with check digit
• Labs used to handing anonymous GUM numbers
• Need to agree methods for entering name eg. Some
  labs prefix the anon number with a V
• Labs will get EITHER the CHI-identifier OR NaSH
  number. CHI and NaSH cannot be linked on
  third-party systems

AN09879862
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Top tests

• Bacteriology
• Gonococcal Culture (U / R / T / Cx)
• Syphilis serology
• HVS
• Virology / PCR
• NAAT Chlamydia Hep B serology
• NAAT GC Hep C / HCV PCR
• HIV HSV PCR / culture

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Typical test set for STI exclusion in
asymptomatic man having sex with men

• Gonorrhoea
• Urethral
• Throat
• Rectal
• Chlamydia
• Urine
• Rectal

• Serology for
• HIV
• HepB cAb
• Syphilis

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Structured lab results

• Bulk testing of key STIs
• Sandyford 05/06
• 20,000 chlamydia
• 19,000 gonorrhoea swabs
• 10,000 HIV
• 11,000 syphilis

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Problems

• Anatomical sites
• Antibiotic sensitivity
• Multiple tests off one sample
• Handling anonymous identifiers
• Structured result format
• SCI store

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Results
Lab and radiology results can be imported
electronically from lab systems and are available
for review by a single click. Manual input is
also supported.
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SCI store issues

• SCI store primarily conceived to allow viewing of
  results
• Microbiology test results simply free text
  imported rather than structured
• Slightest change in automatic wording derived
  from lab code will prevent successful reading of
  the result

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SCI store / lab issues

• No agreed coding for top STI tests
• SNOMED-CT
• Read codes
• Lab system internal codes
• Board-specific rules
• Which tests get sent to SCI store
• How unmatched results are handled

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Apex(RAH)
STI tests
Hapless Patient
CLYSCIstore
HSV test
Telepath (SVC Gartnavel)
GGSCIstore
Masterlabs(Lanarkshire)
STI tests
LASCIstore
Hapless Patient
GC PCR 1
?
GC isolateTreponemal PCR
Telepath (STIBRL ERI)
LOSCIstore
GC PCR 2
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More SCI-store issues.

• Store-to-Store
• Significant proportion of clients cross Board
  areas
• Out-of-board tests eg reference syphilis / GC
  sensitivity now NOT reentered (HDL rule)
• Provisional vs Final results

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Test requested answer expected
Lab request (paper) sample sent
Lab result returned
Imported and mapped
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NORMAL
ABNORMAL
Text / phone collection
Client contacted
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What the clinician wants.
Lab tests / NaSH interface
Positive
Additional info type of test / lab no
Chlamydia endocervical
Negative
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Clinic asks for..
Lab calls it
Lab test
Lab result
Endocervical sw
Chlamydia SDA
DNA detected
Chlamydia endocervical
C. trachomatis PCR
Swab endocervix
Positive
C. trachomatis Real Time PCR
Detected
Endocervix
Internal lab system codeTEST / SAMPLE SITEmay
stay same even if assay changes
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Clinic asks for..
Lab calls it
Lab test
Lab result
Endocervical sw
No growth
N.gonorrhoeae isolated
GC endocervical
Swab endocervix
CULTURE
Heavy growth of N gonorrhoeae
Endocervix
Light growth of Streptococcus(Gp B)
Internal lab system codeTEST / SAMPLE SITEmay
stay same even if assay changes
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List of anatomical sites for sexual health
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Interpreted results
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Syphilis EIA
Positive
Negative
VDRL or RPR
TPPA or TPHA
InnoLIA
IgM
Normal
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Conclusion

• NaSH designed to automate majority of STI test
  handling process
• Improve clinical safety
• Improve access to results by patients
• Increase staff effectiveness
• NaSH is going live near you soon..!!