Bob Young

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Enablers One Informatics and IT
Bob Young
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LTCII Long Term Condition Information Integration

• A Personal Record for People with Diabetes
• An integrated view for care professionals
• A health economy tool for whole systems
  analysis
• A generic solution
• National standards and systems multiple LTCs
  (CHD, CVD, CKD)

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Cardiac Surgery
Direct Access Services
Surgical Wards
Cardiology
A E Emergency Medicine
Primary/Community Ongoing Care
Pediatric Diabetes Specialist Nurses Doctors
Medical Wards Wards

Diabetes Specialist Services
Clinical Psychology
Receptionists Support Workers
Rheumatology
Supporting Specialist Services
Services for Young People
Nephrology
On Call Service
Diabetes Network Hub
Vascular Orthopedic Surgery
Diabetes Specialist Nurses
Web Based Services
Obstetrics
Joint Diabetes Antenatal Service
High Risk Foot-care Team
Diabetologists
NHS Direct
Orthotists Footwear Specialists
Ophthalmology Laser Cataract Services
Eye Screening
Specialist Dietetics
Components of an Integrated Diabetes Care Servic
e
Community Dietetics
Community Podiatry
Optometrists
Pharmacies
Specialist Vitreo- Retinal Services
Primary Care Diabetes Teams
Primary Care Diabetes Teams
Primary Care Diabetes Teams
Primary Care Diabetes Teams
Primary Care Diabetes Teams
Primary Care Diabetes Teams
Community Nurses
Nursing Homes
Call Centres
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LTCII The Rationale

• The effectiveness of LTC management depends on
  effective self care
• Self care needs support e.g. Diabetes NSF
  recommends
• a personal record
• an integrated care plan
• In a distributed, integrated care environment
  patients and professionals need to share
  information efficiently
• Whole systems care needs whole systems
  information for management and planning

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LTCII - The Building Blocks

• Graphnet middleware
• Diabetes Continuing Care Reference Dataset
• (NSF) http//www.ic.nhs.uk/datasets/downloads/sub
  7/diabetes
• HL7 messaging Standards
• User guided Record Design Testing
• Care Planning Design Testing
• Network
• Configuration, security, protocols,
  infrastructure
• Data sharing agreements
• Specific, LTCII, variation of overarching Salford
  DSA
• Projects
• Pilot 2003-4
• Operational 2004-6 (live April-October 2006)
• Phase 2 commenced August 2007

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LTCII Data Flow Model
EMIS Vision
GP
MPI
EXETER Org Links
GP
XML (HL7v3)
Central Data Repository
GP
XML Journal File

Comwise DRSS
Web Server
3rd Party Data Repository
Web view of Integrated Record
3rd Party Audit Tool Excel, Access Crystal Reports
Printed Personal Health Record
Analysis Clinical/PCT Audit/Research
NHS net -www
NHS net -www
WWW View of Personal Health Record
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6months in the Life of a Man with Type2 Diabetes
Typical Distributed Multidisciplinary Scenario

• Background
• 55yr manT2 DM/HBP 8yr MI 1998 Metformin,
  Rosiglitazone, Simvastatin, Aspirin, Perindopril,
  Bendrofluazide, Amlodipine
• Presents to A E with Foot Ulcer Cellulitis
  starts clindamycin ciprofloxacin (penicillin
  allergy)
• MDFC osteomyelitis, poor glucose control, no eye
  screening 3yr home IV antibiotics and toe
  amputation
• Diabetes Centre Dietitian community weight
  exercise plan Consultant-DSN insulin
  start management plan
• Eye screening maculopathy Eye Hospital laser
  therapy
• Community Podiatry Foot healed ongoing
  preventive podiatry offloading footwear
• Care Call support lifestyle medication
  adherence
• General practice integrated DM CHD review
• Personal record with integrated care plan

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Cardiac Surgery
Direct Access Services
The 6 Month Journey
Surgical Wards
Cardiology
A E Emergency Medicine
Primary/Community Ongoing Care
Pediatric Diabetes Specialist Nurses Doctors
Medical Wards Wards

Diabetes Specialist Services
Clinical Psychology
Receptionists Support Workers
Rheumatology
Supporting Specialist Services
Services for Young People
Nephrology
On Call Service
Diabetes Network Hub
Vascular Orthopedic Surgery
Diabetes Specialist Nurses
Web Based Services
Obstetrics
Joint Diabetes Antenatal Service
High Risk Foot-care Team
Diabetologists
NHS Direct
Orthotists Footwear Specialists
Ophthalmology Laser Cataract Services
Eye Screening
Specialist Dietetics
Components of an Integrated Diabetes Care Service
Community Dietetics
Community Podiatry
Optometrists
Pharmacies
Specialist Vitreo- Retinal Services
Primary Care Diabetes Teams
Primary Care Diabetes Teams
Primary Care Diabetes Teams
Primary Care Diabetes Teams
Primary Care Diabetes Teams
Primary Care Diabetes Teams
Community Nurses
Nursing Homes
Call Centres
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Step 2
Referred to the MDFC
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LTCII Data Flow Model
EMIS Vision
GP
MPI
EXETER Org Links
GP
XML (HL7v3)
Central Data Repository
GP
XML Journal File

Comwise DRSS
Web Server
3rd Party Data Repository
Web view of Integrated Record
3rd Party Audit Tool Excel, Access Crystal Reports
Printed Personal Health Record
Analysis Clinical/PCT Audit/Research
NHS net -www
NHS net -www
WWW View of Personal Health Record
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Referred to Diabetes Specialist Team for review
Step 3
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Attending an Ophthalmologist at the Eye Hospital
Step 5
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LTCII Data Flow Model
EMIS Vision
GP
MPI
EXETER Org Links
GP
XML (HL7v3)
Central Data Repository
GP
XML Journal File

Comwise Diab. Retin.
Web Server
3rd Party Data Repository
Web view of Integrated Record
3rd Party Audit Tool Excel, Access Crystal Reports
Printed Personal Health Record
Analysis Clinical/PCT Audit/Research
NHS net -www
NHS net -www
WWW View of Personal Health Record
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Step 8
Accessing the Personal Diabetes Care Record
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LTCII Data Flow Model
EMIS Vision
GP
MPI
EXETER Org Links
GP
XML (HL7v3)
Central Data Repository
GP
XML Journal File

Comwise Diab. Retin.
Web Server
3rd Party Data Repository
Web view of Integrated Record
3rd Party Audit Tool Excel, Access Crystal Reports
Printed Personal Health Record
Analysis Clinical/PCT Audit/Research
NHS net -www
NHS net -www
WWW View of Personal Health Record
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Personal Record QuestionnairePatient feedback
Poor
Excellent
Could you read the information clearly? Could
you understand the information? Was it relevant
to your diabetes? Did you find your personal
record helpful? Did the record have everything
you would want to know about your diabetes? If
this record was routinely available would you
like to be sent one each year?
 
 
 
 
 
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LTCII Data Flow Model
EMIS Vision
GP
MPI
EXETER Org Links
GP
XML (HL7v3)
Central Data Repository
GP
XML Journal File

Comwise Diab. Retin.
Web Server
3rd Party Data Repository
Web view of Integrated Record
3rd Party Audit Tool Excel, Access Crystal Reports
Printed Personal Health Record
Analysis Clinical/PCT Audit/Research
NHS net -www
NHS net -www
WWW View of Personal Health Record
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Using the Data Repository
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LTCII Data Flow Model
EMIS Vision
GP
MPI
EXETER Org Links
GP
XML (HL7v3)
Central Data Repository
GP
XML Journal File

Comwise Diab. Retin.
Web Server
3rd Party Data Repository
Web view of Integrated Record
3rd Party Audit Tool Excel, Access Crystal Reports
Printed Personal Health Record
Analysis Clinical/PCT Audit/Research
NHS net -www
NHS net -www
WWW View of Personal Health Record
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Using the data making it usable
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HbA1c in last 15 Months (87)
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Prevalence of Diagnosed Diabetes in Salford by
area
No of people with diabetes / output area
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35 and over
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Cardiovascular risk
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Diabetes CKD in Salford
Observation Anaemia occurs earlier in Diabetic
Kidney Questions what is the prevalence of
anaemia in diabetic kidney disease and is
mortality related to anaemia in diabetic kidney
disease?

• Initial GFR 2000
• Follow up to December 2006 (mean 5.3 years)
• Mortality, Anaemia Diabetes
• 59,915 people (56.4 years)
• 7,018 GFR lt 60
• 2,951 Anaemic
• 6,519 DM
• 10,309 died (17.3)
• 334 Renal replacement therapy RRT

Up to date
Large (representative) cohort
Links between any data
Links to ONS, Renal Registry
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CKD, Anaemia SurvivalIn Salford People with
Diabetes 2000-2006
GFR gt60, No anaemia GFR gt60,
Anaemic GFR lt60, No Anaemia GFR lt60,
Anaemic
years
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LTCII - Summary Clinical Benefits

• Patient Experience
• Enthusiastic
• Clinical Effectiveness
• Supports integrated Care Planning, Self-Care
  Audit
• Clinical Safety
• Shared medication record, allergy record, care
  plans
• Cost Effectiveness
• Reduced duplication delay
• Reduced labour (audit, planning, research)

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LTCII Long Term Condition Information Integration

• A Personal Record for People with Diabetes
• An integrated view for care professionals
• A health economy tool for whole systems
  analysis
• A generic solution
• National standards and systems multiple LTCs
  (CHD, CVD, CKD)