Integrated care pathways

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Integrated care pathways
Dr Jeremy Rogers MD MRCGPSenior Clinical Fellow
in Health InformaticsNorthwest Institute of
Bio-Health Informatics
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Talk Outline

• ICPs
• eICPs
• Challenges

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History of ICPs

• Industrial process management tool from 1950s
• Healthcare in US from 1980s
• UK from 1990s
• 12 NHS pilots 1991-2
• UK user group 1994, but folded in 2002
• Resurgent interest
• BMiS Workshop May 2003
• NELH database (Colin Gordon)
• International Web Portal (Jenny Gray,Venture TC,
  UK)
• National Pathways Association (Northgate)
• NPfIT

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Where we are nowWhats an ICP ?

• Document
• Describing idealised process
• within health and social care
• Collects variations
• between planned and actual care
• Iteratively developed
• Develop implement review revise

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Whats an ICP ?

• Embed guidelines protocols
• Locally agreed
• Evidence based
• Patient centred
• Best practice
• Everyday use
• Individualised

• Best use of resources
• Record variances
• Compare plan against reality
• Tool for (Clinical) Business Process
  Re-engineering

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Management of Newly Diagnosed Type 1 Diabetes
Diagnosis in Primary Care
Referral to and assessment by secondary care
within 24 hours
Dehydration/vomiting/at weekend Admit to
RBH Diabetes Clinical Nurse Advisor to see
No dehydration or vomiting DNS to commence
insulin within 24 hours
gt60 years twice daily pre-mix
lt60 years Basal/bolus
IV insulin as per protocol
Data collection HbA1c Weight/BMI Islet cell
antibodies
Unless patient and lifestyle dictate otherwise
Ongoing education Support/Assessment by DNS
Referral to dietitian, podiatrist and
psychologist
Group education at 3-6 months
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Current UK Status

• 2401 in NELH database
• 1214 subjects
• predominantly surgical
• Often admission pro-formas
• 170 Trusts writing, 179 using
• 10 PCTs writing, 21 users
• Not many available online
• (lt10 ?)
• Airdale, Battle
• eICP rare
• 60 in use at Gloucester NHS Trust (ERDIP), in
  urology

No. in use per trust
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The FutureWhats an eICP ?
Model pathway
Instantiated pathway

• Versioned
• Iteratively developed
• Links to guidelines, protocols, evidence
• Activity specs
• Valid state changes
• Role specification
• Explicit overall objective

• Patient demographics
• Patient characteristics at start
• Care plan
• Individualised
• Activities carried out or not carried out
• Outcome
• Reasons for variance

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Whats an eICP ?
Ended pathway
Whats an epathway?

• Includes abandoned, rejected, completed
• Record of variances
• Patient characteristics
• Activities or activity states
• Performers
• Timings

• MLMs
• GLIF
• CLIPS
• Protocols
• PRESTIGE
• Protégé
• Proforma
• SOPHIE

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eICP in NPfIT

• Phase I (2004/5)
• Ability to construct and use ICPs
• Migrate paper ICPs to eICPs
• Record total journey times
• Phase II (2006)
• Model care pathway
• Instantiated care pathway
• Ended care pathway
• By 2010
• All singing all dancing

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Automated eICPs ?

• Evidence-based action at the point of care
  instantaneously triggers follow on actions
  elsewhere in the system Tackaberry, iSoft (2000)
• Automatic identification and invoking of
  workflow, alerts, review and guideline
  activation NPfIT OBS 2003

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ImplementationBarriers to the Future

• Human Factors
• Cultural
• Organisational
• Cognitive
• Time
• Patients
• Commercial

• Technical Factors
• Time Scale
• Too many critical dependencies
• Not yet invented
• Lack of EBM
• Political
• Cost
• Expectations

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Human FactorsLikely Hazard Warning

• The usual
• No buy-in, time, skills, training, leader,
  benefit
• Sabotage, fizzling out
• ICP from on high (ie written by consultant)
• Attempt perfection at first draft rather than
  iterate
• Or, alternatively, less enthusiasm for necessary
  iteration
• Biting off more than can chew
• Medicine is complex eat it a bit at a time
• Interdisciplinary friction
• Terminology, working practices, culture etc.

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Technical Barriers Specific Informatics Problems

• Authoring
• EPR Data Quality
• Indexing
• Act management

• Clinical Terminology
• Consent
• Visualisation
• Automation
• Pace of change

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BarriersTechnical eICP Authoring
PROS
CONS

• Automation requires strict logic
• Specialist activity
• Limits ownership participation
• Edge-of-protocol effects
• Can be very complex to view
• Re-use at risk of curly bracket problem
• Chaotic co-behaviour
• Not done yet

• Software supported
• Re-use of modules
• Standard Components
• timeframes, interventions, evidence, references,
  and goals/outcomes
• Geographically distributed authoring
• Increase accessibility of process, buy-in ?

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BarriersPolitical Commercial
POLITICAL
COMMERCIAL

• Unrealistic expectations
• Bad press
• War of authorities
• NICE, BNF, Colleges, BMA, Clinical Evidence,
  NELH, NHSIA, Pharmas etc.
• Covert agendas
• Manage docs, not patients
• Cold feet

• Pharmas
• Snake Oil Distractors
• Apathy in face of
• Low user demand
• More pressing problems
• True development cost