Varya Shaw on the advantages of linking all primary care systems together to offer ‘interoperability’
Keyboard and stethoscope
Interoperability is not the most exciting word in the English language but it represents a quiet revolution. It allows different clinical systems to collaborate, creating endless new possibilities.
INPS is a market leader in the field of primary care interoperability. Its product, Vision, allows the networks most frequently used by GPs - EMIS Web, TPP Systm1 and Vision AEROS - to share and use each other’s information.
Headline tools and benefits include a task manager, online appointments, e-prescriptions, a customisable screen, QOF prompts, decision making support for prescriptions using the online medical dictionary Gemscript, a recall facility which tracks patient response, and simple data entry.
‘If you give GPs an easy solution - just click this thing in front of you and you can improve the patient’s outcome - they will go for it’
These are obviously useful, but as a list they do not capture Vision’s potential to transform the way primary care works.
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At a press of a button
So what can Vision do? It allows CCGs to disseminate local policies, simple templates and even very complicated guidelines to all their practices at a press of a button, regardless of clinical system.
For GPs sitting at their desks, Vision provides prompts that pull together and analyse symptoms and test results, and suggest the next step in the pathway. When a referral is needed, a form is generated at a click of the mouse. There are two benefits to clarifying what pathway stage a patient is at: it helps GPs act sooner when it is appropriate, and stops them referring patients unnecessarily.
Vision supports GPs to help patients they might miss, and help them sooner. It allows CCGs to do the same for practices. A central dashboard aggregates GP data so that CCGs can see which practices are struggling to comply and provide support.
The analytics provided by the dashboard inform commissioning by showing where secondary care is under pressure. They also provide proof of outcomes which allows CCGs to evaluate changes to pathways and start again if they are not working.
‘The question for GPs is how well does a programme integrate with their existing system’
There are currently 60 Vision pathways including the NHS healthcheck, chronic kidney disease (CKD), diabetes, colorectal cancer, wound care, and the Unplanned Admissions DES. Eight of these are being piloted this year.
One of the earliest pathways to be developed was the CKD module, which was authored by GP Dr Jon Behr.
Dr Behr explains why it was an ideal testing ground for Vision: “There is cynicism about CKD from GPs and dealing with the results is very onerous if you want to do it properly in accordance with the NICE guidelines, which are very lengthy. The key thing is those guidelines are objective, dealing with hard numbers, and there are rules you can write based on those numbers.
“With a designer, I developed a plug in manager with clinical decisions report for CKD. We want to make sure that practice CKD registers are more accurate, and that all patients that should be on ACE inhibitors are, unless there’s a good reason not to. But we came to a dead end because we weren’t a company.
Max Brighton on interoperability
INPS is an advocate of interoperability - making existing IT systems across the NHS work together to facilitate integrated care. Interoperability is really about attitude - letting go of short term territorial sensitivities and seeing the long term potential for the health system. Our competitors offer it in varying degrees, but with reluctance. Their strategies are based on dominating an entire area with their systems so it is not really in their interest to facilitate interoperability.
We believe our approach is better for patients, clinicians and the NHS. The alternative of a single monolithic system across a whole CCG stifles competition and innovation, and removes system choice. It lets only those clinicians using the system work together - in the NHS there will always be clinicians and providers on the outside who become isolated.
Vision Outcomes Manager is a common-sense approach to interoperability. It works with all major GP IT systems, allowing CCGs and health boards to involve every single practice and clinician in targeted health improvement initiatives without having to change those systems. This means it can be deployed quickly without incurring the cost, disruption and inevitable data loss of unnecessary wholesale system changes.
The solution is the same for all GP practices regardless of the IT system. This makes it easy to deploy with consistent training for all staff. Data recorded using Vision Outcomes Manager is stored as normal clinical data, using native coding, within the existing GP clinical systems.
Uploading statistics about the number of patients meeting the criteria of each node and decision point on a pathway gives commissioners invaluable insight into the care being provided, but does not involve any patient data moving around. This means that information governance requirements are minimal. Patient permission does not need to be obtained and it is not necessary to undertake a costly and time consuming public awareness campaign - which often costs much more than the IT systems themselves.
We were one of the first suppliers to sign up to the new GP Systems of Choice funding framework, which extends the notion of choice. We believe that GP practices should be able to exercise their right to choose the GP IT system they want, and which works best for their particular circumstances. Vision Outcomes Manager allows CCGs and health boards to realise all of the benefits of a single system, without compromising the choice agenda.
Max Brighton is managing director of INPS
“We heard about the huge potential of Vision Outcomes Manager and got in touch and saw that for CKD it was perfect. It seemed to me Vision was an opportunity to improve diagnosis and management of a condition that is not particularly well managed at the moment.
“For a particular patient you might want to know whether they should be on an ACE inhibitor or should they have been referred because of the pace of decline. Vision will tell you.”
The module, which will be piloted in Hull CCG, will keep CKD registers up to date so QOF payments will be maximised, but it ultimately aims to reduce the numbers of patients reaching end stage kidney failure. This will have a knock-on effect on strokes and heart failure, in which CKD plays a role. But for now the pilot will measure adherence to the guideline, increases in ACE inhibitor and A2A prescribing where appropriate, and improvements in blood pressure.
CCGs do not need much persuading to see the benefits, but what about GPs? Phil Kozcan, a GP and chief clinical information officer for UCL Partners, says: “The question for GPs is how well does a programme integrate with their existing system. If you have a tool like this that is very closely integrated, they will use it.”
Dr Behr adds: “The nature of the alerts is they don’t feel tickboxy - they are useful clinical summaries for CKD. If you can give GPs an easy solution - just click this thing in front of you and you can improve the patient’s outcome - they will go for it.”
He adds that the Unplanned Admissions DES module will provide an even stronger incentive to those GPs who have it to make full use of Vision.
Efficiency as well
Vision provides immediate efficiency gains. The CKD software module costs around £300 per practice, far less than, say, payroll software. Asking each practice to install pathways, guidelines and templates themselves is much more expensive than deploying these centrally through Vision. It also saves clinical time.
Medicine is hugely complex with thousands of pathways. By supporting clinical decision making with prompts which make quick work of the algorithms and flowcharts GPs normally must wade through, they have more time to communicate with the patient.
‘By supporting clinical decision making with prompts which make quick work of the algorithms and flowcharts GPs normally must wade through’
Vision has the potential to do a lot more. It could transform remote care once it is optimised for use on mobile devices. It could also transform patient involvement, for example, it might be possible for someone having a test to access a patient-friendly summary of their results, which could encourage safe and effective use of medication. Dr Behr is working on an app for patients with CKD which will allow them to be more proactive in self management.
But the programme is already changing the landscape. Like any disruptive technology - the internet for example - interoperability creates opportunities that were not there before. Challenges such as efficiency, managing long term conditions, and integrated care are suddenly much simpler.
As Ciaron Hoye, who is piloting three Vision pathways as manager for intelligence at Birmingham CrossCity CCG, says: “It’s a massively different way of thinking. This is a radical change in concept and approach.”
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