1. www.cddft.nhs.uk CDDFT – Key development areas 28/1/16

2. Health care records to provide better health planning Enhanced research and service design Person centred Health Patient access Personalised care mgt Improved clinical info linkage 7 day case mgt Focussed preventative and risk managed care Cohort and individual risk and prevention Key IM&T Development areas

3. www.cddft.nhs.uk Lesson learned from past digital health projects 1.Best results NHS/ Local Authority clinician / patient designed 2.Organisational support and commitment essential 3.Integrate with clinical systems where possible – must have NHS number tag 4.Bridge the digital divide – range of inputs to offer patient lifestyle & input choice 5.Keep it simple and minimise cost - future proofing essential 6.Governance cannot be compromised – IG and clinical – must be in N3 7.Measure, measure ….build in data and evaluation on significant sample sizes 8.Scalability is key to economic sustainability - avoid small / multiple pathways 9.Don’t add work or widgets to existing pathways 10.It is not just a patient outcome / self mgt opportunity – it does offer triaging skill mixing and efficiency

4. Hospital Community GP Pharmacy Urgent Care SIM-enabled Online Access Decision Support GP Care Records

5. NHS-hosted (N3) Platform Digital Pathway Engine My App N3 Patient & Clinical Systems EMIS SystmOne Helicon Health Spine PDS INRstar Available INPS Vision* Ascribe Integrate Patient & Carer Interfaces App Interactive Phone Call Text Patient Portal Clinician Portal (N3) Care Home Portal Communicate API Connect Devices & Apps 3 rd Party Software Platforms Partner Systems App Exchange INR Self-Testing Undernutrition COPD Chronic Pain Falls Healthy Weight Mgmt Vital Signs Wound Management NOAC Monitoring Medication Reminder ABPM * Available Q1 2016 Cerner 4S DAWN In DevelopmentPlanned Apple HealthKit

6. Content available Stroke Prevention AF screening /continuous ECG monitoring INR self-testing Warfarin self- management Long Term Conditions Vital signs monitoring Digital stethoscope Clinical triage with integration with 111 Care Home Support Nutritional assessment Oral Nutritional Supplement Monitoring Diabetes Monitoring Falls Monitoring Haemoglobin Testing CRP testing HBA1C testing Behavioural Change Inhaler reminders Smoking cessation Medication reminders Weight management Falls Management Community Nursing Wound management Digital stethoscope Mental Health Chronic Pain Depression

7. ‘Big data’ analysis Work to date Predictive analysis on hospital readmission - SAS BCF cohort analysis by NHS number and across whole health economy Predictive modelling on A&E admissions Data sharing across larger health economy

8. Why we needed to share information Identified and agreed to develop two phases of information sharing for specific parts of project: Phase 1 - Data analysis ISA - across health and social care organisations to inform planning (e.g. identify patient cohorts, team roles required, capacity) Phase 2 – Pathway ISA - Sharing of relevant client information across partner organisations to support new ways of working and pathways across multiple partners

9. Phase 1 – Data Analysis ISA Data Analysis ISA: Allow sharing of information to identify a cohort of patients we needed to target for the project. 3003 frail elderly patients identified 76% were in GP practice DES (direct enhanced services) Care homes – 12% of DES Assumption 88% care home population were included in the initial 3003 identified patients Data then shared across Social Services/Mental Health and Acute Trust to determine how many of Frail Elderly cohort already known to them Results surprising and very beneficial; informed planning of roles/capacity required

10. Phase 1 – Data Analysis ISA Challenges Question whether using NHS number for planning/commissioning purposes met regulatory/legal framework Issues with NHS number “used only for direct patient care” After local and national review over several months – NHS Number could be used if appropriate ISA was agreed by all partners Link to NHSIQ FAQ’s and Templates http://www.nhsiq.nhs.uk/media/2661213/county_durham_and_da rlington_ig_sg2.pdf

11. Phase 2 - MDT Process ISA Can only start ISA when processes have been agreed by staff involved. ISA detailed what information will be shared, how it will be shared, how it will be transferred, stored and securely disposed of, also covered a range of other areas e.g. training, incident reporting etc. ISA for Third sector organisations were new, challenging and surprising. Full Communication between all parties crucial.

12. Phases 1 and 2 - ISA lessons learnt Must be a single lead / facilitator Standards have to be met by all parties, discussions of how these can be worked towards / met. Version control is a must to track different comments, Central point for all comments and signatories. Sharing and acceptance of the learning outcomes from our experiences - don’t reinvent the wheel

13. Benefits and outcomes Pathway based, predictive planning across multi agencies was critical to truly understanding the patient journey to underpin the Better Care Fund and 7 day working. Admissions and conveyance to Darlington Memorial Hospital from care homes are starting to show a decrease. Improved relationships and inter-dependant working with Local Authority and Voluntary Sector. Voluntary Sector process – three main brokers with access to over 500 other third sector providers. Pharmacists now involved in the MDT’s to enhance prescribing and consistency. 5

14. Data integration / single record Community already on one system Reviewing acute options Electronic enablement of acute pathways – ECDM, e-OBS, e-PMA Mobile working supported by NE&C AHSN