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Learning Health Systems John Robson GP, Reader QMUL Clinical lead CEG, UCLP, Tower Hamlets CCG
“Every patient contact is an opportunity for learning…”
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Clinical Effectiveness Group
Four CCGs: Newham, Tower Hamlets, City and Hackney, Waltham Forest Pop 1.2m: 200 general practices: 1000 GPs. QOF : Highest performing CCGs in England
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Learning Health System
Data into Knowledge Knowledge into practice
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Our learning health system
RAG chart showing practice current performance Consultant diabetologist Guideline
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East London Practices – Exceptional QOF success: trajectory of change
C&H and TH 1st, 2nd in 25% QOF metrics; Newham top 10% C&H 2014 1st AF anticoagulated * 1st Diabetes foot exam 2nd CHD BP 2nd Stroke BP * with exceptions C&H 2016 1st AF Anticoagulated (with exceptions) 1st CHD BP 1st HYPTN BP 1st PVD BP 1st Stroke BP 1st Asthma 3Q 1st COPD Spirom 1st COPD MRC 1st COPD FEV1 1st Diab BP 1st Diab exam 1st Smoking advice 2nd Diab Chol 2nd Dementia C&H 2013 21st COPD FEV1 41st AF anticoagulated 148th Diabetes BP 181st Diabetes chol C&H 2015 1st BP target CHD, Stroke, PAD, CKD 1st AF anticoagulated (with exceptions) 1st COPD x spiro, MRC, FEV1 1st Asthma review 1st Diabetes exam 2nd Diabetes education 2nd Dementia review 3rd Hyptn BP 3rd Diabetes BP
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Kaiser Permanente S. California
Kaiser Permanente S. California. Vs East London Top 10% USA HEDIS vs QOF data without exceptions Kaiser Tower Hamlets C&Hackney Diabetes HbA1c <9% 76% 80% 81% COPD Spirometry 82% 89% Child imms 2yrs 94% 90%
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Improvement Tower Hamlets 2015-16
Q1 2015 Q3 2016 Improvement >75 CVD or diabetes high intensity statin 33.8% 42.3% +28% LAA Insulin T2 D 4.7% 4.1% - 11% CVD on long term NSAIDs 2.7% 2.2% - 18% ceph/quin/co-amox (as % all Antibiotics) 17.5% 9.7% - 45%
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PULSE CHECKS > 65 years
Waltham Forest Newham 2016
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Achieving Successful improvement
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Belief Action Motivate
Evidence Stakeholders Consensus Guidance and KPIs Education IT support On screen prompts Script switch Trigger tools Patient recall and review lists Financial targets Dashboards Peer performance Not just improvement but learning Learning
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BELIEF – Stakeholder consensus and guideline
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ACTION Web enabled - Single systems for IT
And also facilitated Web enabled - Single systems for IT IT decision support, search and analysis capability Locally engineered and responsive CCG, GP provider, and public health facing Academically supported
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Facilitation + Analysis
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MOTIVATE – Dashboards in near real time
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AF Dashboard
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It’s a system… not a plug-in ….
GUIDELINES TEMPLATES: Multimorbid smart templates FACILITATION workshops, in-practice, telephone support TOOLS: AF-APL HF-APL eGFR SEARCHES - practice searches and patient recall DASHBOARDS – including PROMIS; LTCs
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The result – A learning health system
Diabetes CVD Imms COPD 2008 4 yrs top in UK and London bottom quartile performance
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East London Community Kidney Service Sally Hull, Neil Ashman, Sec Hoong, Nicola Thomas, Helen Rainey 4 April 2017
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What is the Problem? Fastest rising ESRD rates in London – ever more people needing dialysis Haemodialysis rates per million population, three inner east London boroughs High rates of ESRF and rising Around 20% arrive as crash landers (previously unknown to the service) The 4% growth per annum costs the NHS about 6M Data from the UK Renal Registry 2015
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What are we doing about this?
E-referrals and local guidelines Community CKD eClinic Community-based Nephrologist doing e-clinic in EMIS Web Referrals ALL electronic (through e-referral)- unless urgent All reviews and opinions recorded in EMIS Web Locally relevant guidelines. Community based education 2. Practitioner and Patient education Practice based education Patient one on one and group education Virtual clinics with nephrologist having access to primary care record Encourage GPs to code and manage CKD with trigger tools to find those with a falling eGFR Find and code cases 3. Community CKD overview CCG/Practice dashboards with KPIs CKD Prevalence searches to find un-coded patients ‘Trigger tools’ to alert GPs to patients with a falling eGFR Practice safety alerts
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Patient consent for shared record
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Renal opinion visible in GP record
GP opens shared record
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Early Wins for the service
Waiting times for consultant advice slashed! In the six-week pilot period 19/35 practices referred into the community e-clinic. Over 70% of referrals are managed without the need for patients to attend a hospital appointment. During 2015 the average wait for a renal clinic appointment was 64 days. Using the e-clinic the average time to get nephrology advice is 5 days. GPs say… A model for future care happening right now in Tower Hamlets! Consultants say… We can provide comprehensive management advice whilst avoiding unnecessary duplication of tests.
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Summary metrics of trigger tools (all 35 Tower Hamlets practices)
Population 200,000 Practices 35 Trigger tool alerts over 3 months in 2016 343 Alerts completed 91% Action (review, retest, medication review) 44% Referrals into e-clinic 15% (50 cases) We see that 90% of alerts were completed, with 15% additional referrals to the virtual CKD service
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East London Community Kidney Service
CKD managed in a single care record Coding improved to prevent medicines errors and enable CKD monitoring Trigger tools to find unknown “at risk” patients Patient self-management through education & information
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Discovery – a learning health system for east London
A collaboration between four boroughs: Newham, Tower Hamlets, City and Hakney, Waltham Forest and two hospitals, Homerton and Barts Health Pop 1.3 million: 200 general practices and 700 GPs, two hospital trusts. ….strive to become learning health systems by making clinical data research grade and lowering the cost of data acquisition and knowledge generation Victor Dzau. Transforming Academic Health System for an uncertain futures Every consenting patient’s characteristics and experience is available to learn from Best practice immediately available Improvement is continuous This happens routinely and efficiently This is part of a culture
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Social Services EMIS CERNER HSCIC
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Discovery Discovery - Gets all our data into one place, links GP and hospital data Managed by an NHS community interest company of local practices, NHS organisations and patients. We, the clinicians, remain data controllers. Funded by Endeavour Healthcare Charity (approx. £4m, and small contributions £225k per year total shared from the 4 CCGs) .
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Data Service clinically driven with third party access
Near real time reporting Outcomes relate to process * bleeding in NOACs vs warfarin * hip replacement failure * safety: hypoglycaemia, renal function Efficiency – no duplicate tests Predictive scores Decision support Research Patient connection Social services, OOH, 111 etc ………….
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Discovery Architecture
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A learning health system
Who am I consulting? Discharge dates, summaries, reconcile medicines Care plans Patient system flows Patient Apps Views: HIE/MIG Record sharing Virtual clinics Performance Dashboards Real time outcomes Basic science/genomics Trials Predictive scores Child risk and drug safety Targeted medicines Efficient pathways: Cancer delay Meds optimization: Stroke reduction Monitoring eGFR: CKD prevention Intervention: Gestational diabetes Prevention: Colorectal screening Workflow Visualise & Review Discovery Improve Research + safety
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PATIENT Patient PATIENT FLOWS CLIENTS TRANSLATION & IMPROVEMENT
GP OOH A&E Hospital Community CLIENTS Public health Safe Effective Efficient PATIENT Commissioner Clinician Researcher Patient TRANSLATION & IMPROVEMENT Basic science genome Trials Cohorts Registers Precision medicine Implementation
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Where are we now? 29 practices out of 36 in Tower Hamlets streaming all data daily into Aimes N3 cloud Plan to upscale to all of TH, Newham, City & Hackney and Waltham Forest by end of March, with EMIS Web Community to follow Homerton Hospital ADT data successfully received. Barts Health to follow Data validation Vaccination UK data agreed to stream TH GP out of hours, NHS 111 and PELC Negotiations with social care providers and councils Discovery Project manager in post at CEG with brief Patient and Public Involvement Board Development Fair processing – publicity campaign Link with UCL Partners – Andrew Morris 5 projects agreed at first board meeting
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Five initial projects Existing CEG Work NLP / Clinithink
East London Genes & Health Atrial Fibrillation Child Health But in the pipeline AI/machine learning Patient apps
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Child Health Three areas for learning health system Childhood Obesity
HPV Immunisation Newborn Screening
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2015-2016 Prevalence of obesity: England School Year 6 (age 11 years)
Benchmark England (19.8%) Red Worse, Amber Similar, Green better
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2011-2016: Prevalence of obesity: England School Year 6 (age 11 years)
Tower Hamlets Hackney Newham
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Childhood Obesity Currently NCMP data not communicated to GP
Adult trials (eg Aveyard) suggest GP is effective in motivational engagement with weight management programmes Opportunity to evaluate similar approaches in children and - potentially - households with multiple obese members Stage 1: link static data extracts of NCMP data to EMIS Stage 2: create near real time data flow from NCMP to EMIS Stage 3: develop and evaluate primary care initiated intervention
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2015-2016: HPV vaccine coverage, England
HPV vaccine coverage in England for females completing a two-dose HPV schedule by school year 9 was 85.1% (PHE 2016) Hackney 64.1% ie 1 in 3 not immunised Newham 90.9% ie 1 in 10 not immunised Tower Hamlets 74.1% ie 1 in 4 not immunised No data flow to GP record Patchy flow to Exeter system GP ‘mop up’ lacks system to support Aim Via Discovery link immunisation record to EMIS in near real-time enabling unimmunised to be identified and offered vaccine ? Extend to boys, other age groups??
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Learning Health Systems John Robson GP, Reader QMUL Clinical lead CEG, UCLP, Tower Hamlets CCG
“Every patient contact is an opportunity for learning…”
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