Dr Jonathan Richardson Chair Clinical Health Informatics Forum, Consultant in old age psychiatry and Clinical Director of Informatics, Northumberland, Tyne and Wear NHS Foundation Trust

Introduction Programme Background Electronic patient record (RiO) in NTW Clinical Dashboards in NTW Lessons Learned In 1997, Tony Blair announced that ”if you live in Birmingham and you have an accident while you are, for example, in Bradford, it should be possible for your records to be instantly available to the doctors treating you.” In 2007 when I stated as a consultant patient from Benton being admitted to a hospital in Benwell 2 2 2

Programme 9.00am Registration and Refreshments 9.30am Welcome & Introductions Dr Jonathan Richardson, chair clinical health informatics forum, consultant in old age psychiatry and clinical director of informatics, Northumberland, Tyne and Wear NHS Foundation Trust 9.45am The Campaign Jon Hoeksma, editor eHealth Insider 10.00am What clinical leadership can bring to informatics in the NHS Bill McAvoy, Deputy Transition Director, Patients and Intelligence,NHS Commissioning Board Authority 10.30am The business benefits of clinical leadership in informatics Dr Daniel Birchall, consultant neuroradiologist and chair of the Information Systems Strategy Board, the Newcastle Upon TyneHospitals NHS Foundation Trust 11.00am Breakout session with refreshments Facilitated discussion groups 12.00pm Breakout group session feedback 12.45pm Concluding remarks Dr Jonathan Richardson, consultant in old age psychiatry,acting chair clinical health informatics forum, Northumberland, Tyne and Wear NHS Foundation Trust 1.00pm Lunch

Linkages between the main elements of an information revolution Ownership Our patients Together Active best results Tell family mbers

Information strategy to give people more control over their care More efficient, with more time Sharing information safely to improve care Recording real time, accurate data and sharing it with people Ensuring patients are fully involved in decision making The information system More efficient, with more time Greater and better use of IT will help you improve the efficiency and quality of your practice of care, and you will be able to prioritise more of your time for those who need face-to-face care. Basingstoke and North Hants NHS Trust have a system that allows clinicians to access and update a patient’s information without leaving their bedside. Sharing information safely to improve care You will recognise that it is your duty to ensure people can access their records online if they wish and have the support they need to understand information in their records. Patient RenalView and Graham Care Homes are already allowing patients greater control over who they share their personal records with. Recording real time, accurate data and sharing it with people You will better understand the needs of the people you work with and understand more about the impact your care is having on them. This will rely, in turn, on your recording data directly into their care records and sharing it. Midwives in Portsmouth record patient notes straight to a blackberry device, halving time on administration and ensuring the hospital are near real-time data. Clinicians and managers involved in stroke care can use the StrokeNav system to share information across a multidisciplinary team and across locations. You will record accurate information, as close to the point of contact as possible, in line with national information standards, and linked by the person’s NHS number. You will share it with other professionals along care pathways and with the Health and Social Care Information Centre, where it can be held and linked securely to support broader health and care improvements. IT will support safer handling of medicines in care homes. The introduction of barcode technology has transformed processes in a number of Bristol care homes Ensuring patients are fully involved in decision making Your patients and service users will be increasingly well informed about their conditions, needs and the services available to them, what good quality care looks like, and the experience of others like them. You will be able to recommend information resources available via the national portal to the people in my care, being confident in their quality. Online decision aids produced by NHS Direct are available to health professionals and can be used when discussing treatment preferences with patients. The information system You will have an increasing appreciation of how recording high quality data record in care records not only benefits the individuals concerned, but also contributes to improvements in the care I provide or commission, to population level health and to research. You will increasingly be drawing on data held and made available by the Health and Social Care Information Centre to benchmark the care you provide or commission against others and to improve that care. The Health and Social Care Information Centre has launched a new portal to make primary care data easily available You will also be able to see how that information is driving more efficient care and reducing burdens across the health and care system. You will be able to compare your practice against Quality Standards that define key elements of a high quality service.  All cancer diagnoses are registered by a cancer registry which then allows clinicians and commissioners to benchmark services and outcomes. You will know who your local board level information champion is, and will have an appreciation of the contribution your local information and IT specialists play in helping to improve care.

More efficient, with more time Greater and better use of IT will help you improve the efficiency and quality of your practice of care, and you will be able to prioritise more of your time for those who need face-to-face care. Basingstoke and North Hants NHS Trust have a system that allows clinicians to access and update a patient’s information without leaving their bedside. Sharing information safely to improve care You will recognise that it is your duty to ensure people can access their records online if they wish and have the support they need to understand information in their records. Patient RenalView and Graham Care Homes are already allowing patients greater control over who they share their personal records with. Recording real time, accurate data and sharing it with people You will better understand the needs of the people you work with and understand more about the impact your care is having on them. This will rely, in turn, on your recording data directly into their care records and sharing it. Midwives in Portsmouth record patient notes straight to a blackberry device, halving time on administration and ensuring the hospital are near real-time data. Clinicians and managers involved in stroke care can use the StrokeNav system to share information across a multidisciplinary team and across locations. You will record accurate information, as close to the point of contact as possible, in line with national information standards, and linked by the person’s NHS number. You will share it with other professionals along care pathways and with the Health and Social Care Information Centre, where it can be held and linked securely to support broader health and care improvements. IT will support safer handling of medicines in care homes. The introduction of barcode technology has transformed processes in a number of Bristol care homes Ensuring patients are fully involved in decision making Your patients and service users will be increasingly well informed about their conditions, needs and the services available to them, what good quality care looks like, and the experience of others like them. You will be able to recommend information resources available via the national portal to the people in my care, being confident in their quality. Online decision aids produced by NHS Direct are available to health professionals and can be used when discussing treatment preferences with patients. The information system You will have an increasing appreciation of how recording high quality data record in care records not only benefits the individuals concerned, but also contributes to improvements in the care I provide or commission, to population level health and to research. You will increasingly be drawing on data held and made available by the Health and Social Care Information Centre to benchmark the care you provide or commission against others and to improve that care. The Health and Social Care Information Centre has launched a new portal to make primary care data easily available You will also be able to see how that information is driving more efficient care and reducing burdens across the health and care system. You will be able to compare your practice against Quality Standards that define key elements of a high quality service.  All cancer diagnoses are registered by a cancer registry which then allows clinicians and commissioners to benchmark services and outcomes. You will know who your local board level information champion is, and will have an appreciation of the contribution your local information and IT specialists play in helping to improve care.

The purposes of the clinical record To record risk assessments to protect the patient and others To record the advice given to general practitioners, other clinicians and other agencies To record the information received from others, including carers To store a record to which the patient may have access To inform medico-legal investigations To inform clinical audit, governance and accreditation To inform bodies handling complaints and inquiries To inform research To inform analyses of clinical activity To allow contributions to national data-sets, morbidity registers To act as a working document for day-today recording of patient care To store a chronological account of the patient’s life, illnesses, its context and who did what and to what effect To enable the clinician to communicate with him- or herself To aid communication between team members To allow continuity of approach in a continuing illness To record any special factors that appear to affect the patient or the patient’s response to treatment To record any factors that might render the patient more vulnerable to an adverse reaction to management or treatment Key fi ndings Th is study was commissioned by the Health Foundation to examine the extent, type and causes of failures in reliability in diff erent healthcare systems: failures which have the potential to create risk or cause patient harm. Th e research shows that: Failures in reliability pose a real risk to patient safety A signifi cant proportion of the reliability failures were associated with risks to patient safety. For example, we found 15% of outpatient appointments were aff ected by missing clinical information at our study sites. In 20% of these cases patients were exposed to risk (as judged by the doctors involved). Important clinical systems and processes are unreliable Fully reliable systems would function correctly under expected conditions. Th e four clinical systems for which reliability could be measured had an average failure rate of 13%–19%. Th ere are wide variations in reliability Diff erent organisations varied signifi cantly in their reliability: problems such as faulty or missing equipment aff ected 37% of operations at organisation D but only 12% at organisation F. Unreliability is the result of common factors Across the fi ve systems and organisations, unreliability was usually the result of the same factors. Th ese included: a lack of feedback mechanisms for both individuals and systems; poor communication; and a widespread acceptance on the part of clinical staff that systems are going to be unreliable, and that this is not their responsibility. It is possible to create highly reliable systems Th e variation between and within organisations suggests that it is possible to create systems that are more reliable. HOW Improving standards in clinical record-keeping,Ian Pullen & John Loudon,Advances in Psychiatric Treatment (2006), vol. 12, 280–286

15% of outpatient appointments were affected by missing clinical information In 20% of these cases patients were exposed to risk (as judged by the doctors involved). Key fi ndings Th is study was commissioned by the Health Foundation to examine the extent, type and causes of failures in reliability in diff erent healthcare systems: failures which have the potential to create risk or cause patient harm. Th e research shows that: Failures in reliability pose a real risk to patient safety A signifi cant proportion of the reliability failures were associated with risks to patient safety. For example, we found 15% of outpatient appointments were aff ected by missing clinical information at our study sites. In 20% of these cases patients were exposed to risk (as judged by the doctors involved). Important clinical systems and processes are unreliable Fully reliable systems would function correctly under expected conditions. Th e four clinical systems for which reliability could be measured had an average failure rate of 13%–19%. Th ere are wide variations in reliability Diff erent organisations varied signifi cantly in their reliability: problems such as faulty or missing equipment aff ected 37% of operations at organisation D but only 12% at organisation F. Unreliability is the result of common factors Across the fi ve systems and organisations, unreliability was usually the result of the same factors. Th ese included: a lack of feedback mechanisms for both individuals and systems; poor communication; and a widespread acceptance on the part of clinical staff that systems are going to be unreliable, and that this is not their responsibility. It is possible to create highly reliable systems Th e variation between and within organisations suggests that it is possible to create systems that are more reliable. HOW

Brief history of RiO in Newcastle 1997 – Trust completed clinical information system procurement – began implementation of InteHealth 2002 – Migrated from InteHealth to RiO 2003 – Started clinical rollout in Community Mental Health and Early Intervention In Psychosis teams 2006 – NTW Trust formed through merger  - One of the largest MH Trusts in the country Direct contract with supplier 2010 – Trust achieved Foundation Trust status 2011 – Currently 3500 users covering a population of 1.2 million At peak approx. 900 concurrent users Complete coverage by March 2012 including a diverse range of services. In 1997, Tony Blair announced that ”if you live in Birmingham and you have an accident while you are, for example, in Bradford, it should be possible for your records to be instantly available to the doctors treating you.” In 2007 when I stated as a consultant patient from Benton being admitted to a hospital in Benwell 10 10 10

Enhancing RiO Access Data Collection Variety of data collection methods used Recurring themes raised in all areas Directorate Medical Trust All users email Over 700 responses Team / Ward Data Medical Staff Data Trust Survey Recurring Themes

Progress on issues Clinical Forms Lean workshop over 80 clinicians and patient user groups Went live with core documentation for 3500 users in October 2011 Care Programme Approach Association National Award Currently in the process of a further review Data Entry/Mobile Access Vodafone mobile access solution available 300 deployed To deploy 1000 Great feedback Improved usability Clinical Standards Developed NTW Clinical Standards for Electronic Record Keeping Scanning and Document Capture Upgrade of the scanned document section has gone live Clinical Coding Work stream planned during 2012 Northumberland/Partnership Working Access Newcastle Social Services summary of risk, directly from RiO Speed of RiO Upgrade to v6 included full hardware upgrade

Differences within and out of the national programme for IT RiO in NPfIT RiO out of NPfIT Clinical and risk management information in one place Available to multiple users at multiple sites at all times Changes often in a challenging time frame Local configuration Enables a sociotechnical approach Changes made in a realistic time frame

Clinical Dashboards Good quality information is a driver of performance for clinical teams and helps ensure the best possible care for patients. Clinical Dashboards help to drive this process by: providing timely, relevant information for clinical teams, presented in easy to understand formats, with high visual impact utilising multiple sources of existing data, even across organisational boundaries providing clinical information across multidisciplinary teams displaying information in ‘real time’ without delay for data cleansing allowing local configuration and comparison against national data sets permitting regular changes to displays, as required by the local teams, to keep the information relevant and up to date 17 17

Lessons learned from Clinical Dashboards 18 18 18

Care Pathway Transitions between services / pathways Assessment & Formulation Treatment, maintenance & support Disengagement & Discharge Access

Quality Standards Care Pathways EPR RiO 20 20

Quality Standards Care Pathways EPR RiO Data Warehouse

ESR Data Warehouse Acute Trust Care Pathways EPR RiO Quality Standards Safe guarding

Standardised Quality outputs Quality Standards Standardised Quality outputs Care Pathways EPR RiO Q and P Dashboard Data Quality ESR Data Warehouse Clinical Dashboard Acute Trust PDF Data Quality Safe guarding Spreadsheets

Data Quality ESR Data Warehouse Acute Trust PDF Data Quality Urgent and Planned Care Caldicott and Health Informatics Groups NTW Caldicott and Health Informatics Groups Quality Standards RiO Champions External Communication Standardised Quality outputs Care Pathways EPR RiO Q and P Dashboard Data Quality ESR Data Warehouse Clinical Dashboard Acute Trust PDF Data Quality Safe guarding Spreadsheets

Clinical System Content Build Maintenance Clinical requirements Core Documentation (inc national core headings) Workstream A Workstream B Workstream C <<------------------------------------------------- RiO --------------------------------------- >> Contract\CQUIN e.g communication with GP Workstream D Audit enhanceents Business requirements = Design/Build/Test/Train = minor change = major change 25

Clinical System Content Build Maintenance Clinical requirements Core Documentation (inc national core headings) Unplanned Work Workstream A <<------------------------------------------------- RiO --------------------------------------- >> Contract\CQUIN e.g communication with GP Workstream D Audit enhanceents Unplanned Worlk Business requirements = major change = Design/Build/Test/Train = minor change 26

Benefits of a Clinical Director of Informatics Engagement Clinical validation of systems Education and training Links with professional bodies Networks Promoting innovative practice