Integrated care record … integrated care Geraldine Fitzpatrick 11 Dec 2003 ICR Worshop, Edinburgh Dec

Problems with paper & silos...

NHS Care Record (formally ICRS) Deeper clinical info at local level Access to info that supports integrated delivery Provide clinicians with support and guidance Support bookings Support transfer of prescriptions between GPs and pharmacies Provide clinicians with ability to view summary of national patient record Provide patients with ability to view and contribute to their records (NHS ICRS Introduction to the Output Based Specification, p20)

NHS Care Record (formally ICRS) Deeper clinical info at local level Access to info that supports integrated delivery Provide clinicians with support and guidance Support bookings Support transfer of prescriptions between GPs and pharmacies Provide clinicians with ability to view summary of national patient record Provide patients with ability to view and contribute to their records (NHS ICRS Introduction to the Output Based Specification, p20)

ICR Conceptualisation Information repository passive, decontextualised structured content issues in-between data exchange Formal… bird’s eye view Practice support… care pathways, decision support Change management etc separate from ICR spec “Records as archive”

ICR Conceptualisation Information repository passive, decontextualised structured content issues in-between data exchange Formal… bird’s eye view Practice support… care pathways, decision support Change management etc separate from ICR spec “Records as archive” Where is the local situated day-to-day doing of care work?

Overview Case study 1 – ‘at work’ –practical integration of paper chart into care practices ‘on the ward’ Case study 2 – ‘to work’ –the work to put telehealth to work

Location : hospital medical unit Method: qualitative –observation –in-context interviews –artefact collection Focus: “Understanding paper in practice can direct and inspire new technologies” (Sellen & Harper 97) Implicit, taken-for-granted practices… Case Study 1: (LPR) at work

Overview of the work setting Medical unit across two wards –Assessment and planning ward & medical ward Clinical team –Medical consultant, registrar, resident –Visiting consultants –Ward nurses –Allied health Pharmacy Physiotherapist Social worker –Services Stroke service team Drug and alcohol service Healthcare work –Allocation of patients –Rounds

Firstly… …no such thing as the record... … a diverse distributed collection...

Multiple views Teams with views -concurrent -inter-related Ward round Ward meeting Stroke service & others …

Pharmacist notes

Physio ward-book

Case manager notes Management plan

Individuals with views Integrating multiple working forms Transformations between forms

Ward overview

Nurses work sheet

Summary: The record as diverse distributed collection formal... informal transient... persistent different locations different owners & authors different intended audiences different purposes …no such thing as the record in practice...

Summary (cont) Buff chart (LPR) as –pivot or anchor of the network –the collaboratively-rendered persistent archival trace Working record as –different views as putting information to work –local stores vs central stores –transformations & representations How could the ICR support working records?

ICR supporting working record? Role-specific views of patient –Parallel records –Core and local data –Formal (persistent) and informal (temporary) data Summary templates for ‘paper in the pocket’ –Ward views –Patient allocation views –Basis for note-taking

Secondly … paper is highly flexible & adaptable... supports local adaptation, responsiveness, and directed communication …allows clinicians to respond in a timely way to local needs

Tailorable - supports individual preferences Flexibility & adaptability…

Supports local practice & rapid prototyping

Adaptable - supports local responsiveness

Directed communication at the point of action

Contextualised embedded conversations

Eg: Drugs & prescription screen (

90% Informal communication 90% of information transactions involve informal communication rather than interaction with formal information sources (Coiera 2002) [ 81_fm.html]

Summary: paper-based artefact overlaid functionality annotations conversations at the point of care local practices local responsiveness individual preferences

ICR supporting adaptation & communication? End-user tailorability of screens/forms –Within constraints Context and person specific communication –Informal –At point of care –Asynchronous as well as synchronous

(LPR) at work… Integrally & actively embedded in – the doing of ‘integrated care’ – as part of total environment spatial, organisational, professional, social, medico-legal,... Two themes 1.No such thing as the record … a diverse distributed collection 2.Flexibility and adaptability of paper supports adaptation, responsiveness, and directed communication And many more … a role in communication and coordination, location as information, etc

Overview Case study 1 – ‘at work’ –practical integration of paper chart into ‘on the ward’ care practices Case study 2 – ‘to work’ –the work to put telehealth to work –embedding videoconferencing and data sharing as just another tool

Case Study 2 – ‘to work’ Intensive care telehealth project ICRS: -telemedicine as new technology to support remote diagnosis, near patient testing … -Video conferencing to improve communication and share knowledge

The work to put telehealth to work Getting the technology in place is only the first part of the process In the corner or in use? There is significant effort required to introduce ‘non critical path’ technology and evolve working practices so that it is familiar enough and easy enough to use to be just another tool like the telephone or stethoscope…

Clinician-driven ICU telehealth Three ICUs Experience with remote monitors

Off the shelf technology

The work to put it to work Dedicated project officer Training for ad hoc use Role of serendipity, experimentation Other activities to encourage use

Different ICR conceptualisation as archive & at work designing records … designing practice … information focus … practice focus …

Moving forward Integrated care record to be used in care or Integrated care practice enabled/supported by ICR? Change management –not just macro but on the ground –proactive not reactive –training to evolve practice not just to use How to understand issues, needs –What are the small easy things that will make big differences to care? Who to involve and how –What roles, Time and resource issues,

Acknowledgements Work undertaken while at University of Queensland, Distributed Systems Technology Centre and Centre for Online Health, Australia Partners from hospitals, Telstra and UQ involved in telehealth project