1. Sometimes you have to be the worst to become the best?  2006: My Region was highlighted as having significantly high admissions for diabetes.  Our performance data was terrible.  They sent me to Chicago.  I decided to create an IT solution

2. The Initial Aims of the System 1.Accurate Benchmarking. 2.Automated Risk Stratification with Identification of High Risk Patients. 3.Integrated Care with improved access for Remote Specialist Evaluation. 4.Summary & Self Management Reports for the Patients 5.Improve Safety of Prescribing. 6.Ability to Implement Patient orientated projects. 7.Prevent events like foot ulcers!

3. Benchmarking  Accurate Benchmarking of how the surgery and PCT is performing on clinical markers.  NICE  QOF  How we were performing in terms of outcome data.  How we were performing in terms of cost.

4. Benchmarking (2)

5. 2. Identification of High Risk Patients Six types of High Risk Patients  1. Those that have poor end-point data.  2. Those that have deteriorating end point data.  3. Those that fail to have screening  4. Those who are not on or not collecting appropriate medications  5. Those that are on inappropriate medications.

6. 2.High Risk Patients: b. Deteriorating Scores  Looking at flux of endpoint data helps identify patients earlier.

7. Every Patient has their own eHealthcard  Secure online for ease of access by:  GPs  Other HCPs  Patients

8. 3. Summary Reports  Allows quick overview of patient  Allows pre-diabetes clinics  Allows remote clinics  Allows compliance issues to be identified.

9. 3. Patient Self Management Plan 7 essential steps for diabetes perfection.  Blood Pressure Control  Blood Sugar Control  Cholesterol Control  Weight Control  Healthy Lifestyle  Medication Compliance  Regular Screening

10. 4) Self-management plans  Encourage Patients.  Educate Patients.  Essential in achieving long- term diabetes control.  Reduce complications.  Reduce costs.

11. Diabetes Management Reports There are a number of variations in the way the self-management report can be created and the language in which they are presented. We use these at our weekly Diabetes Clinic to help with the creation of action plans. 15 essential parameters to outline the patients’ condition Colour coding again provides quick and easy referencing

12. Ability for the Patient to Feedback Data

13. 6. Track Overall Cost-effectiveness at surgery level

14. Or at PBC or PCT level  Analyse by surgery or at PBC or PCT level.  Calculate cost per patient for each region.  Calculate savings generated by alterations in performance.

15. 7. Liaising With Specialists

16. 7. Liaising with Specialists

17. But Does it work!  1 year analysis  Diabetes & Primary Care Journal  PCDS

18. Graph of glycaemic control achieved from 2009 QOF data.

19. Table of Hypoglycaemic Agents being used by Patients at 04/2008, 04/2009 and 01/2010

21. Results of Secondary Parameters Blood Pressure

22. Cholesterol / Body Mass Index

24. The Result  Better outcome for patients  Better education of patients (autotranslation etc)  Increasing Self-management  Reduced need for medications.  Easy patient alerts  Easy patient tracking  Reduced Emergencies.  Reduced Admissions  Better project and formulary compliance.  Better access for Healthcare Professionals.  Better education for Patients.  Better outcomes for Patients.

25. But It was Not Good Enough!  Better integration  Easier Extracts  Too GP based  Community Services  Ambulances  Patient Access  Hospital OPAs.  Other Chronic Conditions  Primary Care Diabetes Society  RCGP  Diabetes UK  NHS Diabetes Commissioning

27. www.nhspatient.org was realised. The NHS had wasted £20 billion on a project that would never work. Way of extracting data from all GP systems into secure centralised portal. Allowing a central portal to be accessed by all individuals involved in the Patients Journey. Need the ability to allow that portal to achieve the objectives.

28. “Putting Patients First” Giving them the information needed in an orderly manner. Risk Stratification True Integrated Care Personalised Plans Centralised Management

29. Presenting the Information Only what is needed Easy to read Intuitive Reliable Automatic Alerts

30. Suddenly There Could Be Complete Integration of Data

31. Allowing complete integration of patient care

32. The Patient Portal Must be Cost-effective Must be Patient Friendly Must be secure Must be Confidential Must be able to be accessed anywhere.

33. Secondary Objectives QIPP Long Term Conditions Local Projects National Projects NICE SMC

37. Traditionally the NHS has been Hopeless In Communicating Confusion. Conflicting Treatment Plans. Referral Pathway is mad. Patients Lives put at risk. Sanity of Healthcare Workers put at risk.

38. Healthcare Access to One Another Reliable Educational Saves Admissions Saves Referrals Saves Lives

40. Patient Access to their Team Telehealth Expensive Not been integrated Routine Improves communication Reduces Workload Saves Lives

43. Integrated Self Management Plans We have developed a number of Long term condition interfaces for the Patients.

46. But does it work? Too often we Collect data and don’t do anything with it. When we do something with it we spend lots of money. And then we forget to see if it actually works!

47. Cardiovascular 2006 +21% 

48. Cardiovascular 2 2011 -80%

49. Diabetes 2006 +201% 

50. Diabetes 2011 2011 -71.4%

51. Stokes 2006 -7%

52. Strokes 2011 -73%

53. What About Total Overall Cost? Total Spend on Seconday Care Services in My CCG per Head of Population 2011/12 (Norfolk CCG SAR Dash) Reduction of over 30% in surgeries using the system. (My surgery the cheapest by over £60 per patient.)

54. The Future There is the Possibility to radically change patient care in a way never been seen before. Central Integration and working in partnership with forward thinking regions. Allowing Patients to become the centre of their Healthcare. Using IT where appropriate.