1. Quality Education for a Healthier Scotland Decision Support for Diabetes: Embedding Knowledge in Care Processes Dr Ann Wales, Programme Director for Knowledge Management. NHS Education for Scotland Ann.wales@nes.scot.nhs.uk

2. Quality Education for a Healthier Scotland Who is involved? Dr Ann Wales and Mr Faiyaz Shaik, NHS Education for Scotland Dr Rebecca Locke and SCI-Diabetes Team, NHS Tayside. Dr James Walker, NHS Lothian Dr Nicholas Conway, University of Dundee Digital Health Institute for Scotland. No conflict of interest

3. Quality Education for a Healthier Scotland Overview 1.Aim 2.Drivers 3. Methods Research question Technical approach Analysis and evaluation 4.Initial results 5. Implications for future national decision support.

4. Quality Education for a Healthier Scotland Aim Improve safety and reliability in applying evidence-based guidelines for diabetes…..in a way that reflects the reality of clinical practice…. in a context-sensitive manner that responds to individual patient needs including complex care needs such as co-morbidities.

5. Quality Education for a Healthier Scotland Drivers

6. Quality Education for a Healthier Scotland Challenge of Long Term and Multiple Conditions In the United Kingdom: Long term conditions affect 1 in 5 people 80% of general practice consultations Costs £23.7bn per annum - 10% of NHS annual spend. In Scotland: 77% of people with diabetes in Scotland have co- morbidities. 38% are taking more than 5 medications.

7. Quality Education for a Healthier Scotland Limitations of Research Evidence Classic research evidence, guidelines and pathways focus on single conditions and standardised study populations. Context: Overestimation of impact in research studies compared with real-life contexts. Ioannidis, 2011. Personalisation: Limitations in applying research results and guidelines to individual patients with complex needs. Kent, 2007; Lutgenberg, 2009.

8. Quality Education for a Healthier Scotland New Paradigm for Evidence-Based Practice We need to find innovative ways of integrating knowledge from research and practice into clinical workflow to: Improve reliability of care While Contextualising and personalising care Responding to complex care needs especially co- morbidity and polypharmacy.

9. Quality Education for a Healthier Scotland NHSScotland Knowledge into Action Strategy help practitioners to apply knowledge in the realities of day to day frontline practice. embed use of knowledge in healthcare improvement..

10. Quality Education for a Healthier Scotland Methods

11. Quality Education for a Healthier Scotland Research Questions 1.How does decision support derived from condition-specific, research-based guidelines need to be tailored and adapted for local contexts and individual patients with complex needs such as multiple conditions? 2.What factors influence implementation and spread of such tailored decision support across healthcare organisations? Inform recommendations for decision support in NHSScotland.

12. Quality Education for a Healthier Scotland Choice of Decision Support Platform Requirements: Capability to interact with multiple clinical systems. Editing of decision support scripts and links. Shared pool of decision support scripts. Localisation of scripts. Selection – EBMEDS from Duodecim

13. Quality Education for a Healthier Scotland Technical approach Integration in SCI-Diabetes – national electronic health record system for diabetes in NHSScotland. Community of practice converted SIGN guideline recommendations into 17 decision support scripts, e.g: TSH monitoring UKPDS Risk Engine Weight gain Recall of patients for retinal screening Mapping codes in patient record system to elements in scripts. Prompts, reminders, alerts Links to national evidence, local handbooks and pathways

14. Quality Education for a Healthier Scotland Example: Glitazone Prescribing Script Patient record data Short message Review drug list for insulin useReminder Glitazone contraindicated due to insulin treatment? Last B-Hb measurement less than 120 g/L (OR 12g/dl) Reminder Information given about the risk of anaemia? Review drug list for drugs coded as BNF 6.1.2 Antidiabetic drugs. Message Possible interactions noted? Weight monitoring arranged? Links: Full message Calculators, Formulary, Patient information.

15. Quality Education for a Healthier Scotland

16. Care Alerts/Re Care Alerts/Reminders

17. Quality Education for a Healthier Scotland Quality Improvement Cycles Site 1 Sites 1-3 Sites 1-4 Case controls 1 5 10 15 Month Cycle 1 Cycle 2 Cycle 3 Improvement Spread

18. Quality Education for a Healthier Scotland Evaluating Impact – Outcomes Chain Inputs Activities/ Outputs Reach & Reaction Capacity & Capability Practice change Long-term Outcomes INDIRECT INFLUENCE DIRECT INFLUENCE DIRECT CONTROL Numbers of clinicians accessing prompts. Number of prompts accessed. Before-after comparison of system navigation data. Technology Acceptance Questionnaire Focus group and community feedback. Case-control comparison of clinical processes. Case-control comparison of HBA1c, blood pressure, cholesterol, UACR Patient Reported Experience Measures

19. Quality Education for a Healthier Scotland Pre-intervention attitudes

20. Quality Education for a Healthier Scotland Emerging Results – First Cycle Unified Theory of User Acceptance of Technology (Ventaktesh, 2003; Heselmans et al 2012)

21. Quality Education for a Healthier Scotland Community of Practice Feedback Has influenced some decisions – investigations, prescribing. Script changes. Overriding of prompts when in patients’ interests – e.g.co- morbidities; personal circumstances. Facility to turn off individual scripts important. Different prompts relevant to primary and secondary care. No time to read underlying guidelines/evidence. Full message needed in pop-up. Interest in recording use for CPD.

22. Quality Education for a Healthier Scotland Emerging Implications for National CDSS Responsive and flexible system, continually adaptable to user needs. Segmentation of clinician needs – generalist and specialist. Facility to override, turn off prompts Links across patient care pathways for multiple conditions. Combined decision support for guidelines and medicines. Link with CPD recording

23. Quality Education for a Healthier Scotland Summary: “Adaptive” Evidence-Based Practice 1.Using quality improvement, programme evaluation and research methods to contextualise and personalise evidence-based practice for complex care needs. 2.Decision support as vehicle to combine knowledge from research, practice, patient and professional experience to improve quality of care.

24. Quality Education for a Healthier Scotland Decision Support for Diabetes: Embedding Knowledge in Care Processes Dr Ann Wales, Programme Director for Knowledge Management. NHS Education for Scotland Ann.wales@nes.scot.nhs.uk