1. NHS change challenge Clinical content work in the NHS Tony Shannon Consultant in Emergency Medicine, LTH Clinical Consultant, NHS CfH Travel to HL7 kindly funded by Ocean Informatics

2. Tony Shannon M.B. B.Ch. B.A.O. Ireland Fellow of College of Emergency MedicineEngland Fellowship in InformaticsUSA MS in IT ManagementEngland Consultant in Emergency Medicine, Leeds Teaching Hospitals Clinical Consultant, NHS Connecting for Health Leeds, England

3. Complex Systems Many parts, Many interactions Perpetual novelty Difficult to describe/understand completely Difficult to control/change Identify simple rules –Self-organise e.g. Weather, Economy, Internet, ED

4. National Health Service in the UK Established in 1948 by Labour Government Huge –3 rd largest employer in world, largest in Europe, 1 million+ staff –45+ million patients in England Healthcare free to all at the point of care Quality Costly –Increasingly financially oriented –Payment by Results NHS Plan = Service Reform (inc. IT) –e.g. Leeds Teaching Hospitals City <1million population 4 EDs; 110,000 + 90,000 census 95%/98% 4 hour ED target…

5. Biggest civil IT programme in world 10 year; based in Leeds, England $20+ billion with commercial suppliers 5 Regions of England –North East Cluster 7.5 million population 170,000 NHS staff 23 Acute Hospitals 12 Mental Health Trusts 1200+ Primary Care practices –Care Record Service contract £1 billion

6. Hugely ambitious Primary, Community, Hospitals, Mental Health –Contracts for several interim solutions –Aiming for a single strategic EHR solution National Services –Single NHS patient identifier number –Service Directory –Choose and Book scheduling Local Services –Care Record Service (Electronic Health Record) Guideline based Workflow integrated Cross organisational working

7. NHS + IT = Complex

11. Change – Emergency Medicine

12. Change - Management Benefits = Quality Risk Cost Time Drivers

13. Change - Software Engineering

14. People+ Process + Technology in a Model Community Systems in Silos

15. People –Challenge siloed thinking Process –Look for simplicity within the complexity –? Core generic processes in healthcare Technology –Evolutionary approach –Process related IT requirements esp. at the complex front end. i.e. ED charting –free text/dictation versus forms (e.g. T-system) Aim to reuse –Distributed process-oriented SOA? Balance central control and local innovation

17. Process - Urgent Care Study Identify top/core business processes in Urgent Care Identify and prioritise information/technology needs Methodology –Stakeholders/ core Processes / IT Requirements Site visits –NHS Direct –Ambulance Services –ED (4 in West Yorkshire) –Walk in Centre –GP Out of Hours

18. A view of NHS process …

19. Referral in Assessment Plan Care Deliver Care Referral Out Operational (1 patient) Strategic (++ patients) Tactical ( > 1 patient) Resource Management e.g. staff, beds Performance management e.g. Audit Diagnostics Sorting A view of Generic Processes in Healthcare

20. A journey through the NHS … GP time NHS Direct Emergency Department Acute CCU Taken to A&E: given oxygen in transit Transferred to CCU to complete post-MI care Self care Returns to self / primary care Angina diagnosis & 1 st care plan Ambulance Diagnosis confirmed: & patient stabilised Suspected MI: self-care advice given & ambulance requested

21. Generic Generic Process IT Bricks Specific Patient Journeys IT Library

22. A tale from Denmark …

23. The Danish solution…

24. 15+ years of European & Australian R&D Generic Process based EHR Architecture Related to –European Standard (en13606) –ISO standard OpenEHR

25. Archetypes (Bricks) Templates (Toys) OpenEHR Generic Specific

26. Archetype Reusable list of clinical statements Useful for clinical documentation Can be coded with terminologies e.g. Snomed CT

27. Archetypes & Templates Central control Local flexibility

28. Archetypes

30. North, Midlands and East –60% of England Supplier –Contract with CSC –Single strategic EHR solution –Requirement & Design Stage NHS Clinical Content needed –To support charting Big Opportunity

32. NHS input… example..

33. NHS content – inputs via wiki Collaborative Evolvable Version control comments

34. NHS input… e.g. Head & Neck examination

35. Into Head & Neck exam archetype

36. Archetypes can bind to codes…

37. Archetypes available as XML/HTML etc…

38. NHS Archetype library

39. Archetypes configured in Templates solves central control + local need

40. Template editor output as HTML/XML/Forms etc….

41. Archetypes (Bricks) Templates (Toys) OpenEHR content Can be used for application UI –e.g. forms Can be transformed into messages –e.g. HL7 CDA Can be used for querying +/- Terminology

42. NHS template library

43. .. for use in any supplier system

45. openEHR content cycle.. Clinical content will continue to evolve Archetypes and templates are version controlled Content changes –dont impact application –if fit with openEHR

47. Benefits of Archetypes Quality –Better documentation - for complexity of healthcare Via Standard Archetype + Flexible Templates –Can evolve over time - as medicine changes Via version control –Balances central control and local innovation Risk –Solid foundation for Decision Support Time –Save time Build templates fast Cost –Save NHS money Standard methodology – all can share Non proprietary

48. NHS Clinical Content Service NHS Requirements E-Care Pathways Archetypes & Templates –Archetype outputs 150+ –Template outputs20+ Clinical Coding –Via SNOMED CT Resource Governance

49. NHS Tech Office.. today Clinical Use Case Clinical Content Model Clinical Templates Clinical Archetypes Reference Model, Types, Terminology Logical View Messaging Realisation with templates Story board Message HL7 Templates RIM + Data Types + Terminology Business Use Case Interactions

50. NHS Tech Office.. tomorrow Clinical Use Case Clinical Content Model Clinical Templates Clinical Archetypes Reference Model, Types, Terminology Logical View Messaging Realisation with templates Story board Message HL7 Templates RIM + Data Types + Terminology Business Use Case Interactions Auto Generated

51. International efforts…

52. Key issues…. NHS IT –Hugely ambitious –Learning valuable lessons People issues –How to involve the right people Think beyond current silos –Governance Local versus National? Process issues –look for the generic within Technology issues –Evolutionary –Clinical process oriented approach i.e. archetypes –Ensures clinical content is reusable/evolvable

53. Archetypes (Bricks) Templates (Toys) NHS content library