Health Social Care Scotland 2017

Digital Innovation and Partnership working across health, social
care, housing, third and independent sector organisations.
Diana Hekerem
Head of Strategic Commissioning Support
Christine Owen
Improvement Advisor

National Improvement Programmes
Care Delivery
• Living Well in Communities
• Primary Care
• Mental Health
• Acute
• Dementia
• Place, Home and Housing
• Medicines (SPSP)
• Maternity and Children’s
System Enablers
• Strategic Planning
• Outcomes-based commissioning
• Strategic Commisioning Design
• Third and Independent Sector Engagement
• Board and Partnerships QI Development
• Evidence, Evaluation and Knowledge Exchange
• Person Centred Health and Care
Tailored
and Responsive
Improvement Support
Grants and Allocations
Blending technical QI methodology, design methods and relational change management techniques
Supporting health and social care services to
redesign and continuously improve

…to share new models of care and
generate ideas around alternatives to
overnight support while maintaining safe
and quality support for people who need
it…

Thank you
Questions/Discussion
Twitter:
@ihubscot
@hekermum @cowenotahp
Email: info@ihub.scot
Web: ihub.scot

The Need for Change
Prof George Crooks OBE
CEO Digital Health & Care Institute

…everyone is able to live longer healthier lives at home, or in a homely
setting. We will have a healthcare system where we have integrated
health and social care, a focus on prevention, anticipation and
supported self management. When hospital treatment is required, and
cannot be provided in a community setting, day case treatment will be
the norm. Whatever the setting, care will be provided to the highest
standards of quality and safety, with the person at the centre of all
decisions. There will be a focus on ensuring that people get back into
their home or community environment as soon as appropriate, with
minimal risk of re-admission.
Our vision is that by 2020…

Chronic
conditions
Lack of health
professionals
Financial
unsustainability
Health
inequalities
HLY vs LE
Ageing society

Long Term Conditions - Prevalence
Projections
Macro Trends

Projected prevalence of Chronic Disease

• Increase Inpatient mortality by 20%
• Increase Inpatient Length of Stay by 1-3 days
• Increase likelihood of errors
• Increase complaints and litigation
Which environment will do the following?

• a 15% reduction in A&E visits
• a 20% reduction in emergency admissions
• a 14% reduction in elective admissions
• a 14% reduction in bed days
• an 8% reduction in tariff costs
• a 45% reduction in mortality rates
Which environment produces:

0
200
400
600
800
1000
1200
1400
1967 1972 1977 1982 1987 1992 1997 2002 2007 2012
Publications in PubMed
> 11,000 publications (1967 – 2014)
> 2,000 about chronic disease management
> 180 RCTs
> 130 systematic reviews
Telehealth Publications

Increasing;
• Choice
• Control
• Connectedness
• Collaborations
• Contributions
• Communities
Health, care and wellbeing – person focussed
wider world
locality
home
wider world
locality
home

The EC has funded a number of telehealth projects,
among the largest:
United 4 Health

Gender and age group
Age group (years)
60%
40%
Μale
Female
0%
10%
20%
30%
40%
50%
<65 65-75 >75
51%
29%
20%
DM COPD CHF
Mean age
(years)
56 ±
17
71 ±
10
73 ± 12

Are they familiar with the use of technology?
47%
53%
PC use
YES NO
88%
12%
Mobile Phone use

Non-participation rate
2%
DM
24%
COPD
ACCEPT DECLINE
26%
CHF

Satisfaction with the U4H services
93.10%
DM
96.20%
COPD
YES NO
96.50%
CHF

Internet
TV
Telecare
Face-to-face
SMS
Video
Mobile
Phone
Channels

MADIS TIIK MD, PHD
HOW DIGITALIZATION CHANGES HEALTHCARE
&
E-HEALTH IN ESTONIA

Tartu University, Medical Doctor, 1996
Tartu University, Family Doctor, 2000
Nordic School of Public Health (Sweden) -
Diploma in Public Health, 2003
Estonian Business School, ICT Management,
2001-2003
Tallinn University of Technology, PhD
(Healthcare Engineering) 2012
Scripps Translational Science Institute (San
Diego, USA), Digital Medicine intern, 2014-
2015
EDUCATION

Family doctor 1998-
Estonian Society of Family Doctors, Chairman 2001-2008.
Estonian eHealth Foundation (EEHF), Board member, 2005-2007
Terviseagentuur Ltd. CEO, Owner, 2006-…
Estonian eHealth Foundation, CEO, 2007-2011
Scientific adviser of the President of the Estonia. Preparing report for EU
Commission, how to improve ehealth after 2020. 2011-2012
Tallinn University of Technology (TUT), eHealth Lab, lecturer 2014-
Sitra (Finnish innovation fund), Senior Adviser, 2012-
CAREER

HEALTH 1.0
EMR HIS
AI
1.0
PA
CS
LIS
RIS
PIS
PHR
1.0
DEV
ICE
1
DIGITALIZATION

FACTORS INFLUENCING SUCCESSFUL IMPLEMENTATION
Common infrastructure
Standards
Access rights
National leadership

INFORMATION SOCIETY STRATEGY (2002)
By 2013
All public services are digitaly available
Public infrastruture is service oriented (x road)
Digital authorisation of users, based on the ID card,
is the best available in the world
Data is stored were it is collected and exchange of
the data is available thous who need it

CURRENT SITUATION IN ESTONIA
X-Road launched in Estonia in 2002
More than 170 databases are offering services via X-
Road (producer certificates)
More than 3000 services are available
More than 900 organisations are using X-Road daily
(consumer certificates)
More than 70% of citizens are using X-Road via
Citizen portal
Most of companies (~160 000) are used X-Road via
Entrepreneur portal

INFORMATION SOCIETY INDICATORS
100% of schools and government organisations have broadband
connection
75% of homes have broadband connection
99% of bank transfers are performed electronically
95% of income tax declarations made via the e-Tax Board
E-census (2012) 815,467 persons completed the questionnaire -62%
26% of votes were cast over the internet on 2015 (Parlament elections)
99% of prescriptions are digital
100% citizens has a digital medical record
ALL PUBLIC SERVICES ARE DIGITAL (2013)

HEALTH 2.0
EHR
HIE
AI
2.0
PHR
2.0
DEVI
CE 1
DEV
ICE
2
INTEGRATION

HEALTH INFORMATION EXCHANGE PLATFORM
Operational since 01.01.2009
Implementation strategy (2009-2013)
step by step implementation
User groups in different timeframe
Documents in different timeframe
Only standardized medical documents accepted (HL7v3)
No previous history (before 2009)
Only agreed amount of medical information
Opt out approach for citizens and equal access for all
medical professionals

E-HEALTH SERVICES IN ESTONIA
Nation-wide health information system
Available documents
Time critical data (allergy, chronic diseases)
General practitioners and hospital visits
Summary of ambulatory and stationary case
Link to medical images
Referral letter
ePrescription
Digital images - available all over the county (for physicians only)
eReferral
eAmbulance
eSchool
eConsultation
Patient Portal

ACCESS RIGHTS FOR EHR
All healthcare providers must send data to EHR
Regulated by the law
Access only to licensed medical professionals
The attending doctor concept
ID card for authentication and digital signature
Patient has the right to close his/her own data collected to
the central database (opt out)
Citizen can access their own data
Citizen can declare their intentions and preferences
Citizen can monitor visits to their EHR

ORGANIZATION AND FINANCING OF E-HEALTH
Estonian eHealth Foundation
Standardization
Development of new services
Maintenance of the HIE system
Financed from the state budget
1/3 of the maintenance cost (HIE) is coming through
healthcare providers
Each price in the Estonian Health Insurance Fond
price list contains a ehealth components
Investment cost for ehealth
Maintenance cost

DISTRIBUTION OF COSTS AND BENEFITS OF ESTONIAN
E-HEALTH PLATFORM (DIGIIMPACT STUDY 2010)
Total cost of EHR system development (2005-2010) was
around 10M€ - it is 7.5€ per citizen

EU 2.8 M€
EHR 1,599,705
IT SOLUTION 18%
STANDARDIZATION 34%
PUBLIC RELATIONS 15%
ETHICS AND LEGISLATION 12%
PROJECT MANAGEMENT 21%
DIGITAL PRESCRIPTION 218,822
DIGITAL REGISTRATION 188,223
DIGITAL IMAGES 186,479
EDUCATIONAL PROJECT (INCREASING MEDICAL
PROFESSIONALS SKILLS IN COMPUTING)
624,254

HEALTHCARE SYSTEM TODAY
Specialist
329 will
meet a
medical
profession
al, e.g.
nurse
1000 citizens
During one
month
800 of
them have
some
medical
concerns
Green, LA. Fryer, GE Jr. Yawn, BP. Lanier, D. Dovey, SM (2001). ‘The ecology of medical
care revisited.’ New England Journal of Medicine, 344(26): 2021–2025
EHR
Laborator
y /other
tests
General
practicion
er
Laboratory
/other tests

DETERMINANTS OF WELLBEING
HealthCare
Environmental& social
factors
Genetics
Behaviour& lifestyle

IMPACT OF THE BEHAVIOURAL CHANGE
Cardiovascular disease: 73-83% (Nurses Health Study,
NEJM 2000;343:16-22, NEJM 2001;345:790-97)
Diabetes type II: 58-91% (Tuomilehto, 2001 NEJM 344(18):
1343-50 Nurses Health Study, NEJM 2000;343:16-22, NEJM
2001;345:790-97)
Cancer: 60-69% (De Lorgeril, Arch Int Med 1998;158:1181-87)
HALE Project. Knoops JAMA 2004;292:1433- 1439)

HEALTH 3.0
SOC
IAL
MED
IAENVI
RON
-
MEN
TAL
SOC
IAL
GEN
ETIC
OP
EN
DA
TAMY
DA
TA
BI
G
DA
TA
HEALT
H
ACCOU
NT
AI
3.0
PHR
3.0
DE
VIC
E 1DE
VIC
E 2
HIE
PERSONALIZATION

25
WORKFLOW WITH VIRTUAL CLINIC
Nurse
Self-care
EHR
PHR
Symptom checker
Data extraction
Data analytics
Decision making
Advice and
recommendation
Health account
1000 citizens
During one
month
800 of
them
have
some
medical
concerns
Genera
l
practitio
ner
Speciali
st
Laborat
ory
640
160

AI
Services for
the person
Health
data
PHR
Health and
wellness
DEVICES
SERVICES
Genomic data
MY
HEALTH
Health
Account
IHAN
My
Data
++
EHR
Sickness data
Disease
episode
informatio
n
Medical
services
Open data
VISION OF HEALTH 3.0

ARCHITECTURE OF IHAN
Monitoring and
certification
Mobile App
For person
“Bank”
Personal account
IHAN
consortium
User
B
Trust
Services
(CA/RA +
TSA)
Security Server
Adapter
INTERNET
User
C User
D
User
A
User
Y
User
X
“Central bank”
Services

TRUST NETWORK
FI
VR
YR
VV
M
R EE
RR
MTA
MR
AR
sne
t Xnet Ynet
Xcountr
NIS
NIS -Nordic Institute for
Interoperability Solutions

E-mail: madis@madistiik.com
CONTACT INFORMATION
GET IN CONTACT FOR FURTHER COOPERATION
Key-note presentations
Company and government consultations
Business proposals
Round tables and discussion groups
GSM: +372 510 91 43 Skype: kiitsidam
“Accelerating innovation saves
healthcare”
Madis Tiik
LinkedIn: madistiik
Web: www.madistiik.com

Transforming the Acute Care
Pathway
Dr Jane Eddleston
Consultant in ICM and Anaesthesia
Deputy Medical Director, CMFT

Conflict of interest:
Assisted in customising Patientrack for UK
Clinical lead for NICE 50
Clinical lead for the Acute Care
Competency Framework
Member of the RCOP working group for
NEWS

12 million patients are admitted to
the NHS annually (38,000 daily)
60% of admissions are emergency
Acute Medicine >Acute Surgical
emergencies
In-patient treatment more complex
and interventional
Acutely ill patients are a core
business for Acute NHS Trusts

How effective is our care pathway for
acutely ill patients ?:
Frequently poor recognition of
deteriorating health in our hospitals.
Frequently inadequate processes in
place to deliver safe care.
Avoidable admission to critical care
for some patients.
Avoidable death for others.
Differences in case-mix adjusted
outcomes/morbidity across the
country.

7
2007 Acute care beds Per 1 000 population
Source: OECD Health Data 2009
0
1
2
3
4
5
6
7
8
9
Japan
Korea
Austria
Germany
Hungary
CzechRepublic
SlovakRepublic
Poland
Belgium
Greece
OECDaverage
Finland
France
Switzerland
Australia
Italy
Netherlands
Denmark
Norway
Portugal
Ireland
Turkey
Canada
UnitedStates
UnitedKingdom
Spain
Sweden
England
Mexico
2007 Acute care beds Per 1 000 population

Trend in Emergency Admissions, Acute bed
provision and length of stay
40%
50%
60%
70%
80%
90%
100%
110%
120%
130%
140%
150%
2000-1 2001-2 2002-3 2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11
Acute beds Emergency admissions Length of stay
Acute general beds reduced by 1/3rd in 25 yrs; emergency admissions
increased by ~40%; >65 yrs utilise 70% bed days

The pattern- ED and AMU: pressure to
deliver flow

Impact:
Acute admissions increased
Complexity of in patient work increased
Bed stock reduced
Turnover increased
National Cardiac arrest rate in hospital
static
Weekend effect: mortality 10% higher, why?

90
92
94
96
98
100
102
104
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
HSMR
Weeday of admission
HSMR by weekday, English acute trusts, 2001/2 to 2003/4
12

Why the weekend effect?
Less specialist/consultant presence
Reduced nurse staffing
Fewer junior doctors
Team care fragmented
Continuity of care impaired
More handovers
Delayed or less skilled investigations
Drive to 7 day services:14 hr review, twice daily ward
rounds in Critical Care, AHP input, Diagnostics.
Pattern of admissions ?
13

David Halsall, Clinical Quality and
Efficiency Analytical Team, Jan 2012
14

Pattern of admissions
At weekends, public holidays:
- Less care in community –
fewer nurses in community/care homes
less primary care
- Less sick patients delay seeking help
- Acutely sick call 999 etc
Thus relative shift of severity of illness of admissions
Mortality at weekends complex, multifactorial
15

How do we
meet this
challenge ?

How to cope with increasing acute load?
Improved care in community? – doubtful
More hands to the pump?
-more registrars & consultants from
most specialities on acute rotas
Working Differently: where does IT fit in?
17

NPSA Report 2007
- NPSA 2007 report “ Safer
care for the acutely ill
patient: learning from
serious incidents”. 576
deaths that could be
interpreted as potentially
avoidable and relating to
patient safety issues

Deterioration: issues
No observations made for a prolonged period
prior to a patients death and changes in vital
signs were not detected (21.8%)
Despite the recording of vital signs, there was no
recognition of clinical deterioration and/or no
actions were undertaken (47%)
Deterioration was recognised and assistance
sought but significant delays occurred in the
patient receiving medical attention ( 11%)

Deterioration: actions
Recording of Vital signs: Measurement (technique and
accuracy),and Documentation
Recognition of abnormal values: knowledge of normal
physiological measurements
Interpretation of measurements in context of individual
patients
Intervention appropriate to abnormality
Response being timely and matching skills to patient
needs
Organisational team working

Recording, recognition and interpretation:
EWS: single/aggregated
Medical Emergency calling criteria

EWS v Medical Emergency Teams
UK have preference for EWS
Australia /US mixed preference
Most MET criteria based on extreme values of specific
objective physiological criteria. Response all or nothing
EWS use aggregated scores which have weighted
criteria. Graduated multitiered response.
NEWS of 7 : sensitivity 44.5%, specificity 97.4%
NEWS independently associated with increased
mortality, MET criteria not.
MET systems have lower specificity ( Crit Care Med
2016; Smith et al 2171 -2181) . Workload greater.

Competency
Group
Non clinical Staff "Recorder" "Recogniser" "Primary
Responder“
"Secondary
responder"
Critical
Care
Description of
group role
call for help and
recognition of
illness
recorder and
interpretation within
T&T protocol
recognition and
interpretation of
observations
primary response
and intervention
Secondary
response and
intervention
Tertiary
response
and Critical
care
NICE Response
Level
Low Risk Low Risk Low Risk Medium Risk High Risk
Patients themselves
Relatives
Ward Clerks
Ward Domestics
Porters/support staff
Trainee clinical staff
Band 2-4 HCAs
Band 5-6 Ward Nurses
Band 6-8 Ward Nurses
Physiotherapists
FY 1 Doctors
FY 2 Doctors
ST 1-2 Doctors
ST 3 to Consultant Doctors
Critical care outreach
Critical care advanced practitioners
Critical care ST1-2 Doctors
Critical care ST 3 to Consl
Hospital at night team

Experience with Patientrack
Large tertiary trust (MRI, ST Mary’s, RMCH, REH) plus
DGH (Trafford).
Pilot work 2009/10.
Introduced a tiered response strategy utilising the acute
care competency framework
Trust wide educational strategy
Core adult EWS with paediatric and maternity EWS
Weekly cardiac arrest review
Core business
Weekly reports
Significant reduction in cardiac arrests
Other significant developments eg Diabetes, EOL

What does reliability
look like?
Tertiary University
hospital
~1300 adult beds
Specialist services
Weekly Assurance:
-timeliness of
observations
-completeness
- who is undertaking
the observations
- response
- outcomes

Workload comparison
Medicine Division Surgical Division

Impact:
▪ Assurance in quality of care, recognition of
deteriorating health and effective response.
▪ Robust framework to target educational strategy
▪ Educational strategies geared to medical
emergencies and not cardiac arrests
▪ Surgical division 9 cardiac arrest in 12 months
▪ Fears of increased workload for Critical Care
unfounded
▪ Developments of other initiatives linked to
observation assessment eg “comfort”
observations in EOL care; Diabetic regime

Digital Health and Care
Embracing the Digital Age
Dr Margaret Whoriskey
Head of Technology Enabled Care and Digital Healthcare
Innovation, Scottish Government

Digitalconnectivityischangingthelivesofpeopleallovertheworld
It has only been 25 years since Tim Berners-Lee made the ‘World
Wide Web’ available to the public, but in that time, the internet has
already become an integral part of everyday life for most of the
world’s population.

The 55-75 age range showed the greatest uptake in use of smartphone, rising 6 percentage points to 71%.

Digital InclusionUsedtheInternet(%)
ACCESSED THE INTERNET, BY AGE GROUP, 2006 AND 2015
The
generational
divide is
becoming less
pronounced

Change will never be this slow again
Exponential
technology, and
the accelerated
pace of change

Digital technology is key to transforming health and social care
services so that care can become more person-centred.
Health and Social Care Digital Transformation…..
Health and Social Care Delivery Plan
Empowering people to more actively manage their
own health means changing and investing in new
technologies and services. The time is right to
develop a fresh, broad vision of how health and
social care service processes in Scotland should be
further transformed making better use of digital
technology and data.

Clear signposts
to local support
services
On-line repeat
prescription
ordering
On-line
appointment
scheduling
Digital
Reminders
Exchange
correspondenc
e digitally
Share
information
with those who
need to know
Consistent &
definitive
sources of
information.
VC and
eConsultation
s
The National
Conversation

I have access to the
digital information, tools
and services I need to
help maintain and
improve my health and
wellbeing
I expect my health and
social care information to
be captured electronically,
integrated and shared
securely to assist service
staff and carer that need to
see it.
I expect that digital technology
and data will be used
appropriately and innovatively.
To help plan and improve
services, enable research and
economic development and
ultimately improve outcomes for
everyone.
As a citizen of
Scotland…

Plenty to build on
Patient Platforms – e.g. My Diabetes
My Way and Renal Patient View –
over 10,000 users and growing
National ECS and KIS
Growth in Access to cCBT
Patient Management Systems
Additional 35,000 citizens enabled through
Technology Enabled Care Programme –
including over 3,000 people remotely
managing their health
Scotland’s Leading Four Star
Reference Site Status within Europe
Access to Online Information -
NHS Inform, Care Information
Scotland, ALISS etc.
GP Online
Patient Services
Over 160,000 telecare
users – including
more than 20% of all
over 75s
Development of Innovation Centres
Over 120,000 connected end devices to
the SWAN network
National NHS VC
Infrastucture –
Electronic Prescribing in
Primary Care
eWhiteboards
Electronic Referrals

Cabinet Secretary
for Health & Sport
Health & Social Care
Management Board
Digital Health &
Care Strategy
Strategic Oversight
Group
Digital Health &
Care Strategy
Working Group(s)
Digital Health &
Care Strategy
External Expert
Panel
COSLA
Stakeholders,
including eHealth
Leads and CCLG
Members
Strategy Development Governance

Emerging areas for the strategy
• Digital maturity assessment– The development of an appropriate model and
approach to support and target improvements for digital health and social
care services across Scotland.
• Architecture, Infrastructure, Standards and Interoperability - Defining the
overarching design decisions that should be taken centrally, and supporting a
longer-term view of convergence and rationalisation, including to support
greater integration and sharing of health and care data.
• Information Governance and Data Sharing - Enabling the effective sharing of
data and information to support public service transformation and the
information needs of people, practitioners and organisations.

Emerging areas for the strategy
• Cyber Security – Ensuring a high level of confidence in the resilience of service
provision.
• Data and Analytics – Facilitating the availability of integrated health and social
care data from a diverse range of sources to support quality improvement,
research and innovation.
• Person-centred services - Information and application services, enabling
citizens to manage their own health and care related information, and use a
range of digital applications and services to support their health and
wellbeing.
• User-centred design – Setting expectations for and building the capacity in the
system to undertake user-centred design.

Common themes identified
• Culture and leadership
• Interoperability of systems
• Data sharing and access to records, including for innovation and research
• Connectivity
• Access to appropriate technology and devices, including to support mobile working
• Resources and funding
• Skills development – both staff and public
• Self-management / digital to empower/enable

NextSteps
September – Meet with Panel to discuss their emerging findings.
October – Develop outline draft strategy.
November/December – Engage in stakeholder dialogue on draft strategy.
January/February – Health and Sport Committee publish report on inquiry in to
Technology and Innovation in the NHS.
February/March – Finalise and publish Strategy.
Questions?

Health and social care – the digital
journey

We need your help - thank you!
Join the conversation:
• Please join in with our dialogue platform to help us
shape our new strategy, all ideas are welcome! See -
www.ideas.gov.scot
• Share with colleagues and relevant groups
• Follow us on Twitter @eHealthScotland
@TECScotland

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