Integrated Care Pathway

HL7 and Care PathwaysIntegrated Care Pathway•An integrated care pathway determines locally agreed, multidisciplinary practice based on guidelines and evidence where available, for a specific patient/client group. It forms all or part of the clinical record, documents the care given and facilitates theevaluation of outcomes for continuous quality improvement.National Pathways Association (UK) 2001•An Integrated Care Pathway or ICP describes a process within health and Social Care, which maps out a pre-defined set ofactivities and records care delivered and the variations betweenplanned and actual care. ICPs will be used to support "wholesystems" processes spanning Primary Care and Secondary Care service boundaries.ICRS OBS Part 2, 2003•detailed descriptions of the particular steps taken in the process of delivering care or treatment to a patient,sometimes referred to as the care pathway.•designed at local level to implement national standards, or, by using the best available evidence, to determine care provision.•developed on a multi-disciplinary basis, reflecting local services and staffing arrangements, and integrate the care provided by different groups or differentorganisations.•include specific information on who carries out key parts of the care or treatment, and where that should be delivered.•Protocols also usually incorporate decision support systems that help the practitioner make decisions about the appropriate care for specific clinical circumstances.Source: What is Protocol-Based Care?UK DoH 2002 /protocolbasedcareProtocol / ICP• A protocol is an ICP if it…–is local, agreed, mulidisciplinary –forms part of the care record–captures variancesPoints about care pathways•An actually existing, widely used mainly paper technology•Basically a proforma/checklist with some embedded rules and exception recording•Commonly focussed on one task in one place for one time period –e.g. day-case elective surgery •Locally developed•NeLH has an RCN database of 2000+ locally developed pathways with 200+ full-text examples at /carepathways/•Useful listserver group/groups/clinicalpathwaysCare Pathways –an aspirational conceptAspirations:•Patient-centredness•Joined-up interdisciplinary care•IT geared to service improvement•IT responsive to clinical requirement••Advantages:•Attractive to diverse constituencies•Risks:•’pathways’ can mean anything•Ambiguity, contradiction, multiple vague promisesHealth informatics andguidelines/pathways/protocolsMainly driven by decision support agendas•Oncocin -Musen/Shortliffe -Stanford c 1986•DILEMMA -EU -1991-94•Prestige -EU -1995-99•PRODIGY UK 1997->•GLIF -USA et al 1997->•EON, PROTÉGÉ, ASGAARD -Stanford 1995->•Prompt/ PROFORMA UK 1995->•NeLH-Guidelines UK 2000->•HL-7 working group on decision support 2000->•HL-7 SIG on Virtual HER –cf talk today by Peter Johnson•Holy Grail –standardised clinical knowledge representation linked to health data/comms architecture standards 20??ICRS Specification Elements for ICPs•Proposed lifecycle model of pathway•Focus on care plan definition•Advanced goals –merging pathways•Plan monitoring and reporting objectives•ICPs deliverables in Phase 1 probably few and may be still under negotiation•Current specification may not be the last wordThe NHSIA Disease Management Systems Programme (DMSP)•Commissioned by NHSIA Director of Development, in support of ICRS•Linked to NPfIT DA•Role: develop and prove capability to specify IT support for care pathways in NSFs• 4 examplar sites with national clinical leads:–Newcastle –Breast Cancer –Clive Griffith–Salford –Diabetes –Bob Young–NW London –CHD –Mark Dancy–Walsall –Heart Failure –Martin Cowie•Member of HL7-UK; working with local suppliers forum •Managed by Royal Brompton and Harefield NHS Trust •Lead technical consultant: Ramsey Systems Ltd (C McCay)DMSP Precursor project –Rapid Access Chest Pain Clinics•Initiated by CHD NSF and NeLH, 2001-2•Commissioned by NHS IPU•Working with 5 Acute Trusts, 4 2ndary sector suppliers, GP systems suppliers•Agreed and validated a national dataset/pathway specification for RACPCs with XML message format and tools/heart/racpcs/dataset/index.htmDMSP -current NHS contexts•CHD Collaborative Dr Mark Dancy•National Cancer Collaborative Mr Clive Griffith•Diabetes NSF Dr Bob Young•NICE Prof Martin Cowie•Protocol-Based Care Implementation GroupChaired by NHS Modernisation Agency (Changing Workforce Programme) Forum for interested national players in NHSAims to pool knowledge and map and track related work•National Programme for ITCommunications and Messaging ProgrammeICRS OBS Part II -LSP SERVICES105 -Integrated Care Pathways and Care PlanningDMSP Approach to Pathway•Shared dataset definition as basis of pathway definition•HL7 messages used to define dataset and functional subsets •Uses NPfIT approach to business modelling•W3 Business process•W5 Clinical statements••Complementary to HL7 virtual EHR and decision support initiatives •Earlier feasibility study produced specification proposals on criteria language for decision support•Not currently attempting to implement theseDMSP –Mapping the pathways•Who / what / where /when•Key workflows•Key information flows•Varieties of service configurationReferral proformaCall/recall systems for chronic disease managementPlaced on heart failure registerStabilisationInitiation of Beta blocker &/ spironolactoneUp-titration ofdrugsInitiation of treatment with ACE and diureticsRequires further investigationsPreliminary conclusionsHeart failure clinic Primary careEitherSecondary careFurther treatment LV systolic dysfunctionUnclearTransfer of referral dataa*Sheet 1Sheet 2Sheet 4Sheet 3a*: if continuing care to be in acute trust initiates appropriate arrangements. If to be primary care initiates request message to 1y care to book patient into their clinica*Working with suppliers•HCIF –subgroup on shared care•DSMP Forum established following suspension on HCIF, in consultation with NpfIT•Current active members:–EMIS–IPS–ISoft–ISoft Revive–ORION–TomCat–DMSP Specifications will be made available for review via HL7-UKDMSP Pathway Specification ComponentsA.Pathway process map (NPfIT W3 format)B.Maximum Dataset (NPFiT W5 format)C.W5 subsets (to be provided, captured, communicated) mapped toW3 process elementsD.Additional specification detail for data capture and message-generation templates.E.Recommended minimum dataset for clinical management (subset ofB)F.Draft national audit dataset (subset of E)G.Clinical term mappings.H.Decision-support rules (not currently included).I.Transport protocol definition•DMSP Tools under development•Schema generation toolCollaborations -Datasets, Codes, AuditDMSP collaborates with NHSIA PHSMI work on:–NHSDatasets Programme•datasets definition and term mapping–[e.g. Diabetes User Dataset]–NCASP•national audit datasets and message definition–[e.g. NCASP Diabetes Core Dataset]Specific requirements encountered•Data on information supplied to patient•Data on what the patient has been told•Data on education provided and advice given•Patient access to self-management record –web; ‘bank statement’•Sharing Multi-Disciplinary Team meeting results•Local disease management warehouse feeds•National audit message production•Combined care –functional requirements for virtually shared record •linkage of professional communications to datacommunicationsTechnical issues / work in progress•Data entry templates definition formalism•Transport protocol definition•Managing change in shared data items across message templates•Capturing and supporting local process variance •Links to decision support / virtual EHRDMSP Rationale and future role•Helping to organize Clinical Participation in NPfIT •Focus first on areas where professional consensus isimportant and possible•Use existing consensus and redesign process –MA, NSFs, professions•Link consensus process directly to pathway specification •Common tools, language and purpose •Specification supporting local professional practice variation•Cooperate with suppliers witin standards process。