Systems in Health Care

Overview

I’ve been mulling around this idea for a few months now and thought I’d finally put fingers to the keyboard. It started from a conversation I had with my local commissioning team around how much impact does primary care actually have on “waste” in health care. What I meant by waste is around having to manage patients in a more expensive way which also tends to be worse for the patient too as it can entail non-elective admissions. As the idea evolved it was less around where money is wasted and more about how as health professionals we can make the health care system more efficient.

The ultimate end point is to

  • provide the patient with the best evidenced based care
  • focus on the right patient before they get worse
  • promote “upstream” care which is to encourage patients to live healthy lives to prevent them from even entering the medical engine until later in their lives.
  • Do this together in a joint collaborative way rather than in individual silos.

The diagram above represents providers within health care and how much a provider has influence over another provider. The boxes represent various providers within the health care system, the line of interactions between each provider but more importantly my suggestion on systems or interactions between providers to improve the overall efficiency.

Systems represent keys to unlock the door to prevent waste in health care. The better quality of input into the provider, the more efficient the output provider will be. The boxes in between providers represent this. Others might have different ways in which these interfaces can be made to be more efficient. The areas in grey are just my suggestions and my thoughts around improving the input quality. You may have your own.

As you can see in the UK Primary care is right in the middle which is the reason why GPs make such good commissioners of care whether they like it or not! By commissioners I mean look after patients within the constraints of a budget.

Each System in Turn

As I know a bit of IT, I believe we can really leverage technology to help improve the efficiency of each system and will go each with examples

Access to Primary Care

Lacking Primary Care Skills in relation to Access to Primary Care leads to more A+E Attendances

Patients due to society have an amazon type expectation around how responsive services should be. The government as well has fuelled patient expectation on how the NHS should run. We could ask inappropriate A+E attendees to be redirected or educate patients but if GPs can only see them after a few days and they’ll get want they want in A+E after a few hours guess which service they will go to? The reality also is that A+E staff have to manage the risk of sending someone home and also they just get on with their job which is caring for patients rather rejecting them. “GP Jobs” can also be hard to work out and staff just tend to get on with seeing the patient in front of them rather than worry what the most cost-effective way to manage them is. To be able to get patients to not choose A+E when they should see their GP, you are left with worsening the A+E Experience or improve access to primary care. I occasionally get the odd remark “The waiting time in A+E was >6 hours so I thought I’d come to you!”

It’s a shame the government stopped giving a financial incentive to improve access to primary care as this was an important system due the following

  • The more patients who can’t access their GP in a timely manner the more will go to A+E
  • More patients who go to A+E will result in more Non-Elective Admissions by the sheer volume of numbers.
  • Non-Elective Admissions is the least cost-effective way of managing patients but it is essential if the need arises.

Tech Suggestions

We should deal with today’s problems today and aim for the same day turnover for urgent cases but still allow for some non-urgent slots. Give patients a responsive service in primary care.

Virtual by Default. Managing Access On-Line

In the world of Covid we are in we have the perfect opportunity to continue to contact the patient via more efficient methods rather than face to face and Telephone Triage systems have become the rule rather than the exception. I sure I am with others when I say I’m very surprised at the number which we can manage over the phone and takes my mind back to what we were all told at med school; that diagnosis is mostly from the history; the examination is just to confirm this.

Communication with the patient is the key here with lots of ways to connect

  • Telephone
  • Video
  • Online Consultations
  • Emails (Link to my blog on this)
  • SMS

I think Accurx by luck or design has managed to fill a need in this area although others I know are around. Ironically iPlato and Mjog are more around recall although Mjog has it’s own offering for consultation messaging I guess in reply to Accurx. iPlato offers access to our appointment book but I think this is wrong by default as we need a triage system to be more efficient with access. Patients through no fault of their own have no idea what the best way of managing their problem with their GP is, so require triage.

I’ve found video has its uses more for unwell patients but it’s not for everyone as the price of entry to try to set up can take more than handling the patient via a phone call!

I’ve blogged about emails here but have found pictures of rashes essential via email. Accurx also allows pictures to go into the notes which is very useful but the compression can affect the view we see which is not entirely their fault.

Imaging and Investigations

Primary Care Skill who offer good work up of Imaging and Investigations will result in better quality Outpatient Care

It goes without saying that if you do the work up on a patient before referring you are better off doing a good referral and not waste the consultant’s time.

It’s important to say that there are different reasons for referral. I’ve blogged about this in my blog called Reasons a little while back

Tech Suggestions

Virtual by Default for Secondary Care

  • Just like patients can talk to Consultants why can’t GPs? We should have a portal to allow allocated time slot for a GPs to discuss cases with consultants which are properly commissioned and performance managed
  • We need to use advice and guidance as more productively than just a single fire and single return at least and maybe even forced for some specialities.
  • Microsoft Teams has come at the right place and the right time to be the communication tool we need to achieve this efficiency

Extracting Snomed Codes from the referral letters Letters we get from the hospital contain a wealth of information. At the moment the only way to insert these into our clinic systems is to manually insert them or use OCR via Docman which is slow and cumbersome. We need letters to and from the hospital containing Metadata of important Snomed Code with text which automatically inserts into the clinical system eg Hba1cs and OGD with the result. At the moment eRs is just a wrapper for text with no real intelligence.

Connecting the referral letter with the reply to help to educate GPs in why they referred to help them improve for the next patient. Because there is such a difference in time between our referral and the consultant’s reply you forget why you have referred. It would be nice to automate this connection to reflect on this and prevent further referrals as the GP would learn from the referral and response. Yet again if used properly Microsoft Teams could achieve this endpoint as discussing a case with a consultant in realtime in itself is a learning experience for primary care.

MDT, Risk StratificationTools

Community Care by using MDTs can focus on the right patient to prevent Non-Elective Admissions

Ah, the holy grail of the health system! For those who have seen or read minority report the systems out there are trying to be pre-cogs.

I’ve spoken extensively about my blog in 2012 called The answer is 42, so what is the question

There are 2 aspects to getting a good service

  • The vehicle which is the governance and getting the right people talking at the right time (the easy bit)
  • The content which is choosing the right patient (the challenge)

For those who just want the money slide, this are my thoughts about choosing the right patient in one slide which can be difficult to create an algorithm for as it requires a human element

Tech Suggestions

There are a myriad of precog “solutions” out there so I can’t really comment but bear in mind most of them don’t provide a 100% accurate list as the human factor is difficult to record and analyse. You know what they say…rubbish in…rubbish out.

However, the direction we are travelling in is to try to risk stratify populations not only within the community but within our registers and to tailor care and focus on the most unstable. My product PatientLeaf can help you with this when seeing patients in clinic.

Prescribing and Patient Compliance

Primary Care Skills will help the patient experience and improve compliance and trust which will help patients take their prescribing

For me, no money on prescribing is wasted money to an extent. My pharmacist would probably have a fit hearing this but to clarify. Prescribing drugs to me is the most cost-effective way to treat patients.

Complaince is a huge problem and I believe it’s truely related to

  • How you involve the patient with your care. Patients who you work with tend to take medication more than those you order.
  • How much they trust you. This is normally based on previous experience with them and developing the relationship.

Tech Suggestions

Again please refer to this blog where I talking about PatientLeaf but more importantly talk about compliance as a big issue and is probably under reported.

One of the big strengths of PatientLeaf is exactly to address this problem during the clinic in realtime.

There are several intelligent dashboarding and data analytic tools such as Eclipse and Pincer which help you identify the patient based on medication usage and other factors. PatientLeaf will help you manage this patient in your clinic.

Proactive Care with Good Recall

Primary Care Skills help you to be proactive and with Good Recall can call the patient in to help Preventative Medicine

Not rock science but there are 2 types of patients which keep us busy. Those that come to us (reactive) and those which we call in (proactive). QOF and Target Driven Payment schedules have allowed us to focus on this important aspect of Health Care. As we move forward we need to subcategories these populations into risk or severity of their condition to put more energy on the ones whose values are off kilt.

I’ve always said this but Pharmacists are such an underused resource for preventative medicine and should be working with Practice Nurses around Good Recall systems. We need better coordination with this.

The idea is to automate interfaces as much as possible. These need to require no human interaction more than a simple click of a button. Example of how data should integrate between organisations eg surgeries should just do EMIS exports to get their KPI targets which require no work. Conversely, commissioners should have tools to process this data without manual effort.

Tech Suggestions

As this is my blog I have to promote my products (dammit!)

  • PatientChase which helps you with your recall so one patient with multiple conditions is contacted once a year as well as automatically coding this into EMIS. We are branching into other non-QOF areas such as immunisations and Drug Monitoring and offer SMS, Email and Letter contact.
  • PatientLeaf is our new product. PatientLeaf is a real-time clinical safety and efficiency app which clinicians use in their consultations. Everything users need about the condition is on one page as a filtered timeline of the patient’s medical history to give you the information you need at the time you need it. This allows the user to make better clinical decisions faster. With this, you are able to easily identify patients who you need to focus your attention on

SMS Texting via both iPlato and Mjog offer solutions to contact the patient. If Accurx offers this, they will close the market for these competitors.

Ardens and QMasters offer solutions in terms of enhanced EMIS Templates but my experience of them is that they are busy and take more time during the consultation but I appreciate what they are trying to achieve.

Health Campaigns and Preventative Medicine

Social Services via Health Campaigns will help Preventative Medicine

Preventative Medicine is a gearing ratio which affects the whole system ie if we focus more on preventative medicine we will have fewer patients in the system and as such can manage the load better.

Tech Suggestions

Social Media We should integrate campaigns with social services so if they are promoting a stop drinking week all the web pages other avenues of social media outlet from Health and Social Services should push on the same message at the same time. This requires coordination but also knowledge of social media which has become the defacto way of communicating with the general public

Pulling the Strings

We are constantly given incentives by commissioners around how to improve one budget area but occasionally fail to realise this can have a negative effect on the total health economy in terms of patient care and the budget. You pull the string in one place and it unravels elsewhere
Example of this are schemes to

  • stop referrals to hospital outpatient which improves the elective budget but will have the more detrimental effect of getting them admitted non-electively which will affect the bottom line more
  • reduce investigating patients which is brilliant in terms of us helping the lab test budget until you realise on average a blood test cost 5 pounds and by casting the net wider you could prevent a 50,000 admission.
  • Pushing on reducing the Prescribing Budget. The prescribing budget of one of our local CCGs a little while back was very low. Impressive until you realised that their non-elective admissions were incredibly high and as a result, the bottom line was not good.

GPs in the Middle

GPs are thankfully not employed by the NHS but contracted out and as a NHS protected business actually I believe makes them more efficient as they take more ownership of their own surgery and how it’s run.

Also thankfully there is a disconnect between GPs and the commissioning budgets they hold. This I believe is the cornerstone of the high-quality care we offer as we treat patients based on getting them better rather than how much they will cost us. Patients are the commodity not the budget .

So how can you encourage GPs to improve the systems next to them? In my experience, there are things which make GPs tick

  • Help them optimise their Income
    • pay them more money to achieve a common end point but not in a way which goes against patient care, for example, do not offer money for them to reduce referrals but more money in systems to enhance the quality of referrals
  • Offer more Patient-Centred Care
    • Offer systems to help connect and focus on the patient
  • Provide Evidence Based Medicine
    • Provide and educate GPs
    • provide systems to help them improve and get close to best practice medicine such as PatientLeaf

Schemes which help make the systems more efficient which are out of primary care contracts need to take these 3 above points in mind in order to actually get GPs to implement efficiency changes.

The bottom line is GPs as with normal human nature always ask “What’s in it for me” and schemes need to create a Win-Win for GPs and commissioners.

Summary

In the health care horizon, our focus needs to be on systems to improve on our efficiency between providers

Each interaction represents a system with the aim to focus on best practice

If we can really look hard at redesigning each system in turn and we can improve cost-effectivity yet still maintaining quality.