Tuesday, 25 March 2014

Clinicians in north London are breaking down inter-professional barriers and reducing 'did not attend' (DNA) rates for patients with serious long term conditions.

Their clinical commissioning group (CCG) is using data-sharing to integrate care across primary and secondary care, and help avoid hospital admissions. Subject to patient consent at the point of care, clinicians in Camden have a secure view of vital medical information held in GP records - using EMIS Web - in these key areas:

  • community diabetes
  • community chronic kidney disease
  • community joint CKD/diabetes
  • community geriatrician
  • frailty MDT
  • community heart failure
  • community chronic obstructive pulmonary disease
  • memory service
  • improving access to psychological therapies (IAPT).

Using the system's search and reports facility, clinicians treating 1,407 patients in the diabetes service have reduced the DNA rate from 26 per cent in 2012 to 10 per cent in 2013. It is also helping them to triage care more effectively.

Specialist diabetes nurse Vanessa Sawmynaden said: "Being able to view the GP record means I can check past consultations, history, results and information from hospital appointments - data that is frequently missing from referral letters. We can also track if a patient is seeing another diabetes team, for example in hospital. This enables us not only to prevent duplication of care, but also coordinate it more effectively."

Search and reports has also enabled managers to keep track of DNAs among 70 frail elderly patients. Operations manager Agnes Rieu said: "Patients had been used to going to the hospital, and now they are being seen in community clinics instead. Activity reports revealed where DNA rates were high and we realised there was a job to do in educating patients about accessing the new community-based service."

Clinicians say the data sharing technology is essential to help them manage their caseload and make better clinical decisions.

"EMIS Web Community has helped us break down barriers in our multidisciplinary meeting," said GP Dr Stuart Mackay-Thomas, Frailty Lead. "Up to date medical notes from the GP means we are much better informed to make the right decisions about care for these vulnerable patients who have a range of complex needs. It is a stable and reliable platform."

Community teams are also using the technology to create care plans for patients which are then sent electronically to their GP, keeping them fully informed about specialist treatment outside the practice. Ms Rieu added: "EMIS Web has brought benefits for everyone: patients, clinicians & commissioners. It is so intuitive: just look at the screen and everything you need is there." 

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