While individual healthcare providers may be making great strides in deploying increasingly sophisticated patient record systems, far too many are still operating within comfortable organisational silos.

To integrate care and make value-based care a reality, every local stakeholder must collaborate to intelligently share and use information, not only to improve direct care, but also bolster strategic decision-making for the benefit of entire population groups.

It is this central principle that governs The Healthy Wirral Programme (HWP), a collaboration involving every NHS provider on the Wirral Peninsula, working alongside social care, the region’s clinical commissioning group, and the local hospice movement.

The Wirral has long stood out as an international leader in the way its health and care system deploys informatics solutions and with HWP, its status as a pace setter in this field is set to consolidate yet further.

Wirral University Teaching Hospital (WUTH) NHS Foundation Trust’s Director of IT and Information Paul Charnley outlines the initiative’s key goals:

“We are looking to help reduce sickness and mortality from long-term conditions, improve the timeliness of care, and to support patients to self-manage [chronic conditions].”

The initiative, funded under NHS England’s new care models programme and the Global Digital Exemplar initiative, has three key planks underpinned by Cerner technology.

The first is the Health Information Exchange (HIE), a shared patient record capability which gives GPs, acute hospital staff and other care professionals instant access to the data stored on each other’s EPR systems on an individual patient basis.

No data is stored through the technology, which offers a real-time snapshot of a patient’s electronic notes.

Charnley describes HIE as the 'glue' connecting care records and allowing the region’s health and care system to work better together.

The second is the Wirral Care Record (WCR), which is powered by the global firm’s population health intelligence platform, HealtheIntent.

At the time of its deployment, this was the first use of HealtheIntent of its kind outside the United States.

The WCR represents the partnership’s truly ground-breaking work: a single longitudinal record covering the region’s approximately 330,000 citizens.

As the HWP rolls out, the data held by local mental health, community health, social care, and specialist care providers will also be fully absorbed into this intelligence platform.

Registries

The third strand of the work is based around the use of condition-focused registries, which use the analytics available from the WCR and its associated user traffic.

It is this third strand that is set to bring the most strategic benefit to health provision regionally.

If this model is successfully adopted in other areas, it could even offer a national blueprint for whole population health management.

Charnley says: “The intention is to absorb more and more information that is useful both to the services and the individuals about their health and their care.”

Key to realising the power of patients’ data to improve health outcomes across the region are the wellness and condition registries, which map out certain measurements for individual conditions using data from patients across the locality.

There are currently five such registries (covering diabetes in both adults and children, asthma in both adults and children, and chronic obstructive pulmonary disease) accessible to the region’s 52 practices, as well as acute hospital teams.

A further eight registries are in development. These will encompass:

• Atrial fibrillation
• Heart failure
• Wellness (in both adults and children)
• Mental health
• Frailty
• End of life care
• Social care

Aaron Brizell, Population Health Programme Manager, explains: “The registries have a number of measures which, if met, help improve management of a long-term condition. The key thing is that they identify gaps in care. Some initial analytical work has been done on patients who meet the most measures.”

“How the WCR works is that data from multiple sources is uploaded into the HealtheIntent platform and are merged. For example, blood results are mapped out in the timeline. A patient could have had [a number of] different blood tests, carried out by four different providers, we now have all of these in one single record.

“Our analytics team don’t just have access to information in their organisation but a holistic view of the patient’s journey through the whole system.”

Brizell uses the example of HbA1c levels (a measure of haemoglobin within red blood cells) reported from blood tests carried out on diabetes patients, to show how this data helps with the management of long-term conditions in practice.

He says: “Someone will have had a HbA1c test and [the Wirral Care Record] will show that result. If it is below a certain score, or if someone should have had one done but hasn’t, then the WCR will clearly show this as a risk and we need to take action to reduce this patient’s risk.

"This helps to give an indication of how well the long-term condition is being managed.

"Practice nurses often work to help patients manage long term conditions. We can help ensure the right support is there to the nurses, with training – based on the [HbA1c] results reported from [certain] GP practices.”

A phased approach

The population health elements of the HWP will expand as data from each provider is folded into the WCR.

The first part of the work, incorporating data from WUTH, and the region’s 52 GP practices has already been completed.

Charnley explains that work on the second phase is well underway:

“We're in the stage now of loading and testing the data from community health and mental health providers.

“At the moment [the process for connecting] social care is in design and with the hospice who use the TPP system, we're talking to them as well about a dataset that we can extract and merge with our own data.”

A similar process in underway with the Clatterbridge Cancer Centre, one of the country’s leading providers of cancer treatment serving as the region’s specialist care hub.

Direct care

Behind the dashboards, the strategic use of analytics and the myriad of datasets being pulled together, for the vast majority of the clinicians and support staff, the main advantage of these digital systems comes in improved patient care.

Dr David Lacy, Consultant Paediatrician at WUTH, outlines the positive impact that the HIE brings: “It’s made a huge difference on a day-to-day basis, seeing patients in clinic. “With parents’ permission you can access the child’s GP record. The most useful thing is the ability to see the medication that their GP has been prescribing.

“It is vital to see what medication the patient has been taking, particularly seeing what children have been prescribed following acute episodes like asthma attacks.

"If patients are getting a lot of extra steroids, that’s a sign of badly managed asthma. This is very useful to put the whole picture together.”

Dr Paula Cowan, Medical Director of Wirral CCG and a practicing GP, sums up: “The message I like to give is that an integrated system supports joined up delivery of care, reducing repetition and enabling patients to simply tell their story once.

"It is supporting population health management in a proactive, rather than reactive fashion, improving outcomes for the Wirral Population.”