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Shared learning database

Helicon Health
Published date:
May 2014

HeliconHeart is an integrated web-based package, designed to improve management of patients with atrial fibrillation (AF) to prevent stroke and includes optimal oral anticoagulant choices and management. The web software was developed by CHIME at UCL and is the base of our unique package of services which combine: patient management tools (including clinical guidance and advisory systems which draw on NICE Quality Standards); accredited learning and clinical governance supported by HeliconHeart's standards-based software designed to be interoperable with a wide range of hospital and GP systems and tools. The anticoagulant and stroke prevention module is used by a growing number of CCGs in SE England and is now in clinical use in 35 delivery sites in 5 CCGs (population size 1.6million) enabling 5,500 patients to have their INR levels well managed in accordance with NICE guidance; its features have been refined over 15 years and covers AF and anticoagulation, including the NOACs.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

Helicon Health's mission is to enable HCPs (doctors, nurses, pharmacists) and carers to improve the management of patients with long term conditions such as AF. The better management of such conditions will improve patient outcomes and cut costs.

The main objectives are:
Diagnosis and treatment: Advice and guidance, available 24/7, helps HCPs identify high-risk patients with AF, prescribe the most appropriate course of treatment for their AF, associated co-morbidities and oral anticoagulation. Patient receives care in the most convenient and safe place for them. Tablets and other portable or mobile devices are enabled to access the EHR (Electronic Health Record) server remotely.

Education/training (CPD): The AF and stroke prevention practitioner is demonstrably well trained, up and to date and able to offer a high quality service with a shared care philosophy; this is achieved through accredited blended learning (e-learning and some face-to-face and experiential learning) Patient data/governance: HeliconHeart is easily integrated with other clinical systems and data feeds. Clinical details of the patient and the advisory and management system are available in a timely and secure manner to the practitioner, wherever they are situated. All relevant clinical details about the patient are co-located in one single record. Clinical governance is implemented and learning processes enhanced. The commissioner has access to anonymised patient data enabling comparison of quality measures of performance by and between sites and access to anonymised outcomes data from past years, for benchmarking (insert link to Figure 2 in supporting document). It is easy to measure/monitor patient satisfaction.

Shared care: The hospitals continue to play an important role in clinical support, education of staff, clinical governance and the development of the service. Referral to a specialist is easy, patient data/information can be shared easily and securely. The 'community of practitioners' and the 'community of consumers' are expanded and strengthened. Messaging between practitioners is easy and secure.

Quality Assurance: The financial and contractual mechanisms are designed to enhance high quality care and facilitate the development of seamless care across organisational and professional boundaries. It is easy to extract evidence of the service being delivered.

Reasons for implementing your project

Several North London CCGs have, for many years, pioneered the development of a more community-led approach to deliver anticoagulant and stroke prevention services (which includes atrial fibrillation and anticoagulation), supported by a strong Clinical Governance Board and a unique education programme for the anticoagulant and stroke prevention practitioners. The service has developed in iterative steps, piloting each new model of care delivery before progressing to the next step. The service is now provided in 5 CCGs in London and North Hertfordshire which covers a population of 1.6 million with a broad mix of income brackets in both rural and urban settings and a rich and diverse ethnic mix. There were several starting points to the 'journeys'. The first reflected the increasing need to use information technology for improving patient care. The development of a web based EHR and the creation of the standards of data quality, confidentiality, access control and interoperability (ISO/EN 13606 standards) was an important piece of work. The second reflected the developing evidence that patients with atrial fibrillation needed anticoagulation to prevent strokes; this increased workload was not sustainable within a hospital setting alone. The third was the development of safe near patient testing devices which offered the opportunity for patient self-testing and self-management. As healthcare IT has developed, the team has used UCL's clinical advisory and management systems and introduced an increasingly sophisticated web-based EHR. This has enabled the service to become more distributed, with delivery closer to the home of the patient. Progress has been continuous, but the CCGs wanted to enhance the benefits of these developments with clinical governance and education.

By partnering with Helicon Health, we were able to combine the wealth of knowledge within UCL and the Whittington Hospital with Helicon's innovative, integrated approach, which offers advisory systems, education and clinical governance in one package.

The service currently functions from 30 General Practices, three community pharmacists, one polyclinic and one community hospital. These distributed services are supported by the hospital anticoagulant and stroke prevention services at Whittington Hospital (one of UCL's teaching hospital), and the North Middlesex Hospital, and by the blended clinician education and clinical governance.

How did you implement the project

The implementation was iterative in nature. Academic publications accompanied each phase.
- The validation of a dosing algorithm for warfarin induction and maintenance demonstrated that a nurse using the advisory system could function at the level of an expert; we then developed an outreach service to 5 GP practices.
- The development of an anticoagulant and stroke prevention service to 5 GP Practices in two PCTs, one additional hospital and a community pharmacy used the novel web-based EHR.
- An in depth review for one of the CCGs to better define the costs and benefits if those patients with AF and not yet diagnosed, together with those diagnosed but not treated appropriately, were better managed (insert link to Figure 3 in supporting document).
- The development of services to 3 other PCTs was enabled by considerably increased functionality to support the services:
- The AF functionality embraces:
o Clinical decision support for rate and rhythm control; o Tools to aid the recognition of high-risk AF patients; o Management of other risk factors and co-morbidities associated with AF; o Secure, confidential communication between HCPs in different settings; o Self testing of blood pressure and measurement of pulse or heart rate.
- Anticoagulant services:
o Advice on dosing and monitoring intervals, using trial validated algorithms o Tools to improve the time spent in therapeutic range o Automatic calculation of stroke risk score o Advisory and clinical monitoring system for new oral anticoagulant drugs

- Novel Clinical Governance (CG) framework and educational programmes were introduced. The Helicon Health team worked with the North London CCG's clinicians to develop robust CG across a distributed service. The CG Board includes patients, consultants (haematology,cardiovascular), anticoagulant HCPs, commissioners, clinical GP leads, an academic social scientist, a statistician, a computer scientist, a legal advisor and an IT representative. The Board agreed measures of satisfactory service quality in a changing clinical environment. The educational programme is based on a knowledge based and experiential course, with an associated clinical examination. A twice-yearly educational event is designed for all anticoagulant HCPsand forms part of their CPD and re-validation.

During the early phases funding was achieved through a mixture of research grants and contracts with the hospital and PCTs.

Key findings

NPSA measures showing patient numbers across various sites, and outcome measures over time, can be monitored at the CG Board. INR results by INR range or for specific groups of patients (eg only those with AF) can also be viewed. Real-time monitoring enables early detection of problems and the opportunity to intervene, investigate and offer support. The progress and quality of all the services are monitored regularly by the CG Board. Over 5,500 patients are now seen in community settings. Numbers are increasing as confidence in the quality and safety of the service grows with people being transferred to the community service to keep pace with rising numbers of new referrals resulting from increasing awareness of the need to identify patients with AF and to treat those with a raised risk of strokes. However this proportion of patients managed in the community is still small. There is no reason why 80% of patients requiring anticoagulation cannot be managed outside a hospital; this can only be achieved by increasing community facilities and resources as well as more patient self-testing and self-management. This could result in a better quality more cost effective service. A wide range of data is collated, from blood test results to instruments and devices used enabling monitoring and measuring of all aspects of the stroke prevention services, from education to patient outcomes and the safety of the clinical environment. An annual patient review is performed using the HeliconHeart EHR, the GP record and patient knowledge. This is increasingly being merged with the annual review of medication as well as the review of other long-term conditions.
An independently commissioned survey demonstrated that the patients unanimously favoured the new anticoagulation service over the hospital-based service for the following reasons:
- convenience (closer to home, easier to park)
- shorter waiting time
- friendly staff with professional manager
- minimally invasive test (much less risk of bruising)
- blood test less operator-dependent
- sample analysed in front of patient (very low risk of samples getting lost or mixed up)
- clear, structured paper printout
- good explanation of result and what action to take
- ad hoc advice available from pharmacist on other medication and general health issues
- less risk of hospital acquired infections (especially for immunocompromised patients)

Key learning points

The move of patients from a hospital site for service delivery to the community results in a reduction in income to the hospital. The role of the commissioner in supporting the movement of appropriate patients closer to home is crucial. The number of patients being managed in an individual community site has to be high enough to maintain the skill base of the HCPs. It also has to be high enough to enable flexibility in the times that a patient can come. The development of the hub and spoke model in the community setting addresses these issues.

The development of a self-testing or self-managing service for INR testing. The need for the patient to have to purchase the Near Patient Testing device remains a major barrier; there are equity issues to be considered. Patient enthusiasm for the service and more involvement in the management of their long-term condition is rising.

The interoperability of IT systems. Problems remain and the issues of double entry into different systems is a big issue. Progress is slow but there in an increasing optimism that some resolutions are close to occurring. HeliconHeart is web-based and enables a single patient record to which all the health care providers contribute; this will radically change the means by which clinical and patient communications can occur.

The education of the healthcare professionals. There has been a reluctance amongst some to participate in education. The introduction of blended learning should help resolve these issues. It will also enable a 'community of practitioners' as well as a 'community of patients' to be created for ongoing sharing of knowledge. The Clinical Governance function. A web-based solution facilitates the ability to define the quality outcome measures, collect them easily and to present then in a form that can be compared across several sites and enables the collection of the quality assessment (IQA & NEQAS) of the near-patient testing devices on different sites.

Contact details

David Patterson
Professor of Cardiovascular Medicine & CEO Helicon Health
Helicon Health

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