An audit of Anti-TNFa use in Rheumatoid Arthritis (RA) was conducted to measure whether initiation and on-going therapy was compliant with NICE TA130. The audit recommendation was that a digitalised approach was needed to replace the conventional paper-base system and a new web-based application was developed to ensure biologic treatment complies with NICE guidance.
This application allows the clinicians to capture details of Rheumatology patients' disease activity, drug history and drug intolerances in 'real time', thus supporting both the Clinicians' and Commissioners' data requirements.
A funding outcome report can be electronically generated, automatically populated with all the information needed by commissioners to approve on-going funding approval, avoiding the need for manual entry of data. The data are stored on the Whiteboard which provides a condensed and high-level summary of patients' treatment history to suit clinical and operational needs.
Aims and objectives
Our objectives for the innovation were essentially to introduce a single point of entry for documenting and obtaining patient care information. In doing so the system would facilitate communication across the whole team, provide rapid access to patients' clinical data and support the continuity of care. In addition, these changes would help to avoid lost and redundant documentation. A new web-based application (biologic dataset) was introduced. This is hosted on Generic Clinical Information Service (GCIS), an existing platform which clinical teams routinely use to communicate patients' activities. Main benefits:
A centralised approach allows the clinical team to capture data in 'real time'.
a) The innovation (biologic dataset) facilitates communication and supports multidisciplinary team work at the point of care.
b) A funding outcome report can be electronically generated, automatically populated with all the information needed by commissioners to authorise on-going funding for treatment, avoiding the need for manual entry of data.
c) The data are stored on the Whiteboard which provides a condensed and high-level summary of patients' treatment history to suit clinical and operational needs.
d) Biologics are potentially toxic therapies which can cause infections e.g. TB and blood disorders. Productivity, patient safety and quality care is now enhanced through standardising dataset and improved information management.
The dataset delivers safer clinical interventions through digital tracking and monitoring
a) It uses colour-coding to flag up overdue follow ups and prompts the clinical team to ensure patients undergo regular blood tests.
b) It alerts clinical team to act on side effects and adverse drug reactions reported by the patients.
c) It serves as central access point for operational and patient related information.
d) It improves timeliness of notification. It highlights funding status to the clinical team and prompts prescribers to re-apply for funding to support continuity of care.
The data are stored on the Whiteboard and this facilitates
a) Clinicians to view high-level summary of patient's treatment history.
b) Up-to-date outcome reports to be generated electronically (with clear parameters to measure compliance with NICE guidance.
Reasons for implementing your project
An internal baseline assessment in the form of an audit was conducted for RA patients to measure whether initiation and on-going biologic therapy was compliant with NICE TA130. The audit identified number of issues:
Clinical & operational perspective: Patient data was not captured in a central place. The full history of disease activity scores was not accessible to all. The Clinical team was unable to ensure consistency in the recording of data and efficiency was hampered by the limited ability to access and share information. The clinician seeing the patient in clinic may not have the patient's full history to hand in order to fully monitor the benefits of therapy over time.
Commissioning perspective: Commissioners require confirmation that patients' DMARD history and disease activity meets NICE criteria before they will approve funding, and there is a requirement to provide regular outcome for patients on therapy in order to secure on-going funding.
Historically: Clinical team used a paper-based system to record baseline and on-going patient disease activity scores. This system had numerous shortfalls. It was manual and thus labour intensive. This system restricted the ability of the department to provide the CCG with regular outcome reports to demonstrate that patients were responding to treatment and continued appropriately in line with NICE criteria. The outcome reports had to be filled in manually by the Clinical Nurse Specialists, which was an inefficient use of their time, and reports were not being supplied to the commissioners in a timely way. This posed a significant financial risk to the Trust as potentially commissioners could withhold payment of invoices. Opportunities for improvement: To bridge the gaps between meeting the clinical need, ensuring patient safety and securing revenue for the Trust, a digitalised approach was needed to improve quality, productivity and efficiently manage documentation. Reliable and complete information through standardising dataset would assist clinical team to follow patient treatment pathway, improving patient care.
How did you implement the project
Resources: The Trust's NICE Implementation Analyst facilitated the project by ensuring that details were exchanged between clinical and IT programmer, in order to achieve the final product (biologic dataset). There was some resistance but this was overcome by:
- Ensuring that IT & clinical team were kept informed at each stage of the development.
- Involving the clinical team in decision making.
- Encouraging the clinical team to use the digital system for all patients on biologic therapy.
- Supporting the users by providing training in a form of 1:1 or group basis and be available on demand.
- Supports NICE's agenda to reduce barriers to implementation of NICE Technical Appraisals
Value for money: No cost invested to employ additional staff to develop this innovation however, significant investment of staff time was involved in building this application. Direct financial benefits are related to improved administrative process, such as improved clinical data quality for billing purposes, optimise workflow and enhance communication amongst team members to provide better continuity of care. Minimise financial risk to the Trust due to funding challenges from commissioners. The Trust is contracted to provide biologic therapy only to those patients meeting NICE criteria. If funding approval in not obtained, there is a risk the Trust will not be reimbursed.
Better use of clinical staff time:
Patients' clinical data is entered once in a central point and accessible to all. Form filled in electronically rather than manual. Facilities built in to generate up-to-date outcome reports to measure compliance of NICE approved high cost drugs.
Commissioning groups, trust management and clinicians have all had concerns about the capturing of data for patients on biologic therapy. The annual cost of biologic drugs is approximately 3x the budget for the rest of the Rheumatology Department. Guidance on indications and contraindications is fairly straightforward, but a significant amount of data has to be gathered to demonstrate guidance is fulfilled e.g. full drug history, 2 baseline disease activity scores. Drug funding challenges received in the last 12 months were approximately 1500.
Feedback from Clinical Lead: Rheumatology:
- At our last audit, we achieved in excess of 90% concordance with NICE guidance. Given the number of patients treated with biologics however, the proportion of non-compliant represented a very significant financial risk at nearly 25% of the Department for budget. This system will remove problems as inadequately documented indications and contraindications will prevent funding requests that do not comply with NICE guidance from being submitted.
- A small proportion of patients at the last audit were continuing on biologics having failed treatment according to guidance. The system identifies patients who are not responding adequately and ensured they move down the path to alternative treatment options.
- Our new system is quick, easy to use, ensures compliance with NICE guidance and safety measures for prescriptions (particularly with regard to TB risk), and automatically generates initial and repeat funding requests.
- Feedback has been positive from clinicians, nurse specialists, and pharmacy. Management are assured that the financial risk of inappropriate prescriptions has been removed. Commissioners may similarly be assured.
- The enhanced I.T has helped the clinical team to improve safety and quality of patient care and increase productivity.
To measure success:
- We need to keep drug funding challenges to a minimum.
- We will monitor the drop in drug challenges over time.
- True challenge should only be those where there has been an invoice error made by the Trust.
- Audit the effects of the reporting system and accuracy and completeness of the information entered.
Key learning points
It can support local educational, audit and research activities. The core technology is scalable and systematised to support spread. The same web-based application is transferable to other specialities that prescribe high cost drugs.
Sharing practice national level - NHS England:
On behalf of the team, The Trust's NICE Implementation Analyst has submitted an application to the NHS INNOVATION CHALLENGE PRIZES for the award category of the Use of Technology challenge. It provides an example of how NICE approved drugs are safely implemented and monitored.
Impact of technology over time:
The enhanced information technology has helped the clinical team to improve safety and quality of patient care and increase productivity.
The plan is to continue with this innovation and use the Shared Learning Zone as a platform to spread the word and get recognition.
The vision is to move towards patient led interface to gives patients greater control over their care. This involves patient using a simple portable device (tablet) to capture disease activities scores in the waiting area while waiting for their appointment.
The portable devices should be user friendly with potential translation and audible functions added to overcome language and literacy barriers.