Continuing our series of blogs on the findings from our evaluation of the training element of four projects aimed at enhancing frailty care across Wessex, this blog reflects upon some of the information systems challenges that staff described when identifying and delivering health services to people at risk of or living with frailty.
A key concern for staff was information integration and access to it.
Have you ever thought about the convenience element of setting up direct debits or payments from your online bank system? Imagine having to use individual companies’ websites with online forms that did not share common data (name, address, bank account details) so that you had to enter it for each transaction? And even though we are able to check payments on the online systems of suppliers (using separate accounts e.g. for electricity, gas, water, council tax), the convenience of logging into only one system, our bank account, to review all our transactions surely saves time and allows us to better manage our funds. The notion behind the functionality of online banking is the centralisation of information for the benefit of the end user. Even if it is not always perfect, the convenience and ease of use has been a significant factor in enhancing the use of online services.
Now, let’s think about health systems and the same idea of information centralisation. Staff from the NHS organisations that participated in our study all agreed that integrating systems across the community, social, primary and acute sectors that hold information on those diagnosed with or at risk of frailty, would benefit patients and enable staff to provide better care. Intuitively, in their view, access to better quality information in terms of completeness and being up to date would enhance their decision-making. However, information integration is not simple in the health sector.
It is known that in order to provide effective care for people living with frailty, there is a need to understand not just a patient’s clinical history, but their social and living environment too. A patient who falls frequently and experiences repeated hospital admissions may perhaps benefit from changes at home, such as alterations to a bedroom to fit a device to support getting out of bed. Or, they might be getting up to use the toilet frequently due to recurrent infection. Information on these two issues and what is being done about them sits in systems that are separate to each other. The information may be part of the patients’ records that sit in a system that staff in the community have access to but, when the patient falls and is taken to hospital, staff in the ED do not always have access to this information, thus missing opportunities for providing effective care.
Our participants, based both in the community and hospital settings, talked about the challenges they faced in accessing the information they needed at the time that decisions about treatment and discharge plans were being made. These challenges were associated with the lack of a unified information system that holds records of the patient made by staff in the community and GP surgeries or the hospital.
Staff also talked about the ‘work-around’ solutions that they implement in order to collect the information. These included asking colleagues who have access to relevant systems for the data, or making phone calls to GPs and/or social workers or hospital staff.
However, they reported that time and resources are needed to do these ‘work-arounds’ and it would be simpler to access the information online. This also assumes that something has triggered staff to suspect that there is something happening that they should know about; they discussed situations in which they had no idea that something was being investigated or actioned or was even a consideration, so could make decisions completely unaware of significant circumstances or could even begin duplicating actions.
Proactive identification of patients living with frailty takes place mostly in the community or in GP surgeries. When information and systems between these organisations are not integrated, staff reported duplicate identification of patients and of problems in creating and/or maintaining care plans, which could also be duplicated.
Staff also discussed how having to modify information to fit the requirements of different information systems generated additional work taking time that they felt would be better devoted to direct patient care.
One of the documents that frailty care staff use is the Comprehensive Geriatric Assessment (CGA). CGA is a document that collects a wealth of information about a patient and, importantly, some sections are written with the patient. Including patient wishes and clinical evaluations makes CGA hugely relevant to staff delivering care. Staff said that CGAs available through systems that can be accessed by community staff, GPs and hospital staff, effectively support treatment decisions and discharge plans through a ‘live’ document that tracks the patient’s progress.Their concern was that in many areas CGAs were housed in systems available only to GP surgeries. Also, where the system was available within hospitals, not all staff had access because of organisational affiliations.
In an area of Wessex there was some progress in that one system was providing a solution to the integration of health information and staff working in the community have seen the advantages when surgeries have access to the system. In their words: “Basically it’s good, and we’re lucky here as all our surgeries that we deal with are on the system, so for us here it is pretty good because you can, just go in and see what’s been happening and then you can just see everything.”
However, access to an integrated system is not in itself the key to enhanced frailty care. Some of the other challenges our participants talked about were resistance to change and organisational culture. They talked about their difficulties in adopting a new system, particularly when they had used another one that they felt better suited their needs. They also found that even where CGAs were available and could be accessed by staff in hospitals, they were not always read or used to inform treatment. As a solution, staff suggested that training on their information systems should be mandatory and refreshed regularly, not only on how to access and enter data into the system but to learn how to use it to its full capacity, learn from it and act upon it.
It must be recognised that consolidating health data is a complex process, especially due to issues related with data governance or keeping up with changes to regulations, codes and standards.
However, there are alternatives that might be worth exploring. For instance, when challenges to data consolidation become too costly, alternatives such as data virtualisation can be used to bring together multiple sources of data to one point of access. Perhaps in the delivery of frailty services, organisations may find that it is not necessary to integrate data at the physical level by moving data into new repositories, but might investigate creating interfaces that access data from multiple sources.
It may take longer to organise than online banking, but delivery of frailty care services will be enhanced by having access to all information relevant to a patient, in the right place, at the right time.