CCG IT: Making good Medway

Variation in the quality of primary care that is provided by GP practices is probably the hottest topic for emerging clinical commissioning groups; and tackling it is an area in which IT support will be crucial.

One CCG that is already entering this arena with some success is Medway Clinical Commissioning Group. It has deployed BMJ Informatica’s Audit + to help its clinicians support public health initiatives and work to guidelines.

Rather than using this as a stick with which to beat practices, the GP commissioners have adopted a collaborative approach to the deployment of the software, encouraging practices to use it to make their own lives easier.

So far its successes have included substantial improvements in care for patients with atrial fibrillation and in systematically screening patients for diagnostic indicators such as alcohol and body mass index.

Dr Peter Green, chair of the Medway Commissioning Group and a GP in Rochester, was instrumental in bringing Audit+ to Medway and firmly believes that its success lies in helping clinicians work smarter, not harder.

The CCG can see performance at a practice level, share that with practices and then offer support and training where appropriate. He adds: “We have not used it as a performance management tool but very much as a performance enhancing tool.”

Indeed, Dr Green believes that as a general rule CCGs will be better tackling issues such as variations in care by getting colleagues working together – instead of relying on the existing, contractual-based relationship between practice and primary care trust.

Getting patients on Warfarin

Dr Green began to look at Audit+ more than two years ago after becoming frustrated that there were no business rule sets for NICE guidance, making them much more difficult for GPs to put into practice.

Like many others, he saw that while areas covered by the Quality and Outcomes Framework were gaining from an IT-driven approach to management, other clinical areas were not reaping the same benefits and ran the risk of being neglected.

He says: “I came across Audit+ which was being use for swine flu monitoring and immunisations and saw that I could use it to write clinical audits which would provide prompts and reminders at the time of the consultation.”

Since summer 2010, Audit+, which integrates with most of the major GP clinical systems, has been used in 57 of the 61 GP practices in NHS Medway.

One of its first areas of focus was atrial fibrillation. UK and international guidelines recommend the use of Warfarin in all high risk patients; but current estimates suggest 40% of patients in that category are not receiving the therapy.

Using Audit+ to calculate patients’ CHAD2 scores and to prompt the clinician to prescribe Warfarin has led to improvements across all practices to 71.1% of at risk patients and increased the number of practices with more than 80% of patients on Warfarin from 25% to 38.6%.

Dr Green adds: “Some practices are using it a lot and some practices are using it a little, but what it does do is demonstrate the value of providing computerised support to provide better care to patients.”

Dr Green also argues that the prompts and reminders are a key to the success of the system because they help a clinician to do a better job when the patient is sitting in front of them.

He says: “Conceptually this is far better because it allows you to do something at the time of the consultation rather than retrospectively looking at what you didn’t do.”

Screening for alcohol and high BMI

Another area of focus for Medway has been running audits to encourage clinicians to screen for alcohol use and BMI.

With the help of automated prompts, practices in Medway have now screened more than 11% of adults for alcohol usage, up from 3-4% before Audit+ was used, which equates to an additional 15,000 patients screened.

Dr Green says: “It should be over 80%, the level we have for tobacco usage screening, but we are moving in the right direction.

“The evidence is that high consumers of alcohol consult more frequently so it makes sense to move the bell curve of alcohol usage downwards. If we ask about smoking status we should be asking about alcohol, but at the moment it hasn’t been done systematically in primary care.”

Dr Green is passionate about systematically addressing public health issues in primary care and argues that CCGs will never be able to deliver care within a cash-strapped NHS is efforts are focused simply on reducing the transactional costs of people who are ill.

As well as atrial fibrillation, alcohol and BMI, the Audit+ software is being used to support better management of COPD, end of life care, immunisations, drug monitoring of lithium use, monitoring the use of low dose antipsychotics in dementia and familial hypercholesterolemia.

Turning to other chronic diseases

The CCG is also in the process of developing audits to support better management of patients with chronic kidney disease, improving early diagnosis of long term conditions and supporting better uptake of screening programmes.

Dr Green adds: “We want to pick up people who miss screening for things like aneurism and breast screening by providing a prompt in the consultation. I think it can be a powerful message if it is your own GP reminding you.”

Dr Green is also developing niche audits for diseases likely to affect only very small numbers of patients in each practice or CCG, but where automated prompts for screening and management would help a clinician provide much better care to those affected.

Certainly not short of ambition, the Medway CCG appears to be blazing a trail for the kind of IT support that might help all primary care clinicians get the right care to the right patient every time.