Background and Beginnings
Information is meant to be a window on commissioning. But all too often the view through that window is misty or even opaque. Information can be too dense, too complex, lack clarity or confidence, and all too often it can be missing in its entirety.
Both staff of the PCT and GPs in Somerset have applied time and consideration to these issues. They have been working towards a common set of objectives – to improve both confidence and usability of current commissioning information and to develop new data sources and further management information tools for GP Commissioners.
We quickly moved on from concentrating on issues of data quality.
Many of the first information tasks involved data quality. Somerset data was subjected to a number of arithmetic quality tests. We also relied on the annual audits of Payment by Results (PbR) conducted by the Audit Commission in each of Somerset's Acute Trusts. These have reported data accuracy greater than 90%.
However this does not mean that individual errors cannot be found. Overall one must consider what ‘checks in bulk' can be applied, and beyond whether it would be cost effective to track down further errors and to involve clinical time in that regard.
Improving the usability of information (particularly by non-analysts) is essential
Information work in Somerset quickly moved to matters of usability. Traditional Excel and Access reporting are liable to suffer when they leave the data analysts' office – too complicated, too dense, not informative and thus not used.
We have learnt that improving usability of information is an essential key to creating action. For Somerset, much the secret of success has been in the presentation.
The Somerset Dashboard is neither a database nor a website, it is an App
To present information properly, new skills had to be learnt. At that time, Somerset saw no suitable commercial information products on the market. All were too complicated. All seemed suited for an information team rather than the non-analyst users beyond.
Somerset therefore built its own Dashboard. It was built in Adobe Air which is free to use software. Adobe Integrated Runtime (Air) is a relatively new cross platform runtime environment for building Rich Internet Applications that can be run as Desktop Applications.
In other words and avoiding the ‘techno-babble', this has benefits over web-site solutions in terms of how data can be accessed and stored, and benefits over databases in relation to enabling web-type presentational functionality generally lacking in such tools.
The Dashboard App is a window on Commissioning Information
The Somerset GP Commissioning Information Dashboard App (‘the Dashboard') is a piece of software that sits on every user's desktop – Practices, PCT and also providers. It enables access to all available commissioning information and presents this both graphically and numerically. Most information is no more than three clicks away. It is also self updating, so that once loaded, it is always up to date. It does not necessarily prevent the need to have analytical databases but it does mean the GPs don't have to train to use them.
‘The Dashboard' provides users with the following suites of information:
- Monthly financial activity information against GP commissioning budgets including monthly Consortia, Federation (sub-consortia) and Practice outturns and comparators on elective inpatients, non-elective inpatients, outpatients and prescribing performance
- Key Indicator trends in emergency admissions, elective referrals and booking and choice outcomes.
- Patient risk profiling monthly high climbers. Somerset uses RISC from United Health. It was the only system tested that passed the GP usability test. A local enhancement was built to report monthly movements in patient risk.
- Public Health profiles with Practice and Federation analysis concerning population, deprivation & QOF prevalence rates, cancer screening, life expectancy, immunisations, obesity, smoking and normalised elective, emergency admission & outpatient rates
- Commissioning supportfeatures such as commissioning message board and menus for local prescribing and PCT reports.
- Links to all other systemsavailable to local users so that the Dashboard serves a single point of GP access for all information.
- Link to the local Information Team for support on the further queries which are inevitably generated.
Despite building the tools, it was still important to train, and to discuss
In Somerset, training consisted of sessions where Dr Nick Matthews and Kevin Hudson took over the Somerset IT training suites (banks of computers in a single room) so that GPs and Practice staff could understand the mechanics of how the Dashboard worked (i.e. the mouse clicks) whilst at the same time debate together the interpretations of what the data might be saying – and receive comments both from a clinical and managerial perspective.
This joint working has been a very valuable use of time. The sessions have proven popular and productive. An ongoing programme is planned, particularly around supporting the use of the Dashboard for QOF.
Good information will generate more questions than they answer
A key purpose behind the Dashboard is to stimulate debate and identify the right questions to ask.
Whilst initially, the Dashboard reported just at Practice and Consortia level, it was quickly expanded to report by Federation – which in Somerset are nine groups of 5 to12 Practices in size sharing a common locality. Somerset Federations have their own organisational structure and an individual seat on the interim GP Commissioning Consortium board.
It was found that information patterns not present at other levels of analysis became visible at the level of Federations. Moreover the commissioning questions generated by each Federation were often different.
Responding to this diversity had to be embraced. The Information teams needed to be able to undertake detailed bespoke analysis for individual Federations and offer interpretations as well as simply the information.
The team that offers this support consists of five individuals composed of information developers / designers, analysts and an administrator who works part-time in the team and part-time for a Practice. That particular feedback of detailed information experience in Practices is very valuable.
Establishing other data sources has also been important
Information on hospital activity and prescribing comes from national sources and is generally available 4-6 weeks after any month in question.
Somerset has established other data sources to supplement these ‘scores on the doors'. This information allowed Practices to receive early indications of performance and is generally expressed in terms of activity rather than finance:
- Reporting of Daily Emergency Admissions to Practices was set up from daily data feeds established with individual Acute Trusts. This data is raw but is received the next day and is presented to Practices through a small data tool that makes the information usable in Practices.
- This data source, built up over time, also gives useful indications of Emergency Admission Trends and Comparison, both overall and in relation to GP admissions compared to those admitted through A&E.
- For elective referrals, daily downloads of Choose and Book data are undertaken for each GP Practice. This again is collated into trend and comparison information, both of referral rates and patient choice outcomes.
The learning on developing new information solutions has wider clinical support implications
Information staff have worked with GPs to develop new information tools and to learn new skills. Locally, that learning has created new ways of doing things.
Consequently when paediatric consultants in a local Trust expressed that certain functionality of Choose and Book had some ‘sharp edges', an Advice and Guidance Response App was quickly developed using the same underlying technology as the GP Dashboard. This has improved the quality and efficiency of the review and response process for paediatricians and is now being adapted for other consultants. GPs get a properly formatted treatment plan that they can share with patients rather than the standard free text of the national solution.
Now work has turned to how similar support can be provided in primary care. A Pathway Navigator App has been developed and is being tested in Practices. Ultimately, it is envisaged that this App could sit unobtrusively on every single GP Desktop, using technology originally developed for information requirements but now adapted to support the user in other ways – in this case easily accessible communication and information concerning the local clinical pathways that are increasingly being agreed between GP Commissioners and Providers.
Somerset is discovering an overlap between ‘information' and ‘IT' and is exploring those possibilities. What started as data collection and reporting routines is now leaving that data analysts' office and developing into clinical aids.
Kevin Hudson is the Programme Manager for GP Commissioning Information in NHS Somerset.
Dr Nick Matthews is a GP from Glastonbury, a member of the interim GP Commissioning Consortium Board, and clinical lead for PBC & GP Commissioning Information in Somerset.
Click here for example screenshots of the information dashboard
