1. Continuing development of the
community based anticoagulant and stroke
prevention services
Progressing towards
A STROKE PREVENTION SERVICE (AF AND AC)
Transition from successful pilot services towards more robust and
expanding services
21 November 2011
Professor David Patterson, Professor Dipak Kalra,
Department of Cardiovascular Medicine and Pharmacy, Whittington Health
Centre for Health Informatics and Multiprofessional Education, University College London

2. Electronic Health Record (EHR)
Supporting clinical shared care across organisations
Building on ~20 years of European research
Conforms to the latest international standards
Robust medico-legal and confidentiality features
Standards for clinical knowledge capture enable meaningful clinician
developer interaction and rapid development
Implemented as a web based system
Incorporates decision support and alerts
Cardiovascular modules
•HeartBeat AC: anticoagulation - in live use
• HeartBeat HF: heart failure - ready for live use
• HeartBeat AF: atrial fibrillation - clinical engagement commencing

3. Clinical Governance report
Derived automatically from the EHR
Each site can run its own report at any time
All reports include anonymous service-wide comparisons
Reviewed at quarterly Clinical Governance Board meetings

4. North Central London Community Based
Anticoagulant and Stroke Prevention Services
PROGRESSING TOWARDS
A STROKE PREVENTION SERVICE (AF AND AC)
• Enhancing our ability to prevent patients developing strokes
• Progressed from a doctor delivered service in hospital toward an
increasingly community based service
• Delivered by practice nurses, community pharmacists and GPs,
supported by a state of the art information and advisory system
which uses an Electronic Health Record
• A strong focus on education and on clinical governance
• Our services have been shown to be safe and very well received
by the patients, by the commissioners of health services and by the
community staff

5. Forgetful, elderly person with diabetes, atrial
fibrillation, heart failure and mild aortic valve
stenosis, who lives alone in
poor housing and requires anticoagulation
• Multiple chronic conditions
• Multiprofessional care
• Shared information needs - across boundaries
• Interface with other organisations:
– Social services
– Housing
– Voluntary sector
– Ambulance/car services
– Primary/secondary/tertiary care

6. Development of advisory systems for warfarin
dose and follow-up interval guidance
• CONTEXT - 1
• In latter part of 20th Century – warfarin management
was a doctor delivered service in hospital environment
• Regarded as dull and unchallenging
• Often performed by the most junior doctor with little
experience of anticoagulation

7. Development of advisory systems for warfarin
dose and follow-up interval guidance
• CONTEXT - 2
• And yet
• Developing realisation that warfarin was potentially a
dangerous drug influenced in its effects by many
factors such as diet and use of other drugs
• Increasing evidence that there was an unacceptably
high morbidity and death directly related to warfarin
• Very poor communication between health
professionals when introducing a new drug or starting
new treatment for a patient

8. [1] Evaluation of a decision support system for initiation
and control of oral anticoagulation in a randomised trial
[2] Validation of an algorithm for oral anticoagulant dosing
and appointment scheduling
• [1] The computerised decision support system was safe and effective
• It improved the quality of initiation and control of warfarin by trainee
doctors
• [2] The algorithm performs better than inexperienced clinicians and
as well as experienced clinicians for the non-difficult patients
• Algorithm better at recognising the more difficult case than the non-
expert (ie to see doctor)
• Analysis of combination of dose and interval recommendation showed
remarkable similarity between experts and algorithm

9. 3
2
1
INR -Target INR 0.5
0
-0.5
-1
-2
-3
95%
2.0 - 3.0 2.5 - 3.5 3.0 - 4.0 3.0 - 4.5
90%
Therapeutic range
75%
50%
25%
10%
5%

10. 400
0 therapeutic
range
3000
2000
1000
0
1 00 1.50 2.00 2.50 3.00 3.50 4.00 4.55 5.00 5.50
INR value - patients with therapeutic range 2.0 - 3.0
Total 18881 (full tail at high values not shown)

11. All therapeutic ranges
100
Above range
80
60
Percentage In therapeutic
of INR results range
40
20
Below range
0
0 36
Months into anticoagulation therapy

13. North Central London Sector

14. ANTICOAGULANT AND STROKE
PREVENTION SERVICES at
HOSPITALS AT: WHITTINGTON AND NORTH MIDDLESEX HOSPITALS
PHARMACIES AT: HIGHBURY BARN, N5 BOOTS (WOOD GREEN), N17
POLYCLINIC AT: ENFIELD (1 GP CENTRE/POLYCLINIC), N9
GP PRACTICES AT:
HIGHGATE GROUP PRACTICE, N6 DUKES AVENUE, N8
SOMERSET GARDENS, N15 TYNEMOUTH ROAD, N17
MORRIS HOUSE, N22 GOWER STREET, WC1
HAMPSTEAD GROUP PRACTICE, NW3 JAMES WIGG PRACTICE NW5
MUSEUM PRACTICE WC1B KEATS GROUP PRACICE NW3
PARK END SURGERY NW3 PARLIAMENT HILL SURGERY NW5
REGENTS PARK MEDICAL CENTRE NW1 ROSSLYN HILL SURGERY NW3
BRONDESBURY MEDICAL CENTRE NW6 AMPTHILL SQUARE NW1
ADELAIDE ROAD, NW5 ROMAN WAY MEDICAL CENTRE, N7
RITCHIE STREE GROUP PRACTICE, N AMWELL GROUP PRCTICE, WC1
ELIZABETH AVENUE, N1 RISE HEALTH CENTRE, N19
KILLICK STREET, N1
HOSPITAL OUTREACH SERVICES TO:
GOODINGE HEALTH CENTRE, N7 RIVER PLACE HEALTH CENTRES, N1
TORRINGTON SPEEDWELL HEALTH CENTRE, N12 EDGWARE COMMUNITY HOSPITAL, HA8
STANDARD CLINICAL OPERATING PROCEDURE

15. CLINICAL GOVERNANCE BOARD
Anticoagulation & Stroke Prevention Service
• MEMBERSHIP
• PATIENTS
• HOSPITAL CONSULTANTS – CARDIOLOGY AND HAEMATOLOGY
• ANTICOAGULANT PRACTITIONER FROM EACH OF THE 5 PCTS (GP OR PRACTICE NURSE)
• ANTICOAGULANT PRACTITIONERS FROM HOSPITAL(S) OUTPATIENT SERVICE
• SENIOR PHARMACIST WITH EDUCATIONAL REMIT
• SENIOR PHARMACISTS WITH CLINICAL GOVERNANCE REMIT
• COMMISSIONER FROM EACH PCT
• CLINICAL LEAD FROM EACH PCT
• ACADEMIC HEALTH INFORMATIST
• ACADEMIC BEHAVIOURAL SCIENTIST AND STATISTICIAN
• ACADEMIC LEGAL AND EDUCATIONAL ADVISOR
• IM&T REPRESENTATIVE FROM WHITTINGTON HOSPITAL

16. Generic Ingredients of our integrated services
together with
Our package of support
• Education and training for practitioners
– Formally defined syllabus
– Training sessions including practical skills and use of the information system
– Formal assessment, required certification, periodic reassessment
• Clinical information system
– Electronic Health Record supporting clinical shared care across different organisations
– Disease management system - anticoagulation; heart failure; atrial fibrillation etc etc
– Clinical management advisory system
• Clinical support
– Direct contact with senior clinicians, able to access the same EHR from different sites
• Clinical governance
– Clinical standard operating procedures and site specific operating procedures
– Quality assurance processes and monitoring
– Review and comparison of outcomes
– Multidisciplinary clinical governance board

17. Comments from Patients
• Site 1
–Very satisfied with everything
–Always on time and always most helpful
–I can not fault anything. I only wish I did not have to come
–Nothing at this time
–Very very good
–Appointments always on time treatment well explained
–All your staff are excellent
–Very competent
• Site 2
–To continue this same way as at present
–I am very happy with the service given here, many people take up
this choice
–No Complaints at all
–All very satisfied
–I am very satisfied with the anticoagulant service
–Delighted with the service, I got to compliment you on your lovely
polite staff

18. Quality and safety principles of our integrated care
service
• the patient will receive monitoring care in the most convenient and
safe place for them
• the practitioner will be demonstrably well trained, up to date and able
to offer a high quality service
• the EHR of the patient will be available in a timely manner to all of
the practitioners caring for the patient, wherever located
• clinical governance arrangements will be implemented and learning
processes enhanced
• hospitals will continue to play key roles in clinical support, education
of staff, clinical governance and service development
• the patient or customer is central to the planning and delivery of
services

19. CLINICAL GOVERNANCE BOARD
Anticoagulation & Stroke Prevention Service
• MEASURES OF SATISFACTORY QUALITY AND SAFE PERFORMANCE
• PATIENT FEEDBACK/QUESTIONNAIRES FROM EACH PCT
• TRAINING, EDUCATION AND PERFORMANCE OF ANTICOAGULANT PRACTITIONERS
(OSCE AND RE-ACCREDITATION) FOR ALL PRACTITIONERS
• ANTICOAGULANT CONTROL (BY SITE -- BY WHOLE SERVICE – BY PCT --- BY
PRACTITIONER -- BY TIME - BY THERAPEUTIC RANGE ETC)
• INFORMATION GOVERNANCE (ACCESS CONTROL; SECURITY; BACKUP POLICIES)
• QUALITY CONTROL OF CLINICAL PREMISES - ANNUAL VISITS –
• QUALITY CONTROL OF EQUIPMENT – POCT EQUIPMENT AND NEW REGULATIONS –
SEEKING CPA ACCREDITATION FOR COMMUNITY SERVICE
• THE ANNUAL REVIEW OF PATIENT – NOW BEING PILOTED
• USE OF ROOT CAUSE ANALYSIS (RCA) AND COGNITIVE WORK ANALYSIS (CWA) IN
“NEAR MISSES” OR UNTOWARD INCIDENTS
• REAL TIME ANALYSIS OF PERFORMANCE

20. Link with secure mobile device

21. Make solutions simple and
intuitive

22. North Central London Integrated Care Model
Whittington Hospital
and its collaborating
Hospitals
Collaborative GP Practices
development Consultant-led and
of EHR Community Cardiology Pharmacies
systems Service
CHIME
(UCL)
The Consultant-led Community Cardiology Services
provides protocol-led and formally-evaluated
collaborative care, initially for anticoagulant and
cardiovascular diseases.