Time is an increasingly scarce resource in Primary Care, the length of appointments shorten while patient numbers grow. Even with more healthcare professionals, pharmacists for example, conducting regular reviews, workload remains high, and this can chip away at the time that healthcare professionals can dedicate to patient audit, case-finding and looking at their patient population to spot possible health issues early.
Over the years I built an interest in finding ways to help primary care staff save time and enable them to focus on clinical priorities. For me, this has been about turning “paper into digital”, in other words, developing digital versions of standards and guidelines and using them to build software that can guide healthcare staff through reviews, prescribing and aid quick and informed decision making.
I am based at the Centre for Medicine Optimisation at Keele University, and I began doing this work through a spin-out company that I set up with colleagues and the University, to make better use of funding and partnership opportunities, and to keep these tools free to use. In the case of the Asthma and COPD review toolkit, I was able to apply for funding to cover the development costs. GSK agreed to sponsor it and as part of the agreement, whilst they reviewed the specification, they had no input into the design, development or clinical parameters of the toolkit. They then reviewed the final software to ensure it was consistent with the requirements of the ABPI Code of Practice.
The first of the case-finding tools I developed wasn’t for a respiratory condition, but to help GPs find which patients in their care were at risk of falls. Falls bring a big burden on care and a high human cost, but it is very time consuming for a primary care practitioner to go through hundreds of patient records to see which patients are at higher risk. So, with Keele and Walsall CCG, we developed software, compatible with both the GP systems EMIS and SystmOne, that trawled through records looking for the predictors of risk, and returning a report listing all the at risk cases. It also flashed a reminder on screen when opening the notes of a patient at risk.
We ran an impact assessment in some of the practices that were running the tool, and saw some positive effect on outcomes. The data is being prepared for publication.
With more confidence that this kind of tool was useful to colleagues, I started to look for other areas where similar software could help, and ended up focusing on respiratory conditions. It seemed logical to look into asthma and COPD, as they are two of the most common respiratory conditions in the population, responsible for large numbers of preventable deaths.
This was the start of a collaborative effort, which involved input from chest physicians, healthcare informatics and developers, GPs and the Midlands Practice Pharmacy Network. We went through a thorough review of all the predictors of poor outcomes highlighted in the National Review of Asthma Deaths of 2014 and the later NCPOD reports on Asthma and COPD, and also acknowledged recommendations made in BTS and NICE guidelines. After several iterations, we whittled these avoidable risk factors down to a slimmer, encodable list that could be checked against patient notes, whilst remaining robust.
The aim was to develop a piece of software that could help primary care practitioners to quickly identify which patients in their care are most at risk of poor outcomes and even death, from asthma or COPD, to prioritise these patients for review and ultimately, help reduce the number of preventable attacks and improve disease control. The main users we had in mind were pharmacists, nurses and GPs.
We considered including a template to guide asthma and COPD reviews in line with national guidelines, but were advised that there are already many template solutions available.
The tool we eventually built can analyse all patient records within a practice and produce search reports that show which patients are in greatest need of follow ups or fresh reviews. As before, it also includes the opportunistic flagging mechanism, or protocol alerts, that we implemented in the falls risk tool. This time, however, we have made it more informative and easier for healthcare professionals to prioritise patients for review. Alerts now show more information including the date of the last review, and the issues that triggered the alert, such as high use of relievers, whether they had recently been admitted to hospital and so on.
Similarly, the search reports allow the user to assess patients across a series of measures; for example, patients who may be high users of reliever inhalers can be further prioritised into those who have ‘also’ had an exacerbation in the last 12 months, required more than two courses of oral steroids, etc.
Development started in early 2019 but we ran into a few delays. Firstly, the roll-out of SNOMED CT coding in EMIS hindered our ability to test the toolkit across practices and, more latterly, the COVID-19 pandemic obviously meant that many of our colleagues had to focus their attention on more pressing concerns. However, we managed to test and refine it over a period of about three-four months in around 20 practices, with good feedback so far. One of the pharmacists that tested the tool told us “What I want to do is spend my time reviewing the patients rather than identifying them. Using the toolkit saves me time, and because it has been tested and validated, I know we’re identifying the correct patients”, which was really encouraging.
The final product was released online July this year; initially for the EMIS system, but a SystmOne version will be available very soon. Just like the fall risk tool, the software is free for everyone to download and use.
We are hoping to do a proper impact evaluation of the Asthma & COPD tool later on in the year, or possibly in the coming one, once a sufficient number of practices have adopted the system.