Using integration for clinical care transformation

Plymouth NHS ICT Shared Service has established an industry-standards-based approach that integrates the IT for the cross-organizational care services that it supports. This has enabled its users to protect existing investments, streamline care processes, reduce costs and improve clinical outcomes.

Plymouth“We recognized the importance of integration to support the transformation of clinical care pathways many years ago and have been working closely with InterSystems to develop a generic architecture upon which we can base the cross-organizational information systems that are required today,” says Andy Blofield, Director of Plymouth NHS ICT Shared Service.

In preparation for the NHS National Programme for IT (NPfIT) the Trust chose InterSystems Ensemble®, a seamless platform for integration and the development of connectable applications. It used Ensemble to enable users to share information across more than 20 disparate existing applications. It is now redeveloping its integrated services in line with the nationally defined Interoperability Toolkit (ITK) framework to extend application interoperability across its care communities. This enables it to meet its existing clinical information requirements and build a flexible platform that will adapt to meet future demands.


Plymouth NHS ICT Shared Service supports 15,000 users across the Plymouth Healthcare Community, which comprises the Plymouth Hospitals NHS Trust, the Plymouth Teaching Primary Care Trust and 42 general practitioner practices. Its responsibilities include looking after patient and clinical administration systems as well as specialist software for laboratories and general practitioners.

The acute Trust utilizes iSOFT productsfor many of its core solutions includingpatient administration systems, order communications and emergency department, around which the ICT Shared Service has developed a mature integration framework.The framework enables it to develop new composite real-time solutions.

Using InterSystems Ensemble, we have the capability to interface any system to any other system. Having seen the benefits of a professional trusted integration engine like InterSystems Ensemble, we wish we’d installed it years ago.

Andy Blofield, Director
Plymouth NHS ICT Shared Service

Local interoperability and information sharing

When the Trust first began workingwith InterSystems there were more than20 different clinical applications linked to a central patient administration system via a complex series of interfaces.

This included applicationssuch as iSOFT’siPM patient administrationand iCM clinical management systems, which were linkedto departmental systems through iSOFT’s iIE, the integration engine component of iPM.In preparation for the NPfIT program the Trust was required to transfer its iPM to a remote data center in Maidstone, run bylocal service provider CSC. However, severalof its applications relied on receiving ad hoc data queries from iPM, which would bedifficult to manage from the data center.As a result, the Shared Service teamtook the opportunity to find a new integration solution that could deal with this problem –one that was scalable, futureproof, resilientand cost effective.

Key Benefits

  • Improved patient services
  • Reduced costs
  • Increased productivity

After a thorough market review, theTrust selected Ensemble. In partnershipwith InterSystems, the Trust’s in-house integration team installed Ensemble andrapidly implemented the current interfaces, some taking only a few days. The in-houseteam then created an additional ten new interfaces themselves. These included linksto a remotely hosted radiology system, an interface to iSOFT’s iIE to update iPM withdata returned from the DBS, and links to maternity, infection control, critical care, microbiology and histopathology applications. They also established a local repository using the InterSystems Caché® high-performance object database to hold patient demographic and ADT data for access by several otherclinical systems.

Value-added solutions built on theITK standard

In March 2009 Christine Connolly, the Department of Health’s director general of informatics, first introduced the ITK and its philosophy of “connect all” rather than “replace all”. This was the original ethos envisaged for the national systems in the NPfIT, and it is now the Department’s de facto approach for the NHS in England.

The Trust and InterSystems have worked together to turn this vision into a practical reality to make a real difference to clinicians’ working lives. InterSystems was the first to gain full ITK version 1.0 specification accreditation and it decided to include that capability in its standard Ensemble platform. Plymouth will make full use of the ITK capability in Ensemble to streamline its integration platform in support of all its clinical systems.

We have always preferred a best-of-breed approach, buying the best clinical system we could and then interfacing it.

Andy Blofield, Director
Plymouth NHS ICT Shared Service

Plymouth Shared Service has integrated its patient-centric applications into a unified view promoting patient care and saving valuable clinical time, naming the service Salus, after the Roman goddess of health. This provides real-time links to external systems with its modules that include Risk of Admission Patient Alert (RAPA), Discharge Summaries, Consultant Patient List & Handover and eWARD.

eWARD is a good example of the practical value Salus delivers, providing an operational view of patients on a ward using information collected on a variety of systems. eWARD enables both clinical and ward staff to see:

  • Which patients have care coordinators in the community, supplying them with contact information
  • Which patients have had three or more unplanned admissions in the last 12 months
  • Which patients have been marked by clinicians as being recorded on iPM on the wrong ward or under the wrong consultant or specialty thus improving communication and data quality and allowing ward staff to quickly correct the information
  • The status of a patient’s discharge summary, informing staff when a summary has been sent to pharmacy but pharmacy is awaiting the drug chart

SALUSPlymouth ICT Shared Service – working for Plymouth Hospitals NHS Trust and NHS Plymouth

Another Salus module is RAPA, which provides seamless real-time communication between community and acute staff for patients with long-term conditions who are under the care of a community support worker. It alerts care coordinators immediately via email and SMS messaging when one of their patients is admitted to hospital, transferred between wards or discharged.

Susan Bracey,Head of Software Development and Integration said, “Community staffnow contact thewards when their patients have been admitted to hospital, discharging them early if this is in the best interests of the patient, and updating the ward staff on any current care plans. In the past, patients would often remain in hospital while ward staff tried to organize community careto support their discharge, unaware that community support and care plans were already in place.”

RAPA has quickly established several additional uses, from improving safety for children identified as at risk, to savingmoney by reducing the time patients spend unnecessarily in hospital wards awaiting discharge. As community nurses are alerted immediately when their patients are admitted they can prevent unneeded visits to the patient’s house, cancel agency care that otherwise would have incurred a day’s full charge, and prevent unnecessary use of the police when the patient cannot be contactedat home.

Bi-directional alerts inform hospital staff of patients who may have special care requirements, such as renal patients, diabetics, or those known to the safeguarding children team or alcohol liaison nurses. GP surgeries also have access to RAPA information enabling themto target those patients who need more helpin the community, supporting patients athome and reducing the number of hospital admissions. Bracey added, “The system has generated a lot of interest within the hospital, with many clinical areas wanting to know when their patients are admitted. This enables them to monitor more closely the safety of their patients and we have recently enhanced the system to support this requirement.”

Overview of Salus benefits

  • “Connect all” not “replace all” – ITK enables new solutions to be built easily on top of existing architecture and at minimum cost.
  • eWARD – a real-time ward view that provides up-to-date status information on all admitted patients.
  • RAPA module prevents inappropriate admissions:
    • Community patients spend less time in hospital, freeing beds and reducing costs – previously patients would have to wait until staff had organized community care.
    • Increased inter-organizational data sharing –with reciprocal data sharing with community nurses for at-risk patients, alcohol dependency and children with suspect injuries.
  • Built-in InterSystems Caché database repository enables unique NHS numbers to be updated and duplicates or deceased patientsto be removed.

Future benefits delivered quickly and iteratively

Plymouth ICT Shared Service’s strategic use of integration enables it to support existing services and continuously innovate. Blofield says, “We are utilizing the Ensemble interoperability framework to underpin the local development of a portal, integrated to the Electronic Staff Record for role-based access and utilizing single sign-on to provide a single point of access for staff to all local healthcare applications at the point of care.”

In addition, a real-time bed management solution, Patient Care Manager, is being developed to provide the organization withthe information it needs for the effective management of its patients. Blofield added, “The platform and architecture are already in place with SALUS and the inclusion of bed-level management will complete the suite of products required to fully support the patients’ pathway and to support the needs of our clinical and operational staff.”

The solution at Plymouth is arguably among the most advanced in the country, being adaptable enough to cope with all foreseeable future needs in a cost-effective and intuitive manner. “Having a strategy firmly based on interoperability standards has enabled us to integrate our stakeholder organizations systems and services using a controlled, step-based approach that delivers benefits quickly and iteratively while providing the flexibility to develop generic solutions to specific problems that may thenbe utilized by others with minimal effort,” Blofield concludes.

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