#AboutMeLeeds – It’s A Matter of Trust

Rob Webster

I am really interested in the power of information to transform care and improve safety. You may have picked this up from an earlier blog – “Civil War, Heart Failure, Sex and Big Data” – and some people may know I was a professional statistician for a while. So I was delighted to be asked to contribute a blog to #AboutMeLeeds – a week long discussion on data and privacy and innovation. Details via Victoria Betton’s excellent Digital Mental Health Site are here

All of the blogs are worth reading – and cover diverse and bumpy ground. From using data to transform care, to critical questions like “how private is private?”. Find them all here


“It’s a matter of trust

The Secretary of State for Health, Jeremy Hunt, did a back to the floor session in our services last week. He worked alongside health and social care staff looking after older…

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#NHSChangeDay Reflections 4 – It’s not about the kit it’s the people!

This is the 5th visit made as a result of my #NHSChangeDay pledge to visit frontline services so that I can understand the challenges of using information and technology in the front-line of care delivery.  I’m glad I made the pledge – it’s a journey of learning.NHS+Change+Day_logo_calendar_png_5_____

This time I visited some great people in Hull to look at telehealth.  I enjoyed my visit but came away with a sense of that we were missing the point and that we were looking through the wrong end of the telescope.

Telehealth is controversial. The Whole Systems Demonstrator Programme attracted attention when studies showed no positive effects on ‘quality of life or psychological outcomes for patients with chronic obstructive pulmonary disease, diabetes, or heart failure over 12 months’ (Cartwright, Hirani, Rixon et al 2013) and other studies have shown no cost benefit.  In a recent study about the impact on hospital admissions of telehealth concluded that ‘Long term telemonitoring of people with COPD is unlikely to reduce admissions unless it is a lever for enhancing clinical services’ (Pinnock et al 2013).

Computer stethescope

During my visit to Hull I met Paul, who is a lead nurse for academic cardiology and who leads the telehealth service for heart failure in East Yorkshire.  The location was interesting as, of course, telehealth doesn’t need to be located geographically in offices or organisational buildings that symbolise service, indeed there are nurses working on telehealth who work from home.  I met Paul in his untidy office, shared with an (untidy) colleague (I feel sure he won’t mind me saying that), none of the usual symbols of a care space – it felt strange to me! Changes to the distance between the practitioner and the patient/client alters the way we do things, it changes practice and requires, if not new skills, a flexing of the skills nurses already have, as many of you have heard me say before it requires a new type of professionalism, digital professionalism; working in digital spaces where the location of professional and patient may be remote.

The conversation between Paul and me rarely crossed into the technology itself, we had a quick look at the screens but what was much more interesting was the conversation about what the patients really thought and what skills staff needed to offer the service.  My conclusions are that we have to stop looking at this like it’s an interesting new development that we can all get very excited about and see as a technical service and, instead, think of the patient’s perspective and centre on their care.  Paul told me about patients who were happy to use the system as they were able to detect deterioration early and ask for help.  Some see it as a lifeline and would never want to give it up once they have it in their homes.

The service in Hull is well established. Their service has supported nearly 300 patients and data from the TEN-HMS study, demonstrated a reduction in one year mortality from 45% with usual care to 29% with telehealth. The heart failure service states that it saves around £1000 per patient per year in avoided hospital admissions.  In Hull the patients are supported by visitors from a voluntary sector organisation – Hull Churches Home From Hospital.  They provide visits to support patients getting used to the new equipment and dealing with problems in the early stages as they get used to the monitoring equipment.

One of the things that was very striking for me was that we need to make sure we use the skills of staff appropriately – having the right people doing the right work.  If the service isn’t offered at scale there is a risk that expert staff will spend lots of time dealing with issues that don’t need their expert skills – Paul showed me long lists of patients with an alert on the system but of course many of these were reporting equipment problems or reporting reasons why they would not be sending results in (for example holidays).  This means that services need to be carefully planned and we need to avoid forcing the option on people in order to achieve a critical mass, as people may prefer different alternative options, for example in this instance visits from the health failure nursing team.

Paul also talked about how challenging removing monitoring equipment is once it is in place and how costly this could be.  There was even uncertainty about if equipment was re-usable.  The result of this may be that people end up on the scheme indefinitely by default rather than by design – clear plans of care are needed that include coming off the equipment as well as patients being offered it.  If we don’t do this there is a potential for demand to grow exponentially and become an expensive service that is not related to need.

ScienceI also visited Hull University and met with Jonathan Thorpe who is the manager of the Centre for Telehealth.  Again our conversations centred on the human dimensions of telehealth and less the technology although I did meet an inspirational PhD student, an engineer who was exploring how technology can help in health.  His passion for his ideas and thirst for interesting conversations about the challenges of managing long-term conditions was inspiring – again I was reminded how much of our future relies on young scientists.

All my conversations were about people, ideas, skills and little was about the technology.  We need to think about the patients/service users first and see this as an additional tool to help us deliver integrated patient centred care and stop it being about the technology in its own right.  My ambition is to mainstream informatics, rather than specialise it!  Using information and technology is everyone’s business in care delivery in 2013 and telehealth needs to be considered as part of the portfolio of integrated care options. But we must work in collaboration with patients with an appropriately skilled workforce and infrastructure to get the best from it.  We need to stop seeing telehealth as a technical project and start looking at it from the other end of the telescope as an option, part of an integrated care service not as a service in its own right.

All in all it was a great day for reflecting on the emergence of technology in health but my conclusions were it’s not about the kit – it’s about the people!

Larkin Global Pop Toad at Hull University

Larkin Global Pop Toad at Hull University

Cartwright M, Hirani S, Rixon L et al (2013) Effect of telehealth on quality of life and psychological outcomes over 12 months (Whole Systems Demonstrator telehealth questionnaire study): nested study of patient reported outcomes in a pragmatic, cluster randomised controlled trial British Medical Journal BMJ 2013;346:f653


Pinnock H, Hanley J, McCloughan L, et al (2013) Effectiveness of telemonitoring integrated into existing clinical services on hospital admission for exacerbation of chronic obstructive pulmonary disease: researcher blind, multicentre, randomised controlled trial British Medical Journal BMJ 2013;347:f6070

Informatics: What is Nursing ‘Clinical Content’?

I wrote the content of this post some time ago because I realised that I was having many conversations about what I understood as ‘clinical content’ but many people didn’t know what I was referring to, except if they worked in informatics.  It took me ages to ‘get it’ but increasingly I realise this is a very important part of the future if we are going to develop electronic patient records.Record keeping nurse

So, imagine the scenario, you are a newly qualified nurse and you have had a couple of days on the ward and at last you are sent to assess a newly admitted patient.  You pick up all the documentation and forms and off you go.  I am confident that those pieces of paper would affect the information you collect.  They are clinical content.

Clinical content refers to the components of nursing records that:

1     Structure care processes and;

2     Provides information at the point of care that supports clinical decision making.

Examples include:

1     Templates (for data collection – supporting nursing to make high quality assessments),

2     Risk assessment frameworks (to bring evidence to care processes for example PU risk assessment)

3     Care pathways (to support clinicians in making optimal decisions about care plans with patients).

They may also include alerts and warnings, where professionals’ attention is brought to a particular aspect of a patient’s condition for example an allergy.

Why is clinical content important?

  •  Safety

If we collect consistent evidence based information and use this to deliver care we can improve safety, for example, well structured and common handover documents as patients move across the systems can help to maintain continuity of care and avoid safety incidents.

  • Sharing

If we are to enable sharing of records with patients, attention to clinical content will make sure we document in open and transparent ways that enable people to understand the record.

  • Expertise of workforce

We know that the experience in the nursing workforce is set to fall as the older more experienced nurses leave the workforce. Good quality and evidence based clinical content can be used to guide staff through care processes and build their nursing knowledge and expertise.

  • Efficiency

Implementing electronic systems does not always make work more efficient on its own and only by judicious professional review can we make sure that the paper systems converted to electronic are robust and not wasteful.

  • Improving quality

Providing staff with the best information at the point of care helps to make sure that patients receive high quality evidence based care. It also allows us to robustly review our performance in a structured way; for example, we need to be able to measure pressure ulcer incidence. In order to understand how we might be able to improve and to investigate if we are outliers from a performance perspective we need to be able to compare ourselves with others, so we need data collection that is common. This leads us to conclude that common data collection templates should be important.

  • Information overload

In the new information age there is almost too much information available for staff to integrate into their practice. Well governed and managed clinical content can help staff to be as up to date as possible.

Is Clinical Content just about electronic records?
Clinical content is commonly referred to as a component of electronic records but actually all record keeping systems have a component of clinical content. If you visit any ward or department you are likely to find assessment frameworks and templates for collecting information, as well as possibly local standardised care plans. Sometimes these have strict governance applied but paper records have a tendency to proliferate, for example, in one city they found that they had around 600 pieces of paper to be used in nursing records.
Why should we be concerned about this? Doesn’t the system work we have now work?
As the world we work in becomes more and more electronic so nursing is likely to evolve to catch up with the world around us. We can of course just turn our pieces of paper into electronic versions of the same, but this would represent a huge missed opportunity. Experience of implementing electronic records in the US shows that just making paper electronic, while a low complexity approach, adds the lowest value in terms of quality, efficiency and safety. We have a huge opportunity to improve things but we need to grasp this now, and we need professional leadership to make it happen.

Isn’t this about IT and, therefore, not a professional issue?
This is definitely not about IT. When any clinician starts using a new system it will come as an empty vessel, a bit like a show home. In order to make it useful, and contribute its potential, it needs clinicians to make it work for them through adding high quality well governed content. Also professionals need to work out how it will work for them, to continue with the show home analogy they need to make sure the sofa fits into the room and that the colours match.

Why don’t systems come with content already in place?
Some systems will come with some content from the system supplier or a third party. If anyone takes this content they are likely to find that it perhaps is not fit for their organisation (most content is from the US) and requires a lot of review to make it fit for purpose.

Should we be developing our own content now?
It is a good idea to start to develop nursing content and to streamline existing records now even if you are not planning an electronic record. If this is done carefully it can ease the way forward for implementing electronic records. The downside of this is that it is expensive and time consuming and if every organisation has to do this alone it may represent large sums of NHS funds. Nursing is already behind the curve professionally; the medical profession is already making strides forward to enable standards such as discharge summaries to be used across the service. Nursing has a tremendous track record of innovation and with good leadership clinical content development could contribute to other priorities such as QIPP and the productive initiative.

What needs to happen to make this a reality?
The first step is senior clinical leadership and ownership by the profession. In order for this to happen we need to be clearer about why this is important and what any activity can offer.
Governance, ownership and risk will be key issues to be explored.

So next time you fill in an assessment form, complete a nursing record or perform an admission assessment or discharge – you are using clinical content.  It’s too important to ignore!

medical records

My blogging journey – nearly a Year and 30 posts later

I am always trying out new things; I don’t like repetitive work and always chose unusual jobs, often ones people say are difficult.  I took up blogging because I didn’t understand it; in truth I didn’t understand the power of social media back then either.Blog

I started blogging because I couldn’t talk about social media without a broader experience of what it was all about.  It was good to be on Twitter and chat away but I wanted to do more than that and gain some reflective space beyond 140 characters.

So back on 9th September 2012 I posted my first blog.

I wrote about having a tooth out and reflected about stoicism anniecoops Grandad and Trixie 1979and how it might affect the way we nurse.  I read it now and cringe – but I also do that for my later blogs. But what has happened is I have gained confidence in the writing, I can now work out more easily what I want to say and the points I feel I want to make.

You can read that first post here:

Since then I have added 29 more posts and am amazed to say I have had 12,000 visits to my blog.  I know this is a crude measure as many people just click past but I have also had more than 200 comments – all of which are part of the conversation.  My blogs have also stimulated many discussions on Twitter.

I sometimes enjoy blogging more than tweeting.  It’s different – it has created a space for me to think out loud and enjoy the conversations and responses I have had as a result.  The most popular blog has been this one which got such an amazing response. The people who responded to it recounted a similar experience to mine – a shared history of experiences in nursing which I seemed to tap in to.anne 1989 on ward

But another blog got an unexpected response was about my diabetes where I wrote about something that made (still makes) me feel uncomfortable but again high numbers of visits. POMPOM days also seemed to resonate and the responses I got from people made me cry.

I have blogged about 3 themes; nursing, diabetes and leadership.  All three topics seem to have people who read them but I suspect I’m diluting possible impact through the eclectic nature of my blogs.

When I started out I set my self a goal of a blog every 2 weeks.  I haven’t quite achieved that but not so far off.IMG_1069

So what have I learnt? Here are ‘anniecoops’ top blog tips!

  1. Write about something you genuinely love or feel passionate about – let the reader feel that through your words.
  2. Be yourself – don’t try to write ‘posh’ just write how you express yourself or how you talk in your mind.
  3. Don’t try to be too ‘clever’ expressing thoughts and feelings and recounting experiences has its own magic too.
  4. I always try to have a beginning, a middle and an end.
  5. Check your spelling and grammar over and over again (I always miss something).
  6. Respond to comments and encourage people to comment on the blog (I’m getting better at this).
  7. Pimp your blog – I learnt this from @therealbaglady – basically if no one reads it there will be no conversation! So point people at it in any way you can.
  8. Try to use photographs and illustrations where you can.  I now try to take ‘interesting’ shots with my iPhone that I can use as I don’t want to break copyright law by using images that I don’t have permission to use.  Just click away 🙂
  9. Learn about Creative Commons – look here http://creativecommons.org/
  10. If you are not sure ask a trusted person to read a draft of your blog. Let them tell you if it’s OK or not – it’s easy to blog without thinking and then regret.
  11. Practice makes perfect (or improves at least) – learning how to write down your thoughts doesn’t come easy but it does get easier!
  12. Blog regularly if you want to build the number of people who read your blog.
  13. Watch the stats – its gratifying once you get going to see people reading your blog but don’t be obsessive!
  14. Be patient with yourself – some of the blogging sites are harder than they look to use!
  15. Show your personality. I have found that ‘anniecoops’ has suddenly got a life of her own.  I was never called Annie till Twitter – not that long ago someone I had never met stopped me in the street and said ‘You are anniecoops’ – so be prepared for possible impact if you blog as yourself.
  16. Finally read other peoples blogs and respond to them too.

Blogging has been a great experience for me and I will be continuing.  I have re-discovered a love of words and writing that had got lost after leaving school. Long may it continue!

book pen


Nursing Informatics Study tour to Chicago

Sometimes I think I am just the luckiest person. Chicago 2013I love the NHS and nursing; and working in informatics is exciting and challenging. When I was 18 and embarked on my career I never imagined it would take me all over the world but last week I was so privileged to escort a group of NHS nurse leaders to look at informatics in Chicago, USA.

The study tour was arranged by HIMSS who do an amazing job of supporting nurses who have an interest in informatics as well as their wider activities.  The trip was part of a year long plan of activities in the UK – we have also had free open webinars and a summit to discuss the approach taken to technology in nursing in the US.  You can read more about HIMSS here.

The experience and background of the nurses in the group was broad – mental health, general nursing, midwifery and education were all represented along with commissioning and those with a leadership role in informatics.  They were competitively selected from around 35 applications – there were 9 nurses in the group.  The group also represented the 4 countries of the UK.Nearly all the nurses

This isn’t everyone but its nearly all the people from the trip

The experience proved an interesting one.  The following are my key learning points:

1  Where is the UK compared to the US in informatics development?

I am not sure whether I am reassured or disappointed that I didn’t see anything that surprised me.  Certainly in hospital settings the nurses are using more record systems but they face the same challenges as we face at home.  They still talk about the challenge of clinical content/records and the time it takes nurses away from patients.  The scale of investment, however, is very different.  IT is not seen as an add-on but as an essential part of their business and in some areas it has led to significant improvements.  I will blog more about this when I have the presentations from each site.  The nursing informatics teams in each organisation were much bigger than I see in the UK – with some teams of 10 staff, all nurses!patient call system

Mobile working in its many forms is also a matter of debate for them but in the new build organisations we visited they have invested in much better infrastructure leading to more potential for mobile working.

2  The importance of governance and quality improvement

All of the sites we visited were Magnet Hospitals and this was noticeable and I couldn’t fail to be impressed. The staff were happy in their organisations with some directly expressing how they stayed working at that hospital because they loved working there.  If you don’t know about Magnet hospitals you can read more here.

What was particularly inspiring about this for informatics was how the governance structures of magnet hospitals had ensured that nurses were empowered to positively affect the decisions taken about informatics.  On one site the informatics lead was responsible to the nursing professional practice committee.  It makes perfect sense to me – a positive way of governing and empowering those who use the technology.

The same is true of improvement activities – they were driven through professional groups rather than management with great success.

More about shared governance here.

Different philosophies

Although I noted the similarities in the implementation of technology in the sites we visited there was also a major different in how they viewed patients/service users.  We asked many questions about patient access to records, information ownership and patients’ involvement in services; it was clear from the responses that in the UK we are much more focussed on patients and their involvement. In some areas (not all) the care was very medicalised and neither the patients nor the nurses seemed to be centre stage!

Over the next couple of weeks I will also write up some comments about each of the sites we visited.

A big thank you to HIMSS who were superb but also the brilliant nurses on the trip who asked many searching questions and worked hard to understand what they saw and heard.  I also confess to laughing until I cried on some occasions – there is no better company than nurses!

I also enjoyed Chicago very much; I have never been to a friendlier city.  It is also a beautiful place.Trump tower

Trump International Tower, Chicago

Never, ever back off a challenge! Update on Florence Nightingale Foundation Scholarship

It’s a few months now since I was given my Florence Nightingale Burdett Trust Leadership Scholarship – I’m starting to feel the pressure, yes, I actually have to do something (!) but this week I started to work on how I might add some value through my project.

social media networkI knew I wanted to think more about social media and how professionals behave alongside the public in these digital spaces; I am keen that we recognise the potential for social media, as well as the usual rules that we seem to need to establish, in terms of ‘you must do this’ but more usually ‘you must never do this!’.

I want to interview new people who may not usually get heard in the health space, this includes people who use health services but also those outside the sector. It was this in mind that I travelled to Plymouth Plymouth 2to see Steve Wheeler (@timbuckteeth). I have known about Steve for a while and follow his blog, which almost always makes me think. It was a real privilege to meet him – to put it into context his blogs get massive numbers of reads and comments and his following on Twitter is almost 20,000.

This is how Steve describes himself on Twitter:

‘Web 2.0 researcher, author of The Digital Classroom, Associate Professor of learning technology, Associate Professor of learning technology in the Faculty of Health, Education and Society, at Plymouth Universityinternational speaker, disruptive activist.’

Steve, amongst his many research interests, is interested in Web 2.0 social technology. Steve’s blog is called ‘Learning with e’s’.

I had a long chat to Steve about my scholarship and what I was interested in. Essentially I am interested in trying to help health professionals make the most of the opportunities that social media presents, not just for professional development but also to work with patients and citizens.

Steve has some interesting views about social media and how we interact with it. He is generous and knowledgeable. I made the mistake of asking him how he would tackle the questions I was asking and he came back as quick as a flash – ‘make a video documentary’ – he says. I paused for about 20 seconds and said ‘I’m going to do that’.

Steve Wheeler 1

So here we are. I have no video equipment and no experience of audio-visual ‘stuff’ but there is nothing I like more, than a challenge. It made me reflect on myself as a person and why I always end up with the strangest jobs and doing the things everyone says won’t work, or are too hard – I like it that way 

So I will be going back to Plymouth at some point to video Steve and to put down on record my exploration of social media for my scholarship – putting the output on YouTube seems fitting somehow.

My very great thanks to Steve, Pam (@pam007Nelmes) who arranged the meetings for me and the delightful Ray, Professor of Informatics also at Plymouth (@rjonesplymouth) for his insights and looking after me

If you want to try a taster of Steve’s blogs try this one on digital tribes – I promise it will make you think too.

PS – There is still time to apply for a Scholarship – look here and why not have a go – its a fantastic opportunity!