Health and social care organisations in Greater Manchester have established the GM Care Record (GMCR), a shared care record which amalgamates essential information for 2.8 million citizens and is used by health and social care professionals for direct care across the region’s 10 localities.

Introduction

 

The GMCR was a massive programme delivered at speed, which is now playing a crucial role in the region’s fight against Covid-19. It is a partnership between the GM Health and Social Care Partnership, the 10 GM localities, Health Innovation Manchester and technology provider - Graphnet Health.

This shared care record is seen as a priority in the regional provision of care. The number of unique monthly users grew over 100% between April 2020 and December 2020, with more than 4,000 patient records being accessed each day. Graphnet’s CareCentric shared care record software collates information from and provides information to over 500 health and social care organisations. 

Data held in the shared care record includes:

• appointments and visits
• assessment and test information
• care packages
• critical clinical support requirements such as allergies, medications and alerts

Guy Lucchi, digital innovation director, Health Innovation Manchester Greater Manchester Health and Social Care Partnership on the GMCR:

Frontline staff love it, the system loves it, and the patient needs it.

The Greater Manchester record sharing programme was started in response to a national drive to record a citizen’s care consistently.  It makes the information available across local areas to support joined up and safer care on a day-to-day basis. 

Pre-GMCR, localities had made considerable progress in creating shared care records locally (e.g. Manchester Care Record, Stockport Integrated Digital Care Record and Salford Integrated Record). However, information was not always available from all settings, leaving practitioners and carers relying on phone, fax and paper-based systems.  Where it was available digitally, it was confined to locality boundaries and did not reflect the movement of patients around the region. Targets were set to improve information sharing but they varied and a mandate to change in favour of a more coordinated strategy was initiated.

A ‘war room’-style programme was established in March 2020 to support the region’s Covid-19 response.  The programme was tasked with accelerating the deployment of a single information sharing platform, to fast-track consolidation of citizens’ records into the GMCR. Greater Manchester’s ramped up effort was responsible for rapid deployment progress being made in weeks rather than months.

 

CareCentric works by connecting multiple core systems from diverse vendors and sharing information between them. 

It delivers a detailed, local shared patient record that pulls together health and social care information - providing a unified view of an individual’s whole needs. Available to authorised professionals where they need it, at the point of care, it is used to improve care provision and decision-making.

The GMCR is available in primary care, secondary care, mental health and community trusts, out-of-hours, specialist trusts (including the Christie), social care and ambulance services across the region.

 

 

Information shared includes:

• Full set of GP data, including medications, problems, allergies, family history, vital signs, immunisations, referrals, social history, results, allergies and alerts
• Access to documents and reports, laboratory and radiology results, clinical notes, coded diagnoses and procedures, and advanced clinical data including care plans and care pathways
• Social care data, including involved professionals, support plan, safeguarding, recent and current care record, relationships and episodes
• Mental health records including involved professionals, care plans, appointments, statements, MHA status, notes, risk scores
• Community data including alerts, immunisations, care plans, interventions, diagnosis and medications

In addition, CareCentric has been used to create service plans for people with long-term conditions or complex needs.  Service users consent to having a plan, which includes information about managing their needs based on what their ‘normal’ health condition looks like, crisis plans, informal care and next-of- kin details, combined with existing information held in the shared care record.  This is available immediately to authorised professionals, regardless of location.   

The shared care record software is embedded in host systems, so users can access the solution from their local application of choice, in patient context, with single sign-on.

New functions to support the coronavirus pandemic include a Covid-19 status summary tile for each citizen’s record, remote monitoring and population health tools to support the selection and enrolment of specific groups of patients onto new care pathways. For example, pulse oximetry monitoring for people with Covid-19 and blood pressure monitoring for pregnant women at risk of pre-eclampsia.

 

The Greater Manchester Care Record is seen as a key enabler for integrating health and social care services and as a blueprint for involving patients in shaping their own care pathways.   Having the full patient background brings a raft of benefits in the provision of co-ordinated, timely, well-informed and efficient care. 

Staff in all settings spend less time using phones, faxes and pagers to find out information about the people in their care.  Which means that they have more time released to care. 

The feedback from staff provides clear evidence of the improvements made possible by integrating care.

“It has had a huge impact. For example, now I can see the GP records for a patient who lives in Wigan, which was impossible before. As a consultant in a big tertiary centre, it makes a huge difference. Most patients wouldn’t think that would be such a transformative thing, but it is.

Clinical decision making is simpler as we now have up-to-date information on test results, care plans, medications and social care support.”

Binita Kane, Consultant Respiratory Physician, Manchester University Foundation Trust

 

“One person I support had been waiting for an outpatient’s appointment but had not had a letter. On checking the GMCR, the appointment was detailed with date and time. I was able to contact the department to confirm, and then let my gentleman know the details. He never had a letter so would have missed the appointment otherwise.”

Social worker, user of the GMCR

 

Everyday there are thousands of examples of improved patient experiences arising from the sharing of information. 

• Patients do not need to repeat medical history or social care information every time they encounter a new member of staff, service or organisation. For vulnerable citizens who may not be able to articulate their specific needs, this is pivotal. 
• An individual’s treatment can progress quicker without delays caused by a lack of information. For example, repeat assessments and tests can be avoided because clinicians can see more information about a person’s condition.
• If a citizen is in hospital, knowing the support they have in place normally, along with contact details for those involved in their care and care plans will help professionals to get the individual home quicker.
• Out-of-hours clinicians will know which other services are involved in the individual’s care and are in a better position to provide support that is more customised to their specific needs.
• Community staff can start planning support services as soon as someone is admitted to hospital, so discharge can be smoother and more rapid.

The GM programme is now embarking on a public engagement exercise, working in collaboration with the University of Manchester, to understand and develop patient benefits.

 

There are benefits peculiar to the densely populated and highly mobile Greater Manchester region.  For example, Tameside residents with a suspected stroke will be taken to the specialist stroke centre at Stepping Hill Hospital.  Stroke clinicians can look up that person’s medical history on the spot, check their medications and move immediately to provide safe, swift and specialist treatment that can make a huge difference to stroke recovery.

Likewise, practitioners will have the information they need at their fingertips if a resident is referred to a specialist hospital such as the Christie, regardless of whether they live in Bolton, Oldham or Trafford.    

 

The shared care record is expected to lead to significant efficiency and financial savings. A benefits programme has been established to study and develop them further.

 

Early usage analysis in Manchester city, where care plans are co-ordinating care for 6,000 people with complex needs, shows an 8% reduction in overall hospital activity (9% in costs) for patients with integrated care plans. A&E attendances and emergency admissions are down 19% and 15%, with financial savings of 17% and 8% respectively.

The early benefit findings are being independently validated by the University of Manchester. 

 

The integrated record is providing frontline professionals with vital information in the fight against Covid-19, including whether a patient has been tested or diagnosed with Covid-19 and whether they are self-isolating at home or have been hospitalised. 

 

“Using Graphnet (the GMCR) this morning, I have managed to find out that a patient we were going to see today has suspected COVID, so we have cancelled the face-to-face contact and will communicate by phone. This is good news as reduces risk to staff.”

Consultant Psychiatrist & Associate Medical Director, Manchester & Citywide Services Network

“The record has been particularly useful during the pandemic in the Out of Hours setting, where more consultations have been done over the phone and patients and the doctors have more confidence in safe remote management because of the availability of shared clinical information.”

Dr Dharmesh Mistry, Clinical Director of the Chorley Road Network, GP at Heaton Medical Centre and BARDOC Out of Hours GP

 

 

 

In response to NHS England’s national Covid Oximetry @home and virtual ward models, Greater Manchester and Graphnet have worked together to rapidly develop a Covid Oximetry @Home platform for patients on the programme, which has been rolled out to localities.  The new platform allows clinicians to remotely monitor patients and detect the early signs of deterioration in patients with confirmed or suspected Covid-19 and support early discharge from hospital.

The CareCentric platform records the health status, including pulse oximeter readings for patients being supported on the virtual wards, and includes an app where patients can input their oximetry readings directly into their electronic record. This is monitored and reviewed by the clinical team on a secure internet connection. Clinical teams can also send tailored advice to patients using the app. 

 

Greater Manchester has adopted Graphnet’s inbuilt business intelligence platform as part of its Covid-19 response and is informing recovery plans for non-Covid-19 services.

The population health tool is helping Greater Manchester to proactively target and enrol Covid-positive patients on its Covid Oximetry @Home programme.  The tool provides a candidate dashboard to display members of the population who have had a positive Covid-19 test in the last 14 days, who may benefit from being enrolled on the oximetry @home programme.  Clinicians also have access to a virtual ward caseload dashboard to view and monitor all patients on their virtual ward.

“As well as informing direct care, the GM Care Record will help the NHS to understand more about how Covid-19 is affecting the health and wellbeing of local communities and what services need to be in place, as well as informing the world leading research being conducted by our four GM universities.”

Dr Kiran Patel, Bury GP and Chair of the secondary uses oversight and scrutiny group

 

 

Greater Manchester is extending CareCentric’s remote monitoring and virtual ward feature to support high-risk pregnancies and keep pregnant women out of hospital, wherever possible, to minimise the risk of virus transmission during the Covid-19 outbreak. 

The MyMaternityCare app, developed by Graphnet, allows for remote blood pressure and glucose monitoring.  Women on the programme can take their own readings at home and input into the app that sends the information to their midwives who can monitor the results and escalate for additional treatment if necessary.

 

Graphnet is supporting Greater Manchester in their move away from the traditional paper care plans to a digital solution which aims to support the reduction of premature mortality from cardiovascular disease.

The main areas of focus for this initiative includes: prevention and early detection, diagnosis, understanding symptomology, post diagnosis and management, and support services i.e. rehabilitation. The heart failure care plans and app allow clinicians and patients to record details of their care, and for it to be shared with other practitioners across the Greater Manchester region that are involved in an individual’s care.

 

For more information on the GM Care Record visit https://gmwearebettertogether.com/

To learn how Graphnet Health’s integrated care solutions could help support your community, contact us.