Opportunities and Challenges of SUS

Roger Dewhurst

Director of Operations, Information Centre for health and social care

What are “secondary” uses ?

A considerable amount of information is collected during the provision of care and supporting services

The primary purpose of this information is to support and improve individual patient care

However, this information is of value for many other purposes to support healthcare and providing appropriate steps are taken to meet confidentiality obligations, this information can legitimately be used to support these other purposes. These are called “secondary uses”

[amended from CRDB Secondary Uses Report, August 2007]

Identifiable Pseudonymised or Anonymised

•Individual records•Selected “lists” of records

•Immediate access•Dynamic, up to date

•Workflow, rules based alerts

• Frequent abstracts•Focus on classes

of persons •Time series

•Short time intervals•Prospective indicators

•Focus on classesof persons

•Actual compared withexpected

(inputs, outcomes)• Ongoing

• Indicators

•Focus on classes or cohortsof persons

• Disease, Service and population

based • Forecasting

•Periodic

OperationalDirect Care

Commissioning Analysis / Service Planning

BusinessOperations

Strategic /Policy / Research

Examples of characteristics of requirements

Primary and SecondaryUses

Objectives of SUS

Improve access to data to support the business requirements of the NHS and its stakeholders

Provide a range of software tools and functionality which enable users to analyse report and present this data

Be the single, authoritative and comprehensive source of high quality data to

enable linkage of data across all care settings

ensure the consistent derivation of data items and construction of indicators for analysis

improve the timeliness of data for analysis purposes

Provide a secure environment which enables patient confidentiality to be maintained according to national standards

What is SUS?

A single repository of person and care event level data relating to the NHS care of patients. Data is submitted by all organisations providing NHS care

At present SUS receives data submissions (CDS) relating to: Accident and emergency attendances Outpatient attendances Admitted patient care, including maternity care Elective admission waiting lists Mental health care “spells”

In 2007/8 SUS will also receive data from Choose and Book and the Patient Demographics Service, as well as new CDS relating to future appointments and diagnostic events

In future SUS may receive data relating to patients’ prescriptions and may have the capability of managing data relating to the primary and social care provided to patients and service users.

SUS comprises: A common and consistent information

governance model Access control Use of pseudonyms to replace identifiers Design (e.g. small number suppression etc.)

A core data warehouse and data marts Consistent metadata and reference data Associated applications utilising data from

the core warehouse Consistent analysis and reporting tools

What is SUS?

Current SUS Components

Security and confidentiality ensured by consistent access control and design

La

nd

ing S

tag

ing

Universal DataWarehouse

PBRNHS CDSExtract

A Core Warehouse and Data Marts

NHSComparators

HES

ClinicalAudit

Consistent metadata – business and technical

OtherExtract

Extracts and Reports to all PCTs, Trusts, SHAs

Data submitted byall providers ofNHS “acute” andMental Health Care

Extracts for Non NHSorganisations

Web basedapplication forPractices, PCTs, SHAs

HES reports andextracts

What has been achieved?

First release in 2005, with core NWCS and PbR functionality but suffered from: Poor performance Difficulties with interchange catch-up

SUS “get well” programme of work PbR 06/07 delivered in March 2006 Decommissioning of NWCS required focus on Release 2006-

B-1 in November 2006 Further defects and issues some of which still need to be

addressed BUT … SUS is still dependent on NHS organisations for

timeliness and quality of data

Release 1 for PBR 07/08 and data for PBC comparators (April 2007) – completed

Release 2 giving non-functional upgrade to Oracle 10g and uplift for more users – completed

Release 3L providing “landing” capability for cds v6, plus loads from PDS and Choose and Book (CAB)– December 07

Release 3R providing processing and reporting for 18 weeks and further reporting for CAB and PDS, includes changes necessary for PbR 2008/9 – April 08

SUS Releases in 2007/8

NHS Comparator releases (April and September) – completed

Early reporting of comparative referral to treatment waiting times and elective pathways – early January

Additional comparators and presentation of practice level data, with particular emphasis on support for practice based commissioning resource allocation and budget setting – end January

Extended range of comparators and refresh underlying data, including dispensed prescriptions (Detailed content to be agreed with DH and NHS users) – end March

Data quality dashboard - initial release December, subsequent releases during January –March, sponsored by the DH 18 week team

SUS Releases in 2007/8

20092007Jan JunJulMarDec AprFebDec Mar SepOct OctAug

1

IDAugNov JulSepMayFeb MayJanNov

SUS Release 3L

SUS Release 3R

CDS Version 6

CAB reporting

Splits/Mergers (ex R3L)

PbR algorithm for 08/09

PDS/CDS (ex R3L)

NSTS reporting PDS reporting PDS daily update

CAB landing

Static 18W reports

Ad Hoc Pseudonym’n

Cohort Management

CHRIS Functionality

2008JunApr

PBC Comparators

Pilot 18W reporting

Clinical Audit

PDS daily update

R4 NFRs

BO Infrastructure

PDS 2008BDQ reporting

R3R NFRs

R3L NFRs

18W aggregate reports

SUS October Patch

Specialised commissioning

SUS Release 4

R4 Scope and timing to be confirmed

CDS Authentication

P1 P2

4

Live BO 18W reports

18W drill down reports

18W DQ Reports

18W Linkage Algorithm

18W upgrades

MHMDS – schema and extracts

CAB version update

PDS daily update upgrade

R5 Scope and timing to be confirmed

PbR HRG 4

ETP transactions

Cancer waiting times

NHAIS functionality

Access to WEIS

PSIS DU and reporting

Birth notification data

Mortality data

Primary care

Renal registry audit

ADS

R&D data

Improved DR

Core warehouse updates

SUS Release 5

SUS Opportunities

Opportunities

A single secure data management environment provides an opportunity to reduce “transaction costs” of implementing systems reforms through: Enabling access to data Deriving essential data items

consistently and once Undertaking standard processing

Opportunities

A single secure data management environment provides the ability to construct consistent comparators and indicators

A framework for developing indicators for an “NHS Scorecard”

“Population”Needs

IdentifiedPopulation

Needs

Expressed demand

forservices

ServiceInputs

ServiceOutputs

“Population”Outcomes

Indicators relate to / cover:

Indicators are constructed for:

Populations or groupsof patients

Commissioners

Providers

Efficiency / ProductivityIndicators

Services

Health Status Indicators DemandIndicators

Effectiveness Indicators

Quality Indicators

Service Activities

Data to construct indicators

Population based surveys, whichare required to•establish unidentified need•calibrate local measures of identified need

“Population”Needs

IdentifiedPopulation

Needs

Expressed demand

forservices

ServiceInputs

ServiceOutputs

“Population”Outcomes

Efficiency / ProductivityIndicators

Health Status Indicators DemandIndicators

Effectiveness Indicators

Quality Indicators

Local and national “disease / disabilityRegisters” (within GP ClinicalSystems (QOF) etc., Cancer Registries)provide identified prevalence

Service Activities

Operational data• person and activity specific (e.g. CDS)•aggregated returns.

Operational data• included or implied in activity specific (CDS)• Employee data from ESR• Financial returns and accounts

Operational data• person and activity specific (e.g. CDS)•aggregated returns.• dispensed prescriptions

Population and target groupbased surveys, including Patient experienceTemporal analysis of outputs• subsequent revisions etc.

How SUS might support indicator construction and presentation

SUS functionality in 2008/9 to supportCohort Management and PDS based linkage• could enable “longitudinal” association of operational data with survey population (s)• PDS copy may allow construction of prevalence models as well as linkage

“Population”Needs

IdentifiedPopulation

Needs

Expressed demand

forservices

ServiceInputs

ServiceOutputs

“Population”Outcomes

Efficiency / ProductivityIndicators

Health Status Indicators DemandIndicators

Effectiveness Indicators

Quality Indicators

NHS Comparators• uses data on identified need from QOF in construction of indicators• Future releases will compare identified prevalence and predicted prevalence from population survey information

Service Activities

SUS warehouse includes• operational data on activities and expressed demand (e.g. CDS)NHS Comparators• enables comparisons of demand indicators and quality indicators covering variation in •access to services

Original SUS vision and NASP contract scope includes workforce data as well as (costed) activity data • could enable construction and comparative analysis of efficiency or productivity indicatorsSUS 2008/9 releases• provide for capture and management of prescriptions issued

SUS warehouse includes• operational data on outputs and their value /costNHS Comparators• includes indicators of quality of service, based on linkage of outputs

SUS functionality in 2008/9 • could enable “longitudinal” association of operational data with survey population (s)

SUS Challenges

Challenges

Ensuring that the data currently submitted to and managed within SUS is: Comprehensive Timely (for different uses) Consistent with agreed standards Accurate

Immediate Data Quality Challenges

Improving the coverage of data Missing data Creation of duplicate records

Improving the content of individual records Linkage of data Correct access to and exchange of data Correct financial payments Correct comparators and indicators Reduction in the unnecessary use of identifiable data

Addressing Data Quality Challenges

IC / CfH Ensure improved functionality in SUS

Tracker eDQRS Data Deletions

Publish guidance and provide support Publish data on quality and enable comparison

DH / SHAs Performance manage organisations to improve quality

Regulators and Auditors Audit and review data quality

Commissioners Secure improvements through contract processes

Care Providers Implement quality assurance programmes

Immediate local implementation challenges

Achieving the migration to XML submissions

Improving the timeliness of data submissions Migrating from the use of bulk

protocols for data submission

Context for moretimely submissions

Timely data to support achievement of 18 weeks target for referral to treatment Linkage of activity into elective care

pathways Multiple providers within pathways

Prospective analysis and reporting

Ensure at least monthly submission of comprehensively coded CDS to support PbR Mandate of SUS as authoritative source of

information for payments

Context

Operating framework for 2008/9 Submission of finished activity within 5

working days of activity “finish” date X % by July 2008 Y % by January 2009

Submission of completed (fully coded) data within 22 days of the activity “finish” date from April 2008

Current Situation

0

10

20

30

40

50

60

70

Number of Trusts

North East North West Yorkshire East Mid West Mid East London South East SouthCentral

South West

SHA

Current CDS Submission Protocols

Bulk & Net

Net

Bulk

Interchange submissions

Interchanges received

0

500

1000

1500

2000

2500

3000

3500

4000

Sep-05

Oct-05

Nov-05

Dec-05

Jan-06

Feb-06

Mar-06

Apr-06

May-06

Jun-06

Jul-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07

Aug-07

Sep-07

Oct-07

Net

Bulk

Interchange rejection rates

% Interchanges Rejected

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

Sep-05

Oct-05

Nov-05

Dec-05

Jan-06

Feb-06

Mar-06

Apr-06

May-06

Jun-06

Jul-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07

Aug-07

Sep-07

Oct-07

Total % failed

Net fail

Bulk fail

Benefits

Reduces processing time and complexity 90% of records replaced in bulk

updates are unchanged Quicker access to data Improved linkage

Reduces interchange rejection rates

Reduces the risks of duplicate records

Challenges

Supporting NHS analysis requirements, while ensuring the security and confidentiality of identifiable data: Meeting the Government’s commitment to

minimise the use of such data for non-direct care purposes

Information Governance

Governance - develop & manage consistent, cohesive policies, processes and decision rights

NHS IG - ways & means of handling patient information in legal, secure, efficient & effective manner

Balance - sharing information and privacy

Impact - Encourage & enable improvements in quality and handling of information

Context

Common law of confidence

Data Protection Act

DH Policy Guidance Confidentiality

Care Record GuaranteeThis guarantee is our commitment that we will use records

about you in ways that respect your rights and promote your health and wellbeing

Care Record Development BoardSecondary Uses Working Group

CRDB Principles forSecondary Uses

1. Default - use of data not linked back to individualsUnidentifiable data (aggregate or anonymise)

Where linkage required - pseudonymise

If patient identifiable, informed consent if feasible

2. Patient right - to determine no identifiable information about them should be used for secondary purposes (legal exceptions)Participation in research - approach through GP or relevant

clinician

CRDB Principles forSecondary Uses

3. Identifiable data is required, if consent not feasible, then formal justification for access is requiredSection 60 H&SC Act 2001 (now S251 Health

Consolidation Act 2006)

PIAG Approval may be granted if: Benefit to patients

Not feasible to gain consent or use anonymous data

4. All users of data for secondary care purposes should be subject to enforceable standards regarding confidentiality and security of data

Use of patient identifiable data

Originating clinician – e.g. GP in their practice

Relevant clinician – e.g. GP in their practice

Section 60/251 approval from PIAG

Role allows – e.g. 18 weeks manager

Patient’s consent – e.g. research

Legal basis – e.g. court orders

Implications

De facto use of pseudonymisation for patient record level data for secondary use

For PCTs - data for commissioning - pseudonymise

For Providers - analysis of performance,etc - pseudonymise

For practices - for practice based commissioning - pseudonymise

Where primary use of secondary use data, then patient identifiable data is OK, depending on user’s rights

CRG Requirements

CRG enables patients to useDissent to Store

Dissent to Share

Sealed and Locked Envelopes

Sealed Envelopes

For secondary uses Dissent to store & Sealed and Locked Envelopes - no data

available

Dissent to share & Sealed Envelopes - data available but not attributable to patient

Current SUS Data Flows

CDS

PbRLand Stage

CDS Activity Warehouse

HES

CommissioningDataset Submissions

Reports and extracts for Commissioners and ProvidersPseudon

HES Reports andExtracts

SHA and nationalPbR extracts

Extracts for non NHS OrganisationsWith PIAG approval

Future SUS Data Flows

18 week

CDS

PbR

SUS PDS Copy

Land Stage

CDS and CAB Activity Warehouse

PseudonCohort Linkage

Geo -Derive

SUS IG Components

HES

CommissioningDataset Submissions

PDS Tracing

Other Data Flowse.g. Clinical Audits

Reports and extracts forSHAs, commissioners andProviders

OtherSystemse.g. Audit

Reports, extractsand analyses fromother systems and HES

Pseudonymised extractsfor non-NHS organisations

CAB

Challenges

Ensuring that the data submitted to and available within SUS in the future meets requirements “redefining the information model” “filling the gaps”

Questions and Answers