Southend Hospital and South Essex PCT have been developing an integrated COPD service for over a decade. Information sharing between providers remained a barrier to improved services. SystmOne is a medical management system used by 70% of practises in our area and utilised by community services. We decided to develop a COPD system for primary, secondary and community care using SystmOne.

Development A business case was developed and agreed by the IT strategy groups of the PCT, hospital trust and community trust. A project manager was appointed who worked with clinical leads from the hospital and PCT. The clinicians who would utilise the system including hospital consultants, respiratory nurse specialists, GPs, community matrons, community oxygen team and early supported discharge team all contributed to the design of the template. The system records demographic information, respiratory and smoking history, pertinent respiratory investigations such as spirometry and blood gases as well as whether the patient has been referred for pulmonary rehabilitation, smoking cessation or has a self management plan. At each clinical consultation symptoms and management changes are recorded. Tasks can be sent between members of the team for example allowing community matrons to send queries to hospital consultants.

Implementation All GPs agreed to participate in the scheme. Patients were required to sign a form consenting to sharing of clinical information. The project manager undertook training of all the clinical groups involved as well as hospital secretarial and clinic staff. Community staff were provided with laptops enabling remote access. After a training period of 5 months the system went live in March 2011. We now have 1522 patients registered on the system. 13 patients refused consent to the sharing of information.

Benefits The system has allowed improved communication between members of the team. The template has served as a management checklist ensuring that important components of COPD care are not forgotten. The system has been used to identify patients with very severe disease for discussion at a severe disease MDT and been associated with a 5% reduction in outpatient attendances.