Februaury 2009

Map of Medicine : Mike Stein, Chief Medical Office, Map of Medicine,United Kingdom

The Map of Medicine is a bold step towards the creation of a benchmark of clinical processes so that everyone involved in the management of patients, including patients themselves, can be on the same page. A Map of Medicine has become urgent as the explosion in information and technology available to treat and/or inadvertently harm the patient means that healthcare professionals are working in ever-deepening silos of care; we now expect our orthopaedic surgeon to just “do knees”. A visual benchmark or “SatNav” that covers over 80% of patient journeys is both feasible (The Map of Medicine has made a good start) and necessary to support generalists provide overarching care for their patients.

The challenge to the generalist is the ever-increasing array of healthcare technologies. Individuals cannot possibly stay up to date across all areas of healthcare, yet general practitioners (GPs) and hospital-based consultants on post-intake ward rounds (generalists) are expected to help patients to make informed decisions across a wide range of conditions. In addition, shift working has created many more handover points in a patient’s ever more complex healthcare journey. Few would argue with the need for a professional map of care processes – one that describes the ideal patient journey across all the silos of care, and makes specialist evidence-based healthcare information more accessible to generalists.

However, the task of creating such a map is complex, requiring the distillation of a very large amount of healthcare literature (over 1000 clinical research articles are published every day), which must then be put into context. This distillation requires a resource intensive multidisciplinary team approach including specialists, generalists, specialist nurses and allied healthcare professionals. In addition, there are often conflicts of professional opinion both within and across specialities and any map must be able to accommodate such conflicts in a transparent manner so as not to stifle innovation, nor to promote cook-book medicine. This demands the creation of a tool that is clinically intuitive and can mediate a meaningful dialogue among healthcare professionals about what are (and what are not) acceptable standards of care. A dynamic or “living” map that can continually change and evolve.

The “Map”

The Map of Medicine (the “Map”) is a dynamic web-based clinical knowledge resource allowing the creation and communication of evidence based clinical pathways. Each of the 396 topics in the Map is published as a “first draft” where new evidence-based information can be embedded within the context of the patient journey every 3 months, creating an ever-evolving synthesis of expert opinion-based best-practice and evidence. There is a long way to go; but the first 300 topics cover 80% of a GPs typical week.

Formally starting life in 2001 as a project within University College London in partnership with a large teaching hospital (Royal Free Hampstead NHS Trust), the Map has been entirely clinician-led, and was originally developed to support the re-design of healthcare processes; with a visual interface to mediate a productive dialogue across the care settings and potential silos of care. For example, one of the first uses of the Map was to assist community-based doctors prepare patients in advance of a specialist referral so that specific diagnostic blood or urine tests could be done with the results available in advance of the patient appointment at the hospital. Too often patients would arrive for an appointment only to be brought back following some basic tests that could have been arranged in advance by the GP clinic.

First coming to the attention of national organisations such as the NHS Institute for Innovation and Improvement in 2005, the Map was deployed across 14 NHS Trusts in 2007. Taking little steps and incorporating lessons learnt from each implementation, the Map is now active in 35 “early adopter” local healthcare communities, each comprised of 150,000-600,000 patients. Adoption is driven by the capability to make changes according to local priorities. Indeed, locally specific information allows the merging of local policies and protocols with the power of the international evidence base within the Map to create a flexible national, but locally controlled clinical knowledge framework for the healthcare system.
The Map of Medicine (reference version) is also available license-free to individuals across the NHS England and Wales,  and is named as one of the genuine success stories within the National Programme for IT.  Full organisational deployment is scheduled to be completed in 2009/10 and will cover over 10,000 GP clinics that refer patients into over 2000 hospitals within the NHS England and Wales.

Support from the clinical community

Crucial to the success of the Map has been the support of the clinical community; agreements are now in place with the Royal Colleges of Physicians, the Royal College of General Practitioners, the Royal College of Obstetrics and Gynaecology, and the Royal College of Emergency Medicine with stakeholders within the surgical community expected to come on board in the very near future. Each Surgical Association is asked to provide recommendations for subject experts to undertake peer review of the Maps that are drafted by Map Fellows (up and coming Registrars) supported by a large team of publishing experts using state-of-the-art and web-based information technologies. All topics are peer reviewed and clearly notated as to whether the content has received formal NHS accreditation or not, with the vast majority of topics (over 95%) being accredited.

As a result of its emerging national success and the requirement for major financial and technological investment as well as content expansion to support product development, the Map was acquired by Hearst Corporation in May 2008 remaining a UK company but with the backing of a robust and independent global player. As a consequence of Hearst’s backing, contracts are already in place with the government of Queensland (Australia) with national procurements in process in further nations.

Furthermore, Hearst Corporation is supporting license-free access to healthcare information for the Global South, specifically the World Health Organisation’s (WHO) Sharing eHealth Intellectual Property for Development (SHIPD) initiative. SHIPD was established to strengthen health systems through the adaptation and deployment of shared intellectual property, by partnering organisations willing to provide free access to selected e-health products and services to developing countries. The Map of Medicine was the first product chosen by SHIPD to be provided to six African countries: Nigeria, Tanzania, Uganda, Zambia, Cameroon and Kenya. Following successful pilots, the Map will be deployed license-free across all eligible countries in Africa commencing in 2009. Interested governments can contact the Map of Medicine (see below) for further information.

Current uses of the Map within the UK

The Map is currently being used to support priority projects of the National Health Services (NHS) of both England and Wales, such as healthcare planning (commissioning), cancer management and the diagnosis to treatment programme (also known as the 18-week wait programme). In addition, its visual user interface is proving very popular with trainees and discussions are underway to explore how the Map can be used to support ridation and re-accreditation of doctors in the UK. In the interim, many GP Trainers and Postgraduate Deans are using the Map to support continuing professional development, while both doctors and nurses are promoting its use for multidisciplinary team working at and around the point of care.

Case studies on pathway re-design and commissioning:

The future – getting evidence into practice everywhere – The Map team is passionate about making access to the high quality and validated information within the Map available to all clinicians and indeed, patients whenever and wherever they need. The Map can be loaded onto Windows Mobile compatible devices such as PDAs and related devices. In addition, work over the past two years with Cisco Systems means that the underlying technical platform links directly to all telecommunications platforms with final testing of the “Expert Network” software application due for completion within 2008 and pilots under way early in 2009.

Accessing the Map

Go to www.mapofmedicine.com to learn more about the Map. Please note that individual access is only available to doctors and nurses resident in England and Wales; proof of residence is required. If your organisation would like to request licensed access to the Map of Medicine, please email aneta.lasyk@mapofmedicine.com quoting “Map Asia”. For organisations within the WHO HINARI or SHIPD programmes, please email as above quoting “Map SHIPD programme”.

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