NHS England have recently released the “Safer Hospitals – Safer Wards” initiative which aims to outline the strategy for Trusts to move finally to greater Integrated Digital Care Records with a target date of 2018. Also mandated is the use of the NHS number on all patient records.
The National Programme has delivered some great advances for the NHS. For example, Choose and Book, the greater move to digitisation in primary care, the use of e-Prescribing,(though uptake has not been as expected), PACS, GP-GP records transfer and the use of N3 for the whole NHS and partner organisations. However the programme has not been without its challenges.
Lack of standardisation
A true integrated digital care record across all care boundaries has remained elusive and secondary care is still, in the main, a paper led beast. That is not to say there have not been some great innovations in the area, but overall it does lag behind the primary care sector. This new initiative, which has central funding available to the tune of £260m, will seek to redress this imbalance and put the UK in the driving seat of electronic patient records.
In the UK, we have a number of clinical systems suppliers who have all developed systems to provide electronic management – be that from the simple “PAS-style” patient information and diary management, to more complete EPR solutions where all clinical information is stored electronically, including certain workflows and other enhancements.
However, this array of providers leads to a very mixed picture across the NHS and has resulted in a situation where sharing of electronic records has been held back by lack of standardisation and in turn reduced the uptake of systems, due in part to confusion over best practice and successful implementations.
One local NHS Trust may have a full blown EPR and see clinicians using less paper and more electronic records, but fifteen minutes “up the road” another Trust may still be a running on a basic PAS with a number of non integrated healthcare systems which do not share information well, and the clinicians can only rely on paper records in the main.
This new initiative is the chance for Trusts to change this and become truly paper-light. Trusts may now work closely with various partners to be able to gain access to funding, and to standardise their approach and technologies. Trusts should be seeking to build solutions with a ‘selected’ number of suppliers, to gain the best of breed for what they require, to truly integrate their care records.
Legacy systems and increased storage needs
Systems suppliers will need to have the correct infrastructure on which to run these solutions, and storage and networking ability will be key to this. Infrastructure which is old and may cause bottlenecks in the system, which in turn, may quickly cause any software solution to fail.
A lack of forward planning for the increased needs of enterprise level storage and archiving, generated by new system adoption, can lead to a reduced benefits realisation, and may cause clinicians to revert to paper records as information becomes difficult to manage/store/recover, and the take up of a new technical solution will be curtailed.
Looking at the issue of aged infrastructure in more detail, it is recognised that there has been a lack of investment in Trust ICT for the past several years. Many ICT departments have had to survive on limited budgets which have enabled them to “keep the lights on” (just, in some cases) but have not allowed them to benefit from advances in technology, or even to keep up with standard technology change.
The training aspect to such large scale implementation and change programme is vital to successful integration and adoption. Trusts need to ensure ‘buy in’ by ensuring that their staff are correctly trained in any new electronic system or the benefits are often lost, or even worse, the systems negatively impact the clinical process having an overall detrimental effect on patient care.
Truly Integrated Digital Care Records are good for the patient. Diagnosis and treatment times will be reduce whilst patient safety will be improved. End result, better health outcomes and a greater level of patient satisfaction.
The launch of this initiative may well fill some ICT departments with sense of trepidation, due to the scale of the challenge, but it is great opportunity to deliver the benefits clinicians have been requesting for years and to achieve the main business goal, to provide safe and successful care for patients.
This is Definitely an Opportunity to Shine!
Recently Jeremy Hunt – the Health Secretary – has stated that the NHS will become paperless by 2018 to “save billions”. But this is not a new project. Before the National Programme for IT (NPfIT) and Connecting for Health (CfH) were even a twinkle in a Health Secretary’s eye, the Information for Health (IfH) agenda clearly outlined the need for a paperless NHS (initially released in September 1998).
In fact, successive Health Secretaries, and other NHS leaders, have often suggested dates by when the NHS must become paperless, and yet in 2013, we still have a mainly paper led system. Granted, there have been great developments in this – for example, most GPs work in a paper-light fashion, and referrals, results etc. are all moving to a more paperless system. However, paper – and other hard copy records (e.g. X-rays) – still exists in the NHS.
Most of the changes that have come about in the field have not happened due to some mandated requirement. Instead, they are often brought in by clinical and business leaders to solve real business and clinical issues. Paperless solutions can lead to a reduction in treatment/medication errors, quicker time to diagnosis, shorter time to treatment, more collaborative diagnostics (allowing a wider range of specialists to be involved) and overall better patient care.
From a business perspective there are a number of benefits. As well as reducing the time taken in certain business processes (look at how email has transformed the business world) there is greater traceability, more accuracy and an overall change in the behaviours of many organisations for the good. Unfortunately, the Health Secretary fell short of announcing any new funding to assist with the paperless NHS vision. And so, again, organisations will attempt to become paper-light through localised procurement and innovation.
There are many suppliers in the “paperless office” space and organisations need to ensure that they choose the right partner for what they are trying to achieve. The software solution alone is not the only consideration. What are you trying to achieve? Clinical notes digitisation has a number of specific issues which need to be carefully managed if the digitisation process is not going to negatively impact on clinical care.
Considerations as to the security model and the storage requirements will play heavily into the service definition, and it is often better to overestimate the growth of data by a small margin than to underestimate. Many vendors will offer an assessment as part of their overall offering.
Organisations need to be sure that they are looking at how and where the information will be required. Make certain that various clinicians are part of the working group which defines how the information should be used. Too often projects like this can become centred on the technology, when actually technology is just about enabling the change to information flows. Clinical participation is critical to service success.
In line with other public sector organisations, the NHS is required to make savings over the next few years. In total, these savings will amount to approximately £20Bn and are expected not to come from front line services, but rather to be found in rationalisation and efficiency savings across the board.
One way in which Acute Trusts and Mental Health Trusts are seeking to meet this challenge is to undertake Estates Rationalisation Programmes. Many organisations have a number of sites which are extremely expensive to run and are often providing limited services which can be carried out better in the community or linked with other NHS delivery to bring efficiencies.
For example, at some Trusts Community Nurses are based at a site where they have to attend each morning to log in to systems and collect their workload before setting off to see patients. At the end of the day, the clinician is required to return to the site to input the results of each clinical session undertaken, as well as ordering any follow ups required. This seriously impacts on the total time available to clinicians to meet with patients.
Technology can help. By making clinical systems accessible over mobile and wireless technologies in a completely secure and safe manner ensures that the clinician is able to access notes and patient details at the point of care. In the case of areas where mobile and wireless coverage is far from perfect (anything from rural areas to city centre housing estates and high rise blocks for example) systems can be made available in an “offline” mode. In this mode, the clinician still has access to information which is at most 24-48 hours out of date, but still very relevant to the patient.
The ability of these mobile clinicians not to have to come in to a “base” on a daily basis will reduce the amount of wasted time in travelling, and will increase total clinician-patient face time on a daily basis.
But Trusts need to think carefully about how this is achieved. Requirements of the Data Protection Act, the underlying principles of Caldicott and other NHS specific regulations around patient data security cannot be dismissed. The ICO (Information Commissioners Office) has been fining NHS organisations large sums for the loss of data, and so Trusts must ensure that data is fully secured both at rest and in transit.
Solutions will need to ensure that mobile devices (including BYOD devices) are properly secured and can be centrally managed – including full remote locking and remote wipe. In the case of clinical information, there is a requirement that the information is encrypted at all times. Furthermore, IT Directors and CIOs will have to ensure that such solutions are not open to “screen scraping” technologies.
But it is not only the information which needs to be secure. We also need to secure our staff. Clinicians are already vulnerable when out working in the community. Some are seen as targets for FP10 forms (prescriptions) or for possible drugs they may be carrying. Others invite attack simply for being a clinician. Equipping these staff with expensive mobile devices may increase the risk of muggings etc.
To prevent this, Trusts must employ strong lone worker solutions. A number of these are available ranging from solutions which are manual – based on mobile phone usage – to technically adept solutions which track locations (GPS) and have two way radio built into them which can be operated without patients/citizens being made aware. This then allows an emergency call centre to listen in to the situation and summon the appropriate assistance. The small costs of such systems and the decreasing costs of mobile solutions is quickly saved in the ability of organisations to reduce their estates footprint and to treat more patients in a shorter time.
But a word of warning. It is easy for CIOs and IT Directors to over-promise ROIs and perceived benefits of such systems. Any such implementation should be done in a phased approach allowing impact on services and savings to be correctly measured and monitored before a whole systems roll out. There are issues around ICT training, availability of hardware and solutions, security and even clinical adoption which need to be carefully ironed out before any programme is initiated. And one of the major reasons for failure of IT Programmes in the NHS? Clinician Engagement – the Trust must ensure that key clinicians who represent their areas are involved in the design and build of any mobile solution.
As an IT person, I can design a technical solution which will best meet the technical need – I cannot design a solution to be used in clinical areas without clinical input. I will only look at the technology, I need the clinicians to tell me how they work to ensure that workflows are logical to the use cases. Running a Proof of Concept with a partner of choice who is technology and vendor agnostic will allow Trusts to mix and match all solutions available to find the best approach for their specific clinical and business needs. Not all mobility solutions are the same, and not all security solutions are designed with the mobile workforce in mind. Overall, Trusts need to ensure that they select the right partner who is able to work closely with them to assist them in achieving their goals.