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Christine Walters, Ian Brewer, Ian Hazel and Ikenna Emenyonu form our latest ICT Panel of Experts, in which we discuss the interoperability of healthcare systems, the role of the patient in digital transformation and the engagement of clinical staff
Digital transformation has been a ‘buzz’ phrase for the NHS for a number of years, but never has the need for it, nor the opportunity for it, been greater. At the start of 2019, the NHS Long Term Plan detailed plans for improvement across the NHS estate within the next 10 years. The plan is underpinned by and thoroughly dependent on enhancing the current state of digital care and supporting further digital transformation.
This has been stressed by NHSX, created to deliver such a tech vision, who have established five key areas where technology advances will make the hospital experience better for patients and staff: reducing the burden on the NHS workforce; giving people the tools to access information and services directly; ensuring information about people’s health and care can be safely accessed; aiding the improvement of safety across health and care systems; and improving health and care productivity with digital technology.
Much of this can only be achieved if the wider NHS organisation, with their digital expertise, works better and communicates more directly with front-line NHS workers and hospital IT departments, who have firsthand experience, knowledge and visions for improvements that will collaboratively bring about better patient care.
Ikenna Emenyonu, Solutions Specialist Manager at Netcall, summarised the above point very well, when he said that the biggest benefit that front line health care teams bring is their vision for patient care, but often teams can find their ideas for possible solutions only ‘through the boundaries of their technology understanding’. Their role, more importantly, is that they are closer to the patient - physically and emotionally, often daily. As University Hospital Southampton’s Ian Brewer says: ‘It is important to think about what the patient needs from any solution’. A tech-only focus can rob that advantage. It’s important to identify what is relevant and important to the patient, and understand that the answer might be different from what’s available to clinicians.
It is also worth stressing that technology is more adaptable than people, who can tend to be ‘set in their ways’, which makes balancing the needs of the consumer with the ease of use delivered through the digital device more important. Convincing people that what they have always known will be no more, can be difficult. Ian Hazel points to research which has proven that ‘an activated patient’ has better outcomes, whilst his experience has also highlighted that the more involved in their own care a patient is, the better the results.
Integration and interoperability
Our panellists were also tasked with responding to a question on the ways in which teams can plan for the integration and interoperability of systems with different suppliers. The NHS Long Term Plan had a particular focus on people having more control over their own health, but its predecessor, the Personalised Health and Care 2020 Strategy, outlined that interoperability is a ‘fundamental requirement’ to achieve the health service’s 2020 targets. Former National Director for Patients and Information, Tim Kelsey, used one of his last speeches in the role to call for continued efforts to make all parts of the health and care service technologies able to ‘talk’ to each other.
Ian Hazel, CIO at Chesterfield Royal Hospital NHS Foundation Trust, says that, as an industry-wide challenge, hospitals can deliver integration but can’t force interoperability. Most solution providers have a ‘kind of integration’ solution in place, but interoperability is wider than any single local hospital and instead relies upon the engagement of the wider NHS. Ian says that there needs to be a united approach in working with suppliers to create the momentum for all suppliers to accept that interoperability is essential. And, it will work best as a multi-team approach that includes regulators if we want to get interoperability functioning properly.
Ian’s organisation has a policy in place that affirms that no procurement project will be approved before it has been run through IT, replacing the prior method of departments going through supplier procurement and only then considering the interoperability/integration needs.
This sense of engagement is key at St Helens and Knowlsey Teaching Hospitals as well. Christine Walters says that the best way to plan for the integration of systems with different suppliers is establishing engagement at the first opportunity. This part can be heavily technical, so ensure the technical teams speak to each other from the outset, and then back this up with a strong testing strategy. Christine advises other organisations to look for lessons learned from previous similar projects, and then to speak to other organisations who have gone through it – sharing the knowledge is vital.
Whilst interoperability may be something you implement in piecemeal fashion, it is something that needs to be considered holistically. Ikenna Emenyonu recommends that teams consider immediate interconnectivity and the next desired step at the start of any project. They should know in advance what is essential for go live and then the vision for the medium term. This will allow the requirement scope to be effectively planned.
In terms of integration and user views, Ian Brewer states the importance that the user front end is integrated, with users seeing a unified view of the data. Is the same version of the truth available on, or from, every interconnected system? And the most important way of ensuring that this works is to make sure that users are setup for testing early.
Pitching the business case
Ikenna Emenyonu says that, when it comes to pitching a business case, the two areas which have proven most useful are the money and mitigating risks. Firstly, are there any cashable savings that enable immediate payback against the cost of the solution? And, following this, it’s important to help decision-makers to see how a solution is able to mitigate and assist controlling of a risk. The business case then can quantify the impact of that risk.
The former point is also explained well by Ian Brewer, who adds that, in health, it can be very hard to quantify the ROI in monetary terms, as so many of the technology projects are about gains in quality, delivery and efficiencies. This, according to Ian Hazel, is often aided by a change in approach from the simple ‘I want that..’ to the more appropriate ‘I need the following requirements with these desired outputs’.
On the topic of money and mitigating risks, Brewer also highlights the benefits of clearly defining the cost of doing nothing so that everyone clearly understands all scenarios and you can mitigate any risks.
Commonly, these risks can include that there is no available budget to action the best solution, and, whether we like it or not, the health system is often still guided by a monetary element. Ian Hazel points to the example of the ‘Derbyshire pound’ as a way of navigating potential financial shortcomings with a wider aim. The Derbyshire pound’ represents every £1 spent within the local healthcare system. Supporting an integrated care system ICS approach for the county does alter some decision criteria from hospital cashable savings to total quality improvements. Ikenna Emenyonu is in agreement, emphasising the importance of investigating current investment goals and political pressures within the trust at an early stage, as aligning with priority goals and matching the required timing can be positive for any business case.
Implementing digital transformation projects
Speaking from his experiences as Head of Information Technology for UHS Digital, Ian Brewer points out that the scale of projects in large teaching hospitals presents a big challenge. The hospital and the university may have competing priorities, so understanding how to work with a project at scale is a really important aspect in a large hospital environment. This, he believes, is one of the main challenges that he has had to support his transformation teams to face. A suggestion is to purposefully build a group of people around the team who can dedicate time to the project work streams, otherwise day-to-day business will take over and deadlines will be missed.
Brewer also highlights how the need for change management is all too frequently underestimated. Firstly, in the NHS, change is to be avoided during winter pressures, and that period seems to grow ever longer each year, perhaps more so in this unprecedented of years, meaning that time windows for major change are limited. Additionally, while technical challenges may seem the biggest obstacle, creative people always tend to find a solution. This is not so easy to accomplish with people for whom change can be too big an obstacle to face.
Ian Hazel agrees, stating that change management and cultural change are key when implementing transformation within the NHS. Clinicians and staff are trained to be very certain in the decisions they are making as their decisions affect people’s lives, which means they tend to be very sure-minded in what they put forward.
Not only that, but their many years of training has taught them not to rely on artificial sources to make decisions and care for their patients. Ultimately, Hazel says that the cultural shift has been the hardest thing to deal with. At Chesterfield Royal Hospital NHS Foundation Trust, technical teams work very closely with change managers in the teams whom they are developing apps for.
As an example, his Chief Clinical Innovation Officer, whilst still a senior and practicing clinician, is also a part of the development team, which helps to break down some of the barriers previously had. Christine Walters stresses that clinical advocates who can filter the message through their peers are key in this process, as well.
There is a general expectation across NHS trusts that the transformation team is responsible for all transformation, but Ikenna Emenyonu says that, sadly, this is not aligned to reality. In his experience, one of the main challenges is being a coordinator of change not a doer of change. Transformation is an organisation-wide program and cannot be achieved with a single team. Instead, that team should coordinate the activities of the organisation to deliver the transformation, not to expect to, or be expected to, make everything happen. Walters adds that, alongside this change of mindset, there must also be an increased willingness to be flexible.
More often than not, plans change and teams must be prepared for that and adapt. Whether we like it or not, the change process is organic and involves consultation. When organisations include or exclude certain people or teams this will affect buy-in and slow the project. From this, you can release the staff to attend the training and finally provide them time to be hands-on with the system. Encouraging this environment of consultation ensures that everyone can better understand how they
can play their part in the transformation.
Top tip on managing the change process
You need process owners in operations and a dedicated business change team who understand what you are doing, and importantly the reasons why – what is the ultimate goal – keep coming back to it to ensure you are still heading in the right direction. You also need a robust communications plan to keep everyone’s eye on the goal. And understand your resources to deliver the change - finance in place, people available with the right level of skill, teams ready to accept change.
As with nearly all aspects of day-to-day working in our hospitals, coronavirus has played its part in the way in which digital transformation is considered.
Ian Brewer says that the perception of ‘red tape’ fell away when people were faced with the crisis, and what he found was that projects that might have taken months were achieved in weeks. Essentially, people adopted a ‘get on with it’ mentality, and while all steps were taken and no corners cut, he found that people suddenly saw benefits, and were focused on achieving what was necessary. If that meant testing systems, they got on and did it. An easy to see example of this is telephone appointments and video consultations which are currently widely used, whereas before, many said they were not possible.
On the whole, teams have got much better at predicting the financial and cost side of things and looking at how they can best manage the cost of things moving forward. However, underestimating the amount of resource that deployments are going to take, often because deployments of that scale have never been attempted before, remains an issue that transformation teams still underestimate.
Furthermore, the resource to talk to stakeholders and staff is easily underestimated. Ikenna Emenyonu says that it is important to be realistic and provide the appropriate amount of resource, and give them the necessary time and space in gaining the buy-in and adoption of the transformation agenda.
Data protection is often forgotten and underestimated in IT projects. However, as Christine Walters knows, a Data Protection Impact Assessment (DPIA) is essential to help you identify and minimise the data protection risks of a digital project or change in the way data is processed. It is also a mandatory requirement under the General Data Protection Regulation (GDPR) and, as Ian Hazel outlined, is a key part of everything we do.
Christine and Ian both stress that everyone should do a DPIA at the start of a project to make sure they understand the impact of data and security form the off. In this way hurdles and obstacles are immediately visible and processes put in place. Moreover, while a DPIA must be set out at the start of a task, protecting data also needs to be an on-going goal, not solely a first thought or an afterthought.
Part of the reason it is forgotten is that there remains a belief that data protection applies more to digital then to paper files. As Ian Brewer highlights, if you were to see a doctor on the train open a briefcase of paper files to read on the way home you wouldn’t necessarily think anything of it. But, reading a patient file on a tablet on the train may be deemed wrong.
Additionally, there is a fine balance that needs to be achieved between usability and data protection. Teams will need to make pragmatic trade-offs between security and providing users and patients ease of access. Hard to use systems have low uptake and setback digital plans. For example, Ikenna Emenyonu says that using encryption makes working with data an exact science, and the downside is that there will be reductions in visibility.
If you could go back to your 'pre-digital self', what would you tell your less experienced self?
“Embrace exciting opportunities to transform the way we work and remove less value added tasks. Digital programmes, done well, really make a difference to patient care and patient safety by giving the right information to the right people at the right time to enable clinicians to make informed decisions on individual patients and their treatment and care.”
“Set your sights on the project’s core functionality, and, just as importantly, keep it there. This will enable you to balance objectives and outcomes and make rational decisions in the face of change. The first kind of change is that when you show users the system, they will have personal bias and also focus on bells and whistles. This can distract you. The second is change that needs to be managed, such as any national directives or unexpected events. If you have a strong focus on the core competencies and outputs any adaptations will keep the ‘goal-in-mind’. You will be able to flexibly deliver without going too far of course.”
“I’ve learned that getting clinical staff engaged and involved in your team is essential. It helps project teams to understand the impact of their work, ensures solutions are able to deliver useful cost-effective results and helps with credibility during change management. The results we have had are massive. We are now working with that end-user to jointly deliver solutions as a team. I didn’t used to think like that even ten years ago.”
“First, I would remind myself to communicate widely and openly. Then listen, really listen to the answers through the noise. Projects can stumble when unknown facts are revealed. How often have I heard, ‘If only you had told us, we might have told you…?’.
Second, I’d remind myself to have a flexible approach. When you approach situations flexibly, you can assess how to turn on the most useful functionality first. I’ve learned that a phased approach can be the best route to manage adoption. And finally, use a step-by-step approach tailored to the team, department and organisation. Using a phased approach is more likely to reduce the risks they perceive and allow you to move ahead.”
Christine is Director of Informatics at St Helens and Knowsley Teaching Hospitals NHS.
She was appointed to her board-level role in 2015, managing a shared informatics service that provides technology to three hospitals, a mental health trust, community health trust, CCGs, GP practices and local councils.
Her overall responsibility is to lead and develop an effective health informatics service, supporting over 14,500 users across 155 sites.
Ian is Head of Information Technology for UHS Digital at University Hospital Southampton NHS Foundation Trust.
Ian has over 35 years’ experience in IT, and has worked in healthcare IT since 1991. His special tech interests include technical architecture for whole systems design with a focus on systems integration and interoperability. He is passionate about using IT appropriately to improve the delivery of patient care, but not using tech for the sake of the tech.
Seventeen years ago, when Ian joined the NHS as Chesterfield Royal Hospitals’ IS Manager, he brought considerable knowledge with him, thanks to his background as an IT professional in the private sector.
Although heavily involved in all IT projects, his personal speciality and focus is on the use of digital improvements that enhance experiences for both patients and staff.
His goal is to ensure that every project contributes to the concept of ‘patient activation’.
Ikenna works as a Solutions Specialist manager at Netcall. Ikenna has deep experience in delivering transformation projects within the NHS. He has been pivotal in understanding the goals, agreeing outcomes and working though challenges within many NHS trusts.
His speciality is developing and implementing cost-effective patient experience solutions. Ikenna has been with Netcall for over 15 years.