Making IT Work: Harnessing the Power of Health Information

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Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England Report of the National Advisory Group on Health Information Technology in England

Robert M. Wachter, MD, Chair



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

Members of the National Advisory Groupa Julia Adler-Milstein, PhD

Associate Professor, Schools of Information and of Public Health, University of Michigan

David Brailer, MD, PhD

CEO, Health Evolution Partners; First US National Coordinator for Health IT (2004-6)

Dave deBronkart

Patient Advocate, known as ‘e-Patient Dave’

Mary Dixon-Woods, MSc, DPhil

RAND Professor of Health Services Research, University of Cambridge

Rollin (Terry) Fairbanks, MD, MS

Director, National Center for Human Factors in Healthcare; Emergency Physician, MedStar Health (US)

John Halamka, MD, MS

Chief Information Officer, Beth Israel Deaconess Medical Center; Professor, Harvard Medical School

Crispin Hebron

Learning Disability Consultant Nurse, NHS Gloucestershire

Tim Kelsey

Commercial Director, Telstra Health; National Director for Patients and Information, NHS England (2012-2015)

Richard Lilford, PhD, MB

Director, Centre for Applied Health Research and Delivery, University of Warwick, UK

Christian Nohr, MSc, PhD

Professor, Aalborg University, Denmark

Aziz Sheikh, MD, MSc

Professor of Primary Care Research and Development, University of Edinburgh

Christine Sinsky, MD

Vice-President of Professional Satisfaction, American Medical Association; Primary care internist, Dubuque, Iowa

Ann Slee, MSc, MRPharmS

ePrescribing Lead for Integrated Digital Care Record and Digital Medicines Strategy, NHS England

Lynda Thomasb

CEO, MacMillan Cancer Support, UK

Robert Wachter, MD (Chair)

Professor and Interim Chairman, Department of Medicine, University of California, San Francisco

Wai Keong Wong, MD, PhD

Consultant Haematologist, University College London Hospitals; Past chair, CCIO Leaders Network Advisory Panel

Harpreet Sood, MBBS, MPH

Senior Fellow to the Chair and CEO, NHS England (Staff to the Advisory Group and NHS Doctor)

a.

Sir David Dalton, CEO of Salford Royal NHS Foundation Trust, participated in early deliberations but left the committee in April 2016 due to other obligations.

b.

Declan Hunt, Executive Director of Technology for MacMillan Cancer Support, attended several meetings as an alternate to Ms. Thomas.

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Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

5. Interoperability Should be Built in from the Start Local and regional efforts to promote interoperability and data sharing, which are beginning to bear fruit, should be built upon. National standards for interoperability should be developed and enforced, with an expectation of widespread interoperability of core data elements by 2020. In addition, the Advisory Group endorses giving patients full access to their electronic data, including clinician notes.

6. While Privacy is Very Important, So Too is Data Sharing Privacy is very important, but it is easy for privacy and confidentiality concerns to hinder data sharing that is desirable for patient care and research. It would be a mistake to lock down everyone’s healthcare data in the name of privacy. We endorse the recommendations of the National Data Guardian’s Review of Data Security, Consent, and Opt-Outs, which was commissioned to achieve this balance.

7. Health IT Systems Must Embrace User-Centered Design IT systems must be designed with the input of endusers, employing basic principles of user-centered design. Poorly designed and implemented systems can create opportunities for errors, and can result in frustrated healthcare professionals and patients.

8. Going Live With a Health IT System is the Beginning, Not the End The ‘Go Live’ period in a large hospital or trust is always difficult, but is nonetheless just the start. Health IT systems need to evolve and mature, and the workforce and leadership must be appropriate for this task. While patient safety is non-negotiable, regulators and commissioners need to have a degree of tolerance for short-term slow downs and unanticipated consequences in the period following EHR implementation.

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9. A Successful Digital Strategy Must be Multifaceted, and Requires Workforce Development The NHS’s digital strategy should involve a thoughtful blend of funding and resources to help defray the costs of IT purchases and implementation, resources for infrastructure, support for leadership and informatics training, as well as support for education of leaders, front-line providers, trainees and clinician- and non-clinician informaticians. The Advisory Group was struck by the small number of leaders at most trusts who are trained in both clinical care and informatics, and their limited budgetary authority and organisational clout. This deficit, along with a general lack of workforce capacity amongst both clinician and non-clinician informatics professionals, needs to be remedied.

10. Health IT Entails Both Technical and Adaptive Change Many observers and stakeholders mistakenly believed that implementing health IT would be a simple matter of technical change – a straightforward process of following a recipe or a checklist. In fact, implementing health IT is one of the most complex adaptive changes in the history of healthcare, and perhaps of any industry. Adaptive change involves substantial and long-lasting engagement between the leaders implementing the changes and the individuals on the front lines who are tasked with making them work. Successful implementation of health IT across the NHS will require the sustained engagement of front-line users of the technology.

Recommendations 1. Carry Out a Thoughtful LongTerm National Engagement Strategy The Advisory Group believes that a long-term engagement strategy is needed to promote the case for healthcare IT, identify the likely challenges during implementation, educate stakeholders about the opportunities afforded by a digital NHS, and set the stage for long-term engagement of end users and



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

a plan that demonstrates that the trust is adequately prepared to succeed in both digitisation and in promoting regional interoperability, evaluation of progress, and ongoing accountability that the money was well spent.

8. Organise Local/Regional Learning Networks to Support Implementation and Improvement To support purchasing, implementation, and ongoing improvements by trusts, digital learning networks should be created or supported. Such networks may vary, with some helping in the early stages (choice of EHR system, contracting, implementation) and others at later stages (optimisation, decision support, analytics). The latter category may include IT supplierspecific networks.

9. Ensure Interoperability as a Core Characteristic of the NHS Digital Ecosystem – to Promote Clinical Care, Innovation, and Research The new effort to digitise the NHS should guarantee widespread interoperability. The goals of interoperability are to enable seamless care delivery across traditional organisational boundaries, and to ensure that patients can access all parts of their clinical record and, over time, import information into it. Widespread interoperability will require the development and enforcement of standards, along with penalties for suppliers, trusts, GPs, and others who stand in the way of appropriate data sharing. The system, standards, and interfaces should enable a mixed ecosystem of IT system providers to flourish, with the goal of promoting innovation and avoiding having any one vendor dominate the market. Plans for interoperability should be harmonised with other ongoing efforts to join up elements of the health and social care systems, such as those represented by the Sustainability and Transformation Plans (STPs).

10. A Robust Independent Evaluation of the Programme Should be Supported and Acted Upon In light of the likelihood of unanticipated consequences, the high cost of digitisation, and the chequered history of past efforts to digitise the secondary care sector, the NHS should commission

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and help fund independent evaluations of the new IT strategy. Such evaluations should be formative (conducted and reported as the strategy is progressing) and summative (reporting at the end of each of the two phases of deployment). In assessing the benefits and costs of health IT, evaluations should consider the impact of digitsation on the satisfaction of healthcare professionals.

Conclusion We believe that the NHS is poised to launch a successful national strategy to digitise the secondary care sector, and to create a digital and interoperable healthcare system. By using national incentives strategically, balancing limited centralisation with an emphasis on local and regional control, building and empowering the appropriate workforce, creating a timeline that stages implementation based on organisational readiness, and learning from past successes and failures as well as from real-time experience, this effort will create the infrastructure and culture to allow the NHS to provide high quality, safe, satisfying, accessible, and affordable healthcare. The experience of industry after industry has demonstrated that just installing computers without altering the work and workforce does not allow the system and its people to reach this potential; in fact, technology can sometimes get in the way. Getting it right requires a new approach, one that may appear paradoxical yet is ultimately obvious: digitising effectively is not simply about the technology, it is mostly about the people. To those who wonder whether the NHS can afford an ambitious effort to digitise in today’s environment of austerity and a myriad of ongoing challenges, we believe the answer is clear: the one thing that NHS cannot afford to do is to remain a largely non-digital system. It is time to get on with IT.



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

the UK has established some internationally renowned research programmes, such as the UK Biobank and the 100,000 Genomes Project, whose potential to improve care is tightly linked to their integration with clinical information systems, both for data collection and to support clinical decision making at the point of care. In contrast to the successes in the GP sector, the digitisation of hospitals has been far from smooth, and the patchy computerisation of this sector stands as a considerable impediment to transforming care. The ambitious National Programme for Information Technology (NPfIT), designed to digitise hospitals and trusts, was launched in 2002, only to be shut down nine years later (5). NPfIT did enjoy some successes, including the development of a national infrastructure to provide core services (the Spine); a single national patient identifier (the NHS number); and national electronic prescription and radiology programmes. But, against its primary goal of digitising the secondary care sector, NPfIT failed to deliver – largely because it was too centralised, failed to engage properly with trusts and their healthcare professionals, and tried to accomplish too much too quickly. Since the demise of NPfIT, the NHS has, understandably, shied away from renewed ambitious efforts to digitise secondary care. But over the past few years, a consensus has emerged that the time has come to move forward. This consensus was articulated in a 2014 framework created by the National Information Board and bolstered by the allocation, in 2016, of £4.2 billion to support this work (6). In late 2015, the Secretary of State for Health and the leadership of NHS England asked for the creation of a broadly representative external body: The National Advisory Group on Health Information Technology in England, to advise the Department of Health (DH) and the NHS on its efforts to digitise the secondary care system. The Group was asked to reflect on the experience not only of NPfIT but of other international efforts to digitise the health system, particularly that of the United States, and to make recommendations to help guide the DH and the NHS to the best possible outcomes. The Advisory Group’s Terms of Reference are shown in Appendix A and its members are listed on page 3. The Group’s process is described on page 40. This document represents the findings and recommendations of this Advisory Group.

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This report begins by covering the relevant background, particularly in five areas: 1)

General policy/practical issues that relate to health IT

2)

A brief history of NPfIT

3)

A brief history of health IT in England’s GP sector

4)

A brief history of the US experience with digitising its healthcare system, with some possible lessons for the NHS

5)

The recent consensus on digitising secondary care in England, reflected in the work of the National Information Board, the Five Year Forward View report, and the allocation of £4.2 billion to support digitisation

After exploring this background, we will outline our methods, and then describe 10 overall findings and principles drawn from our interviews, site visits, and deliberations. Finally, we list 10 implementation recommendations and their rationales.

Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

Table 1: Technical versus adaptive problems (4) What’s the Work?

Who Does the Work?

Technical Problems

Apply current know-how

The ‘authorities’

Adaptive Change

Learn new ways

The people with the problem

But digitising large, complex organisations – particularly those, like healthcare, that do not involve repetitive, assembly line-type work but rather work with substantial complexity, nuance, and decision making under uncertainty – is adaptive change of the highest order. Failure to appreciate this leads to many of the other problems: underestimation of the cost, complexity, and time needed for implementation; failure to ensure the engagement and involvement of front-line workers; and inadequate skill mix. It is thus not surprising that many health IT implementations fail, not only in England but around the world. Digitising large, complex organisations is adaptive change of the highest order.

Since efforts to computerise a single organisation (a hospital, for instance) often fail, it is unsurprising that NPfIT – an attempt to digitise an entire sector of a massive healthcare system, operating in a resourceconstrained and politicised environment – proved far more difficult than anticipated. As we try again to digitise the secondary care sector of the NHS, the question is how to learn from the lessons of NPfIT, as well as those of other countries that have traversed this path, particularly the US. Finally, there is a success story to point to: the digitisation of England’s GP sector. In the sections that follow, we will briefly review these three stories: NPfIT, health IT in the GP sector, and the US experience with digitisation. Before we do, however, it is worth ending this section on an optimistic note. Research from other industries demonstrates that the productivity paradox ultimately resolves, usually after about a decade (5). Like the opening of a safety deposit box, there seem to be two keys. The first: the technology needs to get better, and it eventually does. New companies emerge to solve specific problems, user feedback is integrated into product design, and the underlying technologies mature. We start with Version 1.0 and end with

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Version 37.6, and each version gets progressively better. The second key is more interesting, more challenging, and ultimately more important: people begin to reinvent the work. They ask, ‘Why are we doing this thing this way?’ And they become progressively dissatisfied with the answer: ‘Oh, we did it this way when we used paper, and then we just digitised it.’ Over time – particularly if they have the right resources, skills, and culture – they begin to develop new ways of achieving the goals, ways that take full advantage of digital tools and thinking. That is when the major improvements in quality, safety, customer engagement, and efficiency begin to emerge. That is when the productivity paradox resolves, when the technology leads to the creation of real value. The question, really, is how best to promote the digitisation of the NHS in a way that learns past lessons correctly; appreciates that health IT is both technical and adaptive change; and minimises the time required to resolve the productivity paradox without falling into the trap of destructive impatience. Our recommendations are framed around addressing this question, and we are optimistic that – with the right choices – it can be done successfully.

The National Programme for Information Technology (NPfIT) The National Programme for Information Technology (NPfIT) was an ambitious £12.4 billion investment designed to reform how the NHS in England used information to improve service and patient care. The Programme was launched in 2002 under Prime Minister Tony Blair’s leadership. Its aim was to move England’s NHS toward a single, centrally-mandated electronic care record for patients, to connect 30,000 general practitioners to 300 hospitals, and to



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

a meeting between the Prime Minister and then CEO of Microsoft, Bill Gates, after which the Prime Minister is said to have become ‘hooked’ on the technological possibilities for improvement in the NHS. The goal of NPfIT was to use modern information technologies to enhance the way the NHS delivered services, improving the quality of patient care in the process. NPfIT was not a single project but a programme of initiatives with interdependencies, different timescales, and varied contributions to benefits delivery. Its underpinning was to be an IT infrastructure with sufficient capacity to support the national applications and local systems (10). These national applications were: i)

An integrated electronic health records system

ii)

An electronic prescription system

iii) An electronic appointment booking system Central to the Programme was the creation of a fully integrated electronic records system designed to reduce reliance on paper files, make accurate patient records available at all times, and enable the rapid transmission of information between different parts of the NHS. The key components of NPfIT are listed in Table 2.

NPfIT was managed by NHS CfH. The Chief Executive of the NHS was the senior responsible owner for the Programme, while the DH was responsible for procuring and managing NPfIT’s central contracts, including those with the Local Service Providers (LSPs). NPfIT originally divided England into five areas known as ‘clusters’ (11): • Southern • London • East & East Midlands • North West & West Midlands • North East For each cluster, a different LSP was contracted to deliver services at a local level (Figure 1). This structure was intended to avoid the risk of committing to a single supplier and to create competition. The responsibility for delivery was split between the LSPs and NHS trusts, with trusts generally responsible for business change, delivery plans, staff training, and attesting that systems had met their requirements.

Figure 1: Regional clusters for Local Service Providers (12)

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Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

• Holds more than 500 million records and documents

3.

The Programme was felt to have a politically driven agenda. While NHS clinicians and staff were supportive of digitisation, many viewed the Programme’s deployment schedule as rushed and built around political priorities. The initial allocation of Treasury funds was based on unrealistic promises, which led to unrealistic expectations. The Programme also suffered from scope creep – the tyranny of adding on ‘just one more thing’ until a project loses focus and is crushed under the weight of additional work.

4.

Despite what appeared to many to be a generous allocation of funds, local trusts found there was insufficient support available to help them implement the nationally purchased systems.

5.

Procurement and contracting arrangements were problematic. NPfIT’s procurement model called for nearly impossible delivery timelines, with contracts offered on a ‘take-it-or-leave-it’ basis. While procuring contracts centrally resulted in vigorous supplier competition and saved billions of pounds, the speed meant that the NHS had not prepared key policy areas (e.g., information governance), standards (e.g., for messaging and clinical coding), and information system architecture. Moreover, the scope of many contracts was unclear and much work needed to be done after the contract award to agree on key parameters such as scope and deliverables.

6.

The Programme suffered from continuous leadership changes and a shortage of individuals with relevant skills. Specifically, NPfIT was hampered by a workforce that lacked experience in large-scale IT implementation and familiarity with health services. Additionally, the frequent senior leadership turnover plagued the programme. NHS organisations, particularly the trusts, also had limited informatics experience and expertise.

• In peak periods, handles 1,500 messages per second

The Overall Failure of NPfIT Despite these successes, the Programme’s central deliverable – the creation of functioning electronic health record (EHR) systems in all NHS trusts, connected to other key systems (particularly GP EHRs), and producing information leading to better patient care and efficiency – was not met. In 2011, NPfIT was discontinued, and analyses in the popular press were unkind, dubbing the Programme ‘a fiasco’ and worse. While there has been no definitive analysis of the failings of the Programme, consensus opinion supports the following conclusions (6-9): 1.

From the outset, the Programme lacked clinical engagement. The focus was placed upon technology and not service change, and minimal attention was given to the adaptive elements of massive IT installations. There was no comprehensive strategy to engage cliniciansd or NHS executives to ensure they understood the reasons that NPfIT was being developed or implemented. System suppliers and NPfIT leadership underestimated the power of the clinical community and the complexity of the NHS. The focus [of NPfIT] was placed upon technology and not service change, and minimal attention was given to the adaptive elements of massive IT installations. There was no comprehensive strategy to engage clinicians or NHS executives to ensure they understood the reasons why NPfIT was being developed or implemented.

2.

The Programme employed a controlled, top-down approach – a centrally-driven strategy to implement standardised IT systems. Some have likened it to a military procurement program, which, of course, involves far fewer adaptive change elements and far less need for local and professional buy-in.

d.

In this report, the terms ‘clinician’, ‘provider’, and ‘healthcare professional’ are used interchangeably.

e.

Some legacy components of NPfIT still remain; they are now run by other NHS entities. Approximately £500M of the recent £4.2 billion allocation for health IT is earmarked for maintaining these systems.

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In January 2009, the government’s Public Accounts Committee criticised NPfIT, noting that costs were escalating without evidence of benefits. The Committee suggested that it might be time to start looking beyond the NPfIT framework. There were few supporters of the programme at that stage and, in 2011, NPfIT was essentially aborted.e



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

for services provided to the NHS became more datadriven, aimed at more directly linking remuneration and performance (20). The information requirement increased further with the enactment of the Quality Outcomes Framework (QOF) in 2004, a pay-forperformance scheme that now accounts for a significant proportion of practice income. GP performance is currently assessed through 81 indicators linked to clinical guideline recommendations. These indicators are reviewed annually and are mostly extracted from GP EHRs (21). It is not considered practically possible to qualify for QOF payments without an EHR. An example of a QOF indicator is: The percentage of patients with coronary heart disease whose last measured total cholesterol (measured in the preceding 12 months) is 5mmol/l or less.12 The process of purchasing patient care from providers is known as commissioning. Following a series of reforms in 2012, the purchasing function now rests with local organisations called Clinical Commissioning Groups (CCGs). CCGs are led by GPs and now control most of the budget for buying hospital services for patients. Effective commissioning requires a lot of information about patients and referral patterns, which has been facilitated by computerisation (and held back by the patchy digitisation of the secondary care sector). There have been other advantages to widespread computerisation of GP practices. Patient information, collected through GP EHRs, has been used in publicprivate collaborations for research, epidemiological surveillance and quality improvement. As one example, the Clinical Practice Research Datalink (CPRD) extracts anonymised records from more than 600 practices for use in research studies and clinical trials. Specific cohorts of patients (i.e., those with kidney disease or with diabetes) can be created and examined for treatment patterns or clinical outcomes (22). Another project linked anonymised GP data on more than 2 million patients to national mortality data to create a well-validated cardiovascular risk algorithm (QRisk2). In other words, the potential to undertake such innovative work at a national scale and at minimal cost is already being realised for ambulatory practices, and would increase significantly once hospital records are also digitised (23). EHR systems have even supported a major pan-European Learning Health System project, but national efforts to anonymise and share patient information for research, through the care.data g.

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In July 2016, the care.data program was terminated.

programme, have been hampered by public and professional concerns over privacy and information governance.g In any data sharing exercise, GPs are conscious of their legal position as Data Controllers, making them responsible for the security of data that they collect (24, 25). They are also mindful of the trust invested in the doctor-patient relationship and the professional duty of confidentiality. GPs appear to be increasingly willing to share data from their EHRs, and the major GP IT systems support such sharing.

The Systems Government intervention boosted the market for GP computer systems, through subsidy and, eventually, central purchasing. However, it has also curtailed diversity within the market, largely due to the strict accreditation criteria. From the late-1970s to the mid-1990s, many EHR systems designed for GPs were developed in the UK. At one point, there were between 30 and 50 competing systems, many used by only a handful of practices. As the market matured, the number of vendors offering GPSoC-accredited EHRs fell to four (EMIS, TPP, In Practice Systems, and Microtest), with EMIS and TPP dominating the market. There have been no new entrants to this market since 1997. The accreditation criteria – while viewed as helpful in ensuring that systems are fit for purpose, secure, and robust – have also been criticised for imposing a large burden on EHR suppliers. In addition to making it difficult for smaller suppliers to keep up, the requirements may have sapped the capacity for innovations and improvements. Although systems are purchased and funded centrally, GPs have the right to choose which accredited system they use. It should be noted that typical arguments for regional EHR uniformity – namely, interoperability and ease of information exchange – are not terribly salient, since relatively few GP practices share patients with one another and there is now a robust system for transferring patient records between GP practices with Although virtually all GPs now use a computer during patient encounters and operate paper-light practices, much correspondence, particularly that received from secondary care (from both hospitals and consultants), remains paper-based and has to be scanned.



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

should be noted, are not specific to UK GP systems.) They include: • User interfaces are sometimes cumbersome and inflexible • System failures, although infrequent, are very disruptive • Data overload (management reports) and alert overload (during consultations) • Lack of training prevents clinicians from realising the full potential of systems • Data input is a problem for those who can not touch-type • Implementing new systems, and changing systems, is disruptive and impacts productivity. This can be exacerbated by long transitions and extended dual running of paper and electronic systems

Government The government remains highly supportive of GP digitisation. The granular information produced by these systems has given NHS organisations a previously unimaginable view of quality and performance in every practice. It has also given government the ability to measure practices against central targets. There has been vigorous debate about whether such a target-driven approach improves holistic outcomes, but – given the targets – all sides appreciate the role of IT systems in reducing the administrative burden of data collection.

Conclusions and Lessons GP computer systems have evolved greatly over the last 40 years. Early systems, installed by enthusiasts, were simple enough that many were homegrown. Those systems were built by GPs, for GPs, and solved crucial business problems. Moreover, as such systems were being built, the profession established a united negotiating committee that clearly articulated policy requirements to government. Over the past few decades, government funding has allowed for near-universal adoption of EHRs in GP practices, which has yielded major benefits in quality and efficiency. Universal adoption has come only through government subsidy, which was accompanied by a robust accreditation and regulatory framework. This, some believe, has stifled innovation in the market and led to a worrisome degree of consolidation in the supplier community. Despite these critiques, most stakeholders (GPs, government, patients) view the EHR experience in the GP market largely as a success. In 2016, the establishment of an entirely digital infrastructure in England’s GP community is a massive advantage, one that is not yet shared by the rest of the NHS. Leveraging this advantage to enable greater patient engagement, more robust data sharing, better value, and a more innovative environment may require different choices than those that led to the current state. It will be important to learn from this experience in designing the future state of GP practices, as well as in designing systems and policies for the rest of the NHS.

Patients It has long been recognised that the use of computers during consultations can adversely affect GP-patient communications, but there has also been evidence that UK patients accept the role of computers and do not feel that they lead to loss of ‘the personal touch’ (32). Training (in areas like computer use, ergonomics, and doctor-patient communication) may play an important role, but its provision is not centrally funded and therefore varies. One example of patient and media reaction altering the course of IT-related innovation is the recent outcry over the care.data programme (24). It seems likely that this experience will result in a larger role for patients in future discussions regarding health IT.

h.

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An interesting pattern that you may have discerned: Tony Blair was inspired to launch NPfIT after conversation with an American, Bill Gates. Upon learning of the British programme from Tony Blair, George W. Bush was similarly inspired to launch the US government’s effort to digitise its health system.

The US Experience With Health IT, With Possible Lessons for the NHS The US government’s decision to promote health IT began when President George W. Bush first learned of Tony Blair’s national IT initiative in 2003.h Reportedly seeking a domestic issue with broad bipartisan support in the run-up to his reelection campaign, President Bush instructed his advisers to create a framework for government to promote the adoption of health IT (33). The result was the Office of the National Coordinator for Health Information Technology (ONC). In 2004, David Brailer, a physician, economist, and



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

organisations and pharmacies/laboratories is reasonably good, although not uniform. And there is relatively little data-sharing between the growing number of consumer-facing apps and sensors (e.g., Fitbit) and the EHRs in doctors’ offices and hospitals.

Andy Slavitt announced that Meaningful Use would soon end, to be replaced by a more streamlined programme, ‘Advancing Care Information’. ‘We have to get the hearts and minds of physicians back,’ said Slavitt. ‘I think we’ve lost them’ (38).

Patient Portals/Connecting PatientFacing and Enterprise Health IT Systems

Later stages of Meaningful Use involved marked increases in regulation, creating a major burden on both suppliers and delivery systems, stifling innovation, and contributing to the consolidation in the supplier marketplace.

About a decade ago, some of America’s IT giants, including Google and Microsoft, tried to build consumer-facing patient portals. Despite large investments, these efforts mostly failed, in part because they were unable to solve the interoperability and ease-of-use issues. Today, many of the enterprise EHRs come bundled with patient-facing portals, allowing patients to read their laboratory and radiology results, make appointments, and email their doctors. About 10 million patients in the US have full access to their clinician notes (‘OpenNotes’). Although this development was feared by many clinicians, research to date has shown high levels of acceptance by both patients and clinicians (36). But the larger issues of how the increasingly dynamic world of patient-facing health data and the more corporate world of enterprise health IT can fuse into one stream, and how this vast data stream will be managed and protected, remain largely unresolved.

Other Issues Surrounding Meaningful Use The early stages of Meaningful Use, designed to ensure that people and organisations that accepted HITECH subsidies were actually using their EHRs in ‘meaningful’ ways, were popular and widely accepted. However, later stages of Meaningful Use (Stages 2 and 3, Table 3) involved marked increases in regulation, creating a major burden on both suppliers and delivery systems, stifling innovation, and contributing to the consolidation in the supplier marketplace. Many analysts believe the government has a key role in creating standards (perhaps even mandates) for interoperability and in helping to ensure privacy and security. But the fact that many US clinicians and IT professionals now refer to Meaningful Use as ‘meaningless abuse’ illustrates the level of discontent (33). In 2016, Medicarej acting administrator

j.

Medicare is the US government’s insurance programme covering people age 65 and older, as well as younger people with disabilities. It accounts for about one-fourth of US healthcare spending.

k.

With few exceptions, the US system has traditionally been organised around ‘fee for service’. The managed care movement in the mid-1990s sought to shift the system toward capitation (fixed payments to cover a population of patients, putting the delivery system at risk for the cost of care). This movement failed, amid criticism for focusing primarily on cost

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In analysing the impact of Meaningful Use and HITECH, it is important to place these programmes in the context of larger changes in the US healthcare delivery system. As the US system pushes clinicians and delivery organisations to shift their focus from ‘volume to value’ (via the Affordable Care Act and other initiatives),k the hope is that they will seek and buy IT tools that help them meet those goals. This, the theory goes, will drive these organisations to innovate and improve their IT systems, obviating the need for the aggressive regulations found in the later stages of Meaningful Use. The pressure for interoperability has grown tremendously in the past few years. The media and the US Congress have criticised EHR suppliers and some healthcare systems for willful ‘information blocking’; there is even talk of prosecution of individuals or organisations that participate in such alleged blocking (39). While some of this is political hyperbole, it is clear that the pressure on healthcare delivery organisations (the US equivalent of trusts) and suppliers to share information will grow, likely leading to far greater interoperability within the next five years. A primary vehicle to promote interoperability has been the development of regional health information exchanges (HIEs). These are central hubs (usually non-profit organisations created for this purpose, sometimes run by an existing entity such as a hospital association) that mostly depend on fees from users, though there has also been federal and foundation support for HIEs. They are designed to collect and then distribute EHR data to different systems in a region. Unfortunately, the track record of HIEs is uninspiring. A few have been successful. And new ones are cropping up, in response to the growth of Accountable Care Organizations and bundling

reduction and corporate profits, not quality. Moreover, Americans were unwilling to accept the rationing and gatekeeping that are generally accepted in the UK. Over the past five years, driven by evidence of problems with quality, safety, access, and costs, the US system is once again shifting toward global budgets and delivery system-based accountability for outcomes and costs. Today’s terminology is ‘valuebased purchasing’, and the primary vehicles are Accountable Care Organizations (ACOs, a new twist on the health maintenance



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

overreliance on technology, resulted in a 39-fold overdose of a common antibiotic (33).

EHRs and the Health Professional Workforce Rates of physician burnout in the US now exceed 50%, a 9% increase over the past three years (43). A 2013 RAND Corporation study commissioned by the American Medical Association found that many doctors cited EHRs as a major source of burnout (44). The problem lies partly in poor design, and partly in the fact that EHRs have become enablers for third parties who wish to ask doctors and nurses to document additional pieces of information (for billing, quality measurement, etc.), turning clinicians into ‘expensive data entry clerks’. One sign of this documentation burden is the meteoric growth in the number of ‘scribes’, individuals hired to provide real-time EHR documentation, allowing physicians to concentrate on (and make eye contact with) their patients.

EHRs and ‘Big Data’ While there is great enthusiasm for using ‘big data’ to develop personalised approaches for individual patients (‘precision medicine’), provide customised decision support to both clinicians and patients, and create ‘learning healthcare systems’, today all these goals are more promise than reality. Realising the potential will depend on significant changes through the entire system: changing incentives, far better interoperability, more meaningful data, the availability of analysts with skills in genomics, IT, clinical medicine, and more.

unhappiness among health professionals is a dominant theme of the current era. While there are many reasons for this, there is little question that health IT has, to a surprising degree, added to the woes. Why have things gone relatively poorly? Here, we return to the concept of the productivity paradox: the experience of many industries in which the promised improvements in quality and efficiency from IT failed to materialise in the first few years after digitisation (1, 5). But the lessons of the productivity paradox offer room for optimism. By most measures, American healthcare is still in its first five years of widespread digitisation. The US is beginning to see improvements in the technology, a heightened pace of innovation, and early efforts to rethink the work, staffing, and workflow at hospitals with more mature IT systems (1, 5, 47). While the pace of change is slower than anyone would like, the system appears to be on the cusp of major improvements. Which lessons from the US experience might be relevant to England? We offer the following thoughts: 1)

Lessons Drawn From the US Implementation of Health IT While this point can be debated, many observers believe that HITECH was a wise intervention, in that US healthcare represented an IT business failure (i.e., typical business incentives did not drive healthcare delivery systems to implement IT, as happens in most other industries), and the programme created a tipping point for digitisation of the health care sector (33). The major downside of HITECH is that it opened the door to the overregulation of Meaningful Use Stages 2 and 3.l In terms of its impact on clinical care, the US experience with health IT has been disappointing. While the literature points to modest improvements in safety and quality, the promised efficiency gainsm have not yet materialised (45, 46). And, as noted, l.

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Meaningful Use Stage 1 is generally viewed as a success; it was designed to ensure that clinicians were actually using their EHRs, purchased in part with federal subsidies. Most criticisms have focused on the far more prescriptive and onerous requirements under Stages 2 and 3.

Great attention needs to be paid to issues of adaptive change from the start. In particular, the predicament of clinicians, especially doctors and nurses, must be deeply appreciated. The tendency simply to digitise ineffective and inefficient analog processes needs to be resisted. Digitisation offers an opportunity to rethink the work and workflow. If computers make the lives of clinicians substantially harder, if user-centered design is lacking, if the work is not reimagined for a digital environment, clinicians will become obstacles rather than supporters. This will be difficult to overcome; every effort should be made to win the ‘hearts and minds’ of clinicians from the start, and to keep them engaged in optimising systems and rethinking ineffective work processes. If computers make the lives of clinicians substantially harder, if user-centered design is lacking, if the work is not reimagined for a digital environment, clinicians will become obstacles rather than supporters.

2)

m.

The US was well served by several decades of research into information technology and a strong cadre of clinician-leaders in IT, many of whom In a 2005 analysis, the RAND Corporation projected that EHRs would result in $81 billion (£62 billion) in annual savings to the US healthcare system (45). A 2014 analysis found that no savings had yet occurred (46).



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

terminated and few people were bold enough to begin advocating for another ambitious health IT strategy.

regions that would be asked to plan their digital strategies, including plans for regional interoperability.

However, policymakers soon realised that, while NPfIT had been unsuccessful, its goals remained crucial to the future of the NHS. The need for a new strategic plan for digitisation was clear. In 2012, the National Information Board (NIB) was established to create such a plan by bringing together organisations from across the NHS, public health, clinical science, social care, local governments, and the public. The membership of the board includes 37 organisations spanning the health and social care system.

In 2014, the NIB issued its major report, Personalised Health and Care 2020, which laid out the broad strategy (50). In essence, it called for: • Dividing the NHS in England into local ‘footprints’ – geographic areas composed of providers, commissioners, and other elements of the healthcare and social care sectors. The mandate is for footprints to organise themselves to conduct local transformation. A total of 73 footprints have now been established, each led by one or more Clinical Commissioning Groups (CCGs). This work is being aligned with a parallel effort to establish ‘Sustainability and Transformation Plans’ (STPs).p

The NIB Report and the Allocation of £4.2 billion The NIB worked to craft an overarching framework for digitising the secondary care sector and achieving widespread intereoperability. In part informed by its analysis of the US experience with HITECH, NIB leaders chose to emphasise interoperability, rather than just adoption, of health IT. In light of the experience with NPfIT, they recognised that a highly centralised strategy was both politically impossible and undesirable. Their solution: divided the NHS into

• A ‘digital maturity assessment’, which seeks to identify (via a self-assessment questionnaire completed by each of England’s 154 acute trusts) the baseline digital state of local health economies. This assessment will be repeated over time to track progress across the country against national goals for digitisation (see Appendix F).

Figure 2: Key findings on the Digital Maturity Self-Assessment, based on the domains of Capabilities (X axis), Readiness (Y axis) and Infrastructure (colour) Digital Maturity Self-Assessment: Key Findings (Capabilities Theme) 100

There were only 7 providers with an overall score of 70% or above for the Capabilities theme, which indicates they’re doing very well in all or most areas

90 80 70

Readiness

60

109 providers had a self-assessed score of between 40 and 69%, suggesting they’ve made good progress in some areas but still have gaps in a number of key capabilities

50 40 30 20

Key: 10

Red = Infrastructure score 0 39%

0 0

10

20

30

40

50

60

70

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90

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123 respondents (more than half) had a self-assessed score below 40% for the Capabilities theme as whole. This illustrates the significant amount of work most providers still need to do in order to progress towards becoming paperfree at the point of care.

p.

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While efforts are being made to align the activities, today the structural elements of digitisation and transformation are more than a little confusing. The 154 acute trusts, along with their CCGs, have been divided into the 73 digital footprints. In addition, local health and care systems have been asked to come together to produce STP roadmaps. Although the 73 footprints have leadership and governance structures, as of July 2016 the groups that have produced the 44 STP roadmaps do not. Our focus in this report is on digitisation of the 154 trusts, but it is

Amber = Infrastructure score 40 – 69% Green = Infrastructure score 70 – 100% Blue lines reflect the bandings applied in MyNHS

important to realise that the trusts operate in this changing framework, which is attempting to promote more integration between GPs, trusts, and other elements of the health and social care systems. While these integrated entities may ultimately promote a learning health system, efficiency, and interoperability (for example, in the future, it may be that a network represented by an STP would oversee regional digitisation), it is fair to say that they also add to the challenges faced by trust leaders.



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

3. The National Advisory Group’s Methods In November 2015, Professor Robert Wachter of the University of California, San Francisco (UCSF) was asked by the UK Secretary of State for Health, Jeremy Hunt, to organise a group to advise NHS England on digital implementation in the secondary care sector. The committee’s Terms of Reference are shown in Appendix A. After extensive consultations, an interdisciplinary group of experts – including in informatics, policy, interoperability, usability, clinical practice, workforce, and the patient perspective – was convened. Seven are based in the UK (six in England, one in Scotland), seven are from the US, and one each is from Australia and Denmark (page 3). The Advisory Group held nine 2-hour meetings by teleconference, as well as a two-day meeting in London in April 2016. During the April meeting, the Group heard presentations from about a dozen diverse experts and stakeholders. Dr. Wachter also held individual or group meetings with approximately 100 people, met with several stakeholder groups, and received written input from many other individuals and organisations. He conducted on-site visits at the Barts, Salford, and Imperial Trusts; he and several members of the Advisory Group also visited Addenbrooke’s Hospital during the April meeting in England. Appendix B lists all the meetings, visits, and interviews. This report was drafted in sections by the relevant experts on the committee, and written mostly by Prof. Wachter with editorial assistance from Katie Hafner, a journalist with extensive experience in healthcare and technology. In addition, the Group received essential staff support from Harpreet Sood. We also benefited from the assistance of Tom Foley and Peter Thomson. The Group commissioned reports on the history of NPfIT (an edited version begins on page 16; written primarily by Dr. Sood), the experience digitising the UK’s GP sector (page 23; written primarily by Dr. Foley), the American experience with health IT (page 28; written primarily by Dr. Wachter), and another on the structure of the NHS and its entities that relate to digitisation (written primarily by Dr. Thomson; its

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findings are woven throughout this report). Ms. Hafner and other staff members were compensated for their work. Drs. Wachter, Thomson, and Foley, and the Advisory Group members received no remuneration other than payment for travel. The findings and recommendations that follow have been endorsed by the members of the National Advisory Group. While they have been reviewed by relevant officials and senior leaders in the NHS and DH, as well as by selected outside experts (with feedback considered carefully and, where appropriate, accepted), the conclusions and recommendations represent the independent work of the Advisory Group and do not necessarily represent the views of any other parties, including the NHS and the Department of Health.



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

consequences; for creating a system that is nimble and able to adapt over time; and for retaining a relatively long-time horizon.

2. It is Better to Get Digitisation Right Than to Do it Quickly While there is urgency to digitise the NHS, there is also risk in going too quickly. The Advisory Group urges the NHS to digitise the secondary care sector in a staged fashion, in which trusts r that are ready to digitise are catalysed to do so, while those that are not ready should be encouraged and supported to build capacity, a process that can take several years. Digitisation of health systems is a long journey, and rushing the latter group into computerisation is likely to lead to poor morale and costly failures. This is a crucial point. It should not be assumed that a new national strategy to digitise the secondary care sector is without risk simply because it differs from NPfIT in leadership or structure. We worry that, in light of the current austerity conditions, the uncertainties introduced by Brexit, and the somewhat demoralised NHS workforce, a push to digitise the secondary care sector rapidly carries a high risk of failure. Now that national money has been allocated to digitise the secondary care sector, it would be natural to want to ’just get on with it’. We believe that a strong push to comprehensively digitise every trust over the next few years would be an error. We say this for several reasons. First, while the Treasury’s allocation of £4.2 billion is generous in light of today’s austerity conditions, we do not believe it is enough to complete the entire job (recall that only £1.8 billion is targeted at implementing systems to achieve the goal of a ‘paper-free NHS’; page 25). Although a detailed economic analysis is beyond the scope of our review, a rough calculation may suffice here. Let’s assume that it would cost the average acute trust a minimum of £40 million to digitise (including the costs of purchasing or licensing the software, consultants, staff training, and new staff hires). Let’s further assume that half of this £40 million – £20 million – would need to come from the central r.

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Under the National Information Board’s framework, regional ‘footprints’, sometimes composed of multiple trusts as well as other care delivery organisations, may be the entity that purchases and implements technology. For the purpose of this report, we will refer to ‘trusts’ as the unit of purchase/implementation, while recognizing that in some cases, the buyer will be the larger, more integrated organisation represented by the footprint.

government allocation. With 154 acute trusts, the total amount required from the government would be slightly more than £3 billion, or nearly twice the amount allocated. In addition to the practical reality of a funding shortfall, our assessment is that some trusts are currently too financially strapped, and/or lacking the staff, the training, and the culture to digitise effectively. We believe it would be an error to rush these organisations into implementing clinical information systems. Rather, we think it would be better to spend a few years helping these organisations prepare for successful implementations. Both of these factors – the insufficient resources to digitise every trust and the fact that some organisations need time to get ready – lead us to recommend a staged approach to implementation. Staging may also address the political reality that, given the problems with NPfIT, politicians and the public seem ready to pounce on failed implementations as evidence of a poorly conceived and executed plan (See sidebar on the experience at Cambridge University Hospitals NHS Foundation Trust (CUH)). This provides yet additional rationale to ensure that early implementations succeed. We believe that these early successes will lay the groundwork for a powerful argument for additional resources to be made available to get the rest of the job done in a second phase. As one national IT leader told our group, ’Never give money out faster than it can be absorbed.’

Our Group was very concerned that an aggressive push to digitise the entire secondary care sector by 2020 was more likely to fail than succeed.

Importantly, although the new effort is vastly different from NPfIT (with extreme care being taken to avoid calling it a ‘national programme’ and to minimise centralisation), this does not guarantee success. Our Advisory Group was very concerned that an aggressive push to digitise the entire secondary care sector by 2020 was more likely to fail than succeed.



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

The balance between regional and centralised approaches represents a core tension within the NHS. Of course, there is no one right answer – the correct approach needs to consider the problem being addressed and many other factors. In general, centralisation should be applied when its benefits outweigh its harms: when centralising creates economies of scale, when there are market failures that can be remedied only by centralising, or when there is insufficient capacity at the local level. The analyses conducted after the demise of NPfIT typically emphasised overcentralisation as a major explanation for the programme’s woes (11,12). We agree. However, part of the challenge in constructing a new policy approach to digitisation is that NPfIT’s history creates a sizable, and perhaps unfair, bias against centralised approaches. While the overall policy thrust of the new effort should emphasise local and regional solutions (particularly when it comes to which EHR to purchase, the need to achieve local buy-in and engagement, and the locus of support for this work), we believe it would be a mistake to avoid centralisation in certain areas where it just makes sense. We have listed these areas above. One important area relates to contracts with suppliers. In NPfIT, all contracts were negotiated centrally, as were all decisions about which EHR product would be implemented in a given region. While well intentioned (the leaders of NPfIT believed that this approach offered major economies of scale, created tremendous negotiating leverage, and ensured regional interoperability since everyone in a region would be on the same system), the flaws in this approach are now obvious. While our approach emphasises local control of purchasing decisions, we do believe that small trusts may be at a disadvantage as they try to negotiate complex contracts with large international IT suppliers. Because of this, we favour central negotiation of so-called framework contracts with several of the leading suppliers.s That way, local trusts can take advantage of any cost reductions from the negotiation, as well as the central expertise that they may not have regarding the legal and contractual nuances. Importantly, use of these framework contracts would be entirely optional; trusts would have complete choice of products. Maintaining the sense of local ownership of the process by trusts and their clinicians is crucial – particularly on the heels of NPfIT, a failed programme of externally imposed contracts (13). For trusts that do

s.

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A similar programme has now been enacted for trusts using monies from the Tech Fund to purchase ePrescribing systems. At first there was no framework, and most trusts tried to tender contracts themselves. Many of them experienced failed procurements, with flawed contracts, unrealistic expectations, and specifications that were impossible to meet. The situation has improved with the development of a centralised procurement framework. The NHS Diabetes Prevention Programme also utilises a national framework procurement, which also appears to be

not want to avail themselves of a central framework contract, another option may be shared purchases by multiple trusts, particularly those in the same local footprint (14).

5. Interoperability Should be Built in from the Start Local and regional efforts to promote interoperability and data sharing, which are beginning to bear fruit, should be built upon. Not only is interoperability important for individual patients who need their data shared for their own care, but it also promotes life-saving research and innovation – the latter by giving small companies a chance to solve specific problems with apps and other software that can bolt onto larger ‘enterprise’ IT systems. National standards for interoperability should be developed and enforced, with an expectation of widespread interoperability of core data elements by 2020. In addition to data sharing for health professionals, we endorse giving patients full access to their electronic data, including clinician notes (‘OpenNotes’). We also favour creating easy ways for patients to download such data (in a computable format) for their own use, and to upload patient-generated data (via surveys, sensors, wearables, patient-reported outcome measures, and data from other apps) into their electronic record. Such methods need to be built using principles of user-centered design, with careful attention paid to the implications for clinical workflow and workforce. We applaud the NIB’s emphasis on interoperability as a core attribute of any new programme to digitise the secondary care sector (15). The fact that, in 2016, many GP practices – virtually completely digital – still receive faxed versions of printed consultations from hospital-based specialists (and sometimes don’t receive them!) is an illustration of how important it is to build in interoperability from the start. On the other hand, over 70% of acute trusts now share discharges electronically, progress that can be built upon. Interoperability is deceptively difficult. It is important to take a holistic approach to it – just having the right standards and interfaces is not enough if, for example, a GP worries about liability after sharing data. All of functioning well. It will be important to learn from these and similar experiences in developing a centralised framework for EHR contracting.



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

national data assets. We endorse the recommendations of the National Data Guardian’s 2016 Review of Data Security, Consent, and Opt-Outs, which was commissioned to achieve this balance. The problems with privacy and security are obvious and tangible, and there is a vocal group of advocates defending the need for strong steps to protect data from misuse. The benefits of data liquidity are less obvious, more diffuse, and may accrue to individuals in the form of health benefits in the future. It would be a shame if the NHS moved to a more interoperable system, yet the potential benefits – for individual patients and the entire system – were to become unavailable because data were so tightly locked down. We know the National Data Guardian review grappled with these issues and we support her committee’s recently reported findings and recommendations. It would be a shame if the NHS moved to a more interoperable system, yet the potential benefits – for individual patients and the entire system – were to become unavailable because data were so tightly locked down. Issues of design are relevant here as well. Poorly designed systems to ensure privacy and security may encourage – in some cases nearly require – workarounds by healthcare professionals. As one example, as part of NPfIT every doctor and nurse was issued a security card to sign into their EHRs. The idea was that every clinician would sign in with his or her own card, thus ensuring that patient data would be accessed only by authorised individuals (‘role-based access’). The problem: in one A&E department the sign-in process took several minutes, far too long for busy doctors and nurses to wait while seeing large numbers of acutely ill patients. The solution: one healthcare worker signed in early in each shift and simply left his or her card in the machine, thus thwarting the very purpose of the security system. We learned that this kind of workaround is common practice.

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7. Health IT Systems Must Embrace User-Centered Design IT systems must be designed with the input of end-users, employing basic principles of usercentered design. Without user-centered design, such systems are unlikely to meet their full potential and have been shown to create opportunities for new types of errors and risks for patient harm. Poorly designed and implemented systems also result in frustrated healthcare professionals, by adding to their already substantial workloads and diverting them from meaningful work. While the NHS does not possess the skills to judge usability, it should support academic or other partners to conduct such reviews using validated assessment methodologies. Such reviews could then factor into decisions by trusts regarding IT systems. The NHS and England’s funders should also support research in this area. The usability of technology is one of the major drivers of its widespread adoption and use in everyday life. Usability also affects the quality of the data collected, and is thus a major determinant of the power of analytics. In high-risk industries like healthcare, usability is inextricably tied to safety. Poorly designed or implemented EHRs that do not support the way clinicians work also result in increased frustration, increased workload, and workarounds. While there may be short-term gains from education of end-users, in general education and training cannot compensate for poor usability. Consideration should also be given to the patient, who will interact with these new systems and their own EHRs. A negative user experience for the patient may well have consequences for both the individual and the healthcare system. The usability of any device or system can be broken down into two major categories: basic interface design (‘bin 1’) and cognitive support of the user (whether clinician or patient) (‘bin 2’) (17). The basic interface design should follow well-established principles (such as choices of font size and color) that ensure information is clear and readable, while also providing adequate contrast between the text and the background. Good bin 2 design entails much more detailed – and deeper – understanding of the cognitive work of the typical user’s information needs (including



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

Even with perfect preparation, many trusts (along with hospitals in other countries) have experienced challenges, including increased waiting times or budget overruns, during the Go Live period. Such initial turbulence occurs frequently, and generally resolves over 6 to 18 months. While maintaining patient safety is non-negotiable, regulators and commissioners need to have a degree of tolerance for short-term slow downs and unanticipated

consequences in the period following EHR implementation – they are the norm, not the exception. We learned of several Go-Lives in England in which there were problems; perhaps the most famous is the Epic installation at Addenbrooke’s Hospital in Cambridge.

Cambridge University Hospitals (Addenbrooke’s) In April 2013, Cambridge University Hospitals NHS Foundation Trust (CUH), a world-renowned teaching hospital in Cambridge with some 1,200 beds and 575,000 outpatients per year, signed a ten-year, £200 million contract for implementing a trust-wide electronic health record (EHR) system. Eighteen months later, the trust installed the Epic EHR system at both Addenbrooke’s Hospital and The Rosie, its maternity hospital. To put the CUH’s achievement in perspective, it is worth noting that prior to 2013, the trust had been given a rating of Stage 1 (‘minimal digital adoption’) on the Electronic Medical Record Adoption Model (EMRAM), whose stages range from 0 to 7. CUH’s digital transformation programme, dubbed eHospital, entailed the training of some 12,000 staff over a nine-week period, as well as the installation of some 6,750 personal computers and 500 laptops, 395 workstations on wheels, and 420 hand-held ‘Rover’ (iPod Touch) devices. Today, CUH benefits from the integration of all patient-related administrative and clinical information. Every patient wears a barcoded wristband linked to the EHR, which has improved patient safety. Moreover, the trust saves roughly £460,000 annually in staff time for eliminating the need to retrieve paper notes, as well as £655,000 each quarter in charting, thanks to device integration. The fracture clinic now reviews notes and x-rays virtually, freeing up some 4,500 clinic appointments. CUH’s was a classic, by-the-book, Epic implementation. That is, the trust opted to ‘go live’ all at once rather than phase the system in. The strategy behind a so-called ‘Big Bang’ implementation is to feel the pain all at once and work through it, as opposed to continuous pain over an extended period. (Think of a double hip replacement, and throw in two new knees at the same time, and you’ll get the picture.) It was not surprising to the Advisory Group that for CUH – and, we should add, for most healthcare systems that undergo a completely digital transformation – the road to digitisation was anything but smooth. In the immediate period following the Epic installation, CUH experienced a number of service disruptions: disruption to pathology services caused by problems with specimen label printers; disruption to the delivery of results of pathology investigations to primary care and other external consultants; a four-hour period of unplanned downtime necessitating an ambulance diversion plan and a several-day period of instability of one of the transfusion system interfaces; and disruptions in the consistency of clinical care including venous thromboembolism assessment, nursing care plans and community referrals, completion of discharge summaries and complex inpatient prescribing. Further, there was a substantial decrease in productivity, principally in outpatient clinics, in particular in hard-pressed services such as dermatology, cardiology, ophthalmology and ENT. In April 2015, just six months after the Epic implementation, the Care Quality Commission (CQC) carried out an inspection of the trust, and in its report, published in September, the CQC identified eight areas across the Trust that required focus for improvement, including Epic and IT support. CUH’s problems also caught the attention of the national press (‘The NHS’s chaotic IT systems show no sign of recovery,’ wrote the Guardian in December 2014).

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Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

Let’s begin with the nuts and bolts. In order for a clinical information system to be successfully implemented, there needs to be a robust and reliable network, ubiquitous wifi, plentiful and functioning computer terminals, and brisk sign-on. Buying an EHR without them would be akin to buying a modern car but leaving the roads unpaved. As we’ve emphasised, we worry most about the relative absence of a well-trained, professional informatics workforce. Some of today’s informatician shortfall reflects an exodus of workers from the healthcare marketplace in the wake of NPfIT. But the problem also reflects a lack of understanding regarding the adaption and optimisation process. Since Go-Live is just the beginning of an organisation’s digital journey, there simply must be adequate and well trained staff to continue (not complete, since that never happens) the journey. Of particular concern is the need for a cadre of CCIOs and others with both clinical and informatics training. We visited several NHS trusts that had one or, at most, two individuals with such backgrounds – and their aggregate time allocated was less than one whole-time equivalent. That is not nearly enough to get this difficult job done well. Moreover, such individuals are needed to provide support for system improvements – ranging from basic fixes to true innovations. At one trust we visited, a simple problem (the results of point-of-care blood tests could not be entered into the EHR) had gone unaddressed for 18 months, and the doctors and nurses had given up on asking the trust to fix it. These kinds of responses – workarounds and learned helplessness – are predictable if IT systems are created without a deep understanding of the nature of the work, an appreciation of and empathy for the predicament of the workers, and trained staff who can listen to clinicians’ concerns and fix faults in a system.

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10. Health IT Entails Both Technical and Adaptive Change Harvard political scientist Ronald Heifetz has popularised the paradigm of technical versus adaptive change. Technical change is straightforward: simply follow a recipe or a checklist and the problem will be solved. Adaptive change involves substantial and long-lasting engagement between those implementing the changes and the individuals tasked with making them work. Partly because technology adoption in the rest of our lives has become so easy (think about downloading an app on your smartphone), most observers and stakeholders mistakenly believed that implementing health IT would also be a simple matter of technical change. In fact, it is one of the most complex adaptive changes in the history of healthcare, and perhaps of any industry. This means that successful implementation of health IT requires the initial and sustained engagement of front-line users of the technology, whether it is healthcare professionals or patients. It also means that trusts need a robust, well trained, and well supported cadre of experts (CCIOs and others) who understand clinical practice, technology, and change management. These individuals are crucial in promoting the adaptive changes that are needed when an organisation switches from one way of doing work to another. We have made this point earlier and reemphasise it here because it is our overarching message, the message that weaves together all the threads (24). Even after NPfIT, we do not believe the lessons of adaptive change have been fully learnt, and this may well be the greatest threat to the current efforts to digitise the NHS.



We believe this is ambitious but – with additional funding for our proposed Phase 2 – achievable.

Deliverables and Timeline for Recommendation 1: By January 2017: • Create and publicise a name and appropriate branding for the new effort to digitise the NHS. By July 2017: • Create and begin to enact a national campaign to engage clinicians and trust leaders in the new effort to digitise the NHS.

2. Appoint and Give Appropriate Authority to a National CCIO In reviewing today’s NHS organisational chart and meeting with NHS leaders, we were unable to identify any high-level health IT policymakers who have both clinical training/experience and experience/training in health IT. We believe that such a person – a national CCIO – should be identified to oversee and coordinate NHS clinical digitisation efforts. This will signal that the NHS understands the adaptive nature of this effort to change, that it is serious about clinician engagement when it comes to health IT, and that it is putting a premium on clinical, not simply financial, outcomes. Such a person – who will need to have a background in clinical care, informatics, and leadership – should be given appropriate organisational and budgetary authority. Because health IT crosses the domains and budgets of so many NHS organisations, such an individual will assume an important coordinating function, not unlike the National Coordinator for Health IT in the United States. While a single individual and his/her office can do only so much, we found it both practically and symbolically meaningful that we could not identify any individuals who have ever cared for patients among those who have overall strategic authority for health IT in the NHS. We believe this needs to be remedied.u

u.

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We were pleased to learn that, in response to our recommendations, on 7 July 2016 NHS England and NHS Improvement announced the appointment of Prof. Keith McNeil, a seasoned healthcare administrator and former transplant specialist, as the first NHS Chief Clinical Information Officer, supported by Will Smart in the role of NHS CIO.

While it will be important that the individual has a suitable staff, budget and authority, much of the role will be as coordinator and an influencer, and it should be structured accordingly. In the US, the role of the National Coordinator for Health IT was created in 2004; the person in this role reports directly to the cabinet secretary (Secretary of Health and Human Services). In England, we believe that this national CCIO should report directly to the Secretary of State for Health or the NHS England CEO, and serve as chair or co-chair of the multi-stakeholder National Information Board (NIB). He or she needs to be optimally positioned to leverage the informatics capabilities and resources in, amongst others, DH, NHS England, NHS Improvement, NHS Digital, and the Care Quality Commission (CQC). To maximise the return on investment to the UK, it will also be important to work cross-sectorally with the Office for Life Sciences, the Department of Business Innovations and Skills, and other key departments.

Deliverables and Timeline for Recommendation 2: Already completed: • Create a job description for, and then hire, a prominent physician-executive with broad experience in information technology, leadership, and change management to become the NHS’s Chief Clinical Information Officer (CCIO). By January 2017: • Clarify and publicise the national CCIO’s role in leading the digitisation of the NHS, in terms of his or her relationship with NHS England, NHS Digital, NHS Improvement, the National Information Board, and other relevant bodies.



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

availability of such individuals, not only will there need to be satisfying, sustainable positions available to CCIOs in trusts (Recommendation 3), but the CCIO field must also be strengthened and grown. This will involve a major effort by existing professional bodies such as the Royal Colleges, the General Medical Council, and the British Computer Society to create and certify training programmes for clinician-informaticians. It will also require support for the development of vibrant professional societies. In addition to the CCIOs, the workforce of both clinician and non-clinician informaticians, researchers with expertise in clinical informatics, programme evaluators, and system optimisers (data processers, analysts, quality and safety leads) needs to be increased and nurtured. Without the right people and skills, digitisation will fail, or at least not achieve its full potential. Given the importance of the workforce to the success of the overall strategy, we recommend an investment in workforce development of £42 million, one percent of the £4.2 billion currently allocated for health IT. We see the absence of professional, wellsupported CCIOs with appropriate authority and resources as an enormous obstacle to successful deployment and benefits realisation of health IT at the trust level. Again, some of this is described elsewhere in the report. Moreover, the National Information Board report highlighted, in a general way, the need for a more robust CCIO workforce, and some of this effort has already begun under the NIB’s Domain G (1).v Finally, we acknowledge a proposal for the creation of a Faculty of Clinical Informatics, which may help address the issues of certification and professionalisation (2). To inform our group’s work, the CCIO Network undertook a survey of its members in early 2016. One hundred members completed the survey, 64% from acute care trusts. While nearly two-thirds had been clinicians for more than 20 years, less than 20% had been in their CCIO roles for more than five years. Confirming our impressions, about half of the respondents spend one day per week or less on their CCIO role, and most organisations have only one or

v.

40

‘Paper-free at the Point of Care’ domain, previously NIB Workstream 6.



‘My authority comes from my clinical and technical expertise rather than directly as a consequence of the title and position in trust hierarchy. Not holding any budget or having anyone report to me leaves me somewhat as an advisor rather than leader.’



‘Yes – [need] some training to bring all CCIOs up to a level. Yes, needs national recognition that this is really important for an NHS to be fit for 21st Century. My organisation feels a CCIO is a ‘nice to have’, not a mandatory role that requires time, resource and investment.’



‘Huge opportunities and risks. As full time clinician NHS is not releasing me enough to maximise my contribution to this. Difficult job to do ‘winging it’. Too important. But clinical credibility is key too, the balance needs to be better though.’

two clinician-informatics experts with dedicated time for this role. 76% of respondents disagreed or strongly disagreed with the statement, ‘We have enough trained clinicians in health IT and informatics to maximise the potential of our systems’ (Table 4). Three comments from the CCIO survey help illustrate the problems (Box). We emphasise the interdependence of Recommendations 3 and 4: without the availability of high level CCIO jobs in trusts (reporting at the board or CEO level, significant budget and staff, highly respected in the organisation) and a sustainable career track, few talented individuals will choose to leave the full-time practice of clinical medicine, nursing or pharmacy to obtain additional training and certification in informatics, and few students will choose this hybrid path as a career choice. And even those who do choose to pursue careers in health IT will find more attractive positions in the private sector. But even if appropriate roles for CCIOs and other clinician-IT experts became available in many trusts, there are not enough individuals with such training in the UK to fill these roles. Both of these issues – supply and demand – need to be addressed simultaneously. There must also be other well-trained workers, with a wide array of IT-related skills, to round out the team.



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

was in 2009, we believe that an allocation of £42 million – representing one percent of the £4.2 billion current investment in health IT – for workforce development is needed.

Deliverables and Timeline for Recommendation 4: By January 2017: • Confirm allocation of approximately £42 million (1% of the £4.2 billion to be spent on digitising the NHS) to support workforce development and deployment. By December 2017: • Establish and launch a programme designed to rapidly train CCIOs, CIOs, and other healthcare informaticians in executive leadership and informatics. The first few “classes” in this intensive 6-12 month training program should focus on training individual who will work at the trusts in Groups A and B. • The Faculty of Clinical Informatics, working closely with the British Computer Society and the Royal Colleges, should launch an accreditation and professionalisation agenda designed, ultimately, to certify and professionalise the CCIO workforce. • NHS England and other relevant UK bodies should establish a partnership with relevant international partners (including leading international training programmes and informatics certifying organisations) to help inform UK workforce development efforts. • NHS England should complete and begin to implement a workforce plan designed to grow other segments of IT-related workforce, including clinician and non-clinician informaticians, researchers with expertise in clinical informatics, programme evaluators, and system optimisers (such as data processers, analysts, quality and safety leads). • Health Education England, in collaboration with the Royal Colleges and other relevant bodies, should develop and begin to implement a plan to raise the level of digital education in all health professional educational settings, including medical, nursing and pharmacy schools, and in continuing education settings for practicing healthcare professionals. By 2019: • The Faculty of Clinical Informatics, working closely with the British Computer Society and the Royal Colleges, should complete the training and

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certification of at least 100 new graduates of CCIO training programmes in the UK. At least 80% of these professionals should take positions in trusts or other NHS healthcare delivery organisations.

5. Allocate the New National Funding to Help Trusts Go Digital and Achieve Maximum Benefit from Digitisation Given the upfront costs of switching from analog to digital (tens of millions of pounds for a midsized trust, still more for a large one), new investments are required to promote digitisation across the secondary care sector. We applaud the DH and the Treasury for making available £4.2 billion (approximately one-third of which is for IT system purchases and implementation support) to promote digitisation. Given the challenging financial state of many trusts, secondary care digitisation would have been impossible without new central resources. While welcome, this level of funding is likely not enough to enable digital implementation and optimisation in all NHS trusts. Therefore, we suggest a phased approach. During Phase 1 (2016-2019), national funding should be combined with local resources to support implementation in trusts that are prepared to digitise, and to support those that are already digitised and are ready to take the next step. We believe that another tranche of government funding (not yet allocated) will likely be needed to support a second stage (Phase 2, 2020-2023) of the strategy, as described under Recommendation 6. We have described our rationale for this under Finding 2, page 28. For deliverables and timeline, see under Recommendation 7.



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

c)

a description of the return on investment expected (framed in terms of clinical outcomes, service delivery, and financial outcomes);

d)

ongoing accountability that the money was well spent (such as through penalties for failure to deliver under reasonable timescales or a threat of loss of further funding);

e)

evaluation of progress made.

Recognising that levels of digital maturity (and, for those trusts that have not yet gone digital, digital readiness) vary widely across England’s acute trusts, we recommend that Phase 1 funding targeted at implementation be allocated to trusts via three major categories: Group A: Funding to trusts that have already achieved moderate or high levels of digital maturity. These trusts are likely to develop important innovations, to inspire other trusts to digitise, and to help anchor local health IT learning networks (Recommendation 8). Trusts in this category that receive funding will also be required to ‘pay it forward’, helping the next generation of trusts digitise by sharing learning and expertise and, where appropriate, computer code, decision-support tools, and apps. We estimate that approximately 12-15 trusts will fall into Group A. To promote shared learning, we favour the creation of a consortium – a learning network – of these trusts, with the aspiration that they become digitally superb. It would be worth thinking about partnering this network with a US or other non-UK organisation that has a world-class health IT system and strong culture of education and collaboration.

Group B: Funding to trusts that are currently digitally immature but are able to demonstrate sufficient readiness to begin implementing clinical information systems. This funding should not only support the purchasing of software licenses, hardware, and infrastructure improvements, but should also support workforce development, training, and participation in regional health IT learning networks. We estimate that approximately one in three NHS trusts will fall into Group B. Group C: Smaller amounts of funding to trusts that are not yet prepared to digitise. This funding should not be for the implementation of robust clinical information systems in 2016-19. Instead, it should be designed to help these trusts build capacity before they are mandated to implement clinical information systems in 2020-2023. (Some may choose to implement focused IT systems, such as ePrescribing, with their limited Phase 1 funding). The regional learning networks should help these trusts in their preparations and should, where appropriate, temporarily send relevant staff to more advanced organisations so they can shadow and learn. The proposed Phase 2 national funding will be needed to support this group’s digitisation in 2020-23. We estimate that approximately half of the acute trusts will fall into this category. Group D: Trusts that are reasonably far along but are not ready to advance. These trusts should receive no or minimal new funding during Phase 1. We anticipate that relatively few trusts will be in this category. Our approach is summarised in Table 5. This may be one of the more challenging recommendations to meet, but we see it as one of the most important. The information gathered through the digital maturity index surveys (Figure 2, page 24, and

Table 5: Two by two table categorising trusts’ readiness to advance and current state of digitisation Ready to Advance

Not Ready To Advance

Digital Now

Early Adopter (Group A): provide moderate funding to achieve even higher state, serve as role model, and teach others. Consider creation of a consortium of members of this group to promote shared learning.

Stable (Group D): provide no or minimal funding to help advance to next stage. Expect higher level of digital maturity over next 3-6 years

Not Yet Digital

Ready to Launch (Group B): provide substantial funding to buy system, train, Go-Live and support early enhancement. Expect reasonable digital maturity by 2020

Not Ready (Group C): provide modest funding to improve readiness, with hope of digital launch (with additional funding) around 2020; expect high level of digital maturity by 2023

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Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

• NHS England should finalise plans for these Centres, including timelines and deliverables. By December 2018: • All trusts receiving funding in Phase 1 (Groups A and B) should report on progress. Eligibility for additional funding should be approved by the NHS, based on the progress to date. • Specifically, the Centres of Global Digital Excellence (Group A) should be assessed on the following deliverables: –

Achieving high levels of staff engagement



Deployment of and support for appropriate workforce within the trust (including IT professionals)



Digitisation of all key processes of care and integration of all key clinical and administrative systems (both within the trust as well as with national systems such as PACS, eReferrals and Electronic Prescribing)



Substantial use of the electronic patient record to improve care through decision support and practice redesign



Information sharing with patients via patient portals, ability of patients to download key data, and integration with 3rd party apps (including patient-facing apps) through open APIs



Leading efforts to promote digitisation within region, including supporting other trusts



Leading efforts to achieve regional interoperability



Constructive engagement with international partner(s)



Implementation of robust privacy and security standards

By 2019: • NHS England and the national CCIO should identify and announce plans for funding and supporting those trusts that did not participate in initial digitisation efforts (Group C), including plans for dealing with any trusts that still cannot demonstrate readiness to digitise. By 2020: • Launch of Phase 2, with concrete plans to digitise Group C, and to continue improvements in Group A

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and B (will likely require additional central resources). By 2023: • National funding for trust digitisation ends, accompanied by an expectation that the entire NHS is digitised. • The Care Quality Commission should implement a plan to assess the digital status of trusts (including digital maturity and use of digitisation to promote care improvement), and to deem those that are not sufficiently digitally mature as out of compliance on quality/safety grounds.

8. Organise Digital Learning Networks to Support Implementation and Improvement To support purchasing, implementation, and ongoing improvements by trusts, digital learning networks should be created or supported. Some regions already have such networks, sometimes anchored by a trust with a high level of digital maturity. While some support might take the form of offering help in choosing a supplier, once a trust chooses a given EHR product it may wish to take advantage of a supplier-specific user network, since many of the issues are specific to each product. Such networks should also be encouraged and nurtured. A national effort, led by the new national CCIO, would help ensure that lessons are spread, but the primary point of contact for a given trust should be its local or regional network. The networks would link to the three categories of trusts (Recommendation 7) in the following way: 1)

Organisations ready to begin digitising (Group B) would take advantage of the digital learning networks to guide their choice of EHR system, their contracting, and their early implementation work.



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

Unfortunately, there is as yet no sophisticated digital connection between hospitals and GP’s at Trafford. When a patient is admitted to a hospital, or has visited the A&E, the system is alerted. The clinical summary of the visit is then transmitted to the patient’s GP either by post or fax, then scanned into the system. Approximately 10,000 people are currently in the system. Lawrence expects that eventually all 240,00 Trafford resident will be in it. The next project, Lawrence said, is a patient portal, to allow patients to see their entire medical record. If Lawrence has any advice to dispense to other regions seeking to build a fully integrated system, it is this: Don’t rush. ‘You have to build it bit by bit,’ she said. ‘This is a huge system change, and it takes time’. During the implementation of HITECH in the US, significant funding was given to help create a network of regional extension centers that provided support to practices that were implementing health IT systems (13). (It is worth noting that much of this help went to small office practices [the equivalent of GP surgeries], since HITECH aimed to digitise both offices and hospitals. In the current NHS effort, the centres would be orientated to helping trusts with their digitisation.) The development and operations of such regional networks may require some national funding. Once a trust has chosen a supplier, in addition to general help with contracting, implementation and optimisation, it may need advice on how to work with that supplier and its product. While there may be regions with enough volume for a supplier to create product-specific regional networks, we suspect that these supplier-orientated networks are more likely to be national, or even international. For example, there is already an active Cerner network in the UK, and active Epic, Cerner, Athena, and other vendor-specific networks in the US. In some cases, trusts may want support in working on certain problems, such as the management of sepsis or the discharge process. Here, while IT-specific networks may emerge, it is possible such needs may be better served through the network of CLAHRCs (Collaboration for Leadership in Applied Health Research and Care), or through one of the Academic Health Science Networks (AHSNs). The NHS may wish to establish a fund to allow various types of support networks to compete for resources; this would encourage different networks to form around clearly articulated needs of trusts.

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Deliverables and Timeline for Recommendation 8: By July 2017: • NHS England and NHS Digital should approve plans to promote regional learning and improvement within every region in England. These plans should identify the role of the Centres of Global Digital Excellence in helping other trusts go digital, in building regional interoperability, and in linking the region’s IT strategy to its STP and Vanguards programmes.

9. Ensure Interoperability as a Core Characteristic of the NHS Digital Ecosystem – to Support Clinical Care and to Promote Innovation and Research The new effort to digitise the NHS should ensure widespread interoperability. The goals of interoperability are not merely to create the technical capability to exchange digital data. Rather, interoperability needs to enable integrated workflow, service redesign, and clinical decision support. It also needs to support seamless care delivery across traditional organisational boundaries, and ensure that patients can access all parts of their clinical record and, over time, contribute to it. Finally, the roadmap for interoperability must include plans to use



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

10. A Robust Independent Evaluation of the Programme Should be Supported and Acted Upon We have argued that individual trusts need to build capacity to continuously learn as they attempt to implement and optimise their health IT systems. Underinvestment in the people and processes needed for such a learning system markedly increases the risk for failure. In light of the likelihood of unanticipated consequences, the high cost of digitisation, and the chequered history of similar efforts in the past, we believe that the NHS should commission and help fund independent evaluations of the new strategy. The same is true at the national level in the context of launching a new strategy to digitise the secondary care sector and create interoperability. The case for independent programme evaluation was made in a 2014 paper by Sheikh and colleagues (16): ‘Lessons from evaluations of NPfIT demonstrate why it is essential that countries embarking on major healthcare information initiatives build an objective body of evidence to inform policy and practice on how best to successfully design and deliver… national HIT programmes. Such evaluations are also essential to provide clear accountability for investments that use scarce taxpayer resources.’ In light of the likelihood of unanticipated consequences, the high cost of digitisation, and the chequered history of similar efforts in the past, we believe that the NHS should commission and help fund independent evaluations of the new strategy. The evaluations should be both formative (conducted and reported as the strategy is progressing) and summative (reporting at the ends of both Phase 1, in 2019, and Phase 2, in 2023). The evaluations should be conducted by a broadly representative group and led by individuals with

50

a strong track record in programme evaluation. They should utilise multiple modalities (data analysis, site visits, interviews, ethnographic methods), and be insulated from political influence and pressure. As Sheikh notes, such insulation is critical since ‘policymakers find that the results [of independent evaluations] often reveal inconvenient truths’. In the US the adoption of health IT has resulted in growing rates of clinician (particularly physician) dissatisfaction and burnout, in part because of increasing administrative burdens and challenges to efficiency. Therefore, programme evaluations should also consider the impact of digitisation on the satisfaction of healthcare professionals. Moreover, such satisfaction should be added to the list of metrics that trust leaders are evaluated on. Finally, research on the link between digitisation and workforce satisfaction – including studies of human factors, workforce training, and IT usability – should be supported. There simply must be a robust evaluation plan – one that is adequately resourced and insulated from political pressure, and whose results are fed back into the system to allow for iterative improvements and mid-course corrections. Even with all of the background wisdom born of prior experiences in the UK and elsewhere, the chances of getting it perfectly right at the start are low. On the other hand, the chances of having gotten it right at the end are high… if the system remains flexible and if people and organisations are open to learning from experience.

Deliverables and Timeline for Recommendation 10: By late 2017: • National Institute for Health Research (NIHR) should commission a formative evaluation of the digitisation programme by a respected academic leader/centre; the report should be published by mid-2018 to allow for mid-course corrections. By 2020: • Final evaluation of Phase 1 efforts should be delivered by same academic leader/centre. By 2023: • Final evaluation of Phase 2 efforts should be delivered by same academic leader/centre.



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

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Section 5: Recommendations 1.

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Robertson A, et al. The rise and fall of England’s National Programme for IT. J R Soc Med 2011; 104:434-5.

10. Benson T. Why general practitioners use computers and hospital doctors do not--Part 1: incentives. Bmj 2002;325:1086-9. 11. Lydall R. ‘World’s safest hospital’ to mentor east London trusts under plan to improve care. Evening Standard. 16 July, 2015. http://www.standard.co. uk/news/health/worlds-safest-hospital-to-mentoreast-london-trusts-under-plan-to-improvecare-10392492.html 12. http://www.england.nhs.uk/2015/03/tech-fundannounced/ 13. American Institutes for Research. REC Program Evaluation. Interim Report: Round 1 Case Studies. January 2014. http://www.air.org/sites/default/files/ downloads/report/REC%20Case%20Study%20 Round%201.pdf 14. http://www.ieee.org/education_careers/education/ standards/standards_glossary.html 15. Richesson RL, Chute CG. Health information technology data standards get down to business: maturation within domains and the emergence of interoperability. JAMIA 2015; 22:492-4. 16. Sheikh A, Atun R, Bates DW. The need for independent evaluations of government-led health information technology initiatives. BMJ Qual Saf 2014; 23:611-3.

56



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

Appendix A: Terms of Reference (Department of Health, February 2016) The review will inform the English health and care system’s approach to the further implementation of IT in healthcare, in particular the use of electronic health records and other digital systems in the acute sector, to achieve the ambition of a paper free health and care system by 2020. It will have a particular focus on issues around successful clinical engagement with implementation. Professor Wachter and the advisory board will: • Review and articulate the factors impacting the successful adoption of health information systems in secondary and tertiary care in England, drawing relevant comparisons with the US experience; • Provide a set of recommendations drawing on the key challenges, priorities and opportunities for the health and social care system in England. These recommendations will cover both the high levels features of implementations and the best ways in which to engage clinicians in the adoption and use of such systems. In making recommendations, the board will consider the following points: • The experiences of clinicians and Trust leadership teams in the planning, implementation and adoption of digital systems and standards; • The current capacity and capability of Trusts in understanding and commissioning of health IT systems and workflow/process changes. • The current experiences of a number of Trusts using different systems and at different points in the adoption lifecycle; • The impact and potential of digital systems on clinical workflows and on the relationship between patients and their clinicians and carers.

y.

58

The final report of the recommendations was delayed until September 2016 because of the period of purdah preceding the Brexit vote.

Evidence will be gathered through a combination of available written evidence, meetings with senior figures in the health and care system, and site visits to Trusts with varied experience of implementing IT systems. Professor Wachter will report his recommendations to the Secretary of State for Health and the National Information Board in June 2016.y



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

Andy Kinnear

Director of Digital Transformation at NHS South, Central and West CSU

Geoff Lavelle

CCIO Tameside Acute Foundation Trust

Joe McDonald

Chair CCIO LN and Consultant Psychiatrist, Northumberland, Tyne and Wear NHS Foundation Trust

Masood Nazir

GP and NHS England Patient online lead

Paul Sherry

CCIO, Warrington and Halton Hospitals NHS Foundation Trusts

Caron Swinscoe

Chief Nursing Information Officer (CNIO), Nottingham University Hospitals NHS Trust

King’s Fund, 3 February, 2016 Junaid Bajwa

Director of Healthcare Services, MSD

Paul Bate

Executive Director of Strategy & Intelligence, CQC

Julie Bretland

Development Director, DigitalHealth.London

Adrian Bull

Managing Director, Imperial College Health Partners

Diarmaid Crean

Deputy Director, Digital, Public Health England

Cosima Gretton

Academic Foundation Doctor, Guy’s & St Thomas’ NHS FT

Chris Ham

Chief Executive Officer, The King’s Fund

Matthew Honeyman

Researcher, The King’s Fund

Phil Koczan

GP, CCIO and Digital Clinical Champion for London

Charles Lowe

Managing Director, Digital Health & Care Alliance (DHACA)

Arvind Madan

Director of Primary Care, NHS England

Katie Mantell

Interim Director of Communications and Information, The King’s Fund

Kristen McLeod

Director of Strategy, Implementation and Planning, Department of Health

Mike Richards

Chief Inspector of Hospitals, CQC

Mike Short

Chief Executive Officer, Telefonica

David Sloman

Chief Executive Officer, Royal Free London NHS Foundation Trust

Rob Webster

Chief Executive Officer, NHS Confederation

Nuffield Trust Seminar, 3 February, 2016 Maureen Baker

Chair of RCGP Council, RCGP

Derek Bell

Faculty of Medicine, Imperial College London

Gary Davies

Consultant Respiratory & Acute Medicine, Chelsea & Westminster Healthcare NHS FT

Tim Evans

National Director of Clinical Productivity, DH

Stephen Fowlie

Medical Director, Nottingham University Hospitals

Andrew Gibson

Medical Director’s Office, Sheffield Teaching Hospital NHS Foundation Trust

Toby Graves

Consultant Physician, Dorset County Hospital NHS Foundation Trust

Mark Holland

President of the Society for Acute Medicine, Society for Acute Medicine

60



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

Individuals Interviewed by Professor Wachter Maureen Baker

Chair, RCGP Council

Paul Bate

Executive Director of Strategy & Intelligence, CQC

David Behan

Chief Executive Officer, CQC

Ann Blandford

Professor of Human-Computer Interaction & Director of UCL Institute of Digital Health

Beverley Bryant

Director of Digital Technology, NHS England

Fiona Caldicott

National Data Guardian, UK Government

Will Cavendish

Director General of Innovation, Growth and Technology, Department of Health

John Chisholm

Executive Chair, Genomics England

John Connolly

Chief Medical Officer, TPP

Ian Cumming

Chief Executive Officer, Health Education England

Ian Dodge

National Commissioning Director, NHS England

Tim Donohoe

Director of Informatics Delivery, Department of Health

Emma Doyle

Head of Data Policy, Patients and Information, NHS England

Nigel Edwards

CEO, Nuffield Trust

Tamara Finkelstein

Chief Operating Officer, Department of Health

George Freeman

Minister of Life Sciences

Harry Hemingway

Director of the Farr Institute of Health Informatics Research, London

Frank Hester

Chief Executive Officer, TPP

Jeremy Hunt

Secretary of State for Health, UK

Candace Imison

Director of Policy, Nuffield Trust

Samantha Jones

Director, New Care Models Programme, NHS England

Bruce Keogh

National Medical Director, NHS England

David Knight

Deputy Director, Information and Transparency Branch, Department of Health

Michael Macdonnell

Director of Commissioning Strategy, NHS England

Kingsley Manning

Chair, HSCIC (Now NHS Digital)

Alex Markham

Director of Research and Professor of Medicine, University of Leeds

Clare Marx

President, Royal College of Surgeons and Chair National Information Board, Strategic Clinical Reference Group

John Newton

Interim Chair, National Information Board

Shaun O’Hanlon

Chief Medical Officer, EMIS

Paul Rice

Head of Technology Strategy, Patients and Information, NHS England

Sally Davies

Chief Medical Officer, Department of Health (DH)

John Savill

CEO, Medical Research Council

Nick Seddon

Health Advisor to the Prime Minister

62



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

Appendix C: Abbreviations Used in the Report Academic Health Science Networks (AHSNs) Accountable Care Organizations (ACO) American Reinvestment and Recovery Act (ARRA) Application-programme interfaces (APIs) Cambridge University Hospitals (CUH) trust Cardiovascular risk algorithm (QRisk2) Centers for Medicare & Medicaid Services (CMS) Chief clinical information officer (CCIO) Clinical Commissioning Group (CCG) Clinical Practice Research Datalink (CPRD) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Department of Health (DH) Electronic Health Record (EHR) Electronic Medical Record Adoption Model (EMRAM) Electronic prescription service (EPS) General practitioners (GPs) GP Systems of Choice (GPSoC) Health information exchange (HIE) Health Information Technology for Economic and Clinical Health Act (HITECH) Institute for Healthcare Improvement (IHI) Institute of Electrical and Electronics Engineers (IEEE) Local Service Providers (LSPs) National Health Service (NHS) NHS Connecting for Health (NHS CfH) National Information Board (NIB) National IT network (N3) National Institute of Health and Clinical Excellence (NICE) National Programme for Information Technology (NPfIT) National Reporting and Learning System (NRLS)

64



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

Appendix D. Summary of Timetable for Deliverables Related to Key Recommendations Recommendation 1: A Robust Engagement Strategy By January 2017: • Create and publicise a name and appropriate branding for the new effort to digitise the NHS. By July 2017: • Create and begin to enact a national campaign to engage clinicians and trust leaders in the new effort to digitise the NHS.

Recommendation 2: A National CCIO Already completed: • Create a job description for, and then hire, a prominent physician-executive with broad experience in information technology, leadership, and change management to become the NHS’s Chief Clinical Information Officer (CCIO).

By 2019: • Trusts that have received national funding for Phase 1 digital implementation/improvement (Groups A and B) must have in place a CCIO, devoting at least 75% of his or her time to this task, who reports to the board or CEO (for largest trusts, may be to the chief medical officer or equivalent), with sufficient support staff, budget, and authority to lead successful digitisation and benefits realization within the trust. • Average-sized trusts should have approximately five individuals on staff with skills in clinical practice (from any discipline, including medicine, nursing, and pharmacy) and information technology; larger and smaller trusts should adjust these numbers proportionally. These individuals should have at least 25% of their time allocated to their IT and related work.

By January 2017: • Clarify and publicise the national CCIO’s role in leading the digitisation of the NHS, in terms of his or her relationship with NHS England, NHS Digital, NHS Improvement, the National Information Board, and other relevant bodies.

Recommendation 4: Strengthen and Grow the CCIO Field and the Health IT Workforce

Recommendation 3: Grow the Workforce of Trained Clinician-Informaticists at Trust Level

By December 2017: • Establish and launch a programme designed to rapidly train CCIOs, CIOs, and other healthcare informaticians in executive leadership and informatics. The first few “classes” in this intensive 6-12 month training program should focus on training individual who will work at the trusts in Groups A and B.

By January 2017: • Trusts seeking Phase 1 (2016-2019) national funding for digital implementation/improvement (Groups A and B; defined under Recommendation 7) must prepare and defend their workforce plans; plans must include a demonstration that the clinician-IT workforce is sufficiently robust to lead successful digitisation within the trust.

66

By January 2017: • Confirm allocation of approximately £42 million (1% of the £4.2 billion to be spent on digitising the NHS) to support workforce development and deployment.



Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England

Appendix E: Milestones in Digitising the NHS* March 2014 Formation of National Information Board

June 2002 National Programme for IT (NPfIT) launched in the UK under Tony Blair October 2005 1982 CCHIT awarded Micros for contract by ONC to GP develop criteria and programme evaluation process launched for certifying EHRs

1982

2002 2003

2005

2006

March 2010 Patient Protection and ACA enacted – provisions in the act strengthened the HITECH Act and ‘Meaningful Use’ by 2014 2007

2009

1989

1989 DH direct reimbursement to GPs for IT

2004 January 2004 George Bush State of the Union address on the President’s Health IT plan April 2004 - ONC created April 2004 Start of Quality and Outcomes Framework (QOF)

February 2009 Barack Obama mentions investment in EHRs as part of recovery plan – State of Union address HITECH enacted

2012 Formation of Clinical Commissioning Groups (CCGs)

2012

2010

2008

October 2014 NHS Five Year Forward View published

2011

2011-2014 Stage 1 of MU program September 2011 End of NPfIT

November 2014 NIB ‘Personalised Health and Care 2020’ strategy published

2013

2014 2015 2016

2016 DH and NHS accounce 4.2bn for technology investment in the NHS Digital Roadmaps submitted 2016 US announces end of Meaningful Use

* Includes relevant milestones in the US as well. Abbreviations: GP, general practitioners; DH, UK Department of Health; IT, information technology; NPfIT, National Programme for Information Technology; CCHIT, Certification Commission for Health Information Technology (US); ONC, Office of the National Coordinator for Health Information Technology (US); QOF, Quality and Outcomes Framework; ACA, Affordable Care Act (US); HITECH, Health Information Technology for Economic and Clinical Health Act (US); MU, Meaningful Use (US); NHS, National Health Service; NIB, National Information Board.

68



© Crown Copyright 2016 2905632 August 2016 Prepared by Williams Lea for the National Advisory Group on Health Information Technology in England

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