The power of information and digital technology to transform the NHS

I believe passionately in the power of information and digital technology to transform the way we deliver health and care, indeed I consider it essential if we are the meet the growing demands the health and care system faces within the resources likely to be available.

We need to mobilise information to help us redesign services and target the resources available most effectively. We need to use the Single and double battery reviews and digital technology to deliver higher quality more convenient services more efficiently and we need to make information about how services perform transparent  so that the public, patients and health and care professionals can see how they perform and how they can be improved.

However, we need to leave decisions about how local health and care communities realise this potential to them, measure their success in terms of the health outcomes and efficiencies they achieve and avoid mandating particular approaches. While I think it is inevitable that the effective uses of digital technology will lead to a reduction in reliance on paper and an increase in the use electronic record systems it is not true that a move away from paper towards electronic records will necessarily lead to an improvement in the quality of care, indeed when the emphasis is on implementing particular systems rather than improving the processes of care experience tells us that the opposite is more likely. Focusing on becoming paperless and implementing EPRs is a dangerous distraction which potentially provides local health communities with an excuse to fail at their core task of delivering higher quality care.

The primary focus needs to be on how we apply digital technologies to mobilise information and knowledge at the point of care to improve the experience and outcomes for patients and health and care professional at the frontline, while an important secondary focus should be on how we use information and knowledge to design, target, evaluate and improve care.

We should have zero-tolerance for systems that slow down or make tasks at the frontline more difficult (as is so often currently the case) Our expectation must be that good design can create systems that meet upstream information needs without additional frontline burdens.

The incremental upgrading and of digital technology in line with the incremental redesign of care processes is more likely to bring about positive-only changes in care quality than radical big-bang implementations which at best typically result in a substantial negative impact before any net positive benefit is achieved (which in health and care means avoidable death and suffering.)

This requires a new approach from the health IT industry, but one that current technologies can deliver and which can be successfully built on top of the substantial, and in many places excellent IT, already in place. This approach will draw heavily on app and portal technology, open-systems, open-interfaces, open-standards and data transparency. It will require the extension and opening up of existing systems and infrastructure to create an open health IT ecosystem creating a mixed economy for open-source and proprietary components. My experience with both the established health IT vendors and the rapidly growing app community convince me they are more than up to the challenge.

The Centre does have a role to play in creating an environment in which local health and care communities are encouraged and enabled to embrace information driven, digital ways of working, but have to be careful balancing  this with the risk of creating unintended consequences and sub-optimising behaviour in local health and care communities. The Centre needs to ensure that personal and organisational incentives are aligned with the need to deliver integrated patient centred services in ways that improves overall quality and drives down overall cost (which they currently are not) and also has a role in creating the technical, cultural and commercial environment in which successful innovation can be translated in to widespread adoption creating a vibrant market.

In playing its’ part the Centre needs to have a clear understanding of the history – In NHS this history of has many clear examples of both spectacular success and failure and needs to engage with those who not only share their vision, but who also understand this history, what life’s really like on the front-line of the NHS and the practical implementation challenges of achieving the vision.

A Paperless NHS

Given the usual scant regard to the commonly accepted meaning of words that seems to be the norm in the NHS – “Paperless” is something that we now have in the majority of general practices and that many have had for some years and I’m really enthusiastic about the desire from the centre to drag the rest of the NHS into the Digital Age, but am really concerned that the initiative is being driven by a leadership who are, to be frank, clueless.

Firstly, the focus is wrong – Creating electronic records and/or removing paper, desirable as these may be, should not be the objective. The objective should to use technology to support and coordinate the processes of care so that the patient sees a integrated service that delivers greater convenience and quality.

This inevitably means more digital services, and will result in the creation of electronic records and the removal of paper from many processes, but in a way where these changes support process improvement. This is what happened in general practice – Processes were digitised one-by-one  and the data needed to support this digitisation was stored in electronic records. Over time these records became comprehensive and GP practices have become “paperlite”  this approach gave quick wins and avoided the risk of suddenly trying to go to fully electronic records. See Lessons from GP Computing

Secondly, we don’t have the infrastructure. Already nurses and junior doctors fight over ward terminals and the COWS (Computers on Wheels) for access to IT systems and when they finally rest a keyboard from colleagues typically find themselves  using obsolete hardware, operating systems and browsers accessing poorly integrated multiple  systems over inadequate networks. We need to address the infrastructure issues before we can go paperless (or lite). Every health and care professional needs their own device connected with ubiquitous LAN (WiFi) and WAN(3/4G) across the whole NHS estate and out into the community for those realtors. A paperless NHS without the infrastructure to support it will be worse than the current paper based system.

I’m all for putting pressure on NHS Trust to embrace a digital future and have some sympathy with the approach attributed to Richard Nixon: “When you have them by the short and curlies their hearts and minds will follow”. However, to secure the benefits that I believe are possible from the digitisation of the NHS we do have to win the hearts and minds of frontline staff and I don’t think this will be achieved by exhortations to do the impossible which will end up with ill-considered and poorly implement EPR systems  running on wholly inadequate infrastructure damaging morale and undermining patient care.

Creating a truly digital NHS requires careful design involving the public, patients, health and care professionals and digital engineers working together to create digital services to deliver truly holistic care. It requires infrastructure that is fit for purpose and needs the support of a health IT ecosystem that ensures all of the components play nicely together. See the HANDI Vision and the work of OpenGPSoC for more about what this ecosystem might look like.

I’m a firm believer that it is only by using information and information systems in innovative ways, both to support the way we directly deliver services and through analytics to effectively target and evaluate what we do, that we can hope to meet the challenges that the NHS and healthcare systems across the globe face. Headline political targets like  “a Paperless NHS” have their place in stimulating debate, but unless they are followed by meaningful action from those who have sound insight in to how digitisation might transform the way we deliver care and involve the public and patients in the process are little more than an distraction.

The Commissioning Board should focus on the Commissioning of care (both directly and through CCGs) and making sure that personal and organisational incentives for all the actors in the system are aligned with the imperative to deliver better quality more convenient services for less. They also need to ensure that the information flows required to support individual care and monitor the performance of the system as a whole are available by making these the basis on which providers are paid for their services. I can’t see how providers can achieve the transformation required without embracing IT, widespread digitisation and social media, but hold them to account for their outputs, not how they achieve them.  By setting ill-consider targets about a paperless NHS and EPRs the Commissioning Board is just giving providers excuses to fail at their core task.

Theses issues were discussed on the  #CCIO tweetchat on Wed 20 Feb  7-8pm  For the best bits and full transcript can be found here 

There are also themes here to pick up at the PHCSG UnConference on 6th June