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Record breakers

Dr Vijay Magon, managing director of CCube Solutions, weighs up how the UK Government’s extra £2.1 billion for NHS IT should be best spent

Widely considered the best sprinter of all time, with gold medals in 100 and 200 metres from three consecutive Olympic Games, the Jamaican athletics icon Usain St Leo Bolt is a speed phenomenon. Now retired, he still holds the 100 metres record at 9.58 seconds set in 2009 at the Berlin World Athletics Championships. Bolt achieved an average speed of 23.35 mph although data shows he hit a mind boggling 27.8 mph mid-race; no wonder he’s affectionately nicknamed Lightning Bolt.

ccube Old records library

Another record breaker from 2009 – and in this case it’s actual physical records – is St Helens and Knowsley Teaching Hospitals NHS Trust. It was the first trust in the UK to stop using paper medical records in clinical practice after migrating to an electronic document and records management system (EDRMS) to coincide with the opening of two hospitals costing £338 million at Whiston and St Helens.

The implementation of EDRMS software and a scan-on-demand approach allowed the Trust to stop hand delivering 7,000 paper files to outpatient departments each week (which it would then file on return) and close its records library, a building containing over one million folders, each holding on average 250 pages.

The EDRMS cost £1.2 million, but with annual savings of £1.4 million in storage, transportation and staffing costs (existing staff were redeployed), the new digital system paid for itself within a year and has been saving a vast amount of money ever since.

Moreover, by ensuring that the right medical records for the right patient were available to the right doctor at the right time, the Trust has been able to reduce the number of elective care appointment cancellations because notes were lacking; improve clinical productivity as more patients are seen; and enhance patient safety and overall clinical care.

All of which is a useful segue to the focus of this article: the announcement in last October’s Budget Statement of an extra £2.1 billion for the NHS to improve its use of digital technology and data.

Digital transformation is a broad area, but to focus on patient records specifically, it is clear that many Trusts are still far too reliant on paper. Our own Freedom of Information requests show that 50% of the country’s 233 Trusts have yet to transition to computer based systems as St Helens and Knowsley did 13 years ago.

This begs the question why so many have been slow to embrace change and what should be done with the new funds to ensure the best return on investment?

Why has it taken so long to get rid of paper?

The Coronavirus pandemic provided further evidence that the NHS has simply not put enough effort and investment into digitisation despite Health Secretaries – specifically Jeremy Hunt – challenging the NHS to be paperless. He wanted this by 2018, although his predecessor Andrew Lansley pledged to start an information revolution back in 2010.

There are various reasons why this has not happened:

  • First, whilst funding was available at an umbrella level, it didn’t universally filter down to support local digitisation projects.
  • Second, other IT priorities have consumed budget.
  • Third, a lack of people resources and ownership to drive projects through has hindered progress, with records digitisation delayed time and again.
  • Fourth, some Trusts have managed the process poorly by not indexing or classifying information properly, which has meant the digital solution offered is actually worse than delivering paper. Time-pressed clinicians have been presented with a large PDF displaying pages of historical notes which it is impossible to navigate when consultations last just 15 minutes. Enduser system acceptance and adoption therefore failed.

In the post-Covid world, clinicians and their patients are often geographically separate. Nor are paper notes helpful when multi-disciplinary medical teams come together in an individual’s treatment and need access to the same information. Paper notes self-evidently aren’t practicable and compromise patient safety, hence the impetus to revisit digitisation.

Consider also that an average paper record is physically handled 10 to 15 times from storage to delivery. Not only is there an infection risk from touching paper but costs mount each time a file is requested and then put away.

It is now time to address this with an ‘invest to save’ process and to get rid of paper once and for all.

How should the new money be spent?

New money for NHS IT is welcome, but we should be mindful of the errors made in the past. The National Programme of IT championed by the Blair Government in 2002 is the poster child of how not to manage things. It failed because IT systems were foisted upon Trusts in a ‘top down’ approach that didn’t take into account local needs. It cost the taxpayer billions and was dismantled in 2011.

To ensure the new cash is well spent, it is vital to give some thought and consideration to the following:

  1. Digital transformation is a loose term that means different things to different people. There needs to be clearer definition about what it actually involves, including areas of technology, costs and expected benefits;

2.  Spending should be allocated to tackle obvious problem areas first and provide quick wins. Patient records is an obvious example.

3. Innovation should be championed and promoted, with Trusts free to make their own decisions about the IT systems they want based on local requirements.

ccube St_Helens_Newfront

4. Systems deployed must meet uniform data standards enforced by the Department of Health and Social Care (DHSC) so that System A from Supplier 1 can talk to System B from supplier 2 and so on. HL7-FHIR is one standard for exchanging healthcare information electronically, along with SNOMED CT, which contains all the clinical terms required to document procedures, symptoms, clinical measurements, diagnoses, medications and so on.  It gives IT systems a shared language that everyone can use.

5. IT interoperability must be at the heart of any future national NHS IT investment and be enforced fastidiously by the DHSC with penalties imposed on suppliers that act in commercial self-interest. There is too much of this going on already, with the NHS likely to be held to ransom in the long term with costly fees and proprietary ‘lock in’.

Incumbent clinical IT vendors must be managed closely to ensure they do not act in monopolistic ways and prevent additional functionality and value from other suppliers from being easily integrated.

APIs are a good example of this. While all suppliers state in their NHS bidding questionnaires that they have open APIs, some make it difficult for other firms to use them or seek to charge for access – in effect double charging the NHS. Once Trusts have purchased software licenses, APIs need to be free so that integration is simplified and ‘air gaps’ between systems are avoided.

6. Government must not be seduced by big or trendy technology firms that appear to offer ‘the’ perfect solution. It doesn’t exist. Competition is key and must be encouraged. And competition comes from firms of all sizes.

7. The convoluted and complex NHS procurement process which negatively affects SMEs needs to be simplified. Once a firm is authorised on an appropriate framework, they should be free to bid on technical merit rather than wasting time on onerous form filling which impacts smaller firms disproportionately.

8. Care should be taken to ensure the ‘right’ technology is used for specific purposes rather than stretching systems to do things outside their main scope. For example, clinical EPR systems used in both primary and secondary care are perfect for holding structured clinical data. They’re not designed to hold large volumes of unstructured information from scanned legacy patient records that require lifecycle management rules to be applied.

9. The application of any technology should address specific problems and whatever solution is installed must be expandable over time so that ‘roadblocks’ in the future are avoided. Trusts that fail to do this to a reasonable level of detail are likely to suffer from difficulties at some point.

10. IT departments must engage and work closely with their end-user community about system selection, given that it is clinical practitioners who use the technology day to day. There cannot be an ‘us’ and ‘them’ approach.

The numbers associated with UK healthcare provision are staggering, inflated by the Coronavirus pandemic, an ageing population and a growing number of people who need medical treatment every day. The ONS estimates that in 2020 the UK Government spent in the region of £220 billion on healthcare alone.

It is essential that we maximise the use of our finite financial resources and the extra budget announced by Rishi Sunak in October 2021. If the NHS focuses on the requirements outlined above, then like Bolt himself, digital transformation has every opportunity of being a running success.

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