Independent report. Making IT work: harnessing the power of health information technology to improve care in England (7 September 2016)

Summary

In late 2015, the National Advisory Group on Health Information Technology in England was formed to advise the Department of Health and NHS England on its efforts to digitise the secondary care system. Our recommendations fall into two broad categories: 10 overall findings and principles, followed by 10 implementation recommendations.

Content

Overall findings and principles

1. Digitise for the correct reasons

The goal of digitisation of health systems is to promote what has become widely known as healthcare’s Triple Aim: better health, better healthcare, and lower cost. These aims are consistent with those of the NHS’s 2014 Five Year Forward View, which called for improvements in quality and service, as well as £22 billion in efficiencies. The Advisory Group believes that trying to achieve the aims of the Five Year Forward View without giving highest priority to digitisation would be a costly and painful mistake.

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 that are ready to digitise are prompted to do so, while those that are not ready should be encouraged and supported to build capacity, a process that will take several years.

3. ‘Return on investment’ from digitisation is not just financial

While it is natural to seek a short-term financial return on investment (ROI) from health IT, experience has shown that the short-term ROI is more likely to come in the form of improvements in safety and quality than in raw financial terms. In fact, cost savings may take 10 years or more to emerge (the so-called ‘productivity paradox’ of IT), since the keys to these gains are improvements in the technology, reconfiguration of the workforce, local adaptation to digital technologies, and a reimagining of the work.

4. When it comes to centralisation, the NHS should learn, but not over-learn, the lessons of NPfIT

While it is true that NPfIT erred partly through overcentralisation, it is also important to note that centralisation sometimes makes sense, particularly in the context of a national health system. A new digital strategy should seek an appropriate balance between local/regional control and engagement versus centralisation.

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 end-users, 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 electronic health record (EHR) implementation.

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 long-term 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 co-creation of systems and strategies. The campaign needs to emphasise that the goal is not digitisation for digitisation’s sake, but rather to improve the way care is delivered in the NHS, in part by using digital tools.

2. Appoint and give appropriate authority to a national chief clinical information officer

A national chief clinical information officer (CCIO), with a background in clinical care, informatics, and leadership, should be appointed to oversee and coordinate NHS clinical digitisation efforts. This individual and his or her team must be given appropriate organisational and budgetary authority. Because health IT crosses the domains and budgets of so many NHS organisations, this individual and team will assume a crucial coordinating function.

3. Develop a workforce of trained clinician-informaticists at the trusts, and give them appropriate resources and authority

There must be a major effort to place well-qualified clinicians with advanced informatics training in every trust. The Advisory Group estimates that an average-sized trust needs at least 5 such individuals on staff. Their leader, the CCIO, should be a well trained and credentialed clinician-informatician, and should report directly to the board or CEO. In considering whether to offer government money to subsidise digital implementation in a trust, close attention should be paid to the adequacy of the trust’s plan to hire and support this clinical-IT workforce.

4. Strengthen and grow the CCIO field, others trained in clinical care and informatics, and health IT professionals more generally

The dearth of professional, well-supported CCIOs with appropriate authority and resources is an enormous obstacle to successful deployment and benefits realisation of health IT at the trust level. To rectify this gap, not only will there need to be satisfying, sustainable positions available to CCIOs in trusts, but the CCIO field itself must also be strengthened and grown. This will involve a major effort by existing professional bodies to create and certify training programmes for clinician-informaticians. It will also require support for the development of vibrant professional societies. Moreover, the workforce of clinician and non-clinician informaticians, informatics researchers, programme evaluators, and system optimisers needs to be increased and nurtured. We favour a significant allocation of central resources – £42 million, or 1% of the £4.2 billion allocated for digitisation – to support this crucial workforce development.

5. Allocate the new national funding to help trusts go digital and achieve maximum benefit from digitisation

The £4.2 billion the Treasury made available in 2016 to promote digitisation, while welcome, is not enough to enable digital implementation and optimisation at all NHS trusts. Therefore, we suggest a phased approach. During phase 1 (2016 to 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 ready to reach even higher levels of digital maturity. Another tranche of government funding (not yet allocated) will likely be needed to support a second stage (phase 2, 2020 to 2023) of the strategy, as described under recommendation 6.

6. While some trusts may need time to prepare to go digital, all trusts should be largely digitised by 2023

It would be reasonable to expect all trusts to have achieved a high degree of digital maturity by 2023. After that year, we recommend that no more government subsidies be made available, and that regulators should begin to deem trusts that have not reached a high level of digital maturity to be out of compliance on quality and safety grounds.

7. Link national funding to a viable local implementation/improvement plan

The availability of central money to support digitisation should be linked to a parallel investment from each trust (based in part on ability to pay), NHS approval of 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 supplier-specific 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 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 2 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.