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Technology plays an increasingly important role in our health and care system. It allows us to consult specialists and receive care from home, order medications using our phones, and receive new digital treatments. This shift towards technology can, and should, be positive; technology can drive change, facilitating better patient outcomes and experiences. However, NHS patients struggle with aspects of digital health care, such as having multiple apps with siloed records, fragmented digitalisation, a lack of digital options, and insufficient accessibility features.  This study from the King's Fund aimed to understand the skills, knowledge and capabilities needed for health and care systems to do this well. 

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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. 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.

NHS England provides regular updates on progress with the implementation of the Digital Clinical Safety Strategy to show how they've captures insights about digital clinical safety, how they are training their workforce to support safety in this area and how they use technology to drive safer care. October 2023 update: Since the publication of the Digital Clinical Safety Strategy in September 2021, NHS England have been working towards two aims: To improve the safety of digital technologies in health and care, now and in the future. To identify, and promote the use of, digital technologies as solutions to patient safety challenges. The health service continues to see the steady increase of digital health technologies, and with it a heightened interest in digital clinical safety. This has driven progress towards these aims as well as the strategy’s five strategic commitments. Ensuring patient safety is reflected in the digitisation agenda remains a key component of the National Patient Safety Strategy. Commitment 1: Collect information about digital clinical safety, including as part of the Learn from Patient Safety Events (LFPSE) service and use it to improve system-wide learning. Worked with the LFPSE team to ensure the system accurately and thoroughly captures digital clinical safety information. This includes adding three new digital clinical safety specific fields for certain types of incidents. There is now a national process in place to ensure routinely collected patient safety data is reviewed by digital clinical safety experts in the same way that all other safety incidents are reviewed, including a formal review of all incidents indicating severe harm or death. The digital safety teams within NHS England became accredited to issue National Patient Safety Alerts. Commitment 2: Develop new digital clinical safety training materials and expand access to training across the health and care workforce. Developed and launched a new training package called the Essentials of Digital Clinical Safety, with over 1,100 members of NHS staff trained so far. Developed an intermediate training package specifically for senior leaders and patient safety specialists. An innovative ‘train the trainer’ pilot has been commissioned to train 24 digital clinical safety professionals as trainers, enabling regions to rapidly increase the number of CSOs and create an environment of peer-to-peer support and local mentorship for digital clinical safety. Commitment 3: Create a centralised source of digital clinical safety information, including optimised standards, guidelines and best practice blueprints. Created a dedicated FutureNHS workspace to showcase blueprints that share best practice. The workspace also supports the NHS to build communities around digital clinical safety. To date, in partnership with individual NHS organisations, we have published six blueprints to help organisations ensure clinical leadership and involvement at the earliest opportunity when a new digital system is implemented, so that risks are mitigated and plans are clinically focussed with a user centred design approach. Commitment 4: Accelerate the adoption of digital technologies to record and track implanted medical devices. Launched a Scan4Safety website including a suite of Scan4Safety guidance material that enables organisations to understand the key benefits and cost savings associated with a Scan4Safety Programme. It includes key messages from MHRA, NHS England and trusts already using Scan4Safety. It offers trusts a practical guide for how to get started. Continued to provide advice, guidance and support to organisations that were prioritising local implementation of Scan4Safety. In addition, NHS England have also engaged with board members across acute providers to better understand their awareness of and plans to introduce Scan4Safety. The Outcomes and Registries programme will be used to improve patient safety and outcomes in procedures that use high-risk medical devices. Commitment 5: Generate evidence for how digital technologies can be best applied to patient safety challenges. Worked with existing patient safety data to explore patient safety risks associated with certain digital technologies. Built analytic partnerships with organisations like NHS Resolution to explore the potential for patient safety claims data to reveal new insights about digital clinical safety. Leveraged integrated working across patient safety teams to ensure that digital clinical safety features on upcoming national frameworks for patient safety research priorities. Developed a benefits case for major digital transformation programmes in frontline services to evaluate their impact on safety. NHS Resolution worked with a large acute provider to analyse claims data and other patient safety data to consider how digital technologies contributed to or helped mitigate the risk of harm. A machine learning methodology was developed that could be replicated across other organisations.

This blog discusses the need to ensure a safe digital health system. Kelsey Flott, Deputy Director of Patient Safety at NHSX explains how owing to the pandemic, the NHS like others, have had to embrace digital technology at a rapid pace to cope with the challenges faced in the healthcare system. Due to this adoption of digital technology, it is vitally important that digital safety is included in current and future strategies.

This report, from The King's Fund, provides a summary of evidence and analysis to support leaders in health and care to engage in long-term thinking about the role of digital technology in their sector. It looks back at recent developments in digital technology in the health and care system, and looks forward, to a set of potential futures, to distil factors driving change and what this means for leaders now.

As NHS X publishes the first ever Digital Clinical Safety Strategy, Dr Sarah El-Sheikha, Clinical Advisor at NHS X and Anaesthetic Registrar, and Holly Carr, Florence Nightingale Digital Leadership Fellow, discuss why we all need to understand digital safety, and the risks and benefits to patient care.

The Digital Clinical Safety Strategy is a joint publication between NHSX, NHS Digital and NHS England and NHS Improvement. It is an addendum to the NHS Patient Safety Strategy, outlining the case for improved digital clinical safety across health and social care. The aim of the strategy is twofold: To improve the safety of digital technologies in health and care, now and in the future. To identify, and promote the use of, digital technologies as solutions to patient safety challenges. In other words, digital clinical safety is about making sure the technologies used in health and care are safe, and then using those technologies to improve patient safety. Part 1 of the Digital Clinical Safety Strategy provides an introduction to patient safety and defines digital clinical safety. It summarises the evidence base behind this strategy and it explains the regulatory and policy context for the strategy. Part 2 sets out the Digital Clinical Safety Strategy. It directly links to the NHS Patient Safety Strategy, mirroring its structure, which highlights ‘Insight, Involvement and Improvement’, as three strategic priorities for safer systems and safer cultures. Actions are outlined for each of these three areas. The strategy specifies 23 actions, which can be summarised as five national commitments. National commitments for digital clinical safety Collect information about digital clinical safety, including from the Learn from patient safety events (LFPSE) service and use it to improve system-wide learning. Develop new digital clinical safety training materials and expand access to training across the health and care workforce. Create a centralised source of digital clinical safety information, including optimised standards, guidelines and best practice blueprints. Accelerate the adoption of digital technologies to record and track implanted medical devices through the Medical Devices Safety Programme. Generate evidence for how digital technologies can be best applied to patient safety challenges. Part 3 explains how this strategy will be delivered and updated, with a focus on patient safety and digital health networks. This strategy establishes what is needed for digital technologies to enable safety across health and care and how that can be prioritised nationally and delivered with a range of stakeholders. This strategy’s objectives support the wider NHS Patient Safety Strategy’s aim to build safer systems and safer cultures.

This publication from the US-based Joint Commission shares recommendations for organizations to guide effective provision of telehealth services. The alert discusses insights to establish secure and reliable telehealth systems and programs. It highlights creating standards for virtual care delivery, training staff to understand virtual patient monitoring, outlining specific clinician roles, and targeting tasks needed to as tactics to ensure virtual care is complete.

Health IT (HIT) systems are increasingly becoming a core infrastructural technology in healthcare. However, failures of these systems, under certain conditions, can lead to patient harm and as such the safety case for HIT has to be explicitly made. This study from Habli et al., published in Safety Science, focuses on safety assurance practices of HIT in England and investigates how clinicians and engineers currently analyse, control and justify HIT safety risks. Two areas of strength were identified: establishment of a systematic approach to risk management and close engagement by clinicians; and two areas for improvement: greater depth and clarity in hazard analysis practices and greater organisational support for assuring safety. Overall, the dynamic characteristics of healthcare combined with insufficient funding have made it challenging to generate and explain the safety evidence to the required level of detail and rigour. Improvements in the form of practical HIT-specific safety guidelines and tools are needed. The lack of publicly available examples of credible HIT safety cases is a major deficit. The availability of these examples can help clarify the significance of the HIT risk analysis evidence and identify the necessary expertise and organisational commitments.

Helping patients and their families cope during a terminal illness is fundamental to good health care and that depends on professionals and the people in their care having access to the right information at the right time to support them. The Professional Record Standards Body (PRSB) has published the crisis care standard to support better coordination of treatment in primary,acute and community care, as well as hospices, care homes, and social services. The standard will also help patients to avoid unnecessary admissions and procedures.

Over the next three years the Development of the Patient Safety Incident Management System (DPSIMS) project will define and deliver the successor to the National Reporting and Learning System (NRLS) and the Strategic Executive Information System (STEIS). The NRLS is more than 13 years old and due for an upgrade, which is why we're working closely with stakeholders to create a system that will provide resources to support safety improvement and help the NHS learn when things go wrong. The new system will: meet both local and national needs in terms of accessibility to both staff and patients/carers integrate with other systems strike a balance of confidentiality and transparency support an open and honest NHS culture devoted to continuous learning and improvement of patient safety

A Global Digital Exemplar (GDE) is an internationally recognised NHS provider delivering improvements in the quality of care, through the world-class use of digital technologies and information. Exemplars will share their learning and experiences through the creation of blueprints to enable other trusts to follow in their footsteps as quickly and effectively as possible. The GDE Blueprinting workstream forms part of the national Provider Digitisation Programme. GDE blueprints are expected to help other NHS Trusts deliver digital capabilities more quickly and cost effectively than has been possible in the past. The GDE blueprints are a structured collection of knowledge assets and associated methodology for using them. They highlight important ingredients needed for sustainable health improvements such as organisational leadership and culture, technical guidance, clinical and staff engagement as well as the people and processes required to deliver the benefits of technology. They cover a range of digital initiatives such as using software to detect the risk of patients contracting sepsis, having a paperless A&E department or introducing e-prescribing across an organisation to improve safety and quality of care, clinical outcomes, and patient and staff experience. Created by NHS Trusts, who are recognised for using digital technologies to support wider transformation, the GDE blueprints are step-by-step guides that can also be tailored by individual Trusts to suit their own local needs and requirements. The GDE blueprints can be found on the FutureNHS platform. To register, email: [email protected]