No trust is an island: digital maturity for health and care economies

At its January 2020 meeting, Highland Marketing’s advisory board talked to Professor Graham Evans about how North Tees and Hartlepool NHS Foundation Trust has reached HIMSS 5 – and how he hopes to progress digital maturity across the North East and North Cumbria integrated care system.

Members then debated digital maturity. How should this be measured across systems? And how can policy makers, regulators and the healthcare IT industry support digital aspirants and digital equity?

North Tees and Hartlepool NHS Foundation Trust has a tradition of IT innovation, going back to the era of the National Programme for IT. In 2015, it became the first trust in England to deploy the TrakCare electronic patient record from InterSystems and it has been doing important work on tracking as part of the Scan4Safety project.

Professor Graham Evans, the trust’s chief information and technology officer, told the Highland Marketing advisory board how its work had enabled it to achieve level 5 on the HIMSS EMRAM digital maturity model, and how it is now on course to achieve HIMSS 6 and 7.

However, Professor Evans stressed that while TrakCare is the trust’s “crown jewel” it is the “sparkles” around it that have delivered for staff and patients. North Tees and Hartlepool is working to integrate the EPR with the Vocera communications system, to improve working conditions for staff and to close the loop on e-prescribing and medicines administration, which has been shown to improve patient safety.

No trust is an island

Increasingly, though, the intangible benefits of digitisation may be just as important as the quantifiable ones. For example, James Norman, healthcare CIO at DellEMC, suggested that trusts that gain a reputation for doing innovative things with technology may be the ones that manage to attract and retain scarce staff.

Professor Evans agreed. “People who work in the NHS in the North East may want to go to Newcastle as it’s a big vibrant city, with a big, internationally renowned hospital. We understand that,” he said. “But they might want to come and work for us if they can see that we are doing good things. I think that if trusts can’t offer that, many will struggle in the future.”

Indeed, the Health Service Journal reported recently that the trust’s neighbour, South Tees Hospital NHS Foundation Trust, is concerned that its lack of an EPR is not only deterring staff but putting patient care at risk. 

Professor Evans, who is also chief digital officer for the North East and North Cumbria integrated care system, argued that this kind of situation can’t continue if ICSs are going to make the impact that the NHS Long Term Plan wants them to have on joined-up working, population health management, and creating new digital services for patients.

“North Tees and Hartlepool is not an island,” he said. “We can only be as successful as the system we work in, and the system we work in will only be as good as its weakest link. So, we need to think about system success and digital maturity across the piece.”

Many systems, one goal

This doesn’t mean returning to the National Programme for IT days of trying to roll out one system across a region. Some of the four integrated care partnerships that make up the North East and North Cumbria ICS have coalesced around different EPR systems; Cerner is deployed in Newcastle, while Meditech is working in Sunderland.

And Professor Evans said he was fine with this, as long as they can all connect into the Great North Care Record, which is deploying a health information exchange from Cerner, and which has plans for a patient engagement platform that may, eventually, be linked to the NHS App to act as a “digital front door” for patients.

In fact, he argued, there are benefits to maintaining a market that is competitive enough to keep suppliers on their toes. On the other hand, he suggested it would make sense for his trust to be able to help its neighbours.

In response to a question from Ravi Kumar, a long-standing IT developer and entrepreneur,who asked how Professor Evans was mitigating the risk of losing the team that he had built up, he said: “I am hoping that I can use some of my resources to help others.

“If my neighbours adopt the same thinking and technology solutions, then my IT and digital staff can help them, and we would start to create careers, rather than jobs.” Another benefit, he noted, would be that clinicians who needed to move between sites would be more familiar with their IT systems.

“All these systems do the same things, but [different suppliers] put things in different places,” he said. “So, we need a converged approach, where appropriate, that means clinicians can move around and still do their jobs and keep patients safe.”

Knocking heads together

As things stand, there are significant challenges to implementing this kind of cross-health and care economy approach. The NHS Long Term Plan was published in January 2019, but England won’t have fully rolled-out ICSs until April 2021.

And, with legislation promised for the current Parliament, it is still unclear whether they will be put on a statutory basis or exactly what powers they will have to determine the strategies and purchasing decisions of the organisations they cover.

Even so, Professor Evans told Highland Marketing client director Susan Venables that “somebody has to say: ‘You have to do this’ and in the emerging health and care system that would be some kind of healthcare economy-wide organisation.

“I am not a fan of top-down management, but I think this is where the sustainability and transformation partnerships and ICSs can add value,” he said. “They can say: ‘this is the right approach for a locality’.” He also argued that the financial and regulatory regimes needed to support this direction of travel.

For example, he argued it should be impossible for the CQC to rate an organisation as ‘outstanding’ if it was working in a struggling system; or had IT that would put it at the bottom of HIMSS EMRAM.

Stop aspiring, start digitising

There must also be a role for national IT bodies. NHSX, the unit set up a year ago by health and social care secretary Matt Hancock to lead on policy, standards, and a host of other IT issues, has quietly let the GDE programme languish without announcing an alternative approach to digitising the acute sector.

But the NHS operational planning and contracting guidance for 2020-21 indicates that there may be some kind of ‘digital aspirant’ programme for struggling trusts. So, the bones of a programme to fund trusts to reach a set level of digital maturity and then support neighbours in the same health and care economy to do the same may be starting to become visible.

Professor Evans said: “I think organisations like NHSX need to look at what hospitals are doing well and then encourage it to happen elsewhere. We have just had an announcement about funding to tackle long login times. The trusts that it is aimed it will probably have old IT and multiple systems.

“Instead of just addressing single sign-on, we need to get them to invest and accept help from trusts that have already done it.” Andrena Logue, consultant at Experiential HealthTech, argued that for this approach to work, national organisations might need to specify the modules that a digital aspirant should deploy.

“If you have got a number of vendors in the mix, do you see them being asked to provide certain modules to get this basic equity in place across the piece?” she asked. “Because these systems do different things.” Professor Evans said he could certainly imagine this.

“To make a difference locally, we need a common API, a common integration approach, and some basic modules like A&E,” he argued. “And e-prescribing. We rolled out e-prescribing in nine months, start to finish, and it has made a huge difference. Nurses say it is the best thing we have done. If we could deploy that elsewhere, it would make a big difference across the patch.”

A part for vendors

Other factors will need to be in place to secure success. Andy Kinnear, the director of digital transformation at Central and South West Commissioning Support Unit, pointed out that trusts that had tried to digitise had sometimes struggled because they had not had the right leadership in place.

Also, because they had failed to “sort out basics” of infrastructure and devices, as North Tees and Hartlepool has done, and to properly engage their staff. Andrena Logue asked whether, in that case, vendors also had a responsibility to say that an organisation was not ready to deploy or optimise its use of their system.

Professor Evans, who has often praised InterSystems’ partnership with his own trust, said suppliers were an overlooked part of the picture. “Vendors need to be providing technology that is proven, and that can be tweaked when necessary,” he said.

“The commercials are always going to be important. But I think it is incumbent on them to say that a project is not ready or needs additional resourcing to work, and to be ready to walk away if that is not forthcoming.”

However, he also looped back to the point that it is not enough to focus on EPR deployments. “The EPR is the core, but it is the ‘sprinkles’ that make it interesting,” he said. “The communications solution, the BI, the shared care record, the patient solutions.”

Which, the board agreed, makes it imperative for policy makers, trusts and suppliers to think carefully about digital maturity, and how it can be measured appropriately at different levels and, crucially, across health and care economies.

Time for new maturity models?

Different bodies are starting to think about this: NHSX has indicated that it would like to revisit the NHS digital maturity index, while HIMSS has created a continuity of care maturity model that addresses some healthcare economy issues; albeit from a relatively limited, interoperability perspective.

Andy Kinnear suggested that both needed to sit down with the NHS. “We need to bring everything together,” he argued. “NHSX has got the money. HIMSS has got a model. What we are missing is the picture of how it all comes together on the ground.”

Advisory board chair Jeremy Nettle also put in a word for suppliers who, after all, need to know what kind of market they will be operating in and what it will be looking for them to develop in the future. One way or another, Professor Evans agreed that having a roadmap is key.

“This is about creating a narrative and making sure that those that have not done this can see where to go,” he said. “It should warn people about the pitfalls, but make sure they are aware of the benefits. Because, if you are digitally immature and you move from one PAS or EPR to another the benefits are small.

“But if you go from paper to digital, the benefit is huge. And then you have to keep going. You have to get the point where patients and citizens also have some skin in the game, your technology is doing a lot of the basic stuff, and your staff are doing the really high value stuff. Technology is an investment and not a cost: but you need to be clear about why you are making that investment.”