Text: Digital Health ReWired 2020 was one of the last events that most people working in health tech got to go to in person. Even as the event went ahead at Olympia London, there were anxiously jokey questions about which stands had hand gel, how to ‘shake’ elbows, and what the NHS and its IT should be doing to prepare.
So, it was inevitable that the first day of Digital Health Rewired 2021 should focus on the pandemic and on the digital response to it, which turned out to be much wider ranging and more sustained than anyone could have imagined.
On the first afternoon of the online event, Saffron Cordery, the chief executive of NHS Providers, said the “clear and unifying goal” of tackling the pandemic had transformed attitudes to digital.
She said research with senior managers had found that there had been “a step change in pace” as teams had been given more freedom to innovation (“although it’s fair to say that some governance is being re-imposed now”) and staff had shown themselves willing to embrace digital working.
“Covid has put digital at the heart of organisations’ core purpose,” Cordery said. “It is not off to one side. It is not siloed anymore. There has been a critical shift in mindset.” The question now is: “How do we identify and lock-in the beneficial changes, to deliver genuine digital transformation?”
The sheer pace of digital adaption and adoption in response to Covid was demonstrated in the conference’s many five-minute “lightening talks.”
Sandra Shannon, deputy chief executive and chief operating officer at Bradford Teaching Hospitals NHS Trust, said it rapidly adopted added two data and action ‘tiles’ to its GE Command Centre, and “could not have managed” without this “source of truth” on demand and resources.
Adrian Byrne, chief information officer of University Hospital Southampton NHS Foundation Trust, explained how it was able to use its My Medical Record personal health record to support patients; and how lots of its monitoring and support will be done by text in the future.
TEC Cymru explained how it went from 0 to 100,000 video consultations in nine months. NHSX said 99% of primary care practices in England adopted the same technology, while people turned to the NHS’ online information sites in unprecedented numbers.
Even so, Sarah Scobie, deputy director of research at the Nuffield Trust, suggested that identifying beneficial changes might be harder than it sounds. The think-tank has been able to quantify a big increase in virtual clinics and digital consultations.
But it has been unable to find much evidence about the safety of these interventions, about their outcomes, about whether they work for all groups, and about whether the public will continue to support them, once the NHS gets back to face to face working.
Other speakers and attendees raised the challenge of digital exclusion. The UK struggled to educate its children online during the pandemic and the problems shone a light on the uncomfortable reality that many households lack the devices, connectivity, and skills to access digital services.
Gareth Thomas, the deputy national CCIO at NHSX said this meant that, in reality, digital will need to be just one item on a “menu” of options for patients. “We have seen a channel shift,” he said. “But we have also seen challenges, particularly around digital exclusion. So, we need to build on innovations, focusing on the needs of the citizen and the service user.”
Another challenge is interoperability. #DHRewired21 was opened by Grahame Grieve, the “father of FHIR”, a system of schedules and standards developed by the HL7 organisation to make sure computers “speak the same language” and “talk to each other.”
Speaking from his home in Australia, he told an interoperability summit sponsored by Alcidion that his FHIR journey because he wanted to stop family and friends “falling through the gaps” between health and care systems.
Therefore, he said, the point of FHIR was not to create standards, or to get IT suppliers to adopt them, or even to liberate data, but to make sure health and care systems could use digital to break down silos and “pivot around the patient.”
Grieve also said he had expected FHIR to be a 15-year project: “But it is a huge job” and “it is going to take a lot more than that.” Irena Bolychevsky, the director of standards and interoperability at NHSX, said the NHS has a long way to go.
She listed some of the reasons as: the complexity of the system, its lack of investment in IT, the variability of standards, and low levels of adoption, and then said the agency is running two streams of work to try and change things.
The first will build foundations, including resources to help people find standards and check they are up to date, and the second will look to accelerate their use. But conference attendees wanted to start with vendor behaviour.
In chat questions, many complained they still come across suppliers who use data lock-in as their revenue model, carry out a piece of integration work for one customer and then charge others for it, and limit access to APIs. Charters, framework contracts, and standard contract terms already exist to reward commitment to interoperability or stop this.
But, as they are clearly not working, Bolychevsky said she would like to discuss standards with suppliers centrally, and then see them publish their roadmaps. That way, “everybody is on the same page” about what is needed, when it will be done, and who is going to pay.
A series of INTEROPen sessions suggested that another way to make progress is to identify real-world problems and solve them.
For example, Ann Slee, the associate CCIO for medicines at NHSX, said it has a “vision” for the “seamless transfer of medicines information” across the care spectrum, to create “a consolidated medications record”; but it will get there by addressing specific use cases.
Aaron Jackson, product director for medicines, problems and allergies at Orion Health, explained how a series of INTEROPen hackathons are getting standards experts, clinicians and IT suppliers in a room – or, this year, virtual space – to work through the medication transfers needed to support a patient named “Michael”.
While Ethan Richardson, product manager at WellSky, said pragmatism was important. “You need to work on the 80:20 rule,” he suggested. If 80% of a pathway can be delivered using standards-based systems, but 20% needs a paper note, then bank the gains: don’t wait for perfection.
The NHS reset, and another round of health and care reform, will provide another focus for action. Integrated care services will cover England by April, with a brief to join up services and shift from contracting to population health management.
Legislation is promised to entrench these changes next year. On the third day of the conference, Frank Hester, the chief executive of TPP, told a session on ICSs that he had seen “a couple of reorganisations of the NHS” in his time and “never been that interested” but “this one is different” because “it has digital at its core.”
ICSs will need shared care records to drive integrated working and data platforms for analysis and to plug and play a wide range of apps and consumer devices. “To realise the ICS vision, I think techology is 50% of it,” Hester mused. “You might disagree, you might say Frank, it’s only 10%. But this will not work without technology.”
Kate Walker, the digital programme director at Suffolk and North East Essex ICS, didn’t disagree with this, although she said it was important to start with “why” do something rather than “how” or with “what” technology.
She said her organisation’s main aim was to “put the person at the centre and wrap services around them” and to not just address digital exclusion but to actively tackle inequality in the process.
And she also had some tough words for vendors, saying she wanted to “know their thinking” and “see their roadmaps” to “make sure it fits with our approach.” Indeed, she added, she wanted everybody involved to sign up to a Digital Ethics Charter – or what she jokingly called “a nerdocratic oath, a hypocritic oath for the 21st century.”
Local areas can’t do all the heavy lifting. In a breakfast-time start to day four, NHS chief clinical information officer Simon Eccles joked about how he recently turned 50 and used a blood pressure monitor and a British Heart Foundation app to find out that “my heart reached 50 six-months before I did.”
With an increasing number of blood pressure monitors and other consumer devices in people’s homes, and an increasing number of apps and triage services on offer to make use of them, he said the challenge was “to bring it all together” – and the centre has developed tools to do that, in the form of the NHS App, its identity services, and APIs.
“We have a target of five extra years of healthy life, and I think we are starting to get towards something to deliver that, using the mobiles in people’s pockets,” he said. Eccles also flagged that the centre is starting to develop guides or ‘playbooks’ for service redesign, starting with ophthalmology.
Sonia Patel, the chief information officer at NHSX, said making sure the playbooks are used to scale services across the country will be one of the seven planks of the agency’s work on “what good looks like” – which she indicated should be out in quarter one of the coming financial year.
The other planks will be: well led; smart foundations; supporting professionals, “to make sure they feel well supported and skilled to use technology to operate at the top of their licence”; improving care “and not just digitising what we have”; safety; innovation; and empowering citizens.
For all the optimism injected into health tech by the rapid uptake of digital during the pandemic, the flip side of Patel’s list is that where things don’t look good there will be a lot of work to do to get them up to speed, to consolidate progress, and to build for the future.
Boards will need to be engaged or stay engaged. Infrastructure and device basics will need to be sorted and maintained. IT professionalism addressed. Staff trained. Digital pathways created and scaled. Safety kept up. Innovation embraced. Citizens enthused.
Health and social care secretary Matt Hancock acknowledged this in a wide-ranging keynote speech that started with a further challenge, which is that many of the NHS organisations that were not at ReWired telling their digital success stories were not there because they have barely started their digital journeys.
To “digitise more of the NHS that is not yet digitised”, Hancock announced another tranche of funding for the digital aspirant programme: although just seven trusts will get up to £6 million and another 25 will have to make do with ‘seed funding’ of £250,000 to develop strategies for the moment.
Hancock also pleased conference delegates by saying that although patient data is held in electronic patient record systems, it does not belong to their suppliers. He said he wanted to “explore whether… we can separate the data layer from the application layer” so data can be held in the cloud and put to many uses.
The final day of the conference focused on companies that are promoting this open approach and some early adopters of it.
Neil Perry, director of digital transformation at Dartford and Gravesham NHS Foundation Trust, told digitalhealth.net it is using the Alcidion Miya Precision platform to “move away from traditional EPR thinking” and to adopt a more “coordinated and agile approach” to developing functionality that clinicians want.
Hancock suggested that if this kind of thinking was adopted at scale it would be possible to “have a consistent data platform across the NHS.” However, he didn’t set out a strategy for doing this, and most of his speech ranged over the infrastructure, pathway, and patient empowerment projects covered by other speakers.
The leaders of Digital Health’s CIO, CCIO and CNIO networks felt this won’t be enough to meet Saffron Cordery’s opening challenge to “lock in beneficial change and deliver true digital transformation”. In a debate on the health secretary’s speech, Adrian Byrne said: “What people would like is some sustainability and consistency, and we still have a lumpy investment profile.”
James Reed, the CCIO of Birmingham and Solihull Mental Health NHS Foundation Trust, agreed. “Infrastructure was mentioned, but we know there are still big issues there, and a bit of digital aspirant funding won’t fix them,” he said. While Jo Dickson, the clinical informatics director at Nuffield Health, said: “I would like everything to be more joined up. It sounds like pockets of things, not the joined-up strategy we need, heading out of the pandemic.”
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