Health Tech Feature: Interoperability

In our latest feature we focus on interoperability and the exchange of healthcare information.

Matt Hancock has been very clear in his intent for technology to revolution health and care, and it seems interoperability is now higher on the agenda than it ever was before. In our interviews with the industry it was clear there are many challenges to face from the use of legacy systems, to organisations using different and disparate systems, large scale organisations merging to organisations not being digital at all.

However, it was also clear there are many examples of excellence. We spoke to the industry to hear their views on what needs to change, their challenges and learn about some projects breaking new ground.

Contributors include: InterSystems, CCube Solutions, University Hospitals Birmingham NHS Foundation Trust, London North West University Healthcare NHS Trust, Royal Papworth Hospital NHS Foundation Trust and Cambridge University Hospitals NHS Foundation Trust.

David Hancock, client engagement director, InterSystems

The digital vision for Health and Care was published in October 2018 and there was a definite, and commendable, inclusion around interoperability. Now that the NHS long-term plan has also been published, it’s evident that the vision – and interoperability – are vital to help the NHS achieve its plans.

But with so many visions for NHS IT having come and gone, the big question is: how can we be successful this time and avoid failures of previous digital ‘inspirations’?

Implementing health IT today is one of the most complex adaptive changes in the history of healthcare, perhaps of any industry. And interoperability entails huge adaptive change, involving substantial and long-lasting engagement between the leaders implementing the change, individuals on the front lines tasked with making them work, and the other stakeholders, including suppliers.

All the individuals involved become a collective group that need to deliver on this long-term plan – collaboratively.

Our ambition must be higher than ever because we need to integrate areas we have not done before.

And for interoperability to be successful we need to consider the wide variability of end points (systems) across health and care. We also know that there will be differing local priorities and organisations that are at different levels of maturity and capability to implement solutions.

In light of all the above, there’s no question as to why top-down approaches are not suited to solving these adaptive problems and why all previous attempts around interoperability have failed. One-size does not fit all.

To break the pattern of failure and seize the fact that interoperability now sits at the top of the political agenda, we need a solution that involves all parties. We need a demand-pull from the service, based on their local priorities and supply-push coming from a group responsible for the standards. This group should be made up of the service (end-user organisations, NHS Digital and NHS England), suppliers, standards groups and other professional bodies.

This level of collaboration would certainly change the repetition of failure, and by working together could lead to predictable outcomes.

With demand-pull but no supply-push of relevant standards, a local health economy will have to implement something that is specific to them which is likely to be proprietary and typically not re-usable. This risks their ability to integrate if their systems don’t support it.

We could also face a situation where there is a supply-push, from the centre, and no demand-pull. This results in much effort being made defining and building standards into products but with no adoption – like we’ve had before.

If we can address the supply-push and demand-pull, and have the right trust, interoperability could be achieved.

Dr Tanya Pankhurst, Deputy Director of Digital Healthcare, University Hospitals Birmingham NHS Foundation Trust

A key challenge for us over the next 12 months is to share data with GPs, councils, social care, tertiary services and beyond. The priority is to be able to share information across our region and this is being led by our STP.

Another challenge for us will be the ongoing work following our merger with Heart of England NHS Foundation Trust. The challenge here is where there are different systems used across each organisation. Going from paper to digital is one thing, but changing from one electronic system to another will be a challenge. Our plans are to consolidate onto one PAS and then share all our clinical systems going forward.

Years ago nobody wanted to share information, GDPR didn’t exist and you couldn’t get the right people at the table. The time feels right now to really make a difference with technology and with the new focus from Government I think everyone believes digital should be high on the agenda. A challenge will be resources but that hopefully will be less of a challenge than previously, it doesn’t feel like pushing against the tide anymore.

It’s vital that all systems use open APIs and follow data standards, gone should be the days when suppliers try to charge you for your data.

Our organisation is a GDE and we are quite advanced, our advice to any organisation would be to go visit a hospital and see the software in use. Ask frontline staff what they think and be alone with them!

Vijay Magon, CEO, CCube Solutions 

In order to share and have access to information we need to be digital. Matt Hancock has been very bold in recent months to ban outdated technology, yet many organisations still heavily rely on paper. Until this information is digitised it’s impossible to share this information and provide it at the point of care where it’s needed.

For years we have known the inability to share and access information has been a huge cost and time cost for healthcare and its about time we had real government intention and support to drive healthcare into the digital century.

We’ve worked with many organisations such as St Helens & Knowsley Teaching Hospitals to remove its paper medical documents to ensure they were available when and where healthcare professionals needed them. The projected digitised 155,000 medical records. This meant the organisation stopped 7,000 letters being hand delivered each week. They opted for a scan on demand model so they only scanned what was needed. Over a staged roll-out of over 22 months the organisation reported £1.4 million in savings.

Another project we worked on was at Aintree University Hospital who looked to EDRM to digitise. Aintree became the first trust to use forms recognition technology to automate the recognition and classification of pre-printed medical forms. The Trust has digitised 282,000 letters and generated £1 million annual savings.

Similarly, North Bristol NHS Trust, Aneurin Bevan University Health Board, Milton Keynes Hospital, etc. are amongst several other sites we have worked with to help achieve significant benefits from their digitisation projects. Furthermore, these sites are in a much better place to embrace new technologies for analysing and sharing content.

It’s clear there is a need for sharing of information using established open standards such as HL7 FHIR and SNOMED, between systems, professionals, and patients. Once digitised it can open up the use of AI for understanding the huge volume of digital content now available.

Sonia Patel, Joint Chief Information Officer, London North West University Healthcare NHS Trust

This is a unique opportunity, if we get it right to improve coordination and delivery of digital developments and ambition across the NHS. This has to be our top priority to improve coordination that currently straddles across NHSE, NHSI and NHSD.

Our second priority is to catch-up with other industries and that we need a national dev-ops unit. For anyone that wants to know more about dev-ops read ‘The Phoenix Project’ we’ve implemented it at Hillingdon. With right environment and conditions that are agile and adaptive also eases the on-and-off boarding of tech industry’s support as required to help the NHS in the best way.

With the combination of the above should result in thirdly, ensuring digital policies, standards and development get faster to frontline organisations, workforce, patients and citizens and truly embrace the digital opportunity for the NHS top engage in new and meaningful ways.

Top of our agenda is digital apps and correspondence to patients, to rapidly deliver a modern EPR for the workforce and maximising and mainstreaming population health management into health and care delivery.

Within the Acute sector interoperability has never been a challenge, we hit walls when trying to interoperate across care setting boundaries particularly primary care. This has never been a technical issue it is a legacy commercial challenge and this does need national support and attention without resolving some of this big issues we will never really delivery a workable and sustainable long term plan to support integrated care services.

Andrew Raynes, Director of Digital and Chief Information Officer, Royal Papworth Hospital NHS Foundation Trust

Andrew discusses a first-of-type interoperability project to allow blood test orders and results to be shared between DXC Technology’s Lorenzo electronic patient record at Royal Papworth and the Epic system in use at neighbouring Cambridge University Hospital NHS Foundation Trust. 

Royal Papworth Hospital is preparing to move to a brand-new building on the Cambridge Biomedical Campus, alongside Addenbrooke’s Hospital. The two hospitals are going to share a pathology service, so we needed to undertake a complex piece of integration work to make sure our clinicians could order tests and receive results electronically.

The system we had in place was very manual: Royal Papworth orders had to be transcribed into Addenbrooke’s Epic electronic patient record and the results would come back into our document management system in pdf format. Now, our clinicians can order tests and see the results from our Lorenzo EPR.

This was a huge feat because it was the first time a project on this scale had been delivered by a UK NHS Trust. In total, we needed to integrate five systems, but the major challenge was to create an interface between Epic and Lorenzo. There was no reference anywhere else in the country for doing that, but we achieved a bi-directional interface and we did it in just seven months.

The new system is much more efficient for our busy clinicians and has important patient safety benefits. But it is also important because there has been an idea, since the National Programme for IT, that organisations all need to use the same system to be able to exchange information with each other.

The Secretary of State for Health and Social Care, Matt Hancock, and the Wachter Review’s tech vision both say that interoperability is the way forward, and we have shown that is right: what matters is standards and open systems.

Royal Papworth is ahead of the curve. We have put policy about interoperability into practice. We have done it.

Finally, we spoke with Cambridge University Hospitals NHS Foundation Trust to hear about some of their work. 

In May 2018 we launched a technical innovation to enable GPs and community nurses to securely access clinical information about their patients from directly within our EPR, through our digital primary care portal called EpicCare Link.

This portal is currently available at Cambridgeshire’s largest primary care practice group – Granta Medical Practices, which comprises of five GP practices. At the touch of a button GPs, community nurses and administrative staff at these practices use this portal to securely view information in their patient’s hospital record in our EPR to advance shared patient care in a timely and more effective way.

They are able to view latest information about their patients – from conditions, tests and procedures to results, treatments clinical letters and recommended follow-up care. For example, if a patient visited our A&E department and then went to one of Granta’s GP surgeries the following day, their GP would be able to access their hospital record in our EPR, through our EpicCare Link portal, to view the care they received and any follow-up care or treatment that is required.

We asked what systems is the trust using to join-up health and care

We enable our hospital staff to see a single unified view of a patient’s health record, electronically, in its entirely and in real-time, through our fully integrated EPR used across both of our hospitals (Addenbrooke’s and The Rosie).

The Trust also provide our patients the ability to view their electronic health record held at our hospitals through our MyChart patient portal, which automatically pulls information from their electronic record in our EPR into their MyChart (accessible via the app on Apple and Android devices and website link on computers and laptops). MyChart helps to involve patients more in their care and supports them with the management of their conditions.

We enable the sharing of key clinical information with other hospitals also caring for our patients, both nationally and internationally, through the Care Everywhere capability of our EPR. And we are sharing clinical information in a real-time digital way with our patients’ GPs through the EpicCare Link primary care functionality within our EPR.

What is next for your organisation in terms of interoperability? 

We are looking to advance our MyChart patient portal capabilities to allow Bluetooth-enabled devices to be connected from either a wearable or home device via Apple’s HealthKit on iPhones, or via Google Fit on Android phones. Data from these devices can then flow straight into the patient’s electronic record in our EPR; enabling remote review by clinical teams, or providing data in advance of a forthcoming clinic appointment. This data can be graphed, tracked over time, and can drive clinical decision support processes – so in addition to engaging patients with their care, it will enable more timely review and interventions leading to better quality care, as well as greater efficiency.

The Trust is also leading the way with the national CareConnect FHIR Interoperability Standards for Transfer of Care and GP Connect, and are continuing to work with NHS Digital to successfully achieve these national standards.