At HTN Now: January, we were joined by Dr Penny Kechagioglou, Chief Clinical Information Officer and Deputy Chief Medical Officer at the University Hospitals Coventry and Warwickshire, for a presentation on building the clinical informatics team of the future.
To begin, Penny said: “One thing I have learned is that any technical or digital piece of work in transformation is really a social process. It requires a lot of clinical leadership and clinical involvement, alongside technical and digital teams.”
Penny explained that her presentation would focus on building teams not only to implement technologies and go-live with them, but on developing and supporting the internal organisational capability of leadership around digital projects.
“We know the future is digital transformation,” she said, adding that the goal is “to improve the care that we provide, to make it safer and to empower our citizens. How can we ensure that our clinicians are really involved in this and drive the clinical implementation of these technologies?”
The NHS Long Term Plan
In order to establish a wider perspective of the clinical informatics landscape, Penny discussed the aims and ambitions of NHS England in their efforts to integrate digital transformation into the clinical sphere. Some of these are:
- Using technology to the best of their abilities and empowering patients to make informed choices about their healthcare;
- Increasing the use of apps to help people manage their own health;
- Making patient medical information available to the right clinicians wherever they are through remote access;
- Reducing inequalities and access to care;
- Following primary care digitisation for all secondary care trusts to reach digital maturity in 2023;
- Achieving the triple aim of better health, better care and lower costs;
- Global Digital Exemplars and Blueprinting;
- NHS Digital Academy and
- Simplifying and improving the online appointment booking process for hospitals
Penny then drew our attention to two key definitions by the UK Faculty of Clinical Informatics (FCI) which defines clinical informatics as “the application of data and information technology to improve patient and population health, care and wellbeing outcomes, and to advance treatment and the delivery of personalised, coordinated support from health and social care.”
According to the UK FCI: “A clinical informatician uses their clinical knowledge and experience of informatics concepts, methods and tools to promote patient and population care that is person-centred, ethical, safe, effective, efficient, timely and equitable.”
Having established these terms, Penny moved on to examine why digital informatics are so important for the future of healthcare.
She said: “I can speak from experience working in a big organisation – we need to bring people together to be able to make digital transformation happen. That means bringing clinicians, people working in IT and communications together to make a multidisciplinary team and enable digital technologies to diffuse within organisations.
“It’s also about using technologies to provide quality improvements. For example, in our organisation, our lean methodology is embedded in everything that we do. When we deploy technology like the electronic health record, it is important that we take the opportunity to review how we work and create what we call ‘standard work’. Standardisation is really important.”
Penny added that her trust is in the process of reviewing all their policies and procedures. “When we go live with the Electronic Health Record, we will know how our roles have changed and how we are going to work moving forward. We’re going to try to standardise as much as we can, because we know that this reduces human factor error.”
Clinicians also play a “huge role” in user acceptance testing, Penny pointed out. “There are different phases when it comes to testing technologies, but UAT or user acceptance testing is critical because that will ensure the adoption of the new technologies. Ultimately, staff experience and patient experience should improve if we are using it properly.”
In terms of leading transformation and change, Penny suggested a new way to look at digitisation.
“Implementation of digital technologies is not just about bringing them to life – taking paper and digitising it,” she said. “It’s about using the opportunity to change and improve the way we work, looking at our workflows and breaking them down, removing any waste. It’s about seeing how we can make things better.”
Learnings so far
Next, Penny laid out some examples of the knowledge gained so far in digital transformation throughout the NHS, beginning with the National Programme for IT.
She noted that this programme led to successes such as NHS Spine, Choose and Book system and the Electronic Prescription Service. Other areas of the programme did not do so well, such as the creation of an integrated electronic health record and ensuring inoperability of the record with other systems.
“The autopsy of that shows that there was not enough clinical engagement and the programme was very much driven top-down,” Penny said. “With my interest in innovation and leadership, I can absolutely concur with that. Top-down support is absolutely needed in large transformation programmes, but actually the change that is going to be embedded in the organisation has to be also driven in a bottom-up manner. We need to involve clinicians and empower them, distribute leadership to clinicians who are going to influence their peers and create championship of new technologies.
“In that scenario, it was found that there was also a lack of consistent leadership to drive the vision of the programme. Top-down sponsorship is essential for such a complex transformation as the digital one, but ultimately in order to embed the implementation and the benefits of technology, we need clinical leaders on the front line to take ownership.”
Penny mentioned that she has attended conferences in America in order to gain insight into how they are integrating digital informatics in their own health systems. She emphasised the importance of learning from other sources.
“When we’re designing new technology, it’s important to factor in the experience of the end user,” she said. “As clinicians we are risk-adverse and we like our systems to alert us so that we make the right decision at the right time. But the problem with putting too many alerts in a system is that the user gets fatigued with all those alerts and you end up ignoring them or negating them. This can lead to clinical errors because you’ve missed the alert that was a big important one.”
Noting that the UK needs to learn more from other people’s experiences, Penny shared some facts from the US. A survey completed by 21,000 healthcare professionals found that 49 percent reported burnout attributed to the adoption of electronic health records, and clinicians are three times as likely to leave due to dissatisfaction with their EHR. The survey also found that two thirds of the clinical workforce said that they needed more training; that lack of teamwork is an important contributor to burnout; and that the majority of clinicians believe that digital technology can help standardise and automate common workflows.
Moving on, Penny highlighted how lessons learned from the National Programme for IT showed that usability is another key factor in determining the success of digital systems. Penny said, “There is no point in having technology if it is not used correctly”. By focusing on “maximising user adoption” this helps to ensure that data input is of high quality. This promotes a culture of accurate, efficient and confident digital users within the industry which will in turn lead to better patient outcomes.
Penny highlighted the roles of interoperability and communication between clinicians in order to make digital transformation a success, particularly as clinicians are the ones who understand the whole pathway. “How can we ensure that our clinicians, who understand the flow of patient journeys, are at the forefront?”
Clinician input is also required in the interfacing of old and new systems, along with data migration, Penny said.
What Good Looks Like
Penny brought our attention to the What Good Looks Like framework and said, “I particularly emphasise the aspect of leadership. Well-led digital transformation is about having roles such as CCIO, CNIO and CIO, having digital representation on the board, having a Clinical Safety Officer to oversee risk management, and ensuring that there is a digital and data strategy which is supported and co-created by key individuals in the organisation.
“It’s about establishing a good governance framework so that any digital project implementation goes through this process and any risks are considered and mitigated. You also need sound clinical leadership and a benefits realisation plan.”
Experience in building a clinical informatics team
Next, Penny shared some of her own experiences from University Hospitals Coventry and Warwickshire in building a clinical informatics team.
Whilst the electronic health record is set to go live within a few months, there are “many digital projects that are interdependent with an EPR system,” she said, which are running in parallel. “As a result, the same resources are being used to balance the major digital project but also the business-as-usual digital projects which are taking place within the organisation, which focus on tackling the operational pressures we all know.”
Penny added: “The balance of transformation-innovation risk needs to be very well managed. That is where the clinical informatics team should play a key role.”
Executive sponsorship is another important factor underpinning the project, as Penny said: “Our Chief Quality Officer is the executive sponsor for the Electronic Health Record programme and we report to the board which is chaired by our CEO. This immediately sets the importance of digitals transformation for the trust and the whole system.”
Penny noted that her own role involves a 60/40 split between digital transformation and her clinical role. “This is really important, to ensure that I am in constant connection with the clinical groups in the trust, and to ensure credibility in my role,” she said.
Penny has two deputy CCIOs who also split their time between digital and clinical as well as a “robust” CNIO team, along with a CIO to lead on technical system infrastructure and budgeting. “We’ve got a multidisciplinary EPR and digital clinical advisory group,” Penny added, “to ensure that the voice of the clinicians, across the organisation, is heard.”
In terms of governance, Penny highlighted their design authority and digital board, which Penny herself chairs and her close-working with the trust’s clinical safety officer to oversee the programme clinical risk management.
“The important thing is that we link with other parts of the organisation,” she said. “So the digital and data-driven research unit has recently been launched and we’ve got a clinical research information officer who links the EHR project with Research and Development. We’ve got a Chief Pharmacist in the programme and a number of subject matter experts at senior level who have been seconded to the EHR programme from their clinical or operational roles in the trust. That has been a critical aspect of the work, because everybody feels that they own this system and that we are building it together. It’s not something that has been imposed on them. It is something they have helped to build, that gets people excited and ultimately makes them feel valued.”
More than 500 EPR champions are now active within the trust who help to further motivate and spread the message of positive change across the organisation.
Redesigning the future workflows has been another major change; Penny sets this out in a diagram at 23:39 and highlights the process of implementation that has taken place.
Looking ahead, the team will be embarking on a “transformation journey” which will involve “working very closely with the clinical groups and clinicians to develop new procedures, policies and define what we’re going to stop doing and what we are going to start doing when we go live with the EHR. There’s a lot of testing going on at present of the future EHR system and the testing phase will be followed by staff training, which will be around August and September time.”
The journey does not stop at go-live, Penny pointed out. “The clinical informatics team is going to evolve further. Our plans are to further strengthen that team so that we’ve got a sound clinical informatics team following go-live.” This will involve clinicians having hybrid job plans, she explained; the majority of their job plans will focus on clinical time, but they will also be allocated time to lead on digital projects and focus on refining the EHR over the years to come.
Clinicians will take on a more hybrid role going forward, allowing them to lead more digital projects and ensure technology becomes embedded within the organisation – improving both patient care and staff experience.
Other steps will include further work on their benefits realisation plan; communication and engagement work; working with system partners in their ICS as a single EHR incidence; app and mobile solution strategy implementation; and digital leadership and governance. These projects are to include digital dictation, electronic document management system, digital consent, and interfacing with key systems such as oncology, ophthalmology, cardiology and renal medicine.
“Essentially, it’s about changing the mindset when we make any digital changes,” Penny concluded. “It’s not just about bringing a project to go-live, it’s about embedding the change and the benefits to achieve our goals of improving care and improving patient and staff experience.”
We then opened the floor to questions at 30:43.