At HTN: Digital ICS, we hosted a discussion with Adrian Byrne, chief information officer of University Hospitals Southampton NHS Foundation Trust (UHSFT), on the integration challenges for an integrated care system.
The discussion focused on the successes and challenges experienced by the UHSFT in rolling out their digital strategy, covering areas including interoperability, coordination, innovation and environmental benefits.
Adrian began by explaining how the pandemic had forced rapid acceleration in areas which would not normally have been expected to see much progress for quite some time, such as in remote working for thousands of staff, remote multidisciplinary meetings and virtual outpatient consultations. He then highlighted the UHSFT digital strategy, which focuses on measures including patient safety and outcomes, innovation, the changing NHS landscape, efficiency and patient expectations.
“We definitely saw technology make a positive impact during that change,” Adrian said, “and it’s fair to say that we really couldn’t have operated at all as a unit in the way we did without the rapid deployment and change that was adopted.”
UHS digital Strategy and performance
Adrian spoke of the rollout of the UHS digital strategy and his insights into the challenges it had faced.
Another challenge discussed was the introduction of Capital Departmental Expenditure Limits (CDEL), and the impact that this had had on the ability for budget planning and project management. In particular, Adrian referred to the issues surrounding the loss of ability to carry unspent capital forward into the following year, noting the limits that this placed on projects and the ongoing injections of capital that had previously been relied upon to keep things ticking over.
Noting that it can feel as though there are often averse incentives in play, Adrian stated that “last year, for example, we outperformed compared to 2019, yet any extra income for that has not materialised.”
In addition, challenges related to the pressures of the pandemic and rapid rollout meant that often things were done in a sub-optimal way.
“There’s quite a bit of unpicking that now needs to be done, I think, and whether we have the time to do that will be an interesting challenge as people go forward and start to uncover things that were done during the pandemic.”
The danger, he said, is the temptation to slide into a not-fit-for-purpose way of working as a result of having to adapt so quickly to new ways of working during COVID-19. He noted that the implications of this could potentially be worsened by the need to work in the context of ‘less money, more work’.
“Maybe it’s about time we do reset our strategy drivers and think about what we can achieve,” he said, adding: “We’ve got the technology now that can help the service, and provided we can prove our case we can get the investment.”
Adrian also talked about the context in which the UHSFT’s digital strategy had emerged, stressing the impact of constraints such as having to work with technology that wasn’t quite ready, and working in some instances with legacy technology.
UHSFT has been relatively lucky, he said, as the trust had already begun to work toward integration and digitisation in some respects. He noed the launch of the Hospital Information Clinical Support System (HICSS) in 1998-2000; the HICSS Electronic Discharge Summary and eDocs in 2007; doctor’s work listing and electronic prescribing in 2011; and UHS Lifelines electronic patient record (EPR) system in 2012.
Adrian stated that transferring things over to digital working and EPR has not been as easy as simply rolling out a programme, but that it has been a part of an ongoing process whereby the trust has been building and buying functions over a period of many years. This work is still going on, and the outsourcing of inpatient noting and other activities such as outpatient clinic letters, is something that Adrian feels particularly positive about. A KLAS study of approximately 2,500 respondents showed that clinicians at UHSFT spend less time outside of normal shift hours catching up on documentation compared with their peers.
Interoperability and innovation
This was an area that Adrian identified as requiring more effort, noting the need overall to do much better.
“When you look at what needs to be done, organisations need to get together to work out how to exchange documentation information,” he said.
Adrian spoke about the concept of systematic interoperability, noting that just because something is sent across to a different provider, that doesn’t mean that they understand it. In this way, it is important to bear in mind that the ways that information is exchanged within, and outside of, an organisation can be very different.
When discussing innovation at UHSFT, Adrian reflected on the challenges of working with a tertiary cohort of 3.9 million. He expressed that the trust is often waiting for the technology to emerge that can support the work it is doing and the local community it is part of.
“What we’re really hoping is that we can hang on until that emerges, until we can buy something that fits in with our local health community and the other people around us,” he said, “and do that integration and interoperability better.”
An area of innovation and success, thus far, can be found in UHSFT’s work in systems integration.
Adrian shared: “Sometimes people think that we’re a ‘best of breed’ site and that we’ve built hundreds of systems, but actually there’s quite a lot of what we do that’s in a single Oracle database.”
Whereas many organisations still have around a hundred different Apex modules that run within Oracle, UHSFT has managed to build an integrated environment through a mix of strategic platforms. The work in this regard is not done, however, as Adrian notes that there are still many different systems to be integrated. This will, he said, depend on creating the right investment and opportunity for integration, which is something that the trust is already working towards.
Something for other trusts to be aware of, Adrian stated, is that important programmes should be aligned in terms of resource allocation and priorities.
“One of the things I’m seeing is a tendency to put digital into the IT box,” he said, noting that people tend to think of it in the sense of “we’re just providing the rails, somebody else will provide the trains.”
Adrian’s take is that “digital transformation needs to be hooked up very closely with the whole concept of improvement, and we need to work hard with the prioritisation of the work that’s going on there.”
Across the ICS
As the discussion moved on to talk about the challenges in rollout across integrated care systems, Adrian reflected on some of the difficulties that may arise during this process, especially in areas like primary care, which may be steeped in existing systems already. In another example, he looked to community mental health activities; can it really be possible to converge an entire system across a whole ICS? As work continues to try and identify areas in which integration can, and should, occur, other factors are also likely to emerge.
“What happens when the private sector moves in to this is an interesting question, I think,” Adrian noted.
“We need to work on putting the patient at the centre, at the point of care. We need to do local integration between hospitals and regional and tertiary services. As you build out from that core, you tend to get into more ‘batch transfer’ type information, in terms of the type of information that flows between a patient handover and such.”
He commented that it will be interesting to see how rollout across ICSs will be possible in relation to the work of cancer networks, cardiac networks, and so on,. An example is UHSFT’s imaging network, which spans three counties and two to three ICSs, and presents an element of exchange which isn’t picked up solely within the integration process of a single ICS. He acknowledged that there are challenges to consider, such as how to deal with these types of networks and exchanges, as well as how to factor this into maintaining continuity and patient records.
Virtual wards
Adrian reflected on some of the groundwork put in place over the course of the pandemic, citing the development of virtual wards and virtual patient consultations. A challenge in this sphere, however, is having the teams in place to run them.
“Virtual environments can’t just translate to the ward team looking after 30 or 40 more patients,” he said.
Adrian discussed the success of UHSFT’s My Medical Record online portal, which provides patients with results and the opportunity to message with their clinical team, without having to visit the hospital. Efforts to measure the impact of this on the trust’s environmental output, through reduced travel, remain ongoing.
My Medical Record has been rolled out within a variety of hospital services, focusing on developing digital relationships with patients and providing benefits for clinicians in terms of information availability. Clinical teams can, for example, view information on patients, check compliance and see results. In heart failure patients, the success has been in enabling blood pressure readings to be remotely recorded and then viewed by Cardiologists.
Altogether, Adrian said, this is building toward a much more integrated patient health record. He called it “another thing where digital is providing some key enablers for real strategic change.”
ICS-wide maternity service
Adrian considered the possibility of convergence across-ICS in certain areas, citing the example of a common digital maternity system across four maternity units in the Hampshire and Isle of Wight region, and over 200 GP services.
Launching in 2020/21, the system has run for three years, using the SWASH management service which UHSFT had already integrated, to enable work across multiple organisations. Although this was, as recognised by Adrian, an excellent opportunity for collaboration; it was difficult to keep everyone on board. Some of these challenges were mitigated by the use of the CleverMed self-referral portal to provide single point of access; BadgerNet Maternity for clinical records; and BadgerNotes for online personal health records. However, Adrian feels that this does not completely mitigate the challenging nature of this type of convergence.
“When you start to channel that kind of interoperability across a single system, across an ICS, you might lose some of the close links that you have between systems that you had before within the hospital, and we’ve certainly found that. We had much more integrated reporting with things like order communications within our hospital than we do now, in fact.”
Closing thoughts and future directions
On one of his presentation’s closing slides, Adrian presented the following quote: “UHS Digital has proven that it can develop and implement successful digital solutions at scale with an innovative modular, yet integrated approach to clinical systems.”
Adrian added: “We need to work more across the community in future, but nonetheless, we’re progressing toward a high level of digital maturity using the existing methodologies for now.”
Speaking of how the digital systems at UHSFT were one of the main attractions for staff, he shared a final consideration: “if you don’t have good digital systems in future, how can you hope to attract the best and brightest minds to come and work for you?”
Many thanks to Adrian for taking the time to join us.
