In 1990, the contract by which GPs were paid for services provided to the NHS became more data-driven, aimed at more directly linking remuneration and performance (20). Again, some of this is described elsewhere in the report. (Most, it should be noted, are not specific to UK GP systems.) Importantly, although the new effort is vastly different from NPfIT (with extreme care being taken to avoid calling it a ‘national programme’ and to minimise centralisation), this does not guarantee success. In the sections that follow, we will briefly review these 3 stories: NPfIT, health IT in the GP sector, and the US experience with digitisation. Getting this right will require buy-in from trust leaders, engagement of front-line workers, the presence of CCIOs and others who can make the case for IT in clinical (not financial) terms, and a deep appreciation for the adaptive aspects of this new digital strategy. Universal adoption has come only through government subsidy, which was accompanied by a robust accreditation and regulatory framework. To improve bin 1 and bin 2 usability, there are specific policy and non-policy based levers that England should consider. Although a detailed economic analysis is beyond the scope of our review, a rough calculation may suffice here. Here, we return to the concept of the productivity paradox: the experience of many industries in which the promised improvements in quality and efficiency from IT failed to materialise in the first few years after digitisation (1, 5). ↩, Declan Hunt, Executive Director of Technology for MacMillan Cancer Support, attended several meetings as an alternate to Ms. Thomas. CCIOs and other informatics and improvement staff are key to this transformation. Professor Wachter will report his recommendations to the Secretary of State for Health and the National Information Board in June 2016[footnote 25]. Yet, despite a 2005 RAND study that projected $81 billion (£62 billion) in annual savings from digitisation, a more recent study found no clear evidence of efficiency gains, largely because of the extra time that healthcare professionals were spending on documentation (5,6). We believe that the NHS is ready to implement a successful national strategy to digitise the secondary care sector, and to create a digital and interoperable healthcare system. As full time clinician NHS is not releasing me enough to maximise my contribution to this. But it is an argument for keeping sight of the ultimate goals of improved health, better healthcare, and lower costs; for being prepared for unexpected consequences; for creating a system that is nimble and able to adapt over time; and for retaining a relatively long-time horizon. In fact, much of the bin 2 work can only be done by those with a deep appreciation of how work is done in that organisation. However, the limited studies of GP EHR use in the UK have shown that systems are generally valued by the GPs that employ them. All but one of the current systems accredited by GPSoC were originally developed by or in close collaboration with enthusiastic GPs in the UK. This workflow needs to be anticipated and addressed. Even with all of the background wisdom born of prior experiences in the UK and elsewhere, the chances of getting it perfectly right at the start are low. An example of a QOF indicator is: The percentage of patients with coronary heart disease whose last measured total cholesterol (measured in the preceding 12 months) is 5mmol/l or less. Is there a Summary Care Record?). Beyond the productivity paradox: computers are the catalyst for bigger changes. But the problem also reflects a lack of understanding regarding the adaption and optimisation process. We have emphasised that approach in this report. In 2011, NPfIT was discontinued, and analyses in the popular press were unkind, dubbing the Programme ‘a fiasco’ and worse. The 2014 NIB report acknowledges that simply having a plan for implementation and interoperability is not enough to ensure a successful digital deployment. Based on the US experience (where some EHR vendors have forced purchasers to sign non-disclosure agreements that block clinicians from sharing screenshots, even those depicting unsafe conditions), the NHS should require EHR suppliers to allow this kind of transparency (22). We endorse the recommendations of the National Data Guardian’s Review of Data Security, Consent, and Opt-Outs, which was commissioned to achieve this balance. This subsidy, funded by the Department of Industry, attracted 150 practices. Smaller amounts of funding to trusts that are not yet prepared to digitise. Defenders of the policy point to the urgency to spend the money (which, after all, was designed to stimulate the economy), and to a desire to avoid creating barriers to implementation, such as insisting on robust usability testing or on interoperability. Things progressed in a measured way in these early years. The NHS and England’s funders should also support research in this area. Safety risks associated with the lack of integration and interfacing of hospital health information systems. 62000. This consensus was articulated in a 2014 framework created by the National Information Board and bolstered by the allocation, in 2016, of £4.2 billion to support this work (6). These national applications were: Central to the Programme was the creation of a fully integrated electronic records system designed to reduce reliance on paper files, make accurate patient records available at all times, and enable the rapid transmission of information between different parts of the NHS. It would be reasonable to expect all trusts to have achieved a high degree of digital maturity by 2023. It is important to take a holistic approach to it – just having the right standards and interfaces is not enough if, for example, a GP worries about liability after sharing data. This sensibility is also important as we bring patients in as active partners in seeing and contributing to their digital data. In part informed by its analysis of the US experience with HITECH, NIB leaders chose to emphasise interoperability, rather than just adoption, of health IT. But none of the changes are likely to be as sweeping, as important, or as challenging as creating a fully digitised NHS. At the outset, a long-term engagement strategy should be enacted to promote the need for healthcare information technology, identify the likely challenges during implementation, educate stakeholders about the opportunities afforded by a digital NHS, and set the stage for long-term engagement of end users and co-creation of systems and strategies. 62000. Sheikh A et al. He or she needs to be optimally positioned to leverage the informatics capabilities and resources in, amongst others, DH, NHS England, NHS Improvement, NHS Digital, and the Care Quality Commission (CQC). Price ₹2.21 K/sq.ft. This history has also meant that systems have evolved over long periods, utilising technologies that may no longer be state of the art. This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To rectify the gap in the availability of such individuals, not only will there need to be satisfying, sustainable positions available to CCIOs in trusts (recommendation 3: Develop a workforce of trained clinician-informaticians at the trusts, and give them appropriate resources and authority), but the CCIO field must also be strengthened and grown. ‘The question was, “Can we use the technologies to really understand our patients and to really understand what coordination looks like?”’ said Gina Lawrence, chief operating officer of Trafford CCG. In general, centralisation should be applied when its benefits outweigh its harms: when centralising creates economies of scale, when there are market failures that can be remedied only by centralising, or when there is insufficient capacity at the local level. It would be a shame if the NHS moved to a more interoperable system, yet the potential benefits – for individual patients and the entire system – were to become unavailable because data were so tightly locked down. These individuals should have at least 25% of their time allocated to their IT and related work. BMJ Qual Saf 2014; 23:611-3. Review and articulate the factors impacting the successful adoption of health information systems in secondary and tertiary care in England, drawing relevant comparisons with the US experience, Provide a set of recommendations drawing on the key challenges, priorities and opportunities for the health and social care system in England. We estimate that approximately one in 3 NHS trusts will fall into Group B. Without the right people and skills, digitisation will fail, or at least not achieve its full potential. We have made this point earlier and reemphasise it here because it is our overarching message, the message that weaves together all the threads (24). In the case of a new national health IT initiative, areas that would benefit from some degree of centralisation include: establishing a framework to support local/regional implementations, supporting efforts to improve the usability of systems, supporting the development of business cases and contracting, supporting relevant research activities (including developing a national data repository), guaranteeing interoperability, ensuring privacy and security, and leveraging national structures such as the Spine and the NHS number. We also received excellent editorial assistance from Katie Hafner. In the immediate period following the Epic installation, CUH experienced a number of service disruptions: disruption to pathology services caused by problems with specimen label printers; disruption to the delivery of results of pathology investigations to primary care and other external consultants; a 4-hour period of unplanned downtime necessitating an ambulance diversion plan and a several-day period of instability of one of the transfusion system interfaces; and disruptions in the consistency of clinical care including venous thromboembolism assessment, nursing care plans and community referrals, completion of discharge summaries and complex inpatient prescribing. Sheikh A et al. There are also tremendous efficiencies from digitally facilitated research. Vicente KJ. The design called for a clinical team to sit in the Centre – a group of about 8 nurses, and 15 administrators who work with on the ‘onboarding’ of patients, determine a patient’s needs, follow through on referrals, and order tests. These include involving clinical users and patients in design, measuring the usability of systems using standard methodologies, providing usability information to trusts to aid in their purchase and implementation decisions, and creating mechanisms to allow users to share information regarding usability problems in their EHRs. Still, billions of dollars have been invested by governments and foundations in the creation of HIEs, and most have failed, due largely to the absence of a strong business case for information exchange (40). We agree. Most criticisms have focused on the far more prescriptive and onerous requirements under Stages 2 and 3. However, it has also curtailed diversity within the market, largely due to the strict accreditation criteria. Lab investigations conducted by other providers are readily accessible by GPs. New York: McGraw-Hill, 2015. The US has seen massive failures following efforts to digitise the Federal Bureau of Investigation (FBI), the Air Traffic Control system, the Internal Revenue Service, and, most famously, the Healthcare.gov website established to implement the Affordable Care Act. By using national incentives strategically, balancing limited centralisation with an emphasis on local and regional control, building and empowering the appropriate workforce, creating a timeline that stages implementation based on organisational readiness, and learning from past successes and failures as well as from real-time experience, this effort will create the infrastructure and culture to allow the NHS to provide high quality, safe, satisfying, accessible, and affordable healthcare. Here are 2 predictable questions/concerns: These concerns must be tackled head on. While some of this is political hyperbole, it is clear that the pressure on healthcare delivery organisations (the US equivalent of trusts) and suppliers to share information will grow, likely leading to far greater interoperability within the next 5 years. BMJ 2002;325:1086-9. We have described the rationale for this approach earlier. As one example, we believe that the target of ‘paperless by 2020’ should be discarded as unrealistic. To those who wonder whether the NHS can afford an ambitious effort to digitise in today’s environment of austerity and a myriad of ongoing challenges, we believe the answer is clear: the one thing that NHS cannot afford to do is to remain a largely non-digital system. Eligibility for additional funding should be approved by the NHS, based on the progress to date. It is equally critical to design and implement a system of regulation and governance that reassures patients that their rights and interests are fully respected, that provides clear guidance to professionals and managers, that effectively monitors for problems, and that takes actions where needed. It should be guided by participatory principles, so that those affected – patients and their families, professionals, managers, and academics – have a voice in its design and implementation. And the Group A cohort – the early adopters – need very specific support, earmarked both to make them better and to engage them in helping others. While this point can be debated, many observers believe that HITECH was a wise intervention, in that US healthcare represented an IT business failure (that is, typical business incentives did not drive healthcare delivery systems to implement IT, as happens in most other industries), and the programme created a tipping point for digitisation of the health care sector (33). At one point, there were between 30 and 50 competing systems, many used by only a handful of practices. It follows from the prior discussion that measuring digitisation in pure ‘return on investment’ terms is a mistake – both because the ROI is unlikely to be immediate, and because the ‘returns’ should be framed in overall benefit, not simply financial benefit. They and their teams managed to provide us just the right amount of support without compromising our independence. There are no references for section 3. Lawrence expects that eventually all 240,00 Trafford resident will be in it. It is thus not surprising that many health IT implementations fail, not only in England but around the world. Procurement and contracting arrangements were problematic. We believe that the NHS is poised to launch a successful national strategy to digitise the secondary care sector, and to create a digital and interoperable healthcare system. Failure to appreciate this leads to many of the other problems: underestimation of the cost, complexity, and time needed for implementation; failure to ensure the engagement and involvement of front-line workers; and inadequate skill mix.
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