Is the NHS failing to leverage transformation from technology?

Adam Hill.2jpgThe NHS spends a great deal on IT but rarely embraces the service redesign opportunities this offers. Dr Adam Hill, Chief Medical Officer at Sectra, explores how this could change.

The NHS spends significant sums on its valuable IT infrastructure. But despite this investment, our health service often fails to embrace the service redesign opportunities this technology presents, with major deployments still often layered onto existing services.

Redesigning services can dramatically improve care and save substantial amounts of money. Yet missed opportunities mean that we have under-utilised assets, and all this in an era of more for less.

The real opportunity to reshape the delivery of clinical services hand in hand with the deployment of IT programmes can be seen by taking a glance at the recent history of diagnostic services within the NHS. Radiology and pathology are both service delivery specialities within modern day medicine. Consultants from neither speciality have their name above a patient’s bed, but both are mission critical diagnostic specialities, and the bedrock upon which modern day healthcare is based.

One of these specialities has already managed to embrace technology at a remarkable pace. The other has very effectively embarked on service redesign. Yet neither has achieved both—something that must happen in future in order to maximise benefits for patients, enabling a shift to a new era in which cost-effective health outcomes are commissioned.

Radiology and pathology: two sides of the diagnostic coin
Radiology has shifted to digital very rapidly in the NHS. The National Programme for IT (NPfIT) accelerated coverage of picture archiving and communication systems (PACS) to in excess of 95% within 18 months. Despite widely publicised criticism, NPfIT revolutionised the delivery of imaging diagnostic services in the UK. However, the potential to reduce inequality of care provision and improve cost-effective outcomes have been less successfully realised, ultimately impacting upon professional working conditions.

Not only does service redesign impact the health of our population at risk, but it can have any number of indirect benefits. As just one example, it could mean freeing up and consolidating vastly under-utilised real estate in the NHS. Clinicians providing a diagnostic service with a digital workflow can arguably report from an office, a hot-desk reporting hub, from home or whilst on the move with equal fidelity. But radiology is yet to really harness this opportunity.

Pathology, in contrast, has undergone a significant service redesign following the Carter Review in 2008, focused on reducing costs by 20%. However, this diagnostic service has failed to realise the impact upon equality of outcomes and cost reduction that come with implementing a digital workflow, despite the widely held anticipation that pathology will soon be the next big digitisation in healthcare.

IT infrastructure deployment can re-vision service delivery
Embracing IT infrastructure at the same time as the service redesign opportunities that new deployments offer can unlock the potential to transition clinical care provision from centralised environments, through to decentralised models and distributed networks of care.

In diagnostic services, this would mean the ability to balance workloads across a region. It would give hospitals anywhere in a region the ability to access clinicians with the right skillsets to prepare a specimen, perform an examination or report a finding.

Modern PACS systems are cross-enterprise document sharing, or XDS , enabled. They can allow federation of workflow across a region, something that has previously been balkanised by different PACS vendors. This workload balancing can allow hospitals to meet ever stringent service level agreements, whilst improving specialist job satisfaction.

Joining up tasks to join up care
Put simply the tasks of IT implementation and service redesign are currently decoupled. It is very infrequent that a hospital looks for IT to support a service transformation programme. It is equally rare that hospitals will use the deployment of an IT infrastructure project as an opportunity for service redesign to unlock efficiency savings.

We must now move away from a situation where IT is simply layered onto the existing healthcare service as a result of analysing current workflow to inform IT architecture.

The focus must now be on the use of IT to support hospitals and the people within them, whether that is the clinician, the radiology service manager, the CEO, the chief financial officer or the patient.

Innovators will embrace the opportunity to use IT to redesign healthcare, achieving affordable health outcomes today; the risk of being a late adopter is that cost efficiencies are not realised until much later, failing patients that can’t wait for our health system to meet their needs tomorrow.

*Radiology Information System/Picture Archiving and Communication System

About Dr Adam Hill

Adam is a dual-qualified Clinician and Mechanical Engineer, previously having co-founded and led a successful university-based research centre at the interface of both disciplines. Adam’s expertise is in the research, development and optimisation of medical technologies and healthcare services, with over 100 publications and 8 academic awards in the last 15 years.

Having learnt the fundamentals of his clinical trade in the NHS, Adam passed through the Royal Military Academy, Sandhurst, before serving as the doctor to the Household Cavalry Mounted Regiment. Upon retiring his commission, Adam held technical and commercial leadership positions within start-up companies spanning service delivery, skills development and, most recently, technology incubation, before working as a Management Consultant with international clients in the Lifescience and Healthcare industries. During the term of our most recent coalition Government, Adam has provided thought-leadership, advice and content to a handful of its initiatives and programmes.

Adam’s current interests include unlocking the value of networked services, believing that the whole is greater than the sum of its parts; the primacy of imaging in the realisation of personalised medicine; and powering efficiencies in care delivery through standardisation.

Sectra has a rapidly growing share of the RIS/PACS* market the UK, a powerful product portfolio, and a world-class research and development centre at the University of Linköping; these are our foundation, our building blocks and our brain trust with which we can design, develop and deploy solutions to the most complex of problems challenging our NHS customers today.

 

The journey to a single RIS-PACS environment

JJ Alberts2  Main logo and main strapline

Dr Johann Albert, Associate Director, Business Solutions at Alliance Medical, discusses the challenge of varying client requirements in a private diagnostic imaging setting.

Unlike most NHS Acute Trusts, who tend to have large static diagnostic imaging departments located around a single or a small group of hospitals, private diagnostic imaging providers tend to have numerous static locations, a central patient management centre and varying fleet sizes of mobile scanners that move around on a daily basis. Private diagnostic imaging providers also have to contend with varying requirements from their customers that include scan-only services, book-scan-and-report services, or even report-only services. Service levels vary from customer to customer and the actual process of managing a patient differs between NHS, self-pay, medical insurance and medico-legal customers.

RIS PACS Icon logoThis variability highlights the fact that any clinical system deployed within a private diagnostic imaging provider needs to be able to cope with different workflows within the same location. It also implies that the clinical systems need to manage the end-to-end patient pathway in a manner that is completely separated from a fixed geographical location, as different parts of the patient pathway can take place in different locations. An example of this is where a patient calls the patient management centre to make a booking, the scan takes place at one of the scanning locations and the clinical report is completed by a tele-radiology provider. The clinical systems should therefore understand the concept of a workflow and a distributed network of scanning locations, as well as have the ability to move information seamlessly among various locations in accordance with the desired pathway.

The customer base of a private diagnostic imaging provider also varies from a commercial perspective. There are significant differences in customer requirements for management information, payment calculations and billing processes. This is on top of more intricate billing requirements such as factoring, zero-rated VAT or VAT exempt treatments that apply to some, but not all customers.

The realities of a business built up over time
Some of the private diagnostic imaging providers in the market started out in the pre-digital era and in the early days most diagnostic images were captured, stored and reported based on film. Over time RIS and PACS clinical applications appeared and of course private diagnostic imaging providers adopted these as appropriate. Since these technologies were still in their early phases of development, the designs tended to reflect the limitations in technology at the time and it was focussed on serving the needs of specific contracts. Some of these providers also grew by acquiring other smaller companies with their own legacy systems in situ.

These contributing factors typically result in a variety of RIS and PACS applications installed in the same organisation, all of which serve different purposes, different contracts and manage different parts of the patient pathway. To any manager the obvious implications of this scenario are, amongst others, large management overheads, a high degree of complexity in the technology solutions, various manual processes and an inability to rapidly change to accommodate customer needs.

Procuring a single RIS-PACS

To move from a situation where there are multiple RIS and PACS applications in place to a single unified system carries some significant challenges. Engrained manual business processes, distributed staff locations, radiologist availability and varying customer expectations are all significant challenges to overcome and manage. This is not even talking about the technical and logistical issues that a project of this nature would face.

Understanding the customers’ needs must form the core of any such change process and this must be layered on top of the requirements from the relevant operational teams. One of the key decision points in the design and deployment of a unified RIS-PACS environment is the balance that needs to be struck between flexibility and standardisation.

The flexibility within the system to accommodate operational needs and customer requirements is very important for any commercial organisation. On the other hand it is no use accommodating different customer requirements if these cannot be delivered to a consistent level of quality and to a consistent service level. Although there is a degree of overlap, these two system properties tend to be opposing forces in terms of the demands they place on a clinical systems platform. A good balance can only be achieved through proper engagement with customers and the relevant operational teams.

The procurement of a RIS and PACS system, at least from a private diagnostic imaging provider’s perspective, needs to fulfil several criteria and these include:

• It must have an integrated billing engine that can cope with all the requirements from different customers.
• It must manage the entire end-to-end patient pathway in the absence of a hospital information system (HIS), which includes multiple inbound channels and multiple outbound channels.
• It must allow for different workflows to be accommodated within the same clinical application that is a specific property of the contract associated with the patient.
• It must understand and cope with a distributed network of scanning facilities, some of which are static and some of which are mobile.
• It must allow for electronic interfaces and for the integration of any new developments to take place in a consistent way that is easy to manage.
• It must allow the private diagnostic imaging provider to change and configure the system as an inhouse function and not one that requires vendor intervention to the degree it is prevalent today.
• It must accommodate different clinical workflows that include scan only, scan and report, report only, double reads, report audits and also remote reporting.

This list is not meant to be comprehensive, but it is intended to highlight the requirements that a private diagnostic imaging provider will view as essential, as opposed to most radiology departments within a hospital setup. This set of criteria does point out the fact that most of the incumbent RIS vendors, and to a lessor extend the PACS vendors, do not meet all the criteria. It is therefore inevitable that some degree of customisation and development will be required for any clinical systems platform to be successful.

The implementation process
Once the appropriate systems have been procured, attention needs to turn to the implementation process. It goes without saying that a formal project methodology must be followed to have any hope of a successful implementation. Instead of providing an account of all the formal elements that a project of this nature requires, we would rather want to share our experience of the top four learning points:

Change: with any new system, there will be an element of change. The obvious example is the fact that staff members will be using a different clinical system to manage their daily workloads. There is however several areas of change that often get overlooked in a project of this nature. These include items such as the mechanism for how radiographers can move an image from the scanner to a specific radiologist. This is a simple task, but one which is core to the operation of any diagnostic imaging unit. The overall system might work very well, but if the key tasks that staff members need to perform on a daily basis are overlooked then it is easy to undermine the success of the entire project.

Process standardisation: implementing a single unified RIS and PACS implies that the same business process will be followed at each location. To assume that each scanning unit operates in exactly the same way will be a mistake though. Local business processes will have evolved over time and are a function of location-specific factors, customer-driven preferences, individual staff influences and of course head office standard operating procedures (SOPs). There must be a high degree of focus on ensuring business processes are standardised at each location, in order to accommodate a single RIS and PACS application. Deploying a system that enforces a standardised business process on a business environment that operates in a variety of ways, has the potential to stall the entire project.

Communication: with a workforce scattered around the country and a large proportion of it serving a mobile fleet, it is no surprise that communication is one of those tenacious challenges that needs constant attention. No single communication method will suffice in this situation and it is up the project team to use any and all means available to ensure the relevant messages reach the correct target audience. These methods can include anything from formal letters, face-to-face meetings and even social media. Social media is of course playing an increasingly important role in most people’s daily lives and it is a very useful tool in the business environment as well. External stakeholders need to be included at the appropriate times.

Coordination: the nature of most private diagnostic imaging providers is such that different parts of the patient work flow can take place at different locations. The payer of the service is mostly the determining factor that dictates which element needs to take place where. This is however a moving feat for the simple reason that patients from multiple contracts can be scanned at any scanning unit. The respective units therefore need to cope with different contract workflows at different times throughout the day. The implications for implementing a RIS and PACS as a unified platform is therefore that it is easy to undermine the company’s ability to service a patient if the implementation of all the different supporting systems are not well coordinated.

Conclusion
The latest technologies around work flow management will allow most private diagnostic imaging providers to improve productivity as well as quality at the same time, but it is important to realise that any project of this nature and scale requires just as much energy to manage the business change process as it requires to change the technical system. Even though the journey to a single RIS-PACS platform might have its challenges, it is our firm opinion that the benefits far outweigh the costs and the risks.

About Dr Johann Alberts

JJ AlbertsDr Alberts is a qualified medical doctor and his main clinical experience is in emergency medicine, both in the UK and South Africa. his experience includes private, public and military healthcare systems. In 2007 he made a career choice that deviated away from clinical medicine towards healthcare management. His passion is to design and implement healthcare services to ensure that more patients can benefit from what is already a scarce resource.

After completing an MBA at Oxford University, Johann joined BMI Healthcare as a Programme Director, where he managed four divisions that included Physiotherapy, Health Screening, Speech and Language Therapy and Occupational Health.

Johann joined Alliance Medical in 2012, first working at group level designing a quality strategy, implementing benchmarking and assisting on various projects around the company. At present Johann is directing the RIS-PACS implementation project, which will be completed in early in 2015.