Following the passage of the Health and Social Care Bill, the term ‘integration’ is now frequently described as ‘removing the invisible divide that has for many years sat between primary, secondary, community, mental health and social care.
Already we are looking at how integration has the potential to redesign care around the needs of patients rather than NHS structures to provide more joined-up, patient-centred and value-based care, which improves patient outcomes and provides the support needed for our changing and aging population.
There are already limited, but great examples of NHS commissioners and local authorities developing shared visions, plans and budgets and of different sectors collaborating with providers to design coherent, reliable and efficient care pathways.
But with such a vision in mind, healthcare professionals are looking for modern information systems that provide better access to all relevant patient information at the point of care, enabling the provision of the best possible care regardless of the setting and source of information.
There is a growing acceptance by those delivering care that if a new type of national health and social care service is to emerge, it can no longer do so on paper.
Information will need to be in more than one place at one time, for example, if a clinician needs to access it during an outpatient clinic it may well need to be accessible by a community nurse that evening to support that patient at home. However, after failing to implement a national electronic patient record system for more than a decade, there are questions around if and how reducing the reliance on paper or going ‘paper-lite’ can be achieved.
Past experience has shown that whether it is time constraints or a lack of willingness to adopt to new technology, many clinicians simply do not want to move away from their disparate clinical systems, in which a typical hospital there can be up to 200. More likely, their unique system meets their specialty’s unique needs in ways that are not met by a “one-size fits all” approach.
From the conversations that I have had – including those within acute, primary, community and social care – it is also apparent that few seem willing to give-up the “best of breed” philosophy that underpins their IT strategy. The scepticism around single supplier electronic patient records (EPR) certainly has some validity - by implementing a single EPR there is a risk that ‘digital islands’ may be created whereby all data is ‘held’ in one single inflexible system. Doing this may in fact recreate some of the same issues that existed when using paper.
A logical solution is to provide web-based applications that integrate all the various systems they currently use, to present the information to the care-giver on a single screen tailored to that individual’s specialty information needs, whether a PC, a tablet or a mobile phone.
There are many who believe that the NHS could learn from the US Department of Veteran’s Affairs (VA) who have long been evolving a Services Oriented Architecture (SOA) to provide integration and interoperability.
Unlike mass replication of data across multiple and separated repositories using HL7 messaging, SOA is an architectural style that links together different IT systems in different locations and enables clinicians, administrative staff and even patients role-based access in real time in a single view. This architecture enables IT environments of any type to respond easily to changing requirements, as well as providing flexibility, re-usability, interoperability and scalability.
A SOA is a collection of many pluggable services presented in a way that allows clinicians to quickly accomplish tasks with complete information about the patient and condition. It paves the way for interagency integration rather than just the distribution of shared data.
This technology tends to perform faster than traditional centralised data models because it is does not require data synchronisation and relies on the integrity of the data source at the point of care, meaning that if the information is there it can be shared.
It seems that there is very little use or even understanding of SOA within the NHS and that we appear to prefer to replicate information rather than draw it from systems at the point when it is required. However, some of the more ambitious and thought-leading trusts are gradually seeing its validity and are beginning to take it seriously as a way forward.
The idea is similar to iGoogle, the service draws information from everything that you want to see, whether it be the weather forecast or the news you like to read, and presents it to on a single webpage. For example, that weather report remains on the Met Office or BBC News homepage but is presented as a view for convenience to the end-user on a screen or application of their choice.
Integration can occur across multiple boundaries from primary and secondary care, health and social care, and even the whole wider health economy in what Scotland have termed ‘inter-agency’ care. Here, health boards are already working with local authorities to share information beyond their own boundaries with the potential for emergency services, police, prison and education authorities, to access relevant information as well as allowing patient’s to view relevant areas of their records through a patient portal.
We’re also seeing examples emerging in England. In Hertfordshire for example, Central Eastern Commissioning Support Unit is making information available from A&E and GPs to ensure vulnerable children are safeguarded.
Of course, it’s not always as simple as joining up the relevant IT systems and providing the right access to the right people. The cultural barriers of introducing IT to clinicians are now being overcome, but the right infrastructure needs to be in place to support integration. Without working and usable systems the buy-in from end-users, which is often difficult to get, can very quickly be lost.
On top of that different organisations, and the suppliers that hold the data relating to the patients, need to make it securely available to others. Currently there are huge variations across the UK in the willingness to share data, but those providers who are too reluctant to do so may fall behind in their ability to ensure the NHS can deliver seamless and coordinated care.
Equally, there is also a role for suppliers to support each other in enabling the NHS to make the process as simple as possible – not always easy when vendors often fear that this approach may open the door to greater competition.
Since the realisation that having a digital NHS has the potential to provide improved outcomes for more patients using the same amount of resource, NHS England has been eager to get the ball rolling. Health secretary Jeremy Hunt has said that patients would have access to their GP records electronically by 2015 and that the NHS should be ‘paperless’ by 2018. Extra pressure came when he announced that penalties could be incurred if NHS trusts had not put the wheels in motion to deliver an EPR in 2014.
More recently Dame Fiona Caldicott, who led the review on confidentiality in the NHS, suggested that there is “a lot of work to do in terms of IT in order to achieve integrated care.” She added that it should be considered whether penalties are applied to organisations to ensure that they meet a “duty to share” information where it is believed to be in the patient’s best interest that could well accelerate innovations around integration.
But are penalties and deadlines the right way to go? The answer is probably not, as they tend to manifest themselves as “carrot and stick” management – where management beats you with the carrot. While they will certainly help to remind the NHS of the desperate need to move its IT into this century, the real way to convince end users and their organisations of the benefits, both clinically and financially, of investing in technical integration, is to learn from technological best practice and examples of where integration is working well.