FOR CONSIDERATION IM&T strategy development update Page 1 of 27 SPPC 20 December 2011 AGENDA ITEM 2.4 20 December 2011 IM&T STRATEGY DEVELOPMENT UPDATE Report of Director of Innovation and Improvement Paper prepared by Head of IT and Strategic Development Executive Summary Introduction/Progress IM&T is a critical enabler for improving the effectiveness of service delivery and for improving resource utilisation, particularly at a time when overall financial resources are constrained. The UHB requires systems that are fit for purpose to run a £1bn organisation in the 21 st century. The challenge is to develop a strategy which acknowledges that the current infrastructure is weak as a result of years of under investment, but which sets out a clear implementation plan to remedy this within the financial resources available. The strategy must be able to demonstrate the return on investment in IM&T, a clear focus on users’ requirements and will cover six key areas: • Core infrastructure • Operational patient administration systems (electronic patient record) • Clinical systems • Back office administration systems • Utilisation of internet (website, social media etc) • Business intelligence The strategy is being taken forward with key strategic partners, NWIS, Cardiff University,
Transcript
FOR CONSIDERATION
IM&T strategy development update Page 1 of 27 SPPC 20 December 2011
AGENDA ITEM 2.4 20 December 2011
IM&T STRATEGY DEVELOPMENT UPDATE
Report of
Director of Innovation and Improvement
Paper prepared by
Head of IT and Strategic Development
Executive Summary
Introduction/Progress IM&T is a critical enabler for improving the effectiveness of service delivery and for improving resource utilisation, particularly at a time when overall financial resources are constrained. The UHB requires systems that are fit for purpose to run a £1bn organisation in the 21st century. The challenge is to develop a strategy which acknowledges that the current infrastructure is weak as a result of years of under investment, but which sets out a clear implementation plan to remedy this within the financial resources available. The strategy must be able to demonstrate the return on investment in IM&T, a clear focus on users’ requirements and will cover six key areas:
systems (electronic patient record) • Clinical systems • Back office administration systems • Utilisation of internet (website, social
media etc) • Business intelligence
The strategy is being taken forward with key strategic partners, NWIS, Cardiff University,
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Cardiff and Vale local authorities and a commercial supplier (yet to be determined) Core infrastructure There is an urgent need to upgrade core infrastructure (server capacity, administrative software, sharepoint, teleconferencing, system accessibility, hardware etc). There are a number of potential solutions, use of ‘cloud’ technology, connectivity of non NHS Smart devices, in house virtual server farms. Initial discussions have already taken place with the University to maximise utilisation across the two organisations and with one commercial supplier Operational patient administration systems The core systems are the hospital system (PMS), the community system (PARIS), GP systems (currently four suppliers) and the OOH system (ADASTRA). The current strategy is to develop software which will improve the connectivity between these systems and enable an EPR to be created across the whole healthcare system. The UHB is working very closely with NWIS in this respect and is at the forefront of piloting many of the new developments, which will be rolled out across Wales. When fully implemented, these will improve the safety of transactions, the quality of care for patients and provide opportunities for reducing administration costs. In addition accessibility is being improved through the mobile device solution for PARIS and through connecting non NHS Smart devices to the NHS system and clinical portal. Clinical systems The IM&T Department should now have a central record of all the clinical systems in
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the UHB. These are mostly stand alone systems implemented by clinicians with some Divisional IM&T support but often no support from the central IM&T Department. Previous audit reports have identified that some of these systems are at risk of future failure. The benefits and risks of these systems are currently being assessed and the results will be taken account of in the strategy. All future systems will be subject to a cost/benefit analysis and be procured after approval by the IM&T Department to ensure they are consistent with the strategy. Back office administration systems There is significant potential to reduce expenditure on back office services using IM&T as an enabler in rationalising back office processes. A schedule of opportunities has already been prepared for the review of administrative functions. A major improvement project to rationalise medical records is already well underway. Utilisation of internet Capacity has recently been increased which will speed up access. A joint development project is being taken forward with the University, which has already developed an internal social networking site and applications for Smart phones. Business Intelligence The UHB is the only LHB in Wales which has a sophisticated business intelligence system. This system is still not operating at its full potential, although there has been significant development of applications during the last 2 years (clinical workstation, EU dashboard, patient level costing, theatre dashboard). The strategy will reflect prioritisation of future developments to provide information to improve operational
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processes and service management.
Action/Decision required
To note progress and to comment on direction of travel in relation to compilation of the IM&T Strategy
Link to other Board Committee (s) and sub-committees
Information Requirements Group
Link to Standards for Health Services in Wales
19 Information and Communication
Link to Public Health Agenda
The strategy will reflect Public Health Informatics requirements.
Link to UHB Strategic Direction and Corporate Objectives / Legislative and Regulatory Framework
The IM&T Strategy will reflect both National and Local strategic plans and objectives.
Link to relevant evidence base
• NWIS National Applications Strategy • ICT Strategy for the Public Sector in
Wales • National Data Centre Technical
Strategy • GP Clinical Systems Strategy • Telecommunications Strategy
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IM&T STRATEGY DEVELOPMENT UPDATE
1. INTRODUCTION Progress has continued in relation to the development of the IM&T Strategy for the Health Board. The Health Board has embarked upon a challenging programme of IM&T initiatives with the potential to deliver significant improvements and benefits. However in these challenging times it is vital to ensure that the IM&T Strategic Programme is joined up with other key transformation programmes of the Health Board including Turnaround to Transformation (T2T) and the Transforming Administration Pathway Programmes. In addition to taking the time to ensure that the strategy is linked with the above transformation programmes it is also necessary to ensure that opportunities emerging from initiatives to facilitate mobile working, connectivity of non NHS “smart” devices, Digitised Medical Records, eCommunications and Back Office efficiencies are exploited. The Health Board is also currently undertaking an infrastructure review in partnership with Microsoft the outcome of which will help inform the way forward. Finally and crucially, the strategy will need to take into account the latest position in relation to Capital and Revenue resourcing for Health Board IM&T. This paper provides an update on progress and content of this strategy document and highlights relevant linked programmes which need to be taken into account. 2. IM&T STRATEGIC RESOURCE ISSUES In identifying the Strategic way forward for IM&T within the Health Board it will be necessary to understand and address, on an ongoing basis, key underpinning resource issues. These will be highlighted in the IM&T Strategy document. Two key examples are identified as follows: Firstly, the Health Board faces significant risk in relation to the unfunded nature of the sustainability of the IM&T infrastructure. There are many examples of this to consider including Network replacement and Server replacement which will be included in the document. However, the most
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telling example which relates to desktop infrastructure costs is highlighted in the table below. Unit cost Devices Total 3 Year 4 Year Desktop £557 6,617 £3,685,669 £1,228,556 £921,417Laptop £700 532 £372,400 £124,133 £93,100Netbook £350 435 £152,250 £50,750 £38,062PCs in UA 557 80 £44,560 £14,853 £11,147MsOffice Standard £190 7,664 £1,355,450 £451,817 £338,863TOTAL £5,610,329 £1,870,110 £1,402,589
Secondly, despite supporting one of the largest infrastructures in the country and being at the forefront of national development and innovation in the area of IM&T there is a serious under investment within the Health Board in both Capital and Revenue terms. The Health Board spends 0.4% of its Revenue on IM&T compared to a Welsh average of nearly 1% and a WANLESS recommendation of 3%. The disparity is even more stark in relation to Capital expenditure. Both of these issues are illustrated in the NWIS Informatics Capability of Capacity Review exercise. A sample of the graphs is shown below. 2008/09-2010/11 Total LHB & Trust Informatics Spend as a % of Total Revenue Allocation
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2008/09-2010/11 Total ICT Spend as a % of Discretionary Capital Allocation (LHBs & Trusts)
Proposed 2011/12 ICT Capital Spend as a percentage of overall discretionary capital profiled by HB/Trust for comparison (with All Wales Average)
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2010/11 Informatics WTE Staff as a % of all WTE (by Organisation)
Informatics WTE as a % of all staff - C&V
0.68%0.69%
0.63%
0.50%
0.54%
0.58%
0.62%
0.66%
0.70%
0.74%
0.78%
2008/9 2009/2010 2010/2011
Financial year
%
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In comparison to England the resource gap is even more severe. The Leeds Teaching Hospitals NHS Trust is one the largest health organisations in England. In 2010/11 the Trusts total income was £910M. The Informatics department, including ICT and Information, had a revenue budget for this year of £15.5M, or about 1.7% of turnover. The department has a total staff complement of 320. The ICT only budget (excluding Information, Medical Records, Libraries etc) was £8m, or about 0.88% of turnover. In 2010/11 the capital spend on ICT was £4M. 3. DEMAND FOR IM&T RESOURCES The information requirements of the newly established Health Board have resulted in a, to be expected, increase in demand for IM&T resources. The period since the establishment of the Health Board has seen a significant increase in requirements for System and Information developments. There has also been a significant increase in IT infrastructure utilised to support Health Board requirements. This increase has come at a time of reducing resources devoted to IM&T which will need to be considered in the Strategy going forwards. 4. KEY STRATEGIC INITIATIVE EXAMPLES The Strategy will highlight that the Health Board is at the cutting edge of Informatics developments in Wales. Many of these initiatives are being developed in Cardiff for first use here with a view to then being transferrable across Wales often being project managed by this Health Board. There are also areas where Cardiff and Vale are at the forefront of delivery of Informatics solutions where there are no current plans to match this level of delivery elsewhere in Wales such as Community Informatics (PARIS system) and Business Intelligence System (BIS). Being at the forefront of informatics developments provides the Health Board with early service delivery benefits in comparison to the rest of Wales. It does however bring with it a resources challenge, previously described, and a challenge in relation to managing the pace of change in the National and Local programme. These areas will be outlined in the
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Strategy however a number of the key ongoing initiatives are outlined below: ICT DEVELOPMENTS
• e-Referrals - Welsh Clinical Communications Gateway • Medicines Management and e-Discharge (MTeD) • Hospital eReferrals • Bed Management • Ophthalmology Open-Eyes Application • Mental Health and Community System (PARIS) • Mental Health and Community Mobile PARIS System • Connectivity to the NHS Network from “Smart” devices
BUSINESS INFORMATICS DEVELOPMENTS
• Patient Level Costing • Discharge Planning • Ward/Nursing Dashboard • Community and Mental Health Information - PARIS • Theatre Productivity Tool • Divisional Scorecards
In summary, the examples shown above which will be included in the Strategy clearly identify advances being made in Informatics in Cardiff and Vale which will continue to progress over the next three years. Challenges will include resources and managing the pace of change at a national and local level. The IM&T Strategic Work Programme is shown in appendix one. 5. POTENTIAL STRATEGIC BENEFITS As mentioned earlier in these challenging times, it is also necessary to ensure that the strategy is linked with the requirements of T2T and Transforming Admin Pathways programmes as well as exploiting opportunities emerging from new initiatives such as connectivity of “smart” devices and mobile working. Benefits and return on investment are vital. Some potential examples are illustrated below.
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NWIS Strategic Benefits:
NWIS Strategic Benefits Examples of types of outcomes & benefits:
Patient safety increased Increased timeliness and availability of relevant clinical information decreased transcription errors & increases safety.
Positive patient outcomes increased
Easy access to relevant clinical information increases speed and relevance of diagnosis, care, treatment plan and onward referral.
Convenience of care increased
Improved availability of information make the location, timeliness or method of access for patients more convenient
Patient confidence increased
The availability and targeting of accurate and relevant information at the patient’s point of contact increases confidence in service
Legal/policy compliance maintained Requirement to comply with policy or UK/EC legislation is met.
Health system efficiency increased
Processes are faster, or wasteful processes can be reduced to improve productivity.
Overall health system costs decreased
Informatics improvements eliminate wasteful processes and reduce expenditure.
Transformation of Admin. Pathways – Potential Benefits Outlined below are some of the potential benefits that can support
the T2T programme and the Admin pathways programme from key IM&T initiatives. It is important that this potential is included in the IM&T Strategy plan
• e-Referrals
It has been agreed at a National level that electronic referrals (e-Referrals) from GP practices to outpatients will be delivered to hospitals through the Welsh Clinical Communications Gateway (WCCG) utilising clinical designs that have been endorsed by the National Architecture Design Board (NADB). It has been further recognised that there is considerable benefit in continuing the electronic ‘flow’ of the referral beyond initial receipt by hospitals, and to this end, e-Referrals will be received and managed using Hospital e-Referrals (“HeRs” – formerly Hospital Workflow). HeRs development has been led by Cardiff and Vale University Health Board and it is passing through the NADB approvals process. Current HeRs functionality (known as “Phase 1”) allows e-Referrals to be managed up to the point that they need to be
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transferred to clinicians for prioritisation, and includes addition of the patient to the outpatient waiting list. Phase 2 will increase the scope of the system to allow e-Referrals to be transferred to clinicians for on-line prioritisation. Phase 2 will be delivered to clinicians as part of the Welsh Clinical Portal (WCP).
• Potential Impact:
• GP Secretaries and other GP practice admin staff
o Reduced filing/retrieving of specialty/clinic-specific referral
templates, as on-line referring guidance will be used to complete the WCCG generic template, or bespoke templates will be held within WCCG
o In some cases, no need to type up, edit, confirm sign off, or send the referral letter as primary care clinicians may create and send this on the WCCG
o In some cases, where admin continue to type up, edit,
confirm sign off, or send the referral letter, need to do this using the WCCG
o In the majority of cases, no longer need to print, address, and post or fax the referral letter, as this will be sent electronically via the WCCG in real time.
o In some cases, such as where the target specialty cannot receive e-Referrals, or failure of the WCCG system, need to revert to paper systems to create/send the referral letter
o Reduced made phone calls regarding referral progress, appointment booking, and reasons for rejection, as status updates will be provided in real time
o Reduced received phone calls/reprocessing work relating to resending lost referrals
o Reduced received phone calls/reprocessing work relating to transcribing/legibility issues
• Practice managers, GP Secretaries, and other GP practice
admin staff o May need to manage WCCG work lists, checking that draft
e-Referrals are completed and successfully sent, and requests for information are processed
o May need to use WCCG to monitor sent e-Referral status in case of delays or rejections
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• Courier/Hospital Post Room Staff
o Reduced amount of paper letters to be delivered to Health Records and other initial recipients of referrals
• Health Records (including Clinical Referrals Centre) staff,
and admin staff in areas where responsibility for managing referrals is devolved from Health Records
o Reduced amount of paper letters received, opened filed
with the patient paper record or scanned to the electronic record (including fax)
o Reduced received phone calls regarding referral progress, appointment booking, and reasons for rejection, as status updates will be provided in real time
o Reduced made phone calls/reprocessing work relating to resending lost referrals
o Reduced made phone calls/reprocessing work relating to transcribing / legibility issues
o Reduced work locating or requesting required data within letters, due to generic template
o Reduced requirement to transcribe from paper or one system to another
o In most cases, will need to use HeRs system to process e-Referrals
o In some cases, will need to use both HeRs system and PAS system, such as new patients, duplicates, expedites, etc.
o Reduced amount of paper letters to be transferred onwards within admin areas or to clinical areas/clinicians
o In majority of cases, will need to use HeRs system to target recipients of e-Referrals
o In some cases, may use HeRs system to manage availability of receiving clinicians
• Hospital Medical Secretaries
o Significant reduction in the amount of paper letters to be
received and managed within clinical areas and transferred back to or via admin areas
o Reduced made phone calls/reprocessing work relating to transcribing / legibility issues
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o Reduced work locating or requesting required data within letters, due to generic template
o In some cases, may use HeRs system to manage availability of receiving clinicians
o Reduced management of communications to and from GP practices, to request further information or to explain reasons for rejection
• eDischarge
It has been agreed at a National level that electronic discharge (eDischarge) will be delivered through the Welsh Clinical Portal (WCP) utilising clinical designs that have been endorsed by the National Architecture Design Board (NADB). It is important to note that central to the success of eDischarge will be the inclusion of medicines information/data. This will be achieved through the development of a WCP component called Medicines Transcribing and e-Discharge (MTED). Cardiff and Vale University Health Board developers are prime builders of this component contributing directly to this NHS Wales Informatics Service (NWIS) led development. It was recognised that the Electronic Medicines Transcribing development requirement would impact on how quickly the full eDischarge could be achieved and hence an interim solution was implemented. This interim solution delivers electronic copies of the current paper based discharge documents to primary care via the national Welsh Clinical Communications Gateway (WCCG).
Potential Impact:
Both the Interim and the National solution would impact on Admin Staff as follows:
• Hospital Medical Secretaries:
o Will no longer need to type up the Discharge Advice Letter
(DAL) as this will be created on the WCP by medics and pharmacy staff.
o In some cases where local processes (consultants) dictate they will need to be able to edit and/or sign off and send the DAL electronically
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o In the majority of cases they will no longer need to print, address the envelope and post the DAL to the GP Practice as this will be sent electronically via the WCCG in real time.
o In some cases, where the DAL status reports ‘failed to deliver electronically’ they will need to print, address the envelope and post the DAL to the GP Practice.
• Hospital Post Room Staff
o There will be a significant reduction in the amount of paper
letters to be delivered to GP Practices
• GP Secretaries
o There will be a significant reduction in the amount of paper letters received, opened and filed with the patient paper record or scanned to the electronic record.
o Reduction in phone calls regarding the patients stay in hospital as DALs will be provided real time eg between 1-3 days from discharge, taking into account weekends.
• Communication Hub
The UHB has transferred its out of hours call handling services to a Communication Hub in the Vale of Glamorgan. The new service is located in the Vale of Glamorgan Call Centre located in the Barry Leisure Centre. This will represent the foundations to build an integrated service between our service partners and the voluntary sector enabling the patient, citizen and victim in the future to access services via a “single access point” (SAP). Whilst initially the service is primarily focused on handling out of hours contact it has the capacity in future to accommodate more and more citizen contact services.
Potential Impact:
o The Communications Hub model provides the Service and
Technology infrastructure for pooling of manpower virtually or physically which in turn will provide economies of scale in service provision in the future.
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6. Connectivity to the NHS Network from “Smart” devices
This Health Board has led the way in taking forward the evaluation of the potential for the connectivity of “non NHS Smart devices” to the NHS network. NWIS have agreed to pilot this initiative with the Health Board with a view to agreeing an All Wales proposal. The embracing of these new connectivity opportunities is an important factor in the developing IM&T Strategy. There are many potential benefits that may accrue from a successful technical implementation of such a solution as illustrated by the following testimonials from clinicians involved in the pilot: Mr David Scott Coombes: This system is nothing short of a miracle! The greatest advantage for me is the fact that I can now carry around an up to date calendar. The second obvious advantage is that I can read e-mails remotely and therefore keep up to date and respond with better efficiency. It is very easy to set up on an I-phone and very easy to use. I would be devastated if this pilot did not come to fruition as a lasting arrangement. I am the envy of colleagues who have witnessed my phone in action!! Dr Mark Stacey: The functionality of the system is pretty impressive, especially with a good wireless signal, which I have both at Cardiff Uni and at home. The email access is extremely helpful, while the access to the clinical portal is a game changer: enabling me to access patient data and results off site is incredibly useful in helping me to look after my patients even better and enhance patient safety. I look forward to being able to view the radiology data on the Good app!
7. Medical Record Digitisation (MRD) This is another area where the Health Board is exploring a strategic way forward to deliver return on investment. Health Boards across Wales incur significant costs in maintaining physical storage for paper based casenotes. So much so that digitisation or equivalent processes (eg microfiche transfer) have been in place for decades in order to reduce the physical storage requirements. These processes in turn act to reduce rather than remove costs since
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occasional reconstruction of notes (that later become required) is an essential part of this process. Additionally, paper based casenotes present a significant staffing resource impact. Only a proportion of a casenotes lifespan is spent within a Records Library, with significant periods for all active casenotes being spent in transit. Non availability of casenotes requires staff to search for them and additionally runs the risks of loss of information with concomitant patient safety risks. Cardiff and Vale LHB are in the process of constructing a business case that identifies the costs associated with a physical document library and those associated with an electronic document library. Initial indications are that whilst:
• Capital upfront investment would be required, and… • Continued revenue based technological refresh and upgrade would
be required
There seems overwhelming evidence that significant cost savings can be made by the move to a fully digitised electronic casenote via a scanning solution. Obvious savings incurred will be in reduction of admin staff required to manage the case note and its contents. Additional benefits will include:
• Casenotes never 'unavailable' and hence clinicians always work with full information (Patient Safety).
• No requirement to reconstruct notes (cost removal, patient safety) • Multiple access where required • Improved security of access opportunities • Technological correlations at all local and NHS Wales levels. (ie
linking with WCP, National eMPI, etc…) for further improvements in identification and safety.
• Essential part of the long term electronic patient record The IM&T department will work with the Health Records department to deliver this as a strategic initiative with its many potential benefits in reducing administrative costs and improving patient safety.
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8. eCommunication to GPs As described earlier, the Health Board is to be the first to implement eDischarge using the Welsh Clinical Communications Gateway (WCCG) to transfer the message. The WCCG, however, has the potential for use in sending all patient based communication to GPs. It is the intention of the Health Board move towards this Strategic target in line with recent discussions with the T2T programme. The Health Board currently generates in excess of 160,000 clinical letters to GPs per quarter. There are therefore significant potential benefits and return on investment to be accrued from this initiative. 9. Back Office savings The Health Board will explore as part of its Strategy the potential of IT to deliver savings in Back Office functions by evaluating the applicability of appropriate Technology including Digital Dictation and Digi Pens for example. 10. Mobility The Health Board Strategy will need to incorporate the potential benefits of Mobile Working. This Health Board is one of the first in the UK to have a successful pervasive implementation of mobile working for staff working in the community. The technical solution implemented has been rolled out across all District Nurses and Health Visitors. The anticipated benefits in relation to patient care and efficiency are being realised in line with plans. Next steps need to be reviewed in terms of Strategic benefits of roll out to further services. 11. CONCLUSION The exercise to compile an overarching IM&T Strategy for the Health Board is in progress as outlined in this paper. It is however important to ensure that the Strategy is joined up with key Health Board Transformation Programmes. It is also important that the Strategy exploits opportunities from latest developments mobile working and Smart device connectivity, an area which the Health Board is at the forefront of in the UK.
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In these current challenging times it has become increasingly important to ensure that all Strategic initiatives as well as improving Clinical support also provide demonstrable return on investment. 12. RECOMMENDATION The Committee is asked to note the progress in the exercise to compile an IM&T Strategy for the Health Board and to comment on the direction of travel in relation to the completion of the work ensuring that it is joined up with key Health Board Transformation programmes.
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IMPACT ASSESSMENT Health Improvement
IM & T systems have a critical role to play in terms of supporting the delivery of services needed to meet the health needs of the Cardiff and Vale population.
Workforce
IM & T systems underpin the effective deployment of the staff providing these services.
Education and Training
E-learning is an integral part of UHB’s programme of training and development for its staff.
Financial
IM & T systems are essential to maintain robust control and governance arrangements and to support systems that assist UHB in mitigating financial risks.
Legal
The above control and governance arrangements underpin UHB’s statutory duty to break even financially.
Equality
Equity of access is integral to excellence in service provision.
Environmental
n/a
RISK ASSESSMENT Clinical/Service
Excellence in clinical service provision is integral to UHB’s status as a centre of excellence.
Financial
Failure to maintain IM & T systems that are fit for purpose will compromise UHB’s ability to meet its statutory financial responsibilities.
Reputational
Failure to maintain IM & T systems that are fit for purpose will compromise UHB’s reputation as a centre for clinical and academic excellence.
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Acronyms and abbreviations
IM&T – Information Management and Technology NWIS – National Welsh Informatics Service ICT – Information and Communication Technology PAS – Patient Administration System UA – Unitary Authorities PMS – Patient Management System TCIs – To come ins PLC – Patient level costing TPT – Theatre productivity tool
CONSULTATION AND ENGAGEMENT Information Governance Committee Information Requirements Group Information Services eCommunications (ISEC) Board Mental Health and Community Information System (MHCS) Project Board Multiple National Project Boards SOURCES OF INFORMATION
• NWIS National Applications Strategy • ICT Strategy for the Public Sector in Wales • National Data Centre Technical Strategy • GP Clinical Systems Strategy • Telecommunications Strategy • Community Informatics (PARIS) Strategy
FOR INFORMATION
APPENDIX I
IM&T STRATEGIC WORK PROGRAMME
FOR INFORMATION
Cardiff and Vale UHB NWIS Programme PlanIssued: 30/11/2011
