Transforming healthcare in Northern Ireland

Microsoft hosted a round table discussion on the role of technology in transforming healthcare in Northern Ireland.

What role can technology have in transforming healthcare in Northern Ireland?

Paul Duffy

It is essential we see digital embedded in all change across the health service. Technology delivers a number of benefits: it consolidates and conforms practices; reduces variation and improves outcomes. Health outcomes are the primary driver for introducing technology in the first place. It needs to be done in consort with all the stakeholder groups, including patients. If it’s not about change then we should be questioning whether we do digital.

Louise Skelly

Technology should support patients and allow them to own their health and social care. We should make that as simple as possible so that people have the right information and advice to manage their own care. To support those services we need to make that more accessible, particularly as people get older. Technology should also be used to tackle issues like social isolation. 

Sean Donaghy

Northern Ireland is a leader in this area: we are the envy of the rest of the UK with our electronic care record. Northern Ireland is one of the few places in Europe where every citizen, except those who opt out, have a summary electronic care record that clinicians can use to support delivering better care. We need to go further and make it available to more staff, particularly nurses – who are still recording on paper charts in the hospital setting and we need to address that. We also need to create ways citizens can engage with us in their care.

John Woods

The primary role of IT in healthcare is to support clinicians in delivering care to patients. That is our primary mission. Technology should be an enabler; it should not be a barrier and often that means doing the simple things well and at scale.

Stephen McComb

Firstly, technology can support staff who are overloaded, improve the workflow by removing unnecessary steps and also to encourage collaboration. Secondly, technology facilitates the personalisation of care. Rather than deliver care in a wholesale fashion, we can ensure the right care is delivered at the right time and that will remove a lot of the unnecessary activities.

Frank O’Donnell

Healthcare in Northern Ireland is experiencing the same pressures as many other health systems worldwide and the current model of delivery is unsustainable. The general direction of travel outlined in the Bengoa report points towards a transformation of care delivery. If we are looking to shift care from the acute to the primary setting, with more care in the home, technology will underpin the delivery of that. Without joined up technology platforms, which can work together, Northern Ireland will continue to have fragmented care, which is not good for patients.

Technology also gives us data and insight into how care is being delivered. In some areas, we just don’t know how well the health system is working. This data allows better understanding of the system which helps redesign the system into the future.

“Without joined up technology platforms, which can work together, Northern Ireland will continue to have fragmented care, which is not good for patients.” Frank O’Donnell

How has the electronic care record (ECR) changed the way healthcare is delivered?

Sean Donaghy

The electronic care record has won three national awards for being best in class for integrating care but we recognise that there is still much to do. It has also made clear to everyone, managers and clinicians, that we have to invest more heavily in supporting digital care. We have assembled an investment programme that is a long-term project as these are big changes. We need to continue to invest in the ECR to work towards that joined up digital future and build on what we have now. We need to get digital by default and every citizen that wishes can be supported digitally as part of their care regime.

Louise Skelly

It is important that people have access to their ECR and that will be really helpful to patients, particularly those with long-term conditions. These patients are often the experts regarding their own health and even before the advent of ECR a lot of them had started keeping copies of their records themselves. At each stage of interaction with the system they were in control of their own information and that was important to them. We are quite excited about the ECR as many patients, particularly those with long-term or rare conditions, are becoming experts in their own health and having access to their own records will be an important tool for them.   

Stephen McComb

There are also opportunities that the future investment programme creates, including the opportunity for specialist solutions from smaller service providers. These could link into treating some of the longer-term conditions and specific diseases. 

Paul Duffy

Our job is to provide the appropriate digital solution that reduces the variation embedded within the system that is incumbent with the paper processes that we have at present. Our patients will never get to managing their own conditions as long as we are dependent on the paper processes. We need to move away from paper processes so that we can digitally support clinicians and nurses, who know what is best for these patients, in a unified way so that the record can be shared across all groups. 

“It is not our information; it is the patient’s information that has been trusted to us and therefore we have a duty of care to look after it.” Paul Duffy

John Woods

ECR has helped clinicians enormously and there are clear advantages for patients. For example, as a specialist in kidney disease my work involves use of blood tests to determine kidney function. One big advantage of ECR is that it integrates the results of these tests no matter where they were taken. Often when someone comes to see me now, I do not have to request an additional blood test as I can find the result of one done recently by their GP or in another hospital trust. This saves the patient having to have the test repeated. I can also obtain better information about their medical history by viewing letters dictated about their care, and can see details of medications prescribed by their GP. Much of this information was previously unavailable to me. Although the information held in ECR is relatively straightforward, it has changed care for many patients.

Frank O’Donnell

Those relatively simple steps are important in achieving the long-term vision. Little things can make a big difference, particularly for getting the patient engaged in their own care. This also allows the patient to act as an additional resource for the care system, doing more to improve their own care. Often changes can be relatively simple from a technology perspective, particularly in primary care where common technology solutions can make a big difference.

How are data protection and security issues addressed in healthcare?

Paul Duffy

It is not our information; it is the patient’s information that has been trusted to us and therefore we have a duty of care to look after it. The downside is that sometimes that restricts us in making the data more widely available because we first have to understand the purpose. GDPR [General Data Protection Regulation] is not yet fully understood in the healthcare environment and it challenges us with many issues such as the right to be forgotten and should that be applied to someone with a mental health issue, a chronic disease or a debilitating disease that might affect their children. It will be a challenge not only for how we store information but also how we release it in the future. In terms of malware, the health trusts in Northern Ireland are working together in the region to provide the greatest level of security that we can. We have had no breaches to date but we are constantly vigilant. The work we are doing with Microsoft and others around securing information, while making it accessible, is high on our agenda.

Frank O’Donnell

From a Microsoft perspective data security is a fundamental for us. It is something we are constantly working on and investing in and we design our solutions from a security first perspective. We are currently doing a tour across Europe getting policy makers in healthcare together to discuss the ethical issues around patient data, GDPR and other regulatory aspects. We invest around $1 billion a year in data security, aiming to continually improve the capability of our solutions in the face of increasing threat. There remains a perception issue with data security and we need to communicate with patients and citizens to assure them that their data is being handled correctly. People often equate digital with a less secure environment, whereas it is much more secure than cupboards full of paper records.

Stephen McComb

There needs to be a balance. There can be an obsession around the data protection element but we have to balance that with the fact that often if data is shared there is an opportunity to save lives. At the minute ECR is very good at sharing data for one patient but where there are a number of patients with the same condition and treatment it is important to learn across patients in order to save the next life. If we get too absorbed in the data protection side we may miss life-saving opportunities.

“Technology can support staff who are overloaded, technology facilitates the personalisation of care.” Stephen McComb

Frank O’Donnell

There is now a debate about donating your data; much like donating your blood. Data is also important to the care of others as well as yourself. The big challenge is the secondary use of data for research and ensuring that patient identity is protected. The value of the data is what we need to focus on. 

Paul Duffy

We need to take it back to the patient and make sure that they are the custodian of the data. It should be up to the patient with informed consent after discussion with their clinician. We then need to ensure the secure and consented availability of data as much as the confidentiality. We are not the Civil Service, we are here to promote outcomes and we won’t do that by locking away data that is needed to improve healthcare outcomes.

Louise Skelly

It is important that the end user is involved in the debate around risk and balance. We have supported mental health service users to engage with the ECR team on access to mental health records. Those discussions were very successful. People do see the bigger picture when they are engaged properly. The best outcomes are those that are co-produced by professionals, end users and decision-makers. People with mental health conditions or rare conditions that affect small numbers are naturally concerned about who is using the information. The message from patients is that data should be accessible to improve health outcomes for themselves and other people who may have the same condition. I also work with groups who are at the fringes of healthcare, those with very rare conditions, and they are crying out for that information about their condition to be shared.

John Woods

Clearly security needs to be paramount but for clinicians there is a trade-off between access and security. Frequently, the implementation of the necessary level of security is cumbersome and gets in the way of day to day use of the relevant system. For example, I have 15 passwords for systems I currently use. All have different formats and different policies for how long the password can be used before it needs to be changed. It’s demanding to try and keep track of them all!

Where should we look to for good examples of digital transformation in healthcare across the globe that could be applicable in Northern Ireland?

Sean Donaghy

We are health and social care and we value that. At times, we challenge ourselves to ask if we are making the best of having health and social care integrated. Integrating care means integrating data and that has been a challenge. The examples we have looked at are those who are tackling those integration issues and at the same scale we have in Northern Ireland. Scandinavian examples include Finland with its joined-up approach, Gothenberg in Sweden and the Copenhagen and Hofstede regions of Denmark who are integrating care across a number of hospitals. Rivas Healthcare in the Netherlands is another good example. These examples all show that it can be done and that you have to engage with people. It is doable and we have good strong examples. We have invited some of them to Northern Ireland to help us. Intermountain Healthcare in Utah and Geisinger in Pennsylvania provide great examples of clinical engagement and leadership. They agreed a way forward and then set about doing it once. Learning from this approach, we have coined the phrase ‘once in Northern Ireland’.     

“Northern Ireland is a leader in this area: we are the envy of the rest of the UK with our electronic care record.” Sean Donaghy

Frank O’Donnell

Firstly, we need to learn from the success in Northern Ireland and from any bumps in the road along the way. Northern Ireland is the best test bed for the future. When you look at other countries you need to understand what you are looking for: the technical aspects, the change process or the data policies and regulations. Looking at the US, they focused on the implementation of new technology but not on its adoption. They then had to spend enormous amounts of money to incentivise adoption. In New York there is a lot of work going on in joining up care organisations. They spent a full year analysing the care system before deciding what to do with it. The data gathered over that year helped shape the reform programme. The Netherlands had several electronic healthcare record systems and this was problematic in achieving one national health record. Northern Ireland can learn from all of these examples as plans the right approach in their unique context. 

Stephen McComb

The value-based care model in the US takes a joined-up approach and we have a lot to learn in how to join together a number of care provisions both in community and hospital settings. For example, in the UK we budget for 15 minutes of domiciliary care but this is the wrong measure. We should be looking at outcomes and then working out what care is needed to achieve them.

Louise Skelly

The health and well-being teams in England are a good example of small self-managed teams for domiciliary care. They have moved away from the notion of a set number of calls per day. A small team of eight people take responsibility for the care of a number of people in the area. They are supported with good digital management tools that allow them to take responsibility for the delivery of care in a very flexible and effective way. For example, a patient might need only five minutes of care today and someone else might need two hours today. They work around the individual needs and become focused on the end user. At the moment, our system is focused on the service provider.

Another fundamental change we need is a really good information and advice service. We have started with HSCNI online but that will have to be further developed into an advice service for the public rather than them relying on Google.

“We should make that as simple as possible so that people have the right information and advice to manage their own care.” Louise Skelly

John Woods

I’ve noticed from social media that there appear to be good examples of how not to do digital transformation in healthcare. In the US, there has been major investment in EHR systems and yet some physicians seem to really dislike them as their experience of using them is poor.

Paul Duffy

There are a number of good examples but they will not necessarily transfer into the Northern Ireland funding model. We have enough good ideas here and we know what our own problems are. Let’s take the time to really understand the problems we face and then let’s not try to boil the ocean but focus on one thing at a time. It is a journey and not an end point. We also need to take people with us or we will have a big shiny system no one will use.

What one issue should senior managers focus on, over the next two years, in the digital transformation of healthcare in Northern Ireland?

Frank O’Donnell

A lot of the technology in this area is proven and the challenge lies more in implementing the change needed to effectively use that technology. Senior managers should focus on the need for change and understand what that change will mean for individual clinicians and for all those that work in the system. What are they going to have to do to move from what they are doing currently to what they will have to do in the future? They all need to understand that journey and they need to get the time and the right support to make that journey.

Stephen McComb

Personalising care to what the patient needs. Our experience has been that there is quite a lot of activity that doesn’t deliver value to the patient. By focusing on what the patient needs we will remove a lot of cost within the system and get a better outcome for patients. That will make the organisation more sustainable and provide better care by personalising that care using technology.

John Woods

Focus on the end user experience, be that for the patient or the clinician using the technology. When implementing a system, look at the current workflow and try to adapt that to a more efficient state. Don’t, as so often occurs, enforce a different workflow which is slower and less efficient. Focus on supporting the users’ needs while keeping processes simple and fast.

“Clearly security needs to be paramount but for clinicians there is a trade-off between access and security.” John Woods

Sean Donaghy

One of the big challenges for us, if we are to have a fully digital service, is to reduce unwarranted care variation. We know that because the system is built up from individual teams and organisations. People design things that work for them and their practice but that makes it difficult to pass patients across to another service without the knowledge of how that information is going to transfer. Sometimes that creates overlaps and boundaries in how care is delivered. We need to manage these boundaries much better by reducing variation and design end-to-end care which is a really big challenge for all of us. 

Louise Skelly

Focus on accessibility and involve the end user. That involves getting good feedback and testing systems. Get users involved back at the concept stage of any digital transformation programme and having that built in throughout will bring the best outcomes not just for individuals but for the system as a whole.

Paul Duffy

Focus on the change and that means change for a defined outcome – patient improvement. An outcome-focused patient-improvement agenda needs leadership and not just waiting for someone else to do it for you. Take the lead with your own service and trust digital to take things forward. Invest that digital transformation as part of your change programme from the outset and don’t bring digital into the picture at the end. Embed digital and get the experts involved right at the outset. Transformation and patient care will be more effective as a result of that early involvement. 


Participants

Sean Donaghy

Sean Donaghy is Director eHealth at the Health and Social Care Board. His career in health and social care stretches back to 1983. His career began in Finance, and included Director of Finance appointments. Between March 2003 and March 2007, he was Chief Executive of the Mater Hospital Trust. Sean held senior regional posts between March 2007 and September 2010, including the post of Deputy Secretary for Resources and Performance Management at DHSSPS. He was Chief Executive of the Northern Health and Social Care Trust between September 2010 and May 2013, when he took up his current role as Director for eHealth and External Collaboration for Northern Ireland.

Paul Duffy

Paul Duffy is Co-Director for IT and Telecommunications in the Belfast Health and Social Care Trust. He is responsible for the strategic and operational delivery of all of the IT services. There are over 500 applications many of which contribute directly to patient and client outcome. The IT service he leads is focused on delivering safe and efficient services underpinning a dynamic and agile capability. This service has at its core a strong metrics based approach in using innovation to improve outcomes. He has a technical background in networking and service delivery delivering innovative solutions that improve the workflow needed to drive improvements in patient and client care.

Stephen McComb

Stephen McComb is Manager of the NI Connected Health Innovation Centre. He brings companies, academia and government together to develop technology rich solutions which address the health and social care needs. This role is funded by Invest NI to grow innovative Health Technology companies in Northern Ireland. He has a breadth of experience in managing change programmes in health, government, telecoms, and logistics.

Frank O’Donnell

Dr Frank O’Donnell is the Public Sector Lead for Microsoft Ireland. He has over 20 years’ experience working within the public sector as a senior director at Scottish Enterprise and advising public sector clients as a partner at PA Consulting and Head of Health and Public Sector at KPMG. Frank’s work has been focused on the development of technology strategy and policy for the transformation of government. He has specific experience in working with the health and education systems in Ireland, UK and Middle East, including working with the Health Service Executive in Ireland to lead the development of a strategy and business case for a National Electronic Health Record.

Louise Skelly

Louise Skelly is Head of Operations at the Patient and Client Council. She has worked in Health and Social Care since 1980 and joined the Patient and Client Council in 2009. Louise enjoys her work in the Patient and Client Council immensely, particularly because of the opportunity it presents to support people to have a voice in the future of health and social care. She also works as a lay magistrate for the Northern Ireland Court Service. Louise is married with one daughter and her interests include farming and sport horse breeding.

John D Woods

Dr John D Woods is Chair of the Northern Ireland Council, British Medical Association. He trained at Trinity College Dublin and worked as a junior doctor in Northern Ireland and Guy’s Hospital London. He did all his speciality training in the United States and has been a consultant Nephrologist for 20 years. Other interests involve his family, which with five children, takes up most of his time. John is also a keen sailor and has an interest in current affairs and US politics.

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