David Elliott, director of IT at Northumbria Healthcare NHS Foundation Trust, explores the misconceptions of a “best-of-breed” approach to digital transformation and why his trust decided to take this particular approach.
Having worked in utilities for over a decade before joining Northumbria Healthcare NHS Foundation Trust, naturally I made comparisons between the sectors, and I was particularly struck by the limitations to investment. Whilst it was considered normal for a utility company to allocate four to five percent of its annual turnover to digital, it’s just not possible in the NHS. Yet, digital transformation shouldn’t be about the ‘best you can afford’, it should be about the ‘best you can achieve’.
This rhetoric about affordability is often associated with the best of breed (BoB) approach, often in comparison to enterprise-wide single systems. It’s seen as second best when trusts can’t afford an enterprise-wide EPR.
And as a recent NAO report highlighted, it can be considered too complex because of the multiple business cases, integration between solutions and the extensive management of different suppliers. However, I want to redefine BoB.
Redefining best of breed
Northumbria Trust serves a patient population of 500,000 people and provides a wide range of hospital and community services across Northumberland and North Tyneside, so we need technology that can respond to different clinical settings and specialisms.
The technology needs to be agile enough to be customised and integrated into our evolving digital strategy, as we don’t follow the traditional five year waterfall strategy which tends to stifle innovation and limit progress. It also needs to be responsive enough to provide real-time access to patient information and insights into capacity planning across acute and community settings – something that has proven invaluable during the pandemic.
By taking a modular approach, we have been able to achieve this. We retain the technology that is working well (establishing our Silverlink PAS as the hub of the trust which interfaces with NerveCentre’s electronic patient record) and build or buy specialist clinical modules that respond to our immediate needs.
At the moment we’re developing a clinical noting solution that will work with both of these systems. And by using a data warehouse, the integrity of the data is protected, whilst the flexibility of the PAS means information can flow back and forth between the solutions, reporting on clinical and operational information.
Overcoming complexity
This strategy means we are using over 150 different systems, all of which have individual business cases that have been reviewed and signed off by the board. Each deployment comes with its own set of requirements for training, internal clinical buy-in, and maintenance. And there’s integration between the systems and the management of relationships with individual suppliers.
However, none of these challenges have been insurmountable, and they are a small price to pay for the benefits of having better, quicker and cheaper solutions at our clinicians’ fingertips.
And to help avoid duplication of functionality across systems and empower staff to see how digital can improve clinical care, we’ve established an assessment process. Clinicians pitch ideas to me and the CCIOs to see whether an existing system meets their needs. If it doesn’t, it’ll be submitted to our Digital Clinical Advisory Board (DCAB), which is made up of clinicians and the digital services team, to assess how it fits into the digital strategy and whether a new system needs to be procured or developed. The different clinical departments are also encouraged to submit their top three priorities to DCAB to ensure the medical and technology advancements are marrying up as much as possible.
We get about three to five presentations a week, which shows great engagement, and by not having a single cumbersome enterprise system, it’s easier to interface any new solution into the PAS and EPR.
We also have an IM&T committee, which includes board executives and non-executives, the medical director and CCIOs. Any big system change, such as a change to the EPR, are decided by this group, which ensures there’s consistent board buy-in. We’re also very lucky to have an executive board who understands the importance of investing in the right solutions to get the right tools into the hands of staff.
And whilst there are over 150 systems in use across the trust – which is time consuming to oversee – only ten of these are core solutions that need close management with suppliers.
This approach has enabled us to incrementally deploy technology that our different clinical teams need, without the lengthy procurement processes and customisation costs involved in a single enterprise wide solution. Whilst also minimising the complexity of on-going cultural changes, interoperability across systems and multiple vendor relationships.
Best you can achieve
That’s not to say the NAO report didn’t correctly identify the on-going challenges to digital maturity. And more can always be done, both by trusts and central organisations, such as NHSX and NHS Digital.
As trusts, we need to be better at sharing ideas, best practice and lessons learnt from our digital journeys, so that we can fully understand the different routes to the same end goal. And importantly, breakdown common misconceptions.
From the centre, there needs to be a greater drive towards open data, standards and APIs, to encourage more practical interoperability between systems, whether that’s within a trust or across a region, such as an ICS.
But we also can’t let our vision for perfection get in the way of delivering good progress on the frontline – as is evident in the last 12 months.
The recent response to Covid has shown there is an even greater willingness to do things differently. And with so many digital solutions offering new ways of working, BoB has an important role to play in helping trusts be more agile. Not because it’s the best a trust can afford, but because it offers the best option to achieve safer and more cost-effective care for patients.
17 July 2021 @ 21:06
I’m sorry, Best of Breed simply falls down when you ask yourself if it helps clinicians to have a holistic view of the complex clinical information about a patient.
The lack of empirical evidence is stunning for both models, but the market is clearly deciding with its feet as it marches towards core and solid EPRs at the heart of the digital healthcare economy. Of course, even the best single EPR does not solve all digital issues, so they will require interfacing to other solutions – but not by default. As the general rule states: “Keep it Simple”.
The flight deck of an aircraft is carefully designed NOT to have multiple UX’s as a path to reduced errors. Yet, we have this notion that it is OK in healthcare. Madness!
Best of breed is is technical jingoism or parsimoniously driven rhetoric.
Apologies again.
16 July 2021 @ 11:30
How are you overcoming the increasing complexity and risk of passing clinical data between systems? Historical integration (demographics, ADTs, Labs) is relatively straight forward, but despite evolving standards, each vendor implements them in differing ways. Therefore, exchanging something like allergies or blood pressure becomes difficult when there is no agreement on the data items in use. OpenEHR could help resolve this but the market place is still limited. FHIR, like any other, needs agreement on a common set of UK-specific resources.