https://orcid.org/0000-0002-1093-2480
ABSTRACT
The goal of the Foundation Healthcare Group (FHG) Vanguard model was to develop a sustainable local hospital model between two National Health Service (NHS) Trusts (a London Teaching Hospital Trust and a District General Hospital Trust) that makes best use of scarce resources and can be replicated across the NHS, UK. The aim of this study was to evaluate the provision, use, and implementation of the IT infrastructure based on qualitative interviews focused mainly on the perspectives of the IT staff and the clinicians’ perspectives. Methods: In total, 24 interview transcripts, along with ‘Acute Care Collaboration’ questionnaire responses, were analyzed using a thematic framework for IT infrastructure, sharing themes across the vascular, pediatric, and cardiovascular strands of the FHG programme. Results: Findings indicated that Skype for Business had been an innovative and helpful development widely available to be used between the two Trusts. Clinicians initially reported lack of IT support and infrastructure expected at the outset for a national Vanguard project but later appreciated that remote access to most clinical applications including scans between the two Trusts became operational. The Local Care Record (LCR), an IT project was perceived to have been delivered successfully in South London. Shared technology reduced patient traveling time by providing locally based shared care. Conclusion: Lesson learnt is that ensuring patient benefit and priorities is a strong driver to implementation and one needs to identify IT rate-limiting steps at an early stage and on a regular basis and then focus on rapid implementation of solutions. In fact, future work may also assess how the IT infrastructure developed by FHG vanguard project might have helped/boosted the ‘digital health’ practice during the COVID-19 times. Spreading and scaling-up innovations from the Vanguard sites was the aspiration and challenge for system leaders. After COVID-19, the use of IT is scaled up and now, the challenges in the use of IT are much less compared to the pre-COVID-19 time when this project was evaluated.
Introduction
In January 2015, the National Health Service (NHS) invited individual organizations and partnerships to apply to become ‘Vanguards’ for the new care model programme, one of the first steps toward delivering the NHS Five Year Forward View.1The aim of the Foundation Healthcare Group (FHG) Vanguard programme was to develop a sustainable local hospital model that makes best use of scarce resources and can be replicated across the NHS.Citation1,Citation2 The aspiration has been to enhance outcomes and access, improve cost-effectiveness, and meet the challenge of increased demand.Citation3 The FHG linked two hospital Trusts, a London Teaching Hospital Trust (LTHT) and a District General Hospital Trust (DGHT), that could work together more closely in a planned way to improve care without the formal organizational change of a merger or acquisition. This report was commissioned and carried out by a collaborative interdisciplinary team from the School of Business and Management and the School of Population Health and Environmental Sciences, King’s College London._The context of the FHG model was within the Vanguard scheme developed by NHS England (NHSE) in which new models of care would be piloted and evaluated.Citation4 The setting of this model is innovative and of vital importance. The chosen LTHT is the largest hospital trust in England and a center of world-class expertise. The Vanguard attempted to link it with a small District General Hospital and one which was struggling to provide specialist services like cardiology, neurology, etc. Patients, therefore, had to travel long distances to central London for care, which otherwise could have been provided locally. The Vanguard provided IT links enabling some, but not all, services to be delivered locally. While it worked for some specialties, it did not work for others and IT was the critical factor in influencing these outcomes.Citation5 Thus, the role of IT in such a large-scale health and social care organizational change is crucial for the collaboration and execution of the project. The healthcare-related IT evaluation was thus important and was based on qualitative interviews and focused mainly on the perspectives of the IT staff and clinicians across collaborative vascular, pediatric, and cardiovascular care pathways. Scoping literature review techniques were applied to peer-reviewed and ‘gray literature’ in order to provide a context to understanding the FHG change process.1,Citation2
Methods
Qualitative data analysis was used throughout the evaluation to distil complex data into themes that were used to capture the essence of observed and reported experience. Qualitative research findings presented here stem from analyses of interview data with staff, managerial and board meetings, stakeholder events, and documentary reviews. Interviews were semistructured, organized by question prompts, to elicit participant views of the Vanguard model. Six interviews were carried out for this IT evaluation with mid- to senior-level IT, clinical, and managerial Vanguard leads, all of whom are based at LTHT. Eighteen further interviews carried out as part of the clinical pathway evaluation stream included questions pertaining to IT support and infrastructure. An ‘Acute care collaboration’ questionnaire was completed by three senior expert IT leads. In total, 24 interview transcripts, along with ‘Acute Care Collaboration’ questionnaire responses, were analyzed using a six-phase analytic frameworkCitation6 to elicit inductively the significant features associated with IT infrastructure, clinical informatics, and healthcare records sharing themes across the vascular, pediatric, and cardiovascular specialty areas. The six phases involved: 1, Transcription; 2, Familiarization with the data; 3, Coding; 4, Developing a working analytical framework; 5, Charting data into the framework matrix; and 6, Interpreting the data.
Results
The IT evaluation provided an overview of the challenges faced in exchanging patient data across the two Trusts and the implementation of the IT infrastructure required to achieve smooth collaboration between them. It also reported on the pilot projects and implementation of software tools and IT programmes planned to make the collaboration feasible.
The results of this qualitative analysis are presented under various themes and sub-themes.Citation7 An attempt to provide an in-depth insight into the detailed results along with the quotes from the qualitative interviews is made here.
Clinician’s perspective toward the provision, use, and implementation of IT
Sharing of patient records across the two trusts
Clinicians reported that they had to scan and load clinical documents and images manually and that there was a lack of a suitable IT infrastructure and admin support for this purpose. This was time-consuming for the clinicians and a distraction from delivering patient care.
“So, we’re having to physically load up those documents ourselves as opposed to having admin support or IT to do that.”
“Essentially, in regard to patients’ notes, there is no easy information transfer between DVH and LTHT, other than fax/email and scanning them in.”
They voiced their desire to be able to access each other’s desktops to view letters, documents, and images, across both sites to save time.
“What would be the ideal thing is that we would at both sites be able to log on to each other’s desktop and view letters and documents as we can now with the local healthcare record between us, KCL, GPs in our locality. So that would be the ideal but we’re not at that point yet, so we’re having to physically load up those documents ourselves as opposed to having admin support or IT to do that.”
The electronic health record (EHR) and radiology systems between the two trusts appeared to lack interoperability and were unable to ‘talk’ to each other. The LTHT clinicians were able to view the scans at DGHT, but DGHT clinicians were not able to view scans performed at LTHT, and this issue had only been partially resolved by IT.
According to the clinicians, there were variations in the clinical systems and the clinical terminology used in EHRs between the two sites. Sharing clinicians’ letters and patients’ scans (Echo, MRI, CT, etc.) was perceived to be critical for quality holistic care provision. However, they did not feel sufficiently supported by an appropriate IT infrastructure for information sharing and instead, had to upload patient documentation as e-mail attachments or share via Skype screen sharing that was inadequate for patient care.
“No two IT systems will talk to one another. So here in the Trust we use a radiology reporting system which is adequate and most of our scans are diagrammatic, so the surgeons like to see that image, but this radiology system won’t talk to the EPR system which is all over the Trust, so they’ll get inclusion and then manually you have to scan in the diagram. So, it’s time consuming for all the admin staff. Moreover, the clinicians at LTHT are able to see the scans at DVH, but not the other way round. IT has not been able to fix this.”
The clinicians found it problematic that their secretaries could access the systems but were unable to upload the documents/letters from the other Trust or print them, and hence, e-mails were sent in order to transfer information. According to the clinicians, if secretaries could preload required documents and scans, that would enable them to see more patients within the allocated time period for conducting remote clinics.
“The other aspect of IT that we’ve had real difficult with is the transfer of communication from DGHT to LTHT’ in that our secretaries have access to the St Thomas’ system but they are unable to upload anything, they’re unable to print anything, so they’re not able to upload our letters on to the St Thomas’ system, which creates holes in communication and it means that everything that we do we need to email to loads of people to ensure that the information gets transferred to St Thomas.”
Those interviews conducted in the most recent quarter (Quarter 3, 2017/18) demonstrated a change in perception of IT functionality. Clinicians reported that remote access between DGHT and LTHT was operational and that they were able to access a range of clinical applications remotely, resolving most of the data sharing issues.
“So, all of the clinicians have access to the other Trust’s network now which is a significant win and almost to all of the programmes that they need within each Trust.”
Access to electronic patient records (EPR) and its reliability
Clinicians reported that they found it hard to rely on the IT systems as they noted discrepancies between what was recorded and what clinicians were seeing clinically, and the data collected were not sufficiently robust to inform clinical service redesign. They also reported that accessing and organizing data were time-consuming:
“It’s been very difficult to get data together, so it’s needed a lot of hands-on trawling through notes, looking at kind of the information systems that exist, the registrars working at [hospital 2] really working very hard at trying to collect robust data which, when we’ve asked management to provide us with data, then it’s -, and what they have on informatics is clearly not what we observe clinically, so it was very clear that there was a discrepancy between what informatics had on record as opposed to what we were seeing clinically. And so that’s why we couldn’t rely on those systems, it’s ended up being a lot of hands-on trawling of data.”
Need for innovative IT solutions and provision of IT equipment
There was a perceived need for IT solutions to deliver more efficient communication pathways, inpatient transfers, and remote data access. Sharing the electronic images/scans securely on iCloud was an option that the Trusts had been exploring. ‘Skype for Business’ (SfB) was being used for communication between the two Trusts and for running the remote clinics. The clinicians report relatively high levels of turnover of Vanguard IT staff, which led to backlogs in resolving IT issues and that there was scope for further IT development.
“Our current transfer process is quite convoluted, it’s, you know, very labour intensive, there’s lots of people involved and so we’ve got like for example um, it’s called IHT, it’s called the Inter-Hospital Transfer System, it’s used by multiple different hospitals, um, it’s a good idea but it’s very clunky again very labour intensive so I think yes, some IT solutions and some things in terms of just better ways of working in terms of communication pathways or in-patient transfers, I think would reduce, you know, the length of the people experiencing and maybe then make it a bit more efficient on this side as well.”
Laptops were being used for virtual clinics, but their provision was viewed by participants as insufficient. Similarly, the process of upgrading Windows machines was reported as being slow. Occasional difficulties with Wi-Fi access too were reported.
“I’ve asked for eight months to have a laptop I can actually take out of the hospital that has Wifi to do virtual clinics and I can’t do that apparently. So, every little ask has been just a pain actually.”
Clinicians at DGH who received laptops from their Trust reported that they were able to access hospital records remotely in a secure way and had managed to gain access to LTHT EPR systems remotely. However, clinicians at LTHT voiced concerns about not having received laptops requested for the purpose of remote access:
“We finally, so we were very fortunate actually to get given a Trust laptop, so we now are able to access DGH remotely from the laptop, which is amazing and we finally also managed to get access to LTHT’ EPR system remotely, but that took a while, but we basically via the laptop we can access everything now. Without that, before that, that was very difficult.”
IT team’s perspective toward the provision and implementation of IT
The information around the following themes is derived from both interview data and the ‘Acute care collaboration’ questionnaire answered by three senior IT leads, whose perspectives add an additional layer of ‘triangulation’ to the evaluation findings. The feedback from IT leads suggests an awareness of the aforementioned issues ‘on the ground.’ Notably, the greatest reported challenge has been in establishing an effective IT workstream coordination and management capability.
Use of technology for sharing of information
The following technology solutions were implemented for record sharing across the two Trusts. Furthermore, the Vanguard senior leadership team, in response to the evaluation team’s (Quarter 1, 2017) formative feedback regarding IT provision, confirmed that LTHT was the first Trust in England to comprehensively roll out Windows 10 that was likely to provide a solution to many of the difficulties previously cited by interview participants.
a) SfB: Use of SfB facilitated communication between consultants on different sites to allow direct patient care to be discussed and secure sharing of patient information. The wider rollout of SfB to LTHT clinicians in the Cardiovascular pathway was dependent on a desktop (device) upgrade to Windows 10 which was implemented. SfB was used to conduct virtual clinics, consultant-to-consultant, and consultant-to-patient consultations.
“Increased use is reliant on the rollout of Windows 10 devices to LTHT Cardiovascular due in July 2017. Discussions are just getting underway in respect of the use of SfB to support virtual clinics but this work will build on a pilot project that has been run at the Evelina Children’s Hospital.” (Acute care collaboration’ questionnaire May 2017)
b) Remote Access: Remote access to LTHT and DGHT systems was fully tested, available, and functioning and enabled two-way communication between LTHT and DGHT in order to facilitate access to clinical systems regardless of site base. Remote access uses standard Java and Citrix Remote Desktop solutions. Clinicians were able to use their existing credentials to gain access and view patient records through this secure link.
“This relies on pre-existing solutions at each Trust, however, network access changes and local software configuration has been necessary to enable these solutions to work from one Trusts PCs to another Trust’s systems.” (Acute care collaboration’ questionnaire May 2017)
c) King’s Health Partners Local Care Record (LCR): The aim of the Vanguard was to allow DGHT staff access to the King’s Health Partners LCR system. The LCR is a read-only interoperability platform that allows patient healthcare record sharing between healthcare organizations including London Teaching Hospital NHS Trusts and more than 120 GP practices. A ‘proof of concept’ was run to inform the work that was required to implement the LCR at DGHT. The costs and resourcing required for specific projects, such as access to the LCR, were developed as individual proposals that addressed the use of secondments or short-term contract assignments, as necessary.
“A scoping exercise was undertaken so that the resourcing, effort and cost associated with allowing DGT access to the LCR could be defined.” (Acute care collaboration’ questionnaire May 2017)
d) Picture Archiving and Communication System (PACS) Interconnection: The aim of the Vanguard was to interconnect PACS systems between the two Trusts to allow cross-site access to patient healthcare images for direct patient care. The interconnection of PACS was dependent on implementation of Sectra systems provided by a private software supplier at both Trusts and the configuration of software and secure network access. Sectra PACS went live in May 2017 for both the Trusts. DGHT requested Cross-Platform Workflow to be initiated in conjunction with DGHT’s Sectra upgrade. Due to contractual obstacles, implementation was not feasible before programme ends in March 2018.
“This relies on the completion of LTHT’s Sectra PACS implementation, and the extension of Sectra PACS to Darent Valley Hospital, due 2017/18. The planning for this work is due to commence in July 2017.” (Acute care collaboration’ questionnaire May 2017)
Focusing on interoperability, information governance, and data sharing
The pathway to full, real-time, interoperable systems was taken in steps that can be measured by achieving the ‘maturity levels’ 1–5, with level 5 being full maturity. (Appendix)
Data sharing for the purposes of direct patient care was covered by existing data sharing arrangements between Trusts.
“The Local Care Record’ is broadly in line with level-2 in the maturity model. A second phase of the LCR project is likely, once the phase 1 DGT access project has been completed, this will incorporate DGT’s electronic health records into the LCR. No agreed timeframe has been put on this phase 2 development.”
Benefits tracker software and the FHG programme metrics dashboard
The Programme Benefits Tracker was devised by a private company for the purpose of tracking the overall performance of the programme including the IT infrastructure and working, by capturing relevant metrics and monitoring the benefits on a consistent basis.Citation8 Development of such a software package was an IT-related initiative of the programme. When developed, it was not implemented for immediate use and further work was required to clarify the metric definitions and data capture. For indicators that were in place or could be gathered from sources readily available in the NHS (75% of indicators), the programme team needed to work with the informatics teams of both Trusts establishing the regular feeds required to operate these tools. For data not in place (25% of proposed indicators), the programme team needed to work with the informatics teams to establish the relevant audits and surveys (details are given in the Appendix). The Benefits Tracker had been perceived as holding considerable potential to capture the required metrics and evaluate the performance of the new clinical pathways:
“The benefits tracker devised by XYZ is not being used yet and is awaiting further work on the metric definitions which will be progressed in earnest from July onwards. We will be preparing a detailed plan of activity around all metric development. It is expected that the PwC tracker will be used in some form, although may be further iterated depending on final requirements.” (Interview with the IT leads)
However, clinicians were mostly unaware of the involvement of the private company and the ‘Benefits Tracker’:
“No, we don’t know -, I don’t know an awful lot about the benefit tracker.”
A decision was taken in Quarter 3, 2017/18 to discontinue the Benefits Tracker. In its place, an FHG Programme Metrics Dashboard v1.0 has been developed and implemented at both DGT and LTHT. The activity dashboard displays clinic data for the chosen Vanguard specialties, which can then be reported directly to NHS England on a quarterly basis. The specialist dashboards show activity for Pediatrics, Vascular, and Cardiology pathways.
Barriers to implementation faced
Recruitment and retention of personnel to the programme had been very challenging, given the tight timeframes involved and fixed-term nature of assignments.
“The appointment of an IT Workstream Project Manager in February 2017 has made it possible to better identify and prioritise deliverables, and to coordinate the effort of existing resources. Some progress was made prior to this appointment but requirement collation and the status of acknowledgement/response to requirements was less visible leading to some frustration amongst clinicians and staff.”
Consultants expressed the need for continuous and strong IT leadership and coordination of IT systems across both the Trusts to exchange patient data was a challenge.
“One frustration we don’t have strong IT leadership at both sites. Hindsight should have been proper and continuous IT leadership, one person coordinating both sites and solving problems in a systematic fashion.”
Feedback from senior Vanguard programme management leads highlighted that although the Vanguard is a nationally funded programme, delivery is through local IT services that needed dedicated resources to deal with additional demand resulting from the programme. In terms of the financial requirements of an IT programme to support the Vanguard, an underspend of the allocated IT budget was forecasted (Vanguard Programme IT Workstream Summary Progress Report, 30 January 18, v0.2 included in the Appendix).
Discussion and conclusion
The salient features of the IT evaluation findings and its implications are as follows:
The overall impression was that clinicians initially reported they had not received the IT support and leadership expected at the outset for a national Vanguard project. Inefficiencies in clinical delivery occurred as a result of difficulties transferring data from DGHT to LTHT. Clinical activity could have been increased in Virtual clinics if data had been more accessible. Improvements were reported particularly in terms of remote access of EHRs and scans between DGHT and LTHT.
Skype for Business was an innovative and helpful development (Note: This was in the preCOVID-19 time). SfB has become widely available and used at both Trusts. Some participants reported a perceived lack of IT infrastructure. However, more recent Trust-wide Windows 10 rollout will support IT developments and should deliver further benefits for clinical teamsCitation5 (Report in Appendix).
Provision of laptops is the preferred hardware solution for conducting virtual clinics. Those who were allocated a new laptop reported in glowing terms, while those who were not, reported poor access to equipment, stressing the need for better laptop availability.
Programme Benefits Tracker: the programme was initially behind in its implementation plans. It required clinical involvement and engagement and the Q1 Evaluation report showed that there had been minimal clinical involvement in the development of the Benefits Tracker. The evaluation report advised steps for rapidly adopting the tool within the programme to ensure appropriate data capture for the purpose of evaluation. However, it is now the understanding of the evaluation team that proposals to develop the Benefits Tracker have been discontinued, and a centralized solution (FHG Programme Metrics Dashboard) for gathering key performance indicators (KPIs) has been implemented in its place. This involves the collation of KPI data from local clinical pathway teams.
The LCR is an IT project that was perceived to have delivered successfully in south London. On reviewing LCR ‘viewing statistics,’ it is clear that LCR has high levels of uptake and usability. Implementation at DGHT was a quick win with knock-on efficiencies. (Report in Appendix)
The way in which shared technology saved patients from traveling to LTHT and they ended up having shared care, which was locally based, was seen as a successful outcome.
The following lessons learnt from this IT evaluation of the FHG Vanguard project can be applied to other settings as well. There is now a major emphasis on ‘burden of treatment’ for patients with morbidity and multimorbidity.Citation9 An important realization in terms of patient benefit was that many patients were able to access care locally and avoid the travel because of successful implementation of IT linkage between DGHT and LTHT. Conceptualizing this in terms of ‘miles travelled’ for treatment from DGHT to LTHT gives you a fair indication of the patient effort. But traveling from DGHT and LTHT mostly entails a minimum of a half day, often more, taken out of the lives of patients with LTCs. The Vanguard scheme, where it saved journeys to the LTHT, reduced ‘burden of treatment’ considerably. So, the lesson to be learned is that ensuring patient benefit and priorities is a strong driver to implementation; one needs to promote the importance of patient-centered concepts such as ‘burden of treatment.’
Despite being a flagship project, simple and remediable issues became rate-limiting steps in terms of connectivity, for example, supply of laptops, ‘Skype for Business’ access, and remote access to LTHT investigations (especially cardiology scanning investigations). Thereby,the lesson learnt is that one needs to identify IT rate-limiting steps at an early stage and on a regular basis and then focus on rapid implementation of solutions.
IT requirements for interorganizational integration need to be assessed and planned for at the start of the project and resources and people provided, both at a strategic and operational level. A suitable IT infrastructure with scope for interoperability can be pivotal to the success of programmes of work based on partnerships and the requirement for smooth communication flows, in particular, around the care of the patient. As we move toward greater integration of health and social care, along with the push for greater patient-centredness and holism in how we address the global disease burden of multimorbidity, the importance of a robust IT infrastructure cannot be underestimated.
When IT technologies are implemented to healthcare setting, it is important to have compatible systems that would allow quick and reliable access to patient data. In addition to the “systems talking,” it is essential that IT professionals and clinicians are also talking. These lessons can be applied to e-Health and m-Health solutions in the post-COVID-19 era, especially in regions where access to health care or clinical capacity is lacking.
At the time of this evaluation, there was considerable IT inertia and skepticism about remote working. In the post-COVID-19 landscape, which brought with it unprecedented digital change, future work may include revisiting the IT connectivity issues that held back the linkage to see which are now working well. A study in London teaching hospital has shown rapid implementation of Microsoft Teams in response to COVID-19.Citation8
In fact, future work may also assess how the IT infrastructure developed by FHG vanguard project might have helped/boosted the ‘digital health’ practice during the COVID-19 times.
Spreading and scaling-up innovations from the Vanguard sites is the aspiration and challenge for system leaders. Further work is needed at the national level to remove legal and financial barriers and make use of the learning and development of the IT infrastructure done during this FHG Vanguard project that can be applied across the other Vanguard sites and beyond.
Acknowledgement
This research was supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
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References
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