Part One

NHS Plans and Resources

All healthcare professionals understand that digital technology has great potential to improve how the healthcare organisations deliver their services in new and modern ways, thereby providing faster, safer and more convenient care.

The NHS is investing in connectivity, improving NHS Information Technology systems and developing access to new technologies. The NHS must ensure that staff have the technology they need to do their jobs, and that technological systems can talk to each other and share vital information to support the delivery of care.

The NHS states the following will be done:

• Provide digital services and tools to give people more control over their own health and the care they receive from the NHS
• Extend to everyone the NHS App as a new digital ‘front door’ to give people secure digital access to their own medical records; find trusted information about their health online; allow patients to conveniently book appointments and view test results online. In time it will also provide medical advice and consultations securely
• Give health and care staff the technology they need to help them complete administrative tasks more quickly, freeing up time to spend with patients
• Set standards that keep information secure and make sure NHS IT systems talk to each other to provide health and care staff with complete access to joined up patient records.¹

The NHS, through ‘NHSX’ - https://www.nhsx.nhs.uk/ is leading the largest digital health and social care transformation programme in the world. With investment of more than £1 billion pounds a year nationally and a significant additional spend locally. NHSX has been created to give staff and citizens the technology they need, delivering the Health Secretary’s Tech Vision, building on the NHS Long Term Plan. 

NHSX have set out five missions, which are focused on how to make things better for patients and staff. These are:

• Reduce the burden on our workforce, so they can focus on delivering care;
• Give people the tools to access information and services directly, so they can best take charge of their own health and care;
• Ensure information about people’s health and care can be safely accessed, wherever it is needed;
• Aid the improvement of safety across health and care systems; and
• Improve health and care productivity with digital technology.²

Tech plan for health and care

NHSX will publish information iteratively and in phases as they develop the plan and are asking for your views to help shape each section as they go. They want to involve as many people as possible to help understand how to best support the health and care system to deliver the ambition set out in the NHS Long Term Plan and the Department of Health’s Tech Vision, as well as the forthcoming NHS People Plan.

Through this platform, you can register to participate and share your views in the following ways:

• Comment on our vision - this is a working document and will be updated as we continue to engage on this. You do not need to register to see this but you do need to register to leave a comment.
• Register or sign in to share a case study - if you want to share how you have used tech to help transform services then we would love to hear from you. You can see the contributions others have made without signing in.

New ways for you to get involved in the Tech Plan will be added here: Join in the conversation or email This email address is being protected from spambots. You need JavaScript enabled to view it..³  By registering for the platform, NHSX will be able to keep you updated as they develop the Tech Plan.⁴

The Health Infrastructure Plan (HIP)

The NHS and the healthcare services it provides to the nation are underpinned by capital funding for infrastructure comprising of buildings, including hospitals, equipment, ambulances, frontline technology as well as technological advances in areas such as Artificial Intelligence (AI) and genomics. The Health Infrastructure Plan (HIP) will deliver a long-term, rolling five-year programme of investment in health infrastructure, including capital to build new hospitals, modernise our primary care estate, invest in new diagnostics and technology, and help eradicate critical safety issues in the NHS estate.

When we talk about ‘capital spend on infrastructure’ in this document we mean:

• The long-term assets that support the NHS’ delivery of world-class care – including land and buildings (hospitals, community facilities, GP surgeries, pharmacies), equipment (ambulances, x-ray machines, MRI scanners), plant and machinery and technology (computer systems, software and databases); and
• The accompanying healthcare infrastructure that supports health outcomes – including genomics, adapted or specialised housing, public health, research and development (R&D) and more strategic investments by the Department and our arm’s-length bodies – all of which are interrelated with and critical to the quality of frontline care.

The NHS ’infrastructure is not just about ‘bricks and mortar’ – it is also about the digital technologies and data sharing capabilities that are needed to provide better care to the public, in a way that is strategic and joined up with estates planning. The NHS needs technology that reduces the burden on clinicians rather than increases it, for systems to talk to each other, for data to flow to where it is required when it is required, and technology that gives citizens the tools they need to access information and services directly.⁵

ePMA - Electronic Prescribing and Medicines Administration

Ensuring that patients receive the correct medication at the right time is a fundamental part of delivering care safely. By introducing the right technology, trusts are able to manage prescriptions and medications digitally, reducing the risks of incorrect medication being given. ePMA software can also reduce costs. A report in 2015⁶ estimated the national figure for pharmaceutical waste to be a staggering £300 million; electronic prescribing systems in hospitals, doctors’ surgeries and other healthcare establishments would help to reduce this wastage drastically.
 

Part Two

The Internet of Medical Things (IoMT)

Internet of Medical Things (IoMT): Reducing Costs While Improving Patient Care

• Remote diagnostics and video monitoring: These methods can be used to detect patient falls, harms, as well as monitor illness. It can reduce costs by enabling doctors to care for patients without the need for specialised/planned visits and also enhance efficiency. Remote video monitoring can be useful in a multitude of scenarios where patients are not physically present in the hospital, such as monitoring after discharge, identification of patients at risk for readmissions, and daily reminders to patients on medication. Using this technology, patient data can be monitored, recorded, and key parameters can be transmitted back to health care teams. Prompt transfer of data can allow for earlier patient diagnoses, leading to easier treatment and lower cost of care. Additionally, remote diagnostics technology can increase hospital availability while keeping patient health care costs low, as quicker treatment costs less for both hospitals and patients.
• In-patient continuous monitoring: Due to the low nurse to patient ratio in some hospitals, vital signs are monitored every 4–6 hours, instead of continuous monitoring. This can lead to health complications and unexpected death. In-patient continuous monitoring of patients whose conditions require vital signs to be monitored more regularly can alert doctors of patient health deterioration, leading to quicker recovery and lower cost of treatment. For example, patient’s post-op require continuous monitoring; however, a small nurse to patient ratio in ICUs may lead to complications and/or death, as patients’ vitals may change tremendously over a short amount of time. Continuous monitoring would transmit data about patients to nurses continuously, allowing for earlier detection, recognition, and treatment of any abnormalities in a patient’s condition.
• In-ambulance patient monitoring: This would be useful in situations where a patient’s condition requires immediate care while they are inside an ambulance. In these types of situations, an experienced doctor from the hospital would use biotelemetry technology, i.e., monitoring systems, to guide paramedics into properly caring for the patient. For example, when patients suffer from a heart attack, the first hour is the vital period of time in which the patient can be saved. In this scenario, in-ambulance patient monitoring from the hospital might be useful in guiding paramedics to provide successful care for patients. Video and remote patient monitoring technologies would enable the doctors to receive real time access to the patient’s vital signs.
• Prescription auto renewal with remote patient and dosage monitoring: This would entail remote parameter monitoring of patients to send data back to doctors along with auto-renewal requests, where a doctor can prescribe appropriate medicine dosage based on the patient’s conditions. This would eliminate costs and losses that are currently incurred when caring for patients who are delinquent on taking medications.
• Intraocular pressure monitoring for glaucoma: An increase in intraocular pressure can cause permanent damage of eyes (glaucoma), a condition that is irreversible. Remote monitoring of eye pressure using sensors as an add-on on glasses can prevent damage to the eyes by alerting doctors/patients when pressure has reached the limit advising them to seek immediate medical attention.⁷

Healthcare Information and Management Systems Society (HIMSS)

Healthcare Information and Management Systems Society, Inc. (HIMSS) is a global advisor and thought leader supporting the transformation of the health ecosystem through information and technology. As a mission-driven non-profit organisation, HIMSS offers a unique depth and breadth of expertise in health innovation, public policy, workforce development, research and analytics to advise global leaders, stakeholders and influencers on best practices in health information and technology. The HIMSS EMRAM rating system is seen as an international benchmark for the use of advanced IT to improve patient care, with Stage 7 being the highest possible rating. According to HIMSS criteria, stage 6 means that the trust has established clear goals for improving safety, minimising errors, and recognising the importance of healthcare IT.⁸

Artificial Intelligence

Artificial Intelligence (AI) is a broad conceptual category of computer software that is designed to mimic, emulate, or improve human decision-making. AI has been introduced into most electronic medical record systems for a wide variety of tasks. Most are supplemental tools to either accelerate medical decisions, reduce or eliminate errors, and/or improve healthcare quality, compliance to standards, cost-effectiveness, or satisfaction. Most smart infusion pump systems, for example, are now designed with modules and ancillary devices like bar code and radio frequency identification (RFID) readers to help enforce “Five Rights:” right patient, right drug, right dose, and right route, right time.

Clinical decision support systems (CDSS) can assist physicians, nurses, patients, or other care-givers to make better decisions. A common use of CDSS is to analyse past, current, and new patient data and identify or suggest gaps, errors, safety concerns, or care pathway improvements to the user.⁹

Investment in Artificial Intelligence

In the UK, a new National Artificial Intelligence Lab will use the power of artificial intelligence (AI) to improve the health and lives of patients. The AI Lab will bring together the industry’s best academics, specialists and technology companies to work on some of the biggest challenges in health and care, including earlier cancer detection, new dementia treatments and more personalised care.

The AI Lab’s work could:

• improve cancer screening by speeding up the results of tests, including mammograms, brain scans, eye scans and heart monitoring
• use predictive models to better estimate future needs of beds, drugs, devices or surgeries
• identify which patients could be more easily treated in the community, reducing the pressure on the NHS and helping patients receive treatment closer to home
• identify patients most at risk of diseases such as heart disease or dementia, allowing for earlier diagnosis and cheaper, more focused, personalised prevention
• build systems to detect people at risk of post-operative complications, infections or requiring follow-up from clinicians, improving patient safety and reducing readmission rates
• upskill the NHS workforce so they can use AI systems for day-to-day tasks
• inspect algorithms already used by the NHS to increase the standards of AI safety, making systems fairer, more robust and ensuring patient confidentiality is protected
• automate routine admin tasks to free up clinicians so more time can be spent with patients

The AI lab sits within NHSX, the organisation that oversees the digitisation of the health and care system, in partnership with the Accelerated Access Collaborative.

Simon Stevens, NHS England Chief Executive, said:

“Carefully targeted AI is now ready for practical application in health services, and the investment announced today is another step in the right direction to help the NHS become a world leader in using these important technologies. In the first instance it should help personalise NHS screening and treatments for cancer, eye disease and a range of other conditions, as well as freeing up staff time, and our new NHS AI Lab will ensure the benefits of NHS data and innovation are fully harnessed for patients in this country.”¹⁰

Part Three

Digital Enablement

Code of Conduct for Digital Technology in Health and Care

The code of conduct contains a set of principles that set out what is expected from suppliers and users of data-driven technologies. The aim of the code is to make it easier for our suppliers to understand what is needed from them, and to help health and care providers choose safe, effective, secure technology to improve the services they provide.¹¹

Digital lag puts healthcare at risk in an evolving consumer landscape in which digitisation increasingly drives success and failure. Healthcare organisations can follow a basic digital transformation roadmap and customise it to serve each health system’s unique and complex needs. With an effective digital framework, the organisation can fully integrate data, technology, and redesign workflows. Health systems must redefine their technology investment framework, they need a roadmap for digital enablement, to create a digital enablement framework. See below:

Digital Enablement Framework

For effective transformation, a healthcare digitisation framework supports four central goals:

• Engaging healthcare consumers (patients): Providing an engaging self-service experience and giving consumers full access to the necessary data and services to promote healing, health, and wellness.
• Engaging and enabling the clinicians / care team: Enable care teams to effectively collaborate and provide excellent care, to enhance patient safety, productivity, and working together more efficiently.
• Improving clinical and operational outcomes: Facilitate optimised and cost-effective care, digital tools leverage data and analytics to create embedded insights and decision support, thereby improving business and clinical outcomes at the frontline and health and wellness for entire populations.
• Growing the organisation: A digital strategy supports partnerships, organic growth, diversification, and innovation, allowing organisations to harness the power of strategic partnerships, platforms, tools, and data to keep pace with rapidly changing business needs.

This framework allows organisations to make conscientious decisions about systems of differentiation and innovation at the top layers, as well at the data platform layers to support digital process and application interface layers. This allows organisations to build fully integrated, consumer-centric digital interactions based on consumer perspectives, rather than just offering consumers a myriad of non-integrated, vendor-specific digital tools lacking cohesiveness. Following the establishment of the digital investment and enablement frameworks, organisations can start their digital transformation.¹²

Example: NHS at Home

Thousands of patients with cystic fibrosis and dozens recovering from coronavirus are being given devices and apps so that medics can monitor their condition remotely, as part of the NHS drive to give more people connected, supported, personalised care in their own homes. Health and social care secretary Matt Hancock said: “Technology has been an incredibly powerful tool in our response to coronavirus. We have learned so much about what can be done online, and in some cases, what is better done that way. Technology will play a growing and vital role in the future. “While we restore face to face NHS services too, new innovations will ensure patients can benefit from the comfort of home, with the reassurance that they can be fast tracked to support from the NHS should they need. NHS at Home will help keep people safe and out of hospital while providing the best possible care.”

Support digitisation with strategies that guide stable, scalable transformation:

• Formally Define “Digital” for the Organisation

An effective definition of digital includes the innovative meshing of new technologies, data intelligence, re-imagined workflows, and organisational leadership—all aligned to achieve a “sticky” and optimal experience that invites end users to virtually access all relevant information while offering a breadth of interactive self-service capabilities.

• Divide Technology into Appropriate Portfolios

Create 10 portfolio areas and focus on strategy for each area, all governed to support digitisation goals. Build business-driven IT partnerships for each portfolio and each major IT investment with a clinical or business sponsor/champion, who is the face of the initiative, paired with IT champion who’s doing the bulk of work behind the scenes. The partnership allows for two “harmonised” voices on the leadership team and ensures IT and business goals are connected.

Divide Technology into Portfolios

This approach by portfolio results in far fewer vendors with much higher levels of integration, which both supports reducing systems of record costs whilst providing significantly higher levels of integrated capabilities and access to data; key enablers of the digital framework.

Part Four

Clinical Decision Support (CDS)

A firm understanding is required of ‘Clinical Decision Support’ (CDS), in its various forms. Once CDS  is understood, the organisation should embed the five ‘rights’ of CDS. These five ‘rights’ can be used as a framework when planning to implement CDS interventions within a facility or practice, or when creating an extensive CDS program.

The five rights include:

• the right information - The information presented to the end-user—or in some cases, the patient, should be evidence-based, derived from a set of recognised guidelines, or based on a national performance measure.
• to the right person - As healthcare becomes more of a team approach, it is important to make sure that the right information gets to the right person that can then take action. The right person can be a nurse, physician, physical therapist, or in some cases, a significant other.
• in the right intervention format - CDS may be implemented in various formats—alerts, order sets, protocols, patient monitoring systems, and info-buttons. Consequently, it becomes important for implementers to identify the issues and problems they are trying to solve and choose the best format to resolve the problem at hand.
• through the right channel - In healthcare, CDS interventions can be delivered through an EHR, PHR, computerised physician order entry, an app running on a smartphone, and, if necessary, in paper form via flow-sheets, forms, and labels.
• at the right time in workflow - A common problem in health information management is the desire to overlay new technology onto current clinical processes. One negative outcome of this practice is that information may be delivered to a clinician at the wrong time, or it may not be available when it is needed.

CDS Goals and Objectives

In the early stages of developing a CDS intervention, an organisation would be advised to choose a goal to focus their efforts. The goal can be an organisational priority (patient satisfaction, safety, or prevention) or it can be a national priority, such as meaningful use or the CMS quality initiatives. Whatever goal is chosen, a direct link needs to be made between the goal and its potential impact on illness, death, and clinical outcomes. Once the goal is determined, a set of objectives can be defined that when achieved will provide evidence that the goal has been successfully realised.¹³

Cambridge University Hospitals NHS Foundation Trust (CUH) Device Integration

Cambridge University Hospitals NHS Foundation Trust (CUH) has long been focused on creating a digital healthcare environment to improve the lives of patients. In 2014, 99% of the Trust became paperless as a result of its eHospital digital programme and implementation of a Trust-wide EPR. Medical device integration (MDI) was a key component of this initiative.

Areas Implemented:

ICU and ICU contingency unit, surgical theatres and anaesthesia.

Devices Integrated: Cardiac monitors, ventilators, anaesthetic devices and C02 monitors.

Integration To: Electronic patient record, clinical research and future deployments to analytics applications.

Results:

As a result of MDI, Cambridge University Hospitals is experiencing improvements to clinical efficiency, accuracy of information and time redirection to activities supporting patient care and safety. Clinicians no longer spend time on manual charting, often making unintended transcription errors. Overall clinical documentation is faster, more accurate and resulted in many improvements:

• Documentation time savings in Critical Care equivalent to £2.6m annual staff time, or 124 full-time nurses
• Increased number of Anaesthesia/Theatre cases by 225 a year
• Decreased Theatre turnaround time by 3 minutes per case
• Improved patient safety through
  • Returned focus on direct patient care, not on documentation
  • Appropriate clinical interventions based on accurate, quality data
  • Reduced treatment delays
• Improved data availability for EPR documentation, clinical research, and in the future, analytics and clinical decision support such as NEWS2 (UK National Early Warning Score)
• CUH was awarded HIMSS EMRAM Stage 6 status in 2015 (revalidated in 2018) for its digital innovation efforts, and MDI was a key factor in its designation as an NHS Global Digital Exemplar.

Phase two expanded MDI across remaining high acuity care areas and additional device types, and expanded the use of data into clinical research. Phase three will include MDI for the general wards, the emergency department, and the use of data for decision support analytics.¹⁴

The Covid Impact on Implementing Digitisation

Technology has often been introduced conservatively in health services, with the aim of delivering small improvements rather than transforming how services are delivered. Digital technology can be harnessed to support more ambitious transformation of care, for example, overcoming some of the limitations of traditional models of care for long-term conditions and delivering more responsive care for people with unpredictable, cyclical conditions.

Collaborative design involving technology entrepreneurs, health care professionals and patients from the start is an important component of an innovation process. Iterative cycles of improvement to gain feedback from service users and test improvements are also important, particularly given the challenges that particular groups of people face in using digital services. There are ethical and technical challenges around how to transmit, share and use patient data in ways that secure people’s consent, maintain trust, protect confidentiality and ensure equitable benefits sharing between different constituencies.

After many years of slow progress, primary care, community and hospital services in England moved almost overnight to delivering online services during the first months of the Covid-19 pandemic. For understandable reasons, the focus was on making these changes as quickly as possible. There was no time for the governance processes, engagement with staff and service users, or the processes of evaluation and incremental improvement that are normally considered best practice in the implementation of innovation in health care.¹⁵

Technology Enabled Care Services (TECS)

This resource raises awareness of how the wide range of TECS can support commissioning intentions and benefit patients, commissioners, families, health and social care professionals and provider managers. It also addresses the demand from commissioners for information on how to commission, procure, implement and evaluate these types of solutions effectively.

To view our tools and resources for commissioners and other health and social care professionals, please see:

1. Strategic planning and commissioning resources: Access resources to support planning and commissioning of TECS programmes
   1. TECS evidence database: Find recent research and evidence on TECS and the impact it had on patient outcomes and cost-effectiveness
2. Procurement resources: Access tools and resources to support procurement (coming soon)
3. Implementation resources: Access tools and resources to support implementation (coming soon)
4. Measurement and evaluation resources: Access tools and resources to support measurement and evaluation (coming soon)
5. Improvement resources: Access case studies on TECS
   1. TECS Case study database: Read examples of how telehealth, telecare, and telemedicine projects have been implemented in the UK and internationally, what challenges they faced and their key learnings.¹⁶

Telecoaching

NHS Barnsley/SWYPFT telecoaching service: In general, patient feedback so far has been positive. There have been an increased number of people living independently, 20% fewer hospital admissions, a 30% reduction in length of stay (LOS) in hospitals and increased patient compliance with guidelines set by professionals. Further, evidence suggests that there has been an existing service delivering overall 32% cost reduction. That means an average saving of £1,000 per patient per annum.¹⁷

Remote Monitoring to Transform Outpatient Care

Often, patients in disease remission are seen more frequently than necessary, and with missed opportunity to capture disease flares. Remote monitoring is the process of using technology to monitor patients outside of a traditional care setting, such as in their own home, or care home. Using symptom trackers, monitoring devices, portals or patient dashboards, together with remote consultations, enables patients to maintain a holistic view of their well-being through the tracking of disease progress whilst alerting clinicians to any deterioration in their condition, forming meaningful remote clinician patient relationships and optimising user engagement at scale. Design features such as automated reminders, graphical feedback on scores, a red flag system to alert to changes and an SMS template library have supported personalised care for disease flare, emotional well-being and appointment deferment. Delivering care to patients within the comfort and safety of their own homes (including care homes) is being enabled by NHSX through the launch of the remote monitoring procurement dynamic purchasing system or DPS.¹⁸

Wearable Health Technology and Electronic Health Record Integration

Wearables have the potential to transform patient care, issues such as concerns with patient privacy, system interoperability, and patient data overload pose a challenge to the adoption of wearables by providers. Numerous health institutions have started to integrate device data into patient portals. Health systems are increasingly interdependent on EHR capabilities, offerings, and innovations to better capture patient data. Features include secure messaging with patients and features to view, download, and transmit their EHR. Such capabilities are becoming more prevalent to facilitate streamlined patient data exchanges with their provider. A novel capability offered by health systems encompasses the integration between EHRs and medical devices, including wearable health and fitness tracking devices.

Patient Information and Data Overload - Wearable health technology that is integrated into the EHR produces an enormous amount of data that require compilation and interpretation before becoming useful for patients and providers. Storing daily patient data streams can be a barrier to health systems that are not prepared to host a database that is constantly growing. Decisions around the life cycle of such data and how it can best fit into provider workflows pose a unique challenge to using remotely collected data for patient care. For example, the Apple Health and PulseOn Android apps provide heart rate data at 60-second long and 3-second long intervals, respectively; transmission of such large volumes of data will require backend analysis to be processed into a simpler and more usable form. Wearable health technology will play a critical role in greater transparency between patients and providers and chronic condition management. Devices and technologies that enable the streamlined movement of data from patients to providers are key to improving a patient’s care journey and empowering them to manage their own health.¹⁹

Spark Dynamic Purchasing System (DPS) for Remote Monitoring

The Spark DPS, run by the Crown Commercial Services (CCS), aims to support organisations with the procurement of remote monitoring solutions. Commissioners within NHS England and Improvement, social care organisations, Clinical Commissioning Groups, Primary Care Networks, NHS Trusts and NHS Special Health Authorities can use the Spark DPS to buy services.

As Spark is a dynamic system, new suppliers may join the list below over time. This list is reviewed periodically to keep it up to date.²⁰

Conclusion

The complexity of healthcare digitisation cannot be overstated. Delivering digitisation was a goal before the 2020 Covid-19 pandemic, and is now even more important when dealing with the fallout of this pandemic, not just in terms of Covid-19, but also the impact on all the other clinical and surgical services that have been cancelled or delayed.

Digitisation has the potential to deliver substantial gains in both healthcare efficiency and patient outcomes. We should all endeavour to do our best to drive the healthcare digitisation agenda forward, ultimately delivering the best, and most efficient healthcare services for the benefit of the patients.

Bibliography

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