Delivering a digital platform for transformation of Health and Social Care in Northern Ireland

Outline Business Case May 2017 Version 1.5 (Revised Draft)

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Distribution history

Version Number Distribution List Date

1.0 Sections 1 – 6: Encompass Programme Board, eHealth Leads, CCIOs 6 October 2016

1.1 Encompass Programme Board, DoH advisors 13 October 2016

1.2 CCIOs 24 November

1.3 Encompass Programme Board, CCIOs, Encompass Service Leads 7 December 2016

1.4 Encompass Programme Board, CCIOs, Encompass Service Leads, Chief Executives, DoH advisors 16 February 2017

1.5 26 May 2017

Table of Contents

1 Executive Summary ...................................................................................................................................................................................................... 3

1.1 Introduction .................................................................................................................................................................................................................. 4

1.2 Strategic Context .......................................................................................................................................................................................................... 5

1.3 Assessment of Need ..................................................................................................................................................................................................... 5

1.4 Objectives ................................................................................................................................................................................................................... 11

1.5 Options appraisal ....................................................................................................................................................................................................... 13

1.6 Conclusions and Recommendations .......................................................................................................................................................................... 21

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1 Executive Summary

Key Messages

Health Information technologies, including citizen-facing portals, are vital underpinning elements of the world’s highest performing health and care systems. The HSC has a once-in-a-generation opportunity to make best use of the significant investment needed to address ICT ‘burning platforms’ replacements, foremost being the hospital Patient Administration Systems, by pursuing a broader scope for a programme of transformation (Encompass) underpinned by a digital platform for innovation.

The OBC examines a number of key drivers for Encompass:

Urgent ICT replacements

Support for regional reform

Patient safety, quality and efficiency requirements

Rising demand, constrained resources

These drivers inform the programme objectives. This OBC appraises the options for delivering against these objectives. Based on an assessment of benefits, risks and costs, it recommends an Electronic Health and Care Record (EHCR) implementation with significant core functionality across the acute and community sectors. Incorporating international interoperability standards will allow Primary Care and smaller specialist solutions to link, or at a future point to become part of the core EHCR.

No single system solution exists to replace all HSC systems, and a HSC-wide ‘big bang’ implementation is discounted. The OBC envisages a phased implementation approach seeing initial ‘go lives’ and further optimisation over phases during the period 20/21 to 23/24.

The vision is for a digital record for every citizen in Northern Ireland that facilitates their health and wellbeing throughout their life, built on a digital platform that streamlines services and patient journey, links information across primary, secondary, community and social care and provides a platform for innovation. This would support the achievement of the “Quadruple Aim” of:

Improving the patient experience of care

Improving the health of the population

Achieving better value by reducing the per capita cost of health care

Improving the work life of those who deliver care.

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1.1 Introduction The vision set out in Health and Wellbeing 2026: Delivering TogetherError! Bookmark not defined. will require the support of modern technology to deliver real transformation and change. The challenge has been set down:

‘The point has now been reached where maintaining the current delivery models is having increasingly negative impacts on the quality and experience of care for many service users, while constraining the ability of the system itself to transform to meet today’s health needs.

While staff work increasingly hard to mitigate these structural issues, the overall impact is experienced by service users and their families every day, in every part of the system. Regrettably, delays in accessing services and unacceptable waiting times for treatment are commonplace. The quality of our service, and the experience of those providing and receiving it, is not as good as it should be.’

As a number of the HSC’s ICT systems require replacement, most prominently the Patient Administration Systems underpinning HSC Trust activity, this is a real opportunity to make sure that any investment in technology assists health and care professionals and their support staff to deliver a more effective, efficient and high quality service in line with the 10 year vision. Use of new ICT systems delivered as a programme of digital transformation will enable reformed working practices and offer patients new ways of being involved in their care.

Michelle O’Neill, Minister for Health and Social Care, further presented the stark reality in a statement to the Assembly in October 20161:

‘Professor Bengoa helpfully pointed out in his report that, by 2026, the Health Department would need 90% of the block grant. That is the case for change.’

As of today, it is very difficult to get an accurate assessment of our performance as a health and care economy and our patient outcomes, despite the best efforts of talented, dedicated staff – the main problem is the inability to connect our information. The Encompass Programme would address this and give health and care staff the intelligence they need to achieve the improvements they want, as recommended in the Donaldson Report4

‘The potential for information and digital technology to revolutionise healthcare is enormous. Its impact on some of the long-standing quality and safety problems of health systems around the world is already becoming evident in leading edge organisations.’

1 http://data.niassembly.gov.uk/HansardXml/committee-19527.pdf

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1.2 Strategic Context This OBC is a considered response to the needs identified through numerous strategies, plans and reviews carried out over the last five years by HSCNI and other government agencies and departments, including:

Draft Programme for Government 2016-212

Health and Wellbeing 2026: Delivering Together3

The Right Time, The Right Place4

Quality 2020 (Q2020)5

Making Life Better6

eHealth and Care Strategy7

1.3 Assessment of Need Four key drivers for change have been identified by the Encompass Programme, based on an analysis of the needs identified in the strategic documents highlighted above, and from consultation across the wider HSCNI:

Urgent IT system replacements

Support for a programme of regional reform

Patient safety, quality and efficiency requirements

Rising demand, constrained resources

1.3.1 Urgent IT system replacements Our Patient Administration Systems (PAS), supporting mainly acute activity across all the Trusts, are legacy systems with an urgent need for replacement. All of the acute hospitals in Northern Ireland have used Clinicom PAS to process and store administrative and patient data since the mid-1980s. That data and functionality is fundamental to the business of providing care, forming the basis for undertaking, and quality assuring, clinical, corporate and operational activity. Should a Trust’s PAS fail, the ability of the Trust to function safely quickly becomes severely compromised.

Level One Urgency:

PAS 8 Clinicom Patient Administration systems across the 5 Trusts and a legacy orthopaedic PAS (BOIS) in Belfast Trust. Data from PAS

feeds numerous other systems and the regional Data Warehouse.

2 Programme for Government, Northern Ireland Executive, 2016

3 Delivering Together, DoH, 2016

4 The Right Time, The Right Place, DHSSPS, 2014

5 Quality 2020, DHSSPS, 2011

6 Making Life Better, DHSSPS, 2014

7 EHealth and Care Strategy, DHSSPS, 2016

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The supplier of Clinicom has since developed replacement products providing modern electronic patient record capabilities. Whilst continuing to support existing customers on Clinicom, the product is no longer offered commercially or on a development roadmap except for the most fundamental support requirements. The potential to continue to secure support contract extensions even at this level is increasingly at risk beyond October 2020, consequently increasing the likelihood of a systems disruption and the subsequent adverse effects this can have on our patients.

Replacing all 8 PAS will be a significant programme in itself, with the 10 year costs for application software, infrastructure, implementation and support anticipated to be in the region of £80 - £100m, based on information provided by suppliers as a result of a Request for Information issued in 2015 and refreshed in 2017.

In addition to the issues regarding PAS, a significant number of other information systems are also due for replacement over the next 5-10 years, such as community, pharmacy and theatre management information systems. There is a growing burden of supporting increasing numbers of interfaces between systems, including the need to re-engineer and test new interfaces whenever a system is replaced or upgraded in order to purely maintain the current level of benefits being delivered. Having multiple databases and data models also limits the opportunities for meaningful clinical and operational analytics.

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Level Two Urgency

NIECR Clinical Portal The current support contract for Northern Ireland Electronic Care Record (NIECR) can be extended until 2022, after which reprocurement and platform upgrades will be required.

Community Information Systems 3 Trusts have 3 instances of a commercially available CIS (PARIS), at varying stages of implementation. 2 Trusts are using legacy products, and have a more urgent need for a replacement solution.

Emergency Department Currently there are 6 instances of a commercial system and 8 instances of a BSO developed and supported system. Paper triplicate ‘flimsy’ used.

Theatre Management As well as BOIS, used for Theatre Management in Musgrave Park Hospital (among other things), there are 10 instances of a Regional Theatre Management System (RTMS) in use and one instance of the Royal Group of Hospitals Theatre Management System (TMS).

Pharmacy Stock Control Digital solution – currently one regional instance implemented in 2011 plus a further legacy instance in BHSCT, delivering and managing pharmacy stock control, dispensing, production, ward top-ups, homecare supplies, procurement and contracts. 2021 currently recommended as a replacement date.

NIMATS (Maternity) NIMATS is used by 1,500 health and social care professionals in all 10 Maternity departments in the HSC to record the booking details for a mother and the delivery details of both mother and baby/ies

Screening systems Multiple regional digital solutions support a number of screening programmes – Breast, Cervical, Bowel cancer, Triple A, diabetic retinopathy, antenatal and newborn screening.

Child Health System A regional digital Child Health system is in place, generating paper invitations, consent, screening and information gathering forms, and managing vaccinations. The paper Personal Child Health Record (‘Red Book’) is also in use, as the parent-held child health record.

Anaesthetics/Preop Assessment Centricity is a digital solution in place in SET, SHSCT and WHSCT. There are 3 different instances and no shared or coded drug dictionary-each build and maintain their own dictionary locally. Pre-op assessment modules are planned but not yet live.

ICU Currently there are 3 suppliers of 5 instances of digital solutions. These are integrated with patient monitors and devices, PAS and Labs, includes ICU ePMA and care noting

Mental Health The current provision of digital support for mental health is fragmented across PAS, Various Community Information Systems, and standalone solutions.

Cancer Patient Pathways Capps is a regional cancer care information system to monitor cancer waiting times and assure the timeliness of access to diagnosis and treatment services for cancer patients in accordance with the access standards. The current contract for support ends in 2019.

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There are a number of functionalities identified as ‘core’ to support safe and effective care. The replacement of Level One and Level Two system functionality as described above is critical to this. In addition, there are a number of functional areas that are currently missing from the HSC digital platforms. This functionality is identified as ‘missing core’, is absent across the multitude of our existing systems. Whilst there may be isolated instances of these functionalities in place (e.g. eMed Renal includes limited ePrescribing and a patient portal), on the whole these are not implemented at any scale:

‘Missing Core’ Description

Patient/Citizen Portal A Patient Portal will allow patients to access and control their care record directly, receive information resources relevant to their condition, manage their appointments, and communicate with care professionals as an alternative to face to face appointments. It will allow patients to complete pre-treatment assessment forms, and capture patient reported outcome and experience measures.

Care noting Digital solution to allow the capture and sharing of multi-professional care information, risk assessments and care plans

Order Communications Functionality to order diagnostic tests, medications, treatments and other clinical or social interventions or services together with functionality to document and share results or interpretations issued against an order. Parameter based alerts and security settings can be configured once agreed – including escalation.

Electronic Prescribing Digital solution to support safer, more effective prescribing and use of medicines, allow clinical decision support integration at the point of prescribing, enable electronic record of medicines administration, integration with hospital dispensing.

Clinical Decision Support Order sets, Clinical content and guidelines, Assessment tools, Rules engine, Information placement on screen, Alerts, Reminders

Patient flow and pathways

Workflow and task list support solutions – including enterprise wide bed management, caseload allocation and condition specific pathways supporting self-care, admission, discharge and safer transfers of care

Population Health Management

HSC wide ability to link and analyse practice, community, acute, and social care data, assign risk scores, and target preventative services for those most in need.

Integration Platform Core data platform, using international data standards, that allows an ecosystem of applications around the core platform to innovate and provide specialist digital solutions without duplicating or fracturing the patient record.

Open APIs Free to use, internationally standard integration and database storage mechanisms to allow application interfaces to work e.g. FHIR

Device Integration Implementation of middleware to allow biometric data collected by vital signs monitors, ECGs etc., to be incorporated into patient record and used for clinical decision support e.g. automated alerts based on NEWS scores

Reporting and Analytics Dashboards and reporting tools for use by front line clinicians in support of quality improvement and for business intelligence, performance management and statutory reporting.

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1.3.2 Support for a programme of regional reform The HSCNI needs unified, focused reform that supports effective and sustainable redesign across all care sectors across the whole region – acute, community, ambulance, social, primary and independent, as discussed in Section 4.2.

‘The stark options facing the HSC system are either to resist change and see services deteriorate to the point of collapse over time, or to embrace transformation and work to create a modern, sustainable service that is properly equipped to help people stay as healthy as possible and to provide them with the right type of care when they need it.’Error! Bookmark not defined.

The wider programme of transformation coming out of the Bengoa Expert Panel Review and Delivering Together requires the deployment of the right technology, aligning and underpinning the right processes and supporting people to move to smarter, more sustainable working practices that make their jobs easier and more fulfilling while delivering the best possible, equitable outcomes for patients and clients:

Transformation will require key cultural and operational changes in health care systems and in the way these systems are accessed by the public.Error! Bookmark

not defined.

The Expert Panel Review led by Professor Bengoa identified a record of previous attempts at transformation struggling at the implementation stage:

‘In essence, there seems to be a sense that the Health and Social Care (HSC) system has repeatedly spent significant time and resources analysing the challenges it faces, identifying the weaknesses in the current model, making recommendations for change, but subsequently failing to enact the necessary transformation to make these happen.’

Furthermore, a system-wide programme that supports a data interoperability platform can deliver the following benefits to specific segments of the economy outside of health and social care:

Academia and research – attracting increased grant funding, supporting research to improve the quality of both health and social care and for better policy-making

Mobile health technology industry – fostering local development of mHealth applications

1.3.3 Patient safety, quality and efficiency requirements The HSCNI, in common with other health and care economies, recognises the importance of improving outcomes for patients and service users.

Technology is about taking the opportunity to reduce variations in processes, to support people on the frontline, enabling them to work smarter, and allow them to focus on outcomes. The Encompass Programme will deliver a digital platform to help standardise care so that we do the best for our patients predictably and repeatedly. It will connect the process of delivering care with the best proven pathways, enabling staff to deliver evidence-based and outcome-focused care across geographical and specialty boundaries. It will achieve this by breaking down the current data silos and ensuring all care teams are on the same page.

Briefing on Transforming Systems via Digital Technology, by Northern Ireland Chief Clinical Information Officers Network

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Whilst Northern Ireland’s record on patient safety compares favourably with Trusts and health and care providers elsewhereError! Bookmark not defined., the potential for modern digital technology to be used to better support quality improvement and patient safety is relatively untapped in Northern Ireland:

‘Many of the giants of the digital revolution, such as Google, YouTube, Facebook and eBay, were either relatively small or non-existent at the turn of the century. The first iPhone was introduced in 2007, a mere eight (sic) years ago…We are facing a tsunami of technological change, driven by the digital revolution, affecting virtually all areas of our lives.’Error! Bookmark not defined.

Meanwhile, for example, our hospitals currently rely on a paper-based system of prescribing and administering medicine essentially unchanged since introduced in the 1950s, and carries a number of inherent risks to patient safety relating to illegibility, transcribing errors, lost or unavailable kardexes and incomplete medicines administration information.

Technologies that aid clinical decision-making and help clinicians to manage the exponential growth in medical knowledge and evidence offer substantial opportunities to reduce variation and improve the quality careError! Bookmark not defined.. So much so that the Sowerby Report (2014) recommended for NHS England that the NHS Litigation Authority should review its premiums for clinical negligence so that higher premiums are incurred by those trusts without availability and extensive use of shared electronic records because of the risks to patient safety8.

1.3.4 Rising demand, constrained resources Demands on our services and staff are increasing, in line with other health and care economies, in the context of constrained resources. Regional solutions are needed to provide the best possible health and wellbeing outcomes at a cost that represents best value, increases capacity in the system, supports the adoption of proven best practice, reduces waste and duplication of effort, increases time with patients and clients, and increases the degree to which the HSCNI operates as a single, coherent system.

Whilst the HSCNI strives to limit any negative effects of rising demand on services to people, people are waiting longer for their care and increasingly needing to coordinate care for themselves, or for those they care for, across sectoral and organisational boundaries due to multimorbidities.

The HSCNI’s ability to recruit and retain the number of staff needed for the current service delivery model is an ongoing challenge - the HSCNI is currently trying to fill approximately 500 nurse vacancies and 280 medical vacancies9. As the 10 year vision recognises:

‘It has also become clear that even when resources are made available to recruit additional staff, it has simply not been possible to fill all vacant posts. This in turn puts additional pressure on already hardworking staff and has seen our service become increasingly reliant on short term solutions such as locums and agency staff. This creates additional expense with negative implications for the quality of care. It has become a vicious circle which we must stop.’Error! Bookmark not defined.

8 Bringing together primary and secondary care data to improve patient care, the Peter Sowerby Commission Report 2014, Institute of Global Health Innovation, Imperial College London

9 Regional Vacancy Report, BSO, November 2016

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There are efficiencies that will be driven by the Encompass Programme’s potential for reducing unnecessary variation and improving quality and patient safety; and the Encompass Programme will deliver a solution that will help address rising demand and constrained resources in a number of other ways:

Improving use of available capacity - providing a digital toolset to support new ways of delivering services: features such as messaging and videoconferencing via a secure citizen portal supporting new ways of working such as virtual clinics and remote consultations.

Limiting waste, duplication and bureaucracy: digital solutions can help tackle wasted staff time spent on duplicate data entry, transcription, searching for information, assembling and providing datasets for audit and benchmarking, and money spent on paper

Improved management of medicines and control of the increase in drug spend in secondary care - digital solutions to improve medicines optimisation have major potential benefits for patient safety and quality of care and there are also opportunities to be more efficient in what we spend on drugs.

1.4 Objectives Based on analysis of the assessment of need and in order to bring focus to the shaping of options for delivering the Encompass Programme, a number of high level objectives have been set. These high level objectives are expanded and set out in more detail in the section 5.

PRIORITY 1: addressing a risk to the continuity of existing systems and services:

1 Replace at-risk systems in cost effective manner for Northern Ireland

PRIORITY 2: IMPROVEMENTS TO CURRENT SERVICE – providing a source of additional value:

2 Provision of a strategic whole system approach to digitisation as part of overall transformation of HSC

3 Provision of data and insight supporting population health management and commissioning based on value and outcomes

4 Create an open platform for innovation to support research and enable economic development

5 Improve patient safety and quality of care

6 Improve work lives for those providing and supporting care

7 Work and act as a system to help manage rising demand in scheduled care

8 Work and act as a system to help manage rising demand in unscheduled care

9 Optimisation of patients’ medicines and manage rising secondary care medicines expenditure

10 Reduce expenditure on paper records

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1.5 Options appraisal

1.5.1 Shortlisted options A long list of options was developed through consideration of the strategic drivers, an assessment of the “as-is” and the need for change, lessons learned from the Encompass research phase, other regional projects and programmes, engagement with HSC professionals and stakeholders, and input from Programme Board Members. Consideration was given to a number of dimensions namely;

Service scope

Level of integration versus the level of interfacing

Implementation approach

Functionality scope

The following figures describe the option long list and shortlisting decisions:

Functionalities required to meet each objective: this maps functional areas to the delivery of objectives to determine the scope required.

Option definition describes the key dimensions used to determine the long list of options.

Option shortlisting sets out the option sifting decisions based on an assessment of:

The ability of the option to provide the functionality required to meet Programme objectives

Evidence from the RFI and research phase of proven solutions being available and delivering benefits elsewhere

An assessment of how ‘future proof’ each option is – defined as reducing the burden of complexity of maintaining multiple, non-standard interfaces and increasing the ability to meet future service demands.

Map of functionalities to options describes the assumed system-based delivery of in-scope functionality for each shortlisted option that forms the basis for further appraisal of costs, benefits and risks.

The research highlights 3 categories of benefits achievable:

Category 1: Direct benefits from digitisation/automation

Category 2: Benefits mostly driven by digitisation but requiring a programme approach such as Encompass and change management to support delivery

Category 3: Potential benefits in the areas of preventative health care dependent upon wider system transformation.

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1.5.2 Summary of Appraisal

Table 1 Summary of Option Appraisal against all objectives for monetary and non-monetary benefits

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The table below summarises the NPC calculation, the qualitative analysis and risk analysis results for each of the 4 short listed options:

Driver

Obj

No Objective Category

Status

Quo

Develop

NIECR

Best-of-

breed

Core

EHCR/IE

Status

Quo

Develop

NIECR

Best-of-

breed

Core

EHCR/IE

Urgent ICT

replacements1

Replace at-risk systems in cost

efficient manner1

n/a n/a n/a n/a 225 360 360 450

2Deliver whole system approach to

digitisation1

0 10.5 10.5 10.5 n/a n/a n/a n/a

3Provide data to inform population

health and commissioning3

0 0 16.0 16.0 n/a n/a n/a n/a

4 Create an open innovation platform 30 0 6.8 6.8 n/a n/a n/a n/a

5 Improve Quality and Safety 2 n/a n/a n/a n/a 40 240 280 360

6 Improve working lives 2 n/a n/a n/a n/a 0 30 15 105

2 0 50.07 50.07 50.07 n/a n/a n/a n/a

3 0 0 3.35 3.35 n/a n/a n/a n/a

8Manage rising demand in

unscheduled care3

0 0 35.2 35.2 n/a n/a n/a n/a

9Manage rising secondary care

medicines expenditure1

0 1.65 1.7 1.7 n/a n/a n/a n/a

1 0 2.3 2.3 2.3 n/a n/a n/a n/a

2 0 3.4 3.4 3.4 n/a n/a n/a n/a

0 67.9 129.2 129.2 265 630 655 915

0 14.4 14.4 14.4 225 360 360 450

0 53.5 53.5 53.5 40 270 295 465

0 0.0 61.3 61.3 n/a n/a n/a n/a

Support for

Reform

Safety and

Quality

Rising

demand,

constrained

resources

Monetary benefits per annum, £m at year 10 Non-monetary benefits, weighted score

7Manage rising demand in scheduled

care

Reduce expenditure on paper

records

Total

Total Category 1

Total Category 2

Total Category 3

10

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Option 1: Option 3: Option 7: Option 8:

Status Quo Develop NIECR Best of Breed Core EHCR

Systems costs 123.0 140.6 165.1 149.2

Implementation costs 0.9 109.2 93.4 96.8

Total (Pre-OBA1) 123.9 249.8 258.5 245.9

Additional ICT costs 7.6 16.6 19.0 19.2

2 Whole system approach to digitisation 0.0 10.4 10.4 10.4

9 Efficencies in drugs costs 0.0 1.7 1.7 1.7

10 Storage and correspondence 0.0 2.3 2.3 2.3

7 Scheduled Care 0.0 50.1 50.1 50.1

10 Storage and correspondence 0.0 3.4 3.4 3.4

0.0 67.9 67.9 67.9

Total NPC (pre OBA) 585.0 620.9 610.3 583.6

Total NPC (post OBC) 614.9 680.3 682.1 657.3

Difference from baseline n/a 65.4 67.2 42.4

265 630 655 915

166 192 226 177

n/a 16% 36% 7%

3 Population Health Management 0 0 15.95 15.95

4 Innovation Platform 0 0 6.8 6.8

7 Scheduled Care 0 0 3.35 3.35

8 Unscheduled Care 0 0 35.23 35.23

Total potential benefits 0 0 61.33 61.33

1 Optimism bias adjustment2 Per annum, recurring, at year 10

Non-monetary benefits weighted score

Risk severity score (probability x impact)

Cat 3

Potential

Benefits from

transformation2

(£m)

Element of Appraisal

Revenue

Benefits2 (£m)

Total benefits

Cat 1

Cat 2

Total Monetary Impact (£m)

Revenue Costs2 (£m)

Capital Costs (£m)

Risk severity % difference from baseline

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1.6 Conclusions and Recommendations Option 8 has the lowest NPC of all ‘do something’ options. Additionally, where optimism bias is excluded, Option 8 has a lower NPC than the status quo option, and a significant revenue advantage over Option 1, the status quo option (which will continue beyond 2027/28 as shown below). Simply put, whilst Option 8 requires £122m in investment over Option 1, this is outweighed by the reduction in revenue requirements during the 10 year option appraisal period of £156m. On the basis of consideration of the drivers for change, relative risks to successful implementation, the ongoing benefits from the Encompass programme and the potential future benefits from wider transformation Option 8 is recommended as the preferred option.

At Year 10

Annually recurring benefit from the Encompass Programme: £68m

Plus potential further annual recurring benefit from wider transformation: £61m

This is a once-in-a-generation opportunity to make best use of the significant investment needed to address ICT ‘burning platforms’ replacements by pursuing a broader scope for a programme of transformation (Encompass) underpinned by a digital platform for innovation. The conclusion of this analysis is that Option 8 is the best option to realise this opportunity.