Information, Communication,

Technology Strategy

2009 - 2014

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This Strategy Paper broadly articulates a five year programme directed at transforming the Barking, Havering & Redbridge University Hospitals NHS Trust. The starting viewpoint is that the NHS Care Record Service (CRS) implementation might perhaps be the single biggest transforming event and opportunity in BHRT history to date. However delays around the National Programme CRS Acute Solution necessarily influence the Strategy Plan and Roadmap.

The approach taken therefore is use this critical strategic lead time productively to both prepare the ground for CRS and improve and enhance services now. Creating value through continual service improvement and assuring benefit realisation are core objectives from the strategy start point.

Guaranteeing patient safety and constantly improving the patient experience at all Trust service touch-points are main drivers for change and therefore a major consideration when considering solutions and benefits.

Introduction of electronic knowledge systems, resource planning and management, clinical administrative process automation and moving from manual administration and paper based decision support will bring very significant benefits in the areas of cost reduction, improved service quality, patient safety and experience and Information Governance.

Building infrastructure and information systems that support the commissioning and management of clinical services will be key goals. Enabling mobility and collaborative working and extending services interfaces into partner environments will be a critical success factor.

Identifying, extracting and maintaining appropriate levels of revenue from PCT and other acute service commissioners is critical to the efficient operation and evolution of the Trust. Appropriate, timely and accurate service information is required to assure revenues for Trust services.

The proposal is for a stepped staged geometric increase in service capability, infrastructural maturity, and systems' readiness - all preparing the ground and leading to CRS Rollout in stages from 2009 till 2014. The Strategy describes broad-based and comprehensive architecture-based steps designed to assure full eventual CRS benefit realisation. Capital Investment in year one is proposed for items that prepare the way for CRS - acting as essential building blocks. An operational plan has been included in Chapter 6 which provides greater detail and identifies £7 million spend in the first 18 months of the lifecycle of this strategy

However from the outset the plan is to deliver a schedule of work aimed at “doing what we do now but better” and making the most of what we have. Much can be achieved through the next financial year. Year 1 activity focuses on achieving benefit in the areas of Trust-wide customer experience improvement, systems upgrade and capability planning. Activities and financial implications are summarised in the table below and greater detail can be found in Chapter 6 on page 10.

Table One - Year One Operational Activity

* denotes approved funding already received.

All work is organised into tracks for the period. There are project streams that dictate when track related activity is planned.

1.     To improve patient care through innovation in information technology.

2.     To improve patient safety through the use of IT.

3.     To provide easy access to information of all types for patients, staff and customers across the health economy.

4.     To support the business and commercial objectives of the Trust.

5.     To ensure that information systems are reliable, resilient and fully integrated.

6.     To ensure legislative requirements are met, including compliance with Connecting for Health and security and data quality standards.

The six key objectives may be understood better by setting out how they relate to the vision of ICT services.

The prime function of the Barking Havering & Redbridge University Hospitals NHS Trust is to deliver high quality patient care.  As technology and knowledge management advances, new opportunities will appear for patient care to be delivered in better ways.  The enthusiasm and skill of clinical and ICT staff to innovate will be fully exploited as the strategy is implemented. Innovation will require research and development if we are to move beyond tried and tested solutions.

Examples of such innovation include:

Making information readily available at the point of care will lead directly to improved clinical decision making and thereby patient safety.  However, patient safety can be enhanced more directly through information systems that reduce human error and give users greater control of processes.  Examples include:

 In future, information systems will provide knowledge and decision support functions which will enable staff to follow guidelines more easily. 

Increasingly, programmes of care will be delivered across the whole health economy for groups of patients. These care management programmes will be supported by new IT systems. 

Future information systems will require easy but secure access for authorised users via a single user interface that displays information relevant to that user.  The interface will be customised by the user to their specific requirements and be available wherever required, within or outside the hospital sites.  Examples include:

Universal point-of-care access will be made possible by the use of a variety of hardware devices including desktop computers, wireless-enabled tablet PC's and personal digital assistants (PDA's), and mobile phones. Data and text entry will be possible by handwriting and voice recognition, as well as by keyboard and mouse.

Training in the use of this new technology will be reduced by the use of intuitive software and industry standard displays.

As a Trust in financial turnaround and in response to the demands of the NHS, we are a commercial business and to be successful we require efficient business processes and systems which are flexible and can respond quickly to changes in the healthcare market.  The information system architecture and software functions must therefore mirror these requirements of flexibility, responsiveness and reliability.

Trust business demands accuracy in data quality and coding so that performance can be effectively managed.  The data must also be readily transformed into information so that sound commercial decisions can be made. For example:

The information systems within the Trust are no longer a luxury and healthcare already depends upon their constant availability.  The network and hardware infrastructure will therefore be similarly resilient and reliable and have the capacity to deal with increasing demand.  Technical and user support functions will also be available as necessary to ensure business continuity

In the event of hardware failure, reliable disaster recovery systems will be in place to avoid loss of clinical and management information.

To maximise the efficiency and benefit of information technology, systems will be fully integrated across the Trust, the local health economy and with the national NHS care record spine.

The national Connecting of Health programme via the Information Governance Toolkit sets a number of standards and technical requirements with which the Trust's information systems must comply.  The Trust will comply with Legal requirements such as the Data Protection Act and Caldicott Guardian legislation.

Storage of data on Trust activity should facilitate the response to requests for information under the Freedom of Information Act, leading to greater openness and accountability of Trust activity. 

Collection of electronic data within the patient record will allow easier defence against litigation about clinical care through the ability to trace activity to individual users and the legibility of text.

Information systems will also facilitate the audit of Trust activity by external organisations such as the Standards for Better Health.

From the outset the plan is to deliver a schedule of work aimed at “doing what we do now but better” and making the most of what we have. Much can be achieved through the next financial year. Year 1 activity focuses on achieving benefit in the areas of Trust-wide customer experience improvement, systems upgrade and capability planning. Activities are

Infrastructure:

Data Management:

Solutions:

Mobility

Capability:

If a Care Record Service (CRS) Deployment is viewed as the panacea and single event that might dictate likely Trust performance for the next twenty years it becomes critical that BHRT adopt a future-proof and operable information architecture strategy. This section attempts to describe type of systems and an approach that will assure that the Trust is prepared and ready to meet the transformational challenges ahead.

The proposal is that ICT will work with the Trust to formulate and build a contract around a programme of activity upgrading technology services to prepare the ground for a CRS deployment which then focuses on replacing all legacy redundant functionality and introduce broad based process automation and electronic record management.

This will be an approach built around the core requirements and architectural principles listed below

Sections 7.2 and 7.3 below describe an architectural approach to building information management systems and the required supporting communications infrastructure. A key challenge will be to identify the real cost and benefit, this may not be apparent for some time to come. Section 6 will identify initiatives that prepare the ground and provide the step transitions to full CRS deployment.

Adoption and implementation of groups of large multifunctional health systems is fraught with risk, is inherently constrained and is fundamentally at odds with emerging BHRT principles that demand Service Agility, Adaptability and Flexibility. Typical project life cycles can be measured in numbers of years and options where the proposition results in possible multiple serial and concurrent change initiatives are no longer tenable, financially viable or operationally practicable.

ICT therefore intends to adopt an approach that allows safe delivery of discrete and achievable chunks of service development using best of breed tools and open standards. There are a number of powerful and sophisticated solutions that BHRT might choose. The recommendation is to adopt a functionally rich collaborative portal and integration solution that: has an Information Access Layer that transforms and aggregates data, is secure and auditable, enables single sign-on, has patient pathway automation(with forms) and alerting capability, gives a single virtual personalised view of the combined patient record and history and is context aware. Maintaining context becomes important as the Clinician or Informatics Analyst traverses through and across systems and patient related data-sets.

Acquiring and adding a Portal Technology, Integration Framework and Toolkit to the BHRT solutions mix could quickly and cost-effectively resolve many PAS more pressing problems without immediate large systems replacement. More importantly, deploying a Portal and the Application Integration Engine will allow us to decouple, segment and abstract many of the more intractable integration challenges facing ICT. The key benefits are that Patient Pathway Automation can be packaged into small discrete steps, BHRT control the pace of technology change and can minimise risk, effort and cost by standardising to a single cross-Trust Graphical User Interface.

Introduction of these components, in the short to medium term, prior to full National Programme CRS Implementation, might safely extend the lifespan of PAS and would certainly enhance usage of other key clinical Systems. This N-Tier approach is also an effective way to incorporate more sophisticated Business Support Systems capability (Billing, CRM, ERP etc). This option potentially sits very well with one proposed new National Program approach that would give BHRT back the ability to choose if, when and how to adopt Programme Solutions.

The key benefit is that it moves the Trust away from a single “big-bang” systems revolution to a managed evolution - the financial risk profile is thereby reduced. ICT can build confidence through small discrete quick wins.

Figure 1 below depicts the transit of patient information through a Trust mediation layer to secure and central enterprise databases. Patient related operational data is stored in central data repositories in a variety of formats. An information access metadata layer enables all patient data (demographic, test requests/results, notes, treatments, outcomes etc) to be viewed by appropriate Trust users. Information and Performance Analysts have similar access to relevant information from a variety of data sources.

Figure 1

Patient Information flows from subsystems and is referenced at metadata level. This architectural model of Informational Systems development assures that the ICT function delivers an architectural solution meeting the needs of Information Management Group. Clinical systems and corporate business support systems. Users all have access to their dimensions of the Trust Information Universe.

The future target model, based on BHRT Principles (Assumed for now) would perceive clinical and business support systems functionality as groups of adjacent decoupled services referenced by the Clinical Services Catalogue and mediated through an Enterprise Service portfolio that orchestrates both Trust and National Program and Spine based services through to the BHRT Clinical Portal. The Portal experience will be personalised and available through multiple channels to different device types. This is the SOA target vision for the Trust for future development and could look like Figure 2 below.

Figure 2

Getting BHRT Services to the point of delivery is increasingly a head-ache for clinicians. Some of the emerging thinking around “Telehealth” provides Trust and ICT leaders with a conceptual framework that helps brings them back to that electronic/paperless hospital vision.

Achieving this vision will require a unified communications capability that is embedded into BHRT line of business applications using communications and workflow to interleave channels (Video, Voice, Web, Messaging, Email) with clinical information management systems. Combined Telehealth and Unified Communications solutions enable direct virtual and remote management and access to centrally stored or locally generated data assets (digital images, video, audio and clinical data) for diagnostic review by individual or groups of clinicians , potentially extending the reach of hospital based services into the community through a variety of channels to a variety of devices. This “Groupware” driven clinical collaboration can have significant impact to patient experience and resource utilisation. Wrapping Unified Communications Management around Rostering and Active Monitoring Solutions can mean that clinicians, appropriate to the level of escalation, can be contacted through a number of channels and possibly make the diagnosis remotely.

The Telehealth Model was developed in locations and enterprises where traditional delivery of health services is affected by distance and lack of local specialist clinicians to deliver services. Paradoxically there may be a growing requirement for this type services provision in the BHRT local area. The North East London Health Authority demographic is highly urbanised and densely populated. Within the Hospitals and at satellite sites space is at a premium, transport is inadequate and parking can be a major problem. Providing equipment and provisioning clinics is challenging. The Trust must comply with an initiative that takes services and consultants from the hospitals into community based outreach and care centres. There are opportunities to significantly reduce service footprint at source, lowering infrastructure, operating costs travel times and not least to adhere to the Trust's commitment to a Green Agenda. Virtual Service Outreach and Realtime Telehealth well might be the solution that enables fully functional and efficient Polyclinic operation.

Figure 3

The Trust must break from the pattern of acquiring Servers for every service launched. It is imperative that ICT persuade the Trust to invest in a hardware platform architecture built on Blade Servers, Storage Array Networks with remote virtual management tools. Appropriate Facilities and resilient high-bandwidth networks are also to be built. Expenditure and Risk will be less difficult to manage.

Throughout the document there has been the embedded assumption that the whole strategy is really about converting and liberating patient data so the patient experience can be much improved. Patient Data and Intelligence must be managed securely. These considerations must be at the centre of systems and data architecture design. Information Management principles and Information Governance best practises must form part of the design specification and acceptance testing processes.

Embedding Data and Information Governance into Trust Solutions Design at specification stage will deliver massive benefit to the Information Management Group. IM Leaders need to start thinking about designing Views, “Cubes” and dimensions based on their customer requirements. Much of the statutory reporting can be automated. Real-time Dashboards become a possibility and richer utilisation of Business Information Systems becomes a reality.

This section lists and segments a portfolio of projects which are organised into a sequence based on dependency and assumed priorities. The building-block approach defines when some activities must be completed and what resources must be in place before some activities can start.

All technology delivery activity is broken down into four streams.

Stream 0 focuses on Programme and Project Governance and Quality Assurance. For the duration of the Programme this stream runs in parallel with other streams and their associated projects. This Stream is closely associated with the Capability Track. The focus is on ensuring that there is sufficient resource with the appropriate skills to complete project work packages.

Streams One focuses on introducing enhanced and expanded infrastructure and infrastructure management capability.

Stream Two focuses on Track Items that that the stakeholder community consider vital. CRS Phase 1: Implementation for PAS and A&E Replacement, Theatres and Order Comms implementation is launched from this stream as a near-term “high value” project. The Trust might consider a non National Programme solution in this space should there be further delays to Cerner Rollout or a major shift in CfH strategy.

Stream Three is the Strategic Roadmap that ultimately delivers the Trust Target Model articulated in Section 6. Stream One and Two activity are perceived as step transitions to Stream Three Delivery - Delivery Teams will learn much from the challenges and lessons learned in delivering transitional solutions.

Figure 4

The interplay between Roadmap Programme Streams and Tracks is visualised below in figure 5. As a conceptual framework for programme governance it places the strongest emphasis on thinking things through, planning for success, assuring that skilled staff is involved at the outset in all project activity. Stream 0 assures benefits realisation for all tracks thus maximising cost benefit. Track 0 assures that the appropriate competencies and levels of service are in place prior to Track and Stream based activity.

Figure 5

The next section maps a proposed trajectory through the matrix, offering a linear view of the Technology Strategy Roadmap.

Figure 6

Figure 7