eHealth Strategy 2014-2017

4 eHealth Progress, Challenges and Priorities

4.1 eHealth Progress

Since the introduction of the first eHealth Strategy in 2008, and then throughout the period to date covered by the current strategy (2011-2017), the Scottish Government and the NHS Boards have been working collectively to deliver a more interoperable and clinically rich eHealth ecosystem covering local and national needs. The achievements highlighted below are only a few of the many initiatives that have come to fruition over recent years.

This progress has been based on a continued incremental and pragmatic approach that makes the best use of historic investment. Much still remains to be done, however the position that has been achieved compares well with similar health systems and has been delivered at reasonable cost (a Gartner review^[19] that benchmarked £147m of eHealth costs identified that NHSScotland spends £39m p.a. less on IT services than a comparable peer group). Some of the most notable past achievements include:

• the national systems that have been the foundation of electronic communication and shared information. These are the Community Health Index (CHI), SCI Store and SCI Gateway which were adopted universally across NHSScotland and provide a core component of infrastructure and the ability to communicate and share patient information safely;
• widespread implementation of the national Patient Management System across Scotland's hospitals providing patient administration and clinical management functionality and increasing paper-lite operations. The system now has 60,000 users and covers 70% of the population. A number of other NHS Boards are planning to implement the system and this would bring coverage up to circa 90% within the next two years. Importantly, the NHS Boards collaborated on procurement and have committed to maintaining a common core system to realise the benefits of a standardised way of working and shared maintenance and development;
• the implementation in all GP practices of the award-winning Key Information Summary (KIS) for patients with long-term conditions who are likely to require care at weekends or out-of-hours. This is modelled on Scotland's pioneering Emergency Care Summary (ECS) which covers the entire population, and is now accessible by many clinicians in scheduled care from where it is currently receiving 338,000 accesses per month. The KIS record is extracted from the GP record and is a richer information source for clinical professionals including details from the ECS, such as medications, allergies and adverse reactions, plus anticipatory care plans, carer details and particular wishes the patients wants recorded. It can be accessed by any clinical professional who is caring for the patient. The KIS is now available for 120,000 individuals in the target group. In a similar manner a Palliative Care Summary (PCS) is now available for patients with a terminal condition, addressing the key area of recording people's priorities and wishes for this stage of their life;
• the widespread introduction across Scotland of clinical portals based on joint procurement and implementation by three regional groupings of NHS Boards, and national agreement of 14 priority items of patient clinical information that would be displayed. The portals are used to provide clinicians with a single point of access to data held in a range of background clinical systems and to present an integrated view of patient information appropriate to their role in the care of the patient;
• consolidation of GP systems to two commercial suppliers and provision of increasing access for primary and community care staff to a wider range of electronic patient information and support for patient related communication between the professions. Practices are now able to offer electronic repeat prescriptions and some have commenced offering online appointment booking. The provision of GP2GP electronic transfer of patient records between practices is anticipated in 2015/16 and will bring substantial administrative time savings and data quality and patient safety improvements;
• use across Scotland of the same system, Adastra, for the management of out-of-hours care. The system is electronically integrated with NHS24 for referral information and onward to general practice and other services for notification and referral. A national framework has been put in place which offers further opportunities for convergence;
• development of the ePharmacy system to improve the management and flow of prescriptions data and support the background administrative processes and the ability to analyse prescribing and dispensing activity, as well as enabling the Chronic Medications Service;
• introduction of single sign-on at NHS Board level. Although this is currently largely within secondary care, take up has been substantial and it is of significant benefit to users;
• the Renal and the SCI-Diabetes systems are providing specific support for these specialist areas and groups of patients, including significant inbuilt clinical decision support. Both systems are operated across Board boundaries (in SCI-Diabetes case on a national basis). In addition, the 'Renal Patient View' and 'My Diabetes My Way' patient portals are delivering tailored support and information to patients, including access to their own records and two way secure communication with their carers;
• a range of other developments have been undertaken by one or more NHS Boards that add to eHealth capability and afford important learning and experience that can be used across Scotland:
  − NHS Boards have introduced a range of systems to support community staff, with a gradual shift taking place to mobile devices to provide access to records in the patient's home or local community facilities;
  − a number of NHS Boards have introduced mental health systems supporting community and hospital settings and providing standardised care pathways to guide patient care;
  − several NHS Boards are now able to run virtually paperless outpatient clinics with most patient information access and recording being undertaken electronically. Use of paper is decreasing at ward level, in some cases with paperwork being scanned and added to the electronic record at discharge;
  − NHS Ayrshire and Arran has implemented a Hospital Electronic Prescribing and Medicines Administration (HEPMA) system across its hospitals addressing the critical area of safe and effective use of drugs;
  − NHS Fife has introduced a system for recording patients' vital signs in hospital which can provide earlier warning of a deteriorating situation that requires clinical review;
  − NHS Tayside provides access for secondary care staff to an information rich view of the GP record to support continuity of care;
  − NHS Lothian is leading the development of a system to allow patients to receive clinical correspondence via email or SMS and communicate electronically with their care providers. This has been piloted and has potential not only to provide faster and more convenient communication for patients, but to also deliver significant savings in transaction costs for NHSScotland;
• Scotland has a national reputation for telehealth and telecare and substantial experience has been gained at national (NHS24, the Scottish Centre for Telehealth and Telecare, and the Scottish Government Joint Improvement Team) and local (various NHS Boards and Local Authorities) levels, and a number of innovative projects are underway including United4Health, SmartCare and Living It Up^[20], some of which have European funding. In addition, NHS Boards are engaged in local disease specific initiatives such as hypertension, heart failure, diabetes, and COPD, as well as support for patients with multiple conditions. These developments are pioneering new models of patient interaction, support and service delivery and have significant potential to transform care in terms of patient and staff roles, capability and responsibilities.

4.2 eHealth Challenges

Whilst the above achievements are substantial, there remain significant challenges and opportunities for eHealth within NHSScotland over the next period to 2017 and 2020:

• eHealth systems are now vital to the delivery of patient care. Loss of systems or significant downtime have a major impact on NHS Boards' capability to deliver care and this will only increase in significance with a shift to more seven day working. Ongoing investment will be required for business as usual, including maintaining and upgrading the underlying technical infrastructure, ensuring greater system resilience, and enhancing the functionality of existing applications to support more effective working practices and to contribute towards the overall Electronic Patient Record;
• the views of clinical staff using eHealth to deliver patient care are of particular importance. In June 2014 a survey^[21] was conducted of 4,247 clinicians covering all professions and all NHS Boards seeking their views on priorities for future investment. A range of issues were identified including the requirement for more comprehensive information about patients, a desire for faster and easier operation of eHealth systems, and a need for more mobile access (further details are provided in Appendix 3). These views will need to influence and be reflected in eHealth developments;
• less consultation has, as yet, been undertaken with citizens and patients, although there are a range of developments that are informing an understanding of their requirements. Many general practices have electronic ordering of repeat prescriptions and some have online appointment booking. The Renal Patient View and the My Diabetes My Way developments have provided experience of patients accessing their own records, viewing results, contributing their input, and messaging with their clinicians. An ongoing proof of concept patient portal development, and a trial of patient access to their ECS and electronic results will provide further information. The evaluation of these developments together with further consultation will need to inform the sequence and design of information access and digital services to be provided for citizens;
• some national systems are ageing and no longer fit for purpose and will require replacement to provide the capability required by a modern health system. This includes the national Community Health Index system, the Child Health systems, the Support Needs System and the Breast Screening System. Significant specification and options appraisal work for replacing these systems has already been undertaken;
• substantial supplier contracts reach end of life or substantial break points in the period to 2018, including the GP systems contract, the PACS contract and the contract with the national Managed Technical Services supplier. These will require renegotiation or replacement which will require significant resource and effort, albeit they provide an opportunity to ensure NHSScotland's requirements are met for a considerable period into the future. Substantial work is already underway in relation to GP systems to update requirements and the Scottish Enhanced Functionality, to specify integration with other systems, for example to support data sharing and workflow between primary and community care, and with secondary care and social care, and to define an approach to system hosting. A consortium of Boards is currently undertaking similar work to progress replacement of their community systems;
• all NHS Boards still have gaps in their electronic information coverage and systems integration. The most substantial gap is Hospital Electronic Medicines Management and Administration (HEPMA), where significant work is already underway, but most have a number of areas that they wish to substantially improve, including addressing the range of more detailed issues and opportunities that have been identified by clinicians;
• delivery of solutions to support the Health and Social Care Partnerships will be a particular challenge over the next several years as they evolve new operating practices and care processes. Initially, the Partnerships can be expected to continue to use existing solutions and new technical requirements will emerge as new ways of working become established. The Health and Social Care Information Sharing Board has commenced work in this area and new developments can be expected that will require joint working and investment from the host NHS Board and Local Authority organisations;
• the historic investment pattern has resulted in variation across NHS Boards in systems coverage, infrastructure arrangements and applications. This approach has undoubtedly encouraged investment and allowed unrestricted progress based on local priorities. However, in regional and national terms it has resulted in some duplication of activities, effort and cost. Ongoing efforts to drive up healthcare quality that are seeking to minimise variations in care and ensure NHSScotland operates on the basis of a single set of clinical guidelines and, increasingly, decision support, together with substantial flows of patients across NHS Board boundaries, suggest that in future a path of increasing convergence and shared services around eHealth solutions will best serve the needs of patients and clinical professionals. This trend is apparent in developments such as having a national Managed Technical Services provider, the joint procurement and implementation of the national Patient Management System, and the regional consortium approach that has been adopted for a number of developments such as the clinical portals. This path will need to continue although not at the cost of significantly inhibiting local investment and progress;
• the SWAN contract for network services which was led by NHSScotland has demonstrated cross-public sector co-operation and offers substantial opportunities to improve communication within and between organisations, as well as financial savings. This is of particular relevance to the Health and Social Care Partnerships. However, to maximise these opportunities non-NHS organisations will need to fully adopt SWAN and participate in this public sector wide programme;
• the field of 'health maintenance and self-management' is subject to substantial innovation by private sector organisations and increasingly NHSScotland will need to facilitate not only patient access to their own health information, but possibly their interaction and use of other health consumer digital products and devices where interaction with NHSScotland systems may enable them to better self-manage their health and wellbeing. Patients can be expected to express greater ownership of their data and seek to download it for their own purposes;
• information governance that retains the confidence of patients, clinicians and the wider public regarding NHSScotland's management and use of confidential information will remain paramount. Increasing reliance on systems and greater information sharing mean that this will remain a substantial challenge requiring political and clinical leadership, and a continued open and informative approach, and engagement with the public and patient representatives;
• whilst the focus tends to be on operational information to support patient care, Scotland also requires a world class Information and Intelligence Framework^[22] if it is to develop its health and social care system to the highest levels of quality based on up-to-date evidence. All eHealth development must account for the need to build on the existing local and national information resources to build such an infrastructure and capability.

The challenges for eHealth are many and complex, ranging from long term convergence to highly desirable new developments and investments, to the everyday frustrations experienced by clinicians as a result of current limited system functionality or capability. It cannot all be addressed or resolved at once, and the aims discussed in more detail in the next section will need to guide where the available investment and effort are directed consistent with the 2020 Vision and sensible sequencing of activity.