Local Digital Roadmap. NHS North West London January NHS NW London Local Digital Roadmap Page 1

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1 Local Digital Roadmap NHS North West London January 2017 NHS NW London Local Digital Roadmap Page 1

2 NHS NW London Local Digital Roadmap Page 2

3 NHS NW London Local Digital Roadmap Page 3

4 NHS NW London Local Digital Roadmap Page 4

5 Contents 1. Local Digital Roadmap (LDR) a key enabler for the NW London Sustainability and Transformation Plan (STP) Background to the STP and LDR NWL Sustainability and Transformation Plan (STP) NWL Local Digital Roadmap: Vision for Digitally-enabled Transformation Implementing the Vision: NHSE Universal Capabilities Implementing the Vision: STP Local Digital Capabilities Implementing the Vision: mapping to NHS Digital national strategy Implementing the Vision: Challenges and Mitigation NWL Local Digital Roadmap: Strategy for Capability Deployment Automate clinical workflows and records Primary Care Acute Care Community Healthcare Mental Health Care Social Care Remote and Assistive Care Build a shared care record across all care settings New Models of Care Exploit existing investments in NHS Digital Tools NWL Care Information Exchange Support for Clinical Networks Integration of Healthcare and Social Care Systems Interaction between Shared Care Records and Data Analytics End of Life Care Planning Integrated Urgent Care (IUC) NHS 111 and Out of Hours (OOH) services Urgent Care Centres and Walk-in Centres in NWL NHS NW London Local Digital Roadmap Page 5

6 2.2.9 NWL Diagnostic Cloud Issues around Shared Care Records Extend patient records to patients and carers Sharing GP records with patients and carers: NWL Care Information Exchange (CIE) Patients using assistive technology for Personalisation and Self-Care Issues around Sharing Records with Patients and Carers New channels for citizens to engage with Care Providers Dynamic Data Analytics Information and Communication Technology (ICT) Infrastructure Information Governance Digital Care Community NWL Local Digital Roadmap: Delivery Programme Funding Requirements Delivery Timescales Delivery, Leadership and Resources STP/LDR Programme Structure and Governance, Patient & Public Engagement Development Process for Local Digital Roadmap NWL Digital Roadmap: Implementation Minimising the Risks arising from Technology Change Management Benefits Measurement and Realisation Principles and Standards for Digital Health and Care Appendix A Acute Patient Flows within and outside NWL Footprint Appendix B Providers of Community, Mental Health and Adult Social Care with IT systems Appendix C Digital Maturity Self-Assessment Appendix D - STP Local Digital Capabilities Deployment Plan and London Digital Programme Capabilities NHS NW London Local Digital Roadmap Page 6

7 1. Local Digital Roadmap (LDR) a key enabler for the NW London Sustainability and Transformation Plan (STP) 1.1 Background to the STP and LDR The Five Year Forward View made a commitment that, by 2020, there would be fully interoperable electronic health records so that patient s records are paperless. This was supported by a Government commitment in Personalised Health and Care 2020 that all patient and care records will be digital, interoperable and real-time by The Five Year Forward View envisages radically new care delivery models supported by new payment arrangements, which are value and outcome based, which will be enabled by increased digital maturity. The NHS 2016/17 Planning Guidance introduced the concept of place-based Sustainability and Transformation Plans (STPs) for care communities. The STP guidance published in February 2016 stated that, in developing STP content and ensuring delivery of transformation, local health and care systems should harness the opportunities that digital technology offers. The best plans will be coherent across all elements, including digital : STPs are expected to have a golden thread of digital technology running through the ambitions and plans for transformation and sustainability. CCGs are therefore charged with leading local health and care systems to produce Local Digital Roadmaps (LDRs), setting out how they will achieve the national ambition of operating Paper-free at the Point of Care by 2020, and also support local strategic objectives. The North West London STP was submitted to NHS England on 21 October This document sets out in more detail the digital technology capabilities that are already in place in North West London (NWL), and those that are planned, and also actively considers the digital opportunities to support the ambitions of the STP. The NWL STP footprint matches that for the LDR, encompassing eight CCGs and the eight corresponding Local Authorities, and the following Trusts: Imperial College Healthcare NHS Trust London North West Healthcare NHS Trust Chelsea & Westminster Hospital NHS Foundation Trust The Hillingdon Hospitals NHS Foundation Trust Royal Brompton & Harefield NHS Foundation Trust (Specialist Commissioning, but located in NWL) Royal Marsden NHS Foundation Trust (Specialist Commissioning, part located in NWL) Hounslow and Richmond Community Healthcare NHS Trust Central London Community Healthcare NHS Trust Central and North West London NHS Foundation Trust West London Mental Health NHS Trust The NWL care communities have a history of working together on strategic and informatics planning, which is recognised in this footprint. Note that London Ambulance Service NHS Trust is hosted by Brent CCG, but because of its pan-london footprint will be engaged at an NHSE London level. There is significant patient flow across the NWL footprint, with 26% of acute activity being performed by Trusts hosted by other NWL CCGs; and 16% of acute activity performed by Trusts outside NWL: 8.5% by Trusts hosted by NC London (Royal Free, UCLH, Moorfields, GOSH and RNOC), with other significant flows to Ashford & St Peters (8% of Hounslow CCG activity), Guys (7% of C London CCG), West Herts (2% of Harrow and Hillingdon CCG) and BMI (2% of Brent and Harrow activity). NWL will therefore work with these Trusts/providers to develop digital links, concentrating initially on NHSE s Universal Capabilities such as Summary Care Record, e-referrals and electronic discharges, and over time towards cross-border sharing of more comprehensive information, supported by NHSE s London Digital Programme. NHS NW London Local Digital Roadmap Page 7

8 1.2 NWL Sustainability and Transformation Plan (STP) The STP documents the plan of the NWL care community to close the following gaps, identified in the Five Year Forward View: Care and Quality gap implement new models of care, exploiting the digital opportunities to transform care; and put in place the basic digital infrastructure to enable joined up patient records and better information to support care decisions Finance and Efficiency gap maximise the use of technology and digital processes to improve efficiency Health and Wellbeing gap get patients involved in their own care; advanced system-wide analytics, looking at digital innovation and embracing novel approaches to support patients and citizens. If we are to address the challenges set out for the STP in this Triple Aim, we must fundamentally transform our system. The STP has drawn on local place based planning, sub-regional strategies and plans and the views of the sub-regional health and local government Strategic Planning Group to identify five Delivery Areas, each with a golden thread of enabling digital technology running through it, as the following excerpts from the STP show: Delivery Area 1: radically upgrading prevention and well-being: supporting everybody to play their part in staying healthy, digitally enabled as follows: Encourage digital empowerment and enablement to support citizens, including Patient Activation Measures (PAM), online communities, digital engagement via online and apps (especially for young people), social prescribing and sign posting to relevant support. Delivery Area 2: eliminating unwarranted variation and improving Long Term Condition management: ensuring that everyone in NW London has the same high quality care wherever they live; and that every patient with an LTC has the chance to become an expert in living with their condition, digitally enabled as follows: Implement integrated, primary care led models of local services care that feature principles of case management, care planning, self-care and multi-disciplinary working; patients receive timely, high quality and consistent care according to best practice pathways, supported by appropriate clinical systems and analytical data bases and tools; develop protocols for approved health apps to support self-care in collaboration with Digital Health London; develop best practice approaches to online-management solutions; understand digital motivations to support self-management and health education for people with LTCs. Delivery Area 3: achieving better outcomes and experiences for older people: caring for older people with dignity and respect, and never caring for someone in hospital if they can be cared for in their own bed, digitally enabled as follows: commission the entirety of NHS-provided older people's care services in NW London via outcomes-based contracts delivered by Accountable Care Partnerships (ACPs), with joint agreement about the model of integration with local government commissioned care and support services; operate rapid response and integrated care as part of a fully integrated ACP model; 100% of discharge correspondence transmitted electronically, and the single assessment process for transfers of care is built into the shared care records across NW London; improving interoperability of Coordinate my Care with other systems, including primary care, to ensure that people get the care they want at the end of their life. Actively implement digital channels to transform access to care, e.g. virtual consultations (from care homes, for MDTs, from care pods); create e-triaging services to access the right care; pioneer new models of information governance to support ACPs, e.g. single data controllership and/or Caldicott guardian arrangements across the STP footprint. Delivery Area 4: improving outcomes for children and adults with mental health needs: no health without mental health, digitally enabled as follows: integrated shared care plans across the system are held by all people with serious mental illness with agreed carer support; pilot digital systems to encourage people to think about their own on-going mental wellbeing through Patient Reported Outcome Measurements; look at virtual consultations for IAPT type services; implement digital tools to support people in managing their mental health issues outside traditional care models; digital enablement to share information between care settings to support new care models. Delivery Area 5: ensuring we have safe, high quality, sustainable acute services: high quality specialist services at the time you need them, digitally enabled as follows: Improve the productivity and efficiency of our hospitals (including the transition to paperless operations to meet the Finance and Efficiency gap); further progress the work on ICE and the diagnostic cloud to create a de facto platform for digital ordering and reporting of pathology (for NHS and non-nhs providers); join up NHS NW London Local Digital Roadmap Page 8

9 RIS/PACS radiology systems across acute NW London providers forming one radiology reporting network; revolutionise the outpatient model by using technology to reduce the number of face to face outpatient consultations by up to 40% and integrating primary care with access to specialists; NWL Productivity Programme: deliver sector Case for Change covering corporate areas of finance, HR and payroll, IM&T, procurement, estates and facilities, governance and risk and legal services to look at digital tools to increase efficiency and support the Carter recommendations, e.g. apps for Bank and Agency, Timesheets, e- Rostering. 1.3 NWL Local Digital Roadmap: Vision for Digitally-enabled Transformation The LDR has been produced in conjunction with the NWL Sustainability and Transformation Plan (STP) and in collaboration with NHS England London (Healthy London Partnership) s Digital Programme, and other LDRs across London. The LDR is not intended to be a replacement for individual organisations informatics strategies but provides a consolidated view of the plans required to achieve the objectives of the STP and the NHS s National Information Board strategy to become paper free at the point of care, support the delivery of integrated health and care services and also stretch the ambition to harness the digital revolution. It thus describes a five-year digital vision which incorporates plans for progressing both the Universal Capabilities mandated by NHSE, and local capabilities required to deliver specific STP objectives and also seizes the digital opportunity to encourage and cultivate innovation through technology. It has been developed in conjunction with, and is endorsed by, all organisations making up the NWL care community CCGs, healthcare providers and local authorities. At the core of NWL s STP and LDR is the vision of a fully integrated, inter-operative and digitally transformed health and social care delivery system, enabling new models of care that better meet the needs of the population and can deliver better outcomes at a lower cost, including delivering services in new and creative ways through digital channels. The NWL LDR is a key enabler to supporting the identified STP priorities, harnessing technology to accelerate change as the NWL care community moves towards greater digital maturity in delivering clinical and care services, creating digitally empowered and connected citizens and care professionals. The work streams making up the LDR vision are: 1. Automate clinical workflows and records, particularly in secondary care settings; to support transfers of care through interoperability (including fully digital ordering and reporting of diagnostics), thus removing the reliance on paper and improving quality; whilst also progressing digital opportunities to support back office functions i.e. HR and Finance primarily supporting STP Delivery Area 5 2. Build a shared care record across all care settings to deliver the integration of health and care records required to support new models of care, including the transition away from hospital supporting STP Delivery Areas 2, 3 and 4 3. Enable Patient Access through new digital channels and extending patient records to patients and carers to help them become more involved in their own care including novel ways to access care such as virtual consultations - supporting STP Delivery Areas 1, 2, 3 and 4 4. Provide people with tools for self-management and self-care, enabling them to take an active role in their care and wellbeing; and also look at consumer technologies (e.g. wearables such as Fitbits) to inform local care provision - supporting STP Delivery Area 1 5. Use dynamic data analytics to inform care decisions and support integrated health and social care, both across the population and at patient level, through whole systems population health intelligence primarily supporting STP Delivery Areas 2, 3 and 4. Delivering this strategy will require organisations to implement the ten Universal Capabilities identified by NHS England, to fully exploit NHS-wide IT investments; and seven local capabilities identified to meet NWL s specific strategic goals, particularly for integrated care, as documented in the STP and other existing NWL strategies such as the Local Services Strategy. The universal and local capabilities will require the support of the pan-london initiatives to be implemented by the London Digital Programme within NHSE s Healthy London Partnership; and the following local enabling work streams: IT Infrastructure requirements of new models of care, such as mobile data and wireless networking for professionals and citizens, seizing the opportunity of the HSCN Framework to overcome existing N3 challenges, consider a shared NWL network (e.g. a single NWL active directory), shared registration authority arrangements and extending the reach of clinical systems to new locations such as care homes. NHS NW London Local Digital Roadmap Page 9

10 Completion of the Information Governance mechanisms required to underpin shared care records, building on the existing NWL Information Sharing Protocol and Information Sharing Agreements which support direct care, enable new care models and govern patient access, as well as pioneering the secondary use of data. Consider innovative ways of managing Information Governance, such as single data controllership across the STP footprint, shared Caldicott Guardianship and tools such as the data controller console. Continuing to build a Digital Community across the citizens and care professionals of NWL through communication and education. The investment required achieving this strategic, clinical and digital transformation will require an appropriate governance model: the NWL Digital Programme Steering Group, with representatives from commissioners, secondary care providers and social care, will oversee delivery of the LDR, integrated with the governance of the STP. Innovation in digital health will play a major part in achieving our goals set out in the plan and is a key principle underpinning our work. Imperial College Health Partners (ICHP), the Academic Health Science Network (AHSN) for North West London, is working closely with the NWL Strategy and Transformation (S&T) and Informatics teams to support the planning and delivery of its local Sustainability and Transformation Plan, to achieve the change necessary for adoption and dissemination of innovation. The strategic transformation set out in the STP will be delivered through the following Digital enablers as set out in this LDR: NHS NW London Local Digital Roadmap Page 10

11 1.3.1 Implementing the Vision: NHSE Universal Capabilities NHS England has identified ten Universal Capabilities where there is an opportunity to exploit existing investments in healthcare technology and deliver real benefit within a short timeframe. Early in the LDR development process, the team focused on quick wins that would support STP goals and could deliver rapid benefits to patients and clinicians. There was a very strong correlation between these quick wins and the Universal Capabilities (UC A, B, D to H) identified by NHSE in the LDR Guidance: A. Trust access to GP-held information on medications, allergies and adverse reactions, addressing the Care & Quality gap and supporting STP Delivery Areas 2, 3, 4 and 5 by sharing GP records with other settings, to be achieved through full exploitation of the Summary Care Record in 2016/17 B. Access in Urgent and Emergency Care Settings to GP-held patient records, supporting STP Delivery Areas 2, 3, 4 and 5 by sharing GP records with other settings: already under way in some Trusts, with others to go live in 2016/17 D. Electronic referrals to comply with Service Condition SC6 of the standard contract, supporting STP Delivery Areas 2, 3 and 5 by increasing the efficiency and accuracy of referrals: greater adoption of e-rs by GPs and acute Trusts, to be driven in 2016/17 and 2017/18 E. Electronic discharge summaries to comply with SC11, supporting STP Delivery Areas 2, 3 and 5 by increasing the speed and accuracy of information sent from secondary to primary care: already achieved in most Trusts, planning for the next stage of digital maturity in 2016/17 for implementation in 2017/18 F. Electronic notices to social care of admissions and discharges in acute care, supporting STP Delivery Area 2, 3 and 5 by increasing the efficiency and accuracy of discharge planning: already under way in local Trusts and Councils G. Access to Child Protection information supporting STP Delivery Area 4 and 5 by sharing safeguarding information concerning children: CP-IS already under way in local Councils in 2016/17, with adoption by Trusts under SC32 to follow H. Access to End of Life care plans, supporting STP Delivery Area 3 by sharing the preferences of people approaching the end of their lives: adoption of CMC by Trusts under SC34 in 2016/17 These objectives formed the basis of the Digital CQUIN (Commissioning for Quality and Innovation) targets agreed between CCGs and Trusts at the start of 2016/17, or were enshrined in the standard NHS Contract for 2016/17. The other Universal Capabilities are not the subject of CQUINs or contractual conditions as they are restricted to Primary Care, but NWL has identified them as key to Primary Care Transformation or other major programmes in 2016/17 and also as quick wins : C/J.Patient Online appointments, repeat prescriptions and access to full GP record, supporting STP Delivery Area 1 by giving people access to their own records: a drive by CCGs to increase patient registration in 2016/17 (UC C and J) I. Electronic Prescribing between GPs and Community Pharmacies (EPS2), supporting STP Delivery Areas 2 and 3 by increasing the efficiency and accuracy of primary care prescribing: a drive to increase adoption by GP practices and pharmacies, and increase patient nominations, in 2016/17 (UC I). Detailed plans for implementation of the Universal Capabilities have been developed Implementing the Vision: STP Local Digital Capabilities In addition to the Universal Capabilities above, through the STP/LDR process NWL has identified a number of digital capabilities required to support specific strategies: 1. Within secondary care, implementing digital clinical workflows and records where they do not already exist (e.g. electronic hospital prescribing), addressing STP Delivery Area 5: procurement and planning to start in 2016/17 subject to funding approval 2. Full exploitation of the NWL Diagnostic Cloud, addressing STP Delivery Areas 2 to 5: extending to all GPs and radiology tests in all Trusts in 2016/17 and the inclusion of non-nhs diagnostic providers (e.g. InHealth) as soon as possible 3. Co-design of shared patient records and care plans to support integrated out-of-hospital care under new care models, addressing STP Delivery Areas 1 to 5 4. Whole Systems Population Health analytics at a population, organisation and personalised patient level, to be rolled out to GPs and extended to other data sources, including critical information from the shared patient record, addressing STP Delivery Areas 2 to 4 NHS NW London Local Digital Roadmap Page 11

12 5. NWL Care Information Exchange (CIE) linking to clinical systems with a view to sharing information with citizens about their health and care, engaging citizens to have their own personalised health record, addressing STP Delivery Areas 1 to 5 6. Automation of acute-to-acute patient transfers of care, addressing STP Delivery Area 5: to be piloted between Trusts by end 2016/17 7. Social care able to share records with healthcare providers, addressing STP Delivery Areas 2, 3 and 5: planning to start in 2016/17 subject to funding. The detailed plans for implementation of these local capabilities are set out in Appendix D of this LDR. Integrated Urgent Care Capabilities: an additional priority and quick win will be the procurement of a new 111 service in 2016/17, digitally driven, linked to shared electronic patient records, transforming Integrated Urgent Care and addressing STP Delivery Areas 2, 3 and 5. See Section London Digital Programme Capabilities: NWL s work on shared care records to date has highlighted a number of issues where central support from NHSE is required to deliver key system-wide enablers common standards for information to be exchanged, citizen identity management and preferences for data sharing, a pan-london exchange to support cross-footprint patient flows (especially in support of clinical networks such as Cancer and Trauma), linked to individual footprints own CIEs, with a record locator spanning footprints, and a register of Information Sharing Agreements to manage the complexity of Information Governance. NWL is happy to support the London Digital Programme s initiatives in all these areas, which will support STP Delivery Areas 1, 2, 3 and 5 and eventually Delivery Area 4 as well. See Appendix D Implementing the Vision: mapping to NHS Digital national strategy The NWL strategy maps on to the NHS Digital National Information Board strategy and P2020 domains, as follows: A. We will deliver the online services that patients need to take control of their own care, which will reduce the pressure on front line services: increasing adoption of Patient Online and EPS2; implementation of NWL Care Information Exchange, eventually linked to pan-london or national citizen identity and consent registers, and linked to a wide variety of patient-facing digital tools, connected to clinical IT systems. B. We will help to deliver the national urgent and emergency care strategy by providing the digital infrastructure, algorithms and pathways we require: transformation of Integrated Urgent Care through procurement of a new 111 service, powered by a new Directory of Services and Patient Relationship Management system, linked to clinical IT systems across the care community, including out-of-hospital care settings and emergency services. C. We will use technology to free GPs from time-consuming administrative tasks and provide patients with online services: increasing automation of workflows, particularly around transfers of care (e-referrals, electronic discharges, common workflows), and connecting clinical systems with patients and carers as in A above. D. We will better inform clinical decision making across all health and care settings by enabling and enhancing the flow of patient information: enhancement of primary care tools with decision support around referrals and diagnostics; real-time integration with other care settings in support of integrated care planning and delivery. E. We will enable and improve pharmacy decision making and outcomes by providing patients and prescribers with streamlined digital services: increasing adoption of EPS2 by GPs and pharmacies, increasing patient nominations and eventually (EPS Phase 4) extending EPS beyond nominated pharmacies; though streamlining digital services will require a new patient-centric user interface for EPS and integration of pharmacy systems (community and acute) beyond the current roadmap. F. We will improve referral management and provide an improved treatment choice for patients by automating referrals across the NHS: increasing adoption of the NHS e-referrals service for acute care, supported by the incentives set out in the recent draft NHS Operational Planning and Contracting Guidance ; and local intra-system referrals (where patients have opted in to local providers through Patient Choice) for community and integrated care. G. We will create an NHS paper free at the point of care by driving up levels of digital maturity and by enabling the NHS workforce to better utilise the benefits of digital technology: implementing digital clinical workflows and records where they do not already exist (e.g. electronic hospital prescribing), subject to the availability of STP/LDR funding; implementing common systems to support people at end of life (EPaCCS) and safeguarding (CP-IS); and increasing digital awareness and enthusiasm through communication and education. H. We will deliver the heath and care information and insight which is fundamental to informed policy making, commissioning and regulation by informing information collection, analysis and reporting: participation in national data services development; locally, development of the Whole Systems Integrated Care data warehouse NHS NW London Local Digital Roadmap Page 12

13 and dashboards, which deliver dynamic data analytics to inform care decisions and support integrated health and social care, both across the population and at patient level, through whole systems intelligence. I. We will enable information to move safely and securely across all health and care settings by providing robust and future-proofed national systems and networks: as part of the ICT Infrastructure enabling work stream, full use of NHS resources such as NHSmail2 and HSCN, complemented by local implementation, including a fixed and wireless networking infrastructure to support mobile working by clinicians, and digital adoption by patients. J. We will provide the means for citizens to set their consent preferences; we will provide confidence that clinical and citizen information is held safely and securely, and protect health and care systems from external threats: in the short term, consent is set in GP systems and the NWL Care Information Exchange, in the longer term linking to pan-london or national citizen and consent registers, supported by interfaces with clinical systems that are yet to be developed; as part of the ICT Infrastructure enabling work stream, implementation of a cyber security programme that responds to the issues raised by increased sharing of personal information across the health and care system, with patients and carers, and in a wide variety of physical locations, IT systems and technology platforms Implementing the Vision: Challenges and Mitigation The following issues associated with the implementation of the LDR have been identified: There is a significant opportunity for digital technology to transform current delivery models and enable new, integrated models of health and social care, shifting care out of hospitals through shared information between care settings and a reduced emphasis on traditional face-to-face care delivery. This is key to realisation of the NWL STP and is an opportunity that must be taken. The complexity of the NWL environment (10 Trusts, 8 CCGs, 8 Councils), supported by many different IT systems, creating a dependency on standards-based open interfaces - which primary and community IT suppliers (EMIS and TPP) have so far failed to deliver. In mitigation, Trusts and NHS Digital will continue to put pressure on the suppliers, through the GP Systems of Choice contract (GP Connect programme) and providers contracts, and it is now likely that some open Application Programming Interfaces (APIs) will be delivered in 2017, but until that happens, a full shared care record is not achievable. In several Trusts, mergers are in progress, and the focus is on procuring new clinical systems; the risk is that this may detract from or delay cross-system integration in their individual local care communities. From the start of 2018/19 NWL intends to implement Accountable Care Partnerships (2017/18 in Hillingdon) with new models of care which are predicated on the availability of shared care records, potentially requiring procurement of new systems. Over 40% of NWL acute attendances in Trusts are hosted outside their local CCG, 16% outside the footprint, making it difficult to access information about the patient. This will be mitigated by sharing care records and converging with other footprints via national and pan-london NHS systems and capabilities (e.g. Summary Care Record, e-referrals, Co-ordinate My Care, electronic discharges); and in the longer term addressed through the NWL Care Information Exchange and (for the 16% outside the footprint) a pan-london information exchange. There is a barrier to sharing information between health and social care systems due to a lack of open interfaces. This has led to a situation where social care IT suppliers have been looking to charge councils separately. Support is requested from NHSE to define and fund interfaces nationally. The cost and time required for clinical transformation projects to implement digital capabilities once procured (organisation and process change; education, training and field support) are recognised in this LDR, but must be reflected in each organisation s plans. To support clinical transformation, there is a need to increase the level of digital awareness and enthusiasm among service users and care professionals, which must be addressed via communication and education. Despite a long-term programme to make patients aware of their records and capabilities such as online appointment booking, fewer than 2% make use of these capabilities and for many clinicians, promoting them to patients is not a high priority among all their other pressures. NWL will continue to promote these services, and invest in patient and clinician education. The LDR identifies a significant need for central funding for technology, but it is not yet clear how much funding will be available and when, or on what basis it will be distributed, so it is difficult to plan; there is a risk that it will be insufficient to deliver the digital transformation that is required to deliver the national and STP goals within the target timescale set by Paperless by However, NWL has a number of advantages in implementing the LDR: NHS NW London Local Digital Roadmap Page 13

14 The NWL care community has already been working together for several years, co-ordinated by NHS NWL Informatics and supported by a comprehensive governance model, and has numerous examples of delivery of shared records (e.g. NWL Diagnostic Cloud). NWL is a pioneer of Integrated Care, and has made good progress with Information Governance across care settings. New structures are already being built to support new models of care joint health and social care services, GP federations, shadow Accountable Care Partnerships (ACPs) and NWL is developing a good understanding of the IT issues and requirements (e.g. learning from the Community Independence Service integrating health and social care in Hammersmith & Fulham, and the shadow ACP being established in the Metrohealth GP network in Hillingdon CCG). Six of the eight NWL CCGs are implementing common systems across primary and community care (so are not hindered by the lack of open interraces). The NWL Care Information Exchange is under way, funded by the Imperial College Healthcare charity to the end of 2017, to deliver a portal for sharing of information between care professionals and with patients, already being fed by some Acute Trusts systems, but constrained by a lack of interfaces with EMIS and SystmOne. In addition, the NHSE London Digital Programme is providing important support on the key system-wide enablers of shared care records common standards, identity management, pan-london exchange, record locator, IG register and NWL is working closely with the programme team. NHS NW London Local Digital Roadmap Page 14

15 2 NWL Local Digital Roadmap: Strategy for Capability Deployment This section sets out the current baseline position, recent achievements, current activity and summary plans for each sector in NWL to meet the STP goals. 2.1 Automate clinical workflows and records The most urgent area for investment and transformation through digital technology in NWL is within care organisations, particularly in secondary care (primary care is already paper-light and in many areas paperless) where in many areas, care records remain paper-based. This is the main way in which IT can address the Finance and Efficiency Gap identified in the Five Year Forward View, improving the speed and quality of clinical workflows and reducing duplication of processes, driving providers towards the overriding Five Year Forward View goal of Paperless by Digital records in each care setting are also a fundamental enabler for automating transfers of care and providing the information required for new models of multi-disciplinary care, thus delivering the STP goal of integrated health and social care through shared data and whole systems intelligence; and for sharing information with service users, to meet the STP goal to involve citizens in their own health through digital empowerment. Some NWL care organisations are already going through significant transitions such as hospital mergers, and new systems are required so that common clinical processes can be implemented; in others, the current systems will not support new models of care and must be replaced. In many areas the current clinical IT systems are not well adapted to modern practices or easy to use, and need to be enhanced or replaced to make them fit for purpose; in particular, they must reflect the growing need for care professionals to work from multiple locations, using mobile devices as well as traditional PCs. Therefore, a considerable portion of the LDR programme will concentrate on implementing, replacing or improving operational clinical IT systems; but it will also seize the opportunity to encourage and cultivate digital innovation to deliver new ways and channels to improve care and wellbeing Primary Care Clinical IT systems used in primary care are highly automated, and enable GP practices to operate in a paperless or highly paper-light manner. In NWL, five CCGs (Central London, West London, Hammersmith & Fulham, Hounslow and Ealing - CWHHE) have standardised on SystmOne and three (Brent, Harrow and Hillingdon BHH) on EMIS Web/DocMan, with fewer than 1% of practices opting out of the standard. Standardisation across a CCG makes it much easier to integrate primary care systems with the systems used by other care providers in a given care community. The NWL strategy for primary care systems is to make use of these digital capabilities more effectively, enable better access to primary care, further increase digital maturity in areas such as patient engagement, clinical pathway and decision support, and build automated links to other care settings through interoperability, moving away from paper and fax, and reducing telephone follow-ups to a minimum. Improved access to primary care (as mandated in the recent draft NHS Operational Planning and Contracting Guidance ) will be delivered through the following: Increasing the times when primary care is available through additional evening and weekend clinics, generally implemented via GP networks or federations, achieved by sharing patients records from the registered practice to a physical or virtual network hub through which the additional services are delivered. Both EMIS Web and SystmOne offer this capability, and each CCG is working with its GP networks to plan how hub services will be achieved. A new nationally commissioned tool will be introduced during 2017/18 to automatically measure appointment activity by practices (in-hours and in extended hours). Actively implement digital approaches for virtual consultations to support novel ways to access care, whether delivered by phone, online (through secure messaging or ) or video (the NWL Care Information Exchange offers this capability). In combination with increased use of Patient Online tools for appointment booking, prescription requests, these changes are expected to reduce the demand for face-to-face clinical appointments and practice administration. There is some evidence that online access to care can help to overcome inequalities (e.g. multi-lingual online tools and advice). The effectiveness of care will be enhanced by new decision support tools to be integrated with clinical systems (e.g. pathway selection, diagnostic ordering) to assist GPs. Embedded guidelines and decision support in GP systems, to assure evidence-based quality care which follows local guidelines and protocols, and to enforce accurate coding which makes business intelligence effective. NHS NW London Local Digital Roadmap Page 15

16 Patient and carer connection to wider whole system services and care plans, expected to be achieved through the NWL Care Information Exchange and other new online services such as the Integrated Urgent Care patient portal and NHS Online. Within the NWL CCGs, there is a Primary Care IT programme with the following objectives: 1. My Health Empower the patient and carer to be informed about, and part of, the processes of managing their care, through technology (e.g. increasing the uptake of Electronic Prescribing and Patient Online, considering self-care apps, add-ons to GP systems, communication tools including SMS, websites, telephony and videoconferencing to facilitate the opportunity for a virtual GP model). Electronic Prescribing (EPS2) is a programme that spans both primary care and community pharmacies. 2. My Practice Transform primary care systems and processes to ensure efficient service delivery, giving them the knowledge and insight to be effective and sustainable businesses, with tools to report on patients, pathways and practice operations (and including mobile working for GPs). 3. Five Minute Window Enhance early diagnosis and referrals pathways within the primary care setting, providing clinicians with the tools, methods and techniques to support consultations and healthcare, including templates and workflows for referrals, diagnostic test requests, prescribing, assessments and other protocols, and automated aids to clinical decision support. 4. One NHS Integrate care between primary care and other settings of care, defining common standards for clinical communication to and from GPs, including content of referrals and discharge documentation, communication with other care settings using the same system (SystmOne), agreeing a common prescribing formulary, requesting tests using the NWL Diagnostic Cloud, and safeguarding. 5. My CCG Improve the functions of the CCG as an organisation as well as a commissioner of services, including governance of Primary Care IT systems and services, and covering communication tools such as extranets and as well as business and commissioning systems and tools. New Models of Care: the biggest single change under way currently in Primary Care is the grouping of practices into networks or federations which will be able to act as providers, delivering enhanced primary care services in support of the Out of Hospital (including previous Local Enhanced Services) and Seven Day Working strategies (see reference above under access to primary care). This is achieved via record sharing and cross-organisation appointments and tasks between practices, using built-in SystmOne functions in CWHHE and the EMIS Clinical Services module in BHH. These new organisational models will pave the way for Accountable Care Partnerships (ACPs) in due course, with multiple clinical care settings within the same organisation or federated structure. ACPs will require a digital system that continuously collects, connects and shares patient information and clinical decision support among the network(s) of provider(s) making up the ACP; which will require primary care IT suppliers to implement interoperability through open APIs, which are expected to be available during If APIs are not delivered or do not support the clinical information sharing needed by ACPs, it is likely that the only way for ACPs to operate as integrated care organisations will be for them to adopt primary care IT systems, i.e. SystmOne (CWHHE) or EMIS (BHH). Detailed IT requirements for the ACPs have not yet been documented, but will emerge during further work to define and procure ACP provision. ACPs are expected to be implemented from the start of FY 2018/19 (start of 2017/18 in Hillingdon). The approach to delivering integrated records across multi-disciplinary teams and care settings to meet the requirements of ACPs and other new models of care is discussed under Shared Care Records, below. NWL s proposed Primary Care Transformation programme, to be funded through the Estates and Technology Transformation Fund (ETTF), aims to drive primary care technology to the next level of digital maturity, while supporting the Four Core Criteria identified by NHSE (enabling extended access to effective care, increased capacity of clinical services out of hospital, increased training capacity and enabling access to wider services as set out in commissioning intentions to reduce unplanned admissions). In addition, it will support the evolution of new ways to deliver primary care through digital technology such as online and video consultations, shifting the point of care away from the GP practice and the change management required to help clinicians and patients make full use of the new technology. The projects included in the ETTF programme are illustrated below. In relation to community pharmacy, the next stage in realising the benefits of electronic prescribing beyond Phase 4 of the Electronic Prescribing Service will require an automated link between EPS and pharmacy systems, to deliver more comprehensive workflows and more efficient medicines reconciliation. This is expected to be NHS NW London Local Digital Roadmap Page 16

17 supported by the 42m Pharmacy Integration Fund (PhIF) announced by NHSE on 20 October 2016, with the objective of developing new clinical pharmacy services, working practices and digital platforms to meet the public s expectations for a modern NHS community pharmacy service. NHS NW London Local Digital Roadmap Page 17

18 2.1.2 Acute Care The Acute Trusts of NWL are at varied stages in the procurement and deployment of digital systems to support care. For all these Trusts, many specialties are still reliant on paper records, and considerable investment is essential to deliver the vision of making them paper-less at the point of care. The systems required are substantial, with costs to match, including Electronic Patient Record (EPR), Electronic Prescribing and Medicines Administration (EPMA), Electronic Document Management (EDM) and potentially also Decision Support systems; implementation of the software and associated organisational change will involve multi-year projects. Mobile working and improved end-user interfaces on portable devices, supported by campus wi-fi networks, are being considered by all Trusts. The Trusts strategies are summarised below: Imperial College Healthcare NHS Trust (Imperial) has implemented Cerner Millennium and is moving rapidly towards a fully electronic record, including clinical documentation, electronic prescribing, diagnostic results and orders and observations. The next phases will include EDM to digitise history, with specialist data capture to remove paper, which will create a paper-light environment; automated capture of observations saving nursing and midwife time and improving patient safety; voice recognition to streamline and accelerate correspondence production; telehealth and out of hospital services to reduce length of stay and improve patient experience and access; closed loop prescribing to shorten the time to start treatment and reduce length of stay; and clinical reporting to create a virtuous circle of awareness and feedback for clinical staff. Imperial has applied to NHS Digital to be a Global Digital Exemplar, in conjunction with Chelwest. Chelsea & Westminster NHS Foundation Trust (Chelwest) has decided to implement Cerner Millennium as its new pan-trust EPR system following the merger with West Middlesex Hospital, to include Electronic Document Management and Electronic Prescribing and Medicines Administration, Clinical Portal, Patient portal, Think Vitals, Sensium, Mobile working, Enterprise Resource Management e-rostering for all clinical staff, and medical device integration. The Cerner implementation will use the same instance as Imperial, thus saving costs, and will make use of resources and experience rom Imperial, to take place during 2016/17 and 2017/18. The CIO of Imperial, Kevin Jarrold, has recently been given responsibility for ICT at Chelwest as well. London North West Healthcare NHS Trust (LNWHT) is planning a new pan-trust EPR following the merger with Ealing Hospital; but following much work on requirements and design, the project is on hold awaiting funding. LNWHT intends to proceed with procurement of a Clinical Portal and EDM system in 2016/17 (to be implemented by 2018/19) and subject to availability of funding, a new EPR, including EPMA and decision support functionality, in 2017/18 (to be implemented by 2019/20). LNWHT is keen to work with and learn from Imperial/Chelwest in its exemplar capacity, with a view to potentially reducing costs, risks and timescales. The Hillingdon Hospital NHS Foundation Trust (THH) has older systems, but is well along the path to integrating them together and deploying its own software to present information to clinicians. It has implemented the Hillingdon Care Record to bring patient information from across the hospital; this clinical portal also draws on GP patient records via the MIG (Medical Interoperability Gateway) to create a comprehensive picture of the patient from the day of admission. However, THH is currently reliant on paper records at key stages of care delivery and has identified the need for EPMA and EDM systems, subject to funding, in order to meet the target of becoming paperless. Royal Brompton & Harefield NHS Foundation Trust (RBHT) is part way through the delivery of its Digital Care Transformation Programme, with a Patient Information System (PAS) from Lorenzo, EPMA for inpatients, and EDM all due to go live in summer Phase 2 of this programme will see implementation of a fully functional EPR between summer 2016 and the end of 2017, subject to funding. Completion of this phase will enable the rationalisation of clinical applications and enable richer data about patient care to be made available to other care settings. Royal Marsden NHS Foundation Trust (RM) is currently developing a business case to procure a replacement EPR, together with a clinical and patient portal to bring together all information relating to the patient across care settings, digitise workflow and transform the hospital to replace paper with the appropriate digital process. The outline business case is scheduled for submission in January 2017 with implementation, subject to funding, during The new IT platform will provide integration to the Summary Care Record, MIG and other sources of data through the Integrated Care Exchange (ICE), the underpinning architecture which already supports Co-ordinate My Care (CMC the pan-london repository for end-of-life care plans which is operated by RM). The Trust is also working with NHSE and vanguard care communities to design and create a standard cancer treatment care plan, including details for pain management and urgent care, which will also be available outside the Trust (see Shared Records, below). NHS NW London Local Digital Roadmap Page 18

19 In order to achieve NWL s STP objectives for better integrated care, the Commissioners are focused on driving the automation of transfers of care between acute and other care settings, using contractual mechanisms and a local Digital CQUIN (Commissioning for Quality and Innovation) incentive programme for 2016/17. Some of these requirements are also supported through national initiatives, identified by NHS England as Universal Capabilities: Summary Care Record all local Trusts have already made the NHS SCR available to some or all clinicians and are using it to support clinical decisions, as per Service Condition 24 (SC24) of the standard NHS contract. Under the Digital CQUIN they are working with CCGs to report back on SCR usage and identify any improvements. Electronic Referrals ensuring that Trusts meet their contractual requirement to receive referrals electronically, whether via the NHS Electronic Referrals Service (e- RS) (as per SC6). All NWL GP practices have enabled e-rs, though only 95% of practices are currently using it; patients are provided with information to enable their choice of provider where this is available. Generally, where providers make slots available, utilisation is high. However, many of the NWL providers do not currently make full use of e-rs, which has constrained overall utilisation. In addition to local providers, 17.5% of NWL acute outpatient referrals are to Out of Area providers including UCLH, Royal Free, Moorfields, Guys and Ashford Trusts; NHS NWL must engage with these providers to increase usage of e-rs. The draft NHS Operational Planning and Contracting Guidance mandates the use of e-rs by April 2017, sets the expectation that all outpatient referrals will be sent via e- RS from April 2018, and states that from October 2018, providers will be able to reject referrals not sent via e-rs. On the provider side, a national CQUIN (0.25% of income) for 2017/18 will incentivise providers to increase utilisation of e-rs; all First Outpatient referrals must be available on e-rs by end March 2018, with Appointment Slot Issues (ASIs) reduced to 4% or less; and from October 2018, providers will not be paid for referrals not received via e-rs. These changes are expected to drive a step change in the usage of e-rs. The ability for Trust systems to interface electronically with e-rs (via APIs due for delivery in late 2016) will be a key enabler. Providers will also be incentivised to work with CCGs to implement Advice and Guidance services for non-urgent GP referrals, under the planned national Advice and Guidance 2017/18 CQUIN (a further 0.25% of provider turnover), allowing GPs to access consultant advice prior to referring patients in to secondary care, to reduce inappropriate referrals; either through the e-rs platform or local solutions where this offers a better alternative. Clinical Correspondence ensuring that Trusts meet their contractual requirement to transmit discharge correspondence via an approved electronic mechanism, using the standards set out by the Academy of Medical Royal Colleges (SC11) and working with them in to optimise the timeliness of correspondence and plan the transition to structured messaging (under the 2016/17 Digital CQUIN). Child protection alerts to ensure information is shared and clinical staff are alerted to those at risk of abuse or neglect (SC32). The efficacy of this capability will be constrained by the delay in Local Authorities adopting the national Child Protection Information Sharing (CP-IS) system. Only two of NWL s eight boroughs (Hillingdon and Kensington & Chelsea) had done so by April 2016 (source: NHS Digital newsletter May 2016); a further five boroughs (Brent, Hounslow, Ealing, Hammersmith & Fulham and City of Westminster) will have done so by the end of 2016/17; Harrow is constrained by its network infrastructure, so is planning for a possible implementation in 2017/18. In many of these boroughs, however, the health and social care safeguarding teams are co-located, so information is already shared manually with Trusts outside CP-IS. End of Life Care Planning ensuring that Trusts meet their contractual requirement to implement and use the pan-london solution (Co-ordinate My Care - CMC) for end of life planning in (SC34). The current usage of CMC varies across NWL from 5% of the expected end-of-life population in Hounslow CCG to 30% in Hillingdon CCG; in Brent and Ealing it is 10%; in Central London 12%; in West London 18%; in Harrow and Hammersmith & Fulham 21%. Increased use of CMC is a key priority of the NWL Sustainability and Transformation Plan (STP); therefore, CCGs are expected to put pressure their GPs to adopt the system and reach critical mass. The CCGs will also drive Trusts to implement CMC during 2016/17 by reference to the standard NHS contract (clause SC34). CCGs will take the lead in monitoring the End of Life Health and Wellbeing Indicator scores for their care communities, reporting to Health and Wellbeing Boards. Other interfaces to be developed by acute Trusts will respond to locally identified STP requirements: Integrated care: moving to new models of care, with greater emphasis on out-of-hospital care, will require hospital systems to link to health and care systems in other settings. Trusts have committed under the Digital CQUIN to participate in clinically led co-design across all care settings (including social care and the third NHS NW London Local Digital Roadmap Page 19

20 sector) to develop a standard approach, templates and message formats for integrated care plans. In addition, the CQUIN incentivises Trusts to provide updates on admissions, to inform GPs and also community services to avoid unnecessary visits when patients have unexpectedly been admitted. Linking acute systems to the NWL Care Information Exchange. Inter-acute transfers of care: patient transfers between acute hospitals are relatively common, but currently rely on paper records; local Trusts are already supporting the Major Trauma network by sharing information electronically, and will extend this to other inter-acute transfers, e.g. step down from hyper-acute stroke units to stroke units, ante-natal follow up by local maternity units. This will link into the London Digital Programme s work on standard message content for clinical networks. Approximately 16% of NWL s acute activity is delivered by providers from other footprints. The highest volume providers are as follows: Provider Footprint Activity % of NWL Main CCGs (year to 9/15) total Royal Free (inc Barnet) NC London 130, % 8% of Brent CCG activity, 6% of Harrow CCG UCLH NC London 120, % 14% of Central London CCG activity, 3% of Brent CCG Moorfields NC London 100, % 5% of Ealing CCG activity, 6% of Harrow CCG Guys SE London 51, % 7% of Central London CCG Ashford & St Peter s Surrey Heartlands 41, % 8% of Hounslow CCG BMI none 32, % 2% of Harrow CCG, 2% of Brent CCG West Herts Herts & W Essex 26, % 2% of Harrow CCG, 2% of Hillingdon CCG InHealth none 20, % 1% of H&F CCG, 1% of Brent CCG Barts NE London 14, % 0.7% of Central London CCG No other Trust receives more than 0.2% of NWL acute activity per annum (< 10,000 episodes out of 4.5m) Activity = total of acute attendances, inpatient elective + non-elective + day-case episodes, and outpatient first appointments + follow ups + procedures NWL will therefore work with these Footprints and providers to understand their LDRs and/or IT strategies and develop digital links, concentrating initially on NHSE s Universal Capabilities such as Summary Care Record, e-referrals and electronic discharges. In due course, a greater degree of cross-footprint information sharing will be facilitated by the enabling services to be developed by the London Digital Programme: citizen identity management and preferences for data sharing, pan-london exchange to support cross-footprint patient flows and record locator spanning footprints Community Healthcare NWL has four main community providers: Central London Community Healthcare (CLCH) in Central London, West London, Hammersmith & Fulham and Harrow CCGs; London North West Healthcare (LNWHT) in Ealing and Brent; Hounslow and Richmond Community Healthcare (HRCH) in Hounslow; and Central and North West London (CNWL) in Hillingdon and (following recent re-procurement) in the Community Independence Service (CIS) in Central London, West London and Hammersmith & Fulham. Other community contracts, typically for specialised services, are delivered by acute Trusts such as Imperial. All these providers have implemented SystmOne Community as their clinical system (apart from CLCH in Harrow, where it will be deploying EMIS Community). The new clinical systems are delivering significant benefits in digital maturity in terms of record keeping and workflow, with the ability for primary and community clinicians to share records; and as part of this implementation, the Trusts are rolling out mobile capabilities to support clinicians working at patients homes and other remote locations. The mapping of providers to CCGs is shown in the Appendices. CCGs will incentivise community Trusts to implement the NHSE Universal Capabilities through contract mechanisms (Summary Care Record SC24, Electronic Referrals SC6, Clinical Correspondence SC11, Child Protection SC32, End of Life Care Planning SC34) and to enhance those capabilities via the 2016/17 Digital CQUINs. Sharing community healthcare records and care plans with other care settings, and digital transfers of care (especially between primary and community, and community and acute settings), are critical to supporting the new models of care identified in the STP, in particular the out of hospital agenda: NHS NW London Local Digital Roadmap Page 20

21 All community Trusts will participate during 2016/17 (under the Digital CQUIN programme) in clinically led co-design across all care settings (including social care and the third sector) to develop a standard approach, templates and message formats for integrated care plans. In the five CWHHE CCGs, the Trusts are implementing integration with primary care using SystmOne to exchange tasks such as electronic referrals, alerts and appointments, and share patient records and plans. However, the current lack of an open interface has made it impossible to exchange information with other care settings, either directly or via the Care Information Exchange. Work is under way to link primary and community care within SystmOne, so that where the patient chooses to use the local provider, community referrals will be transmitted electronically via the SystmOne referral wizard. In Harrow, CLCH will be implementing EMIS Community during 2016/17, so integration with primary care (though not other care settings) should be possible. In Hillingdon and Brent, there is no current integration with CNWL or LNWHT because of the inability to share information between SystmOne Community and EMIS Web, which means that communication between care settings can only be achieved via phone, or written documents which causes delays in care and wastes clinician time. After much effort on the part of providers, CCGs and NHS Digital, it is believed the IT suppliers (EMIS and TPP) will deliver such interfaces during 2017 under the GP Connect component of the NHS Digital GP Systems of Choice (GPSoC) contract, supported by the NHS Code4Health Interoperability community. Initially this is expected to be via HTML screen views, eventually via structured messaging, including tasks and appointment booking (message formats likely to include Clinical Document Architecture CDA). By the end of 2017/18 it is expected that this approach will result in access to structured primary and community patient records across the care community. For referrals, community services will be encouraged to use NHS e-referrals, but work is required on a service by service basis, to enhance both EMIS in primary care and SystmOne in the community to capture referral information in templates, send and receive referrals appropriately. Currently it is believed that the sharing of care plans is not included in the proposed interface, and this needs to change; there are ongoing discussions with NHS Digital, but further pressure on the suppliers from NHSD would be appreciated. For the Imperial contracts, community clinicians invariably use the same system as local GPs, and services will be integrated with primary care Mental Health Care NWL has two providers: Central and North West London (CNWL) in Central London, West London, Brent, Harrow and Hillingdon CCGs; and West London Mental Health Trust (WLMHT) in Hammersmith & Fulham, Hounslow and Ealing. CNWL uses Jade as its clinical IT system, but will replace it with SystmOne during 2017; WLMHT has implemented Open RiO. The mapping of providers to CCGs is shown in the Appendices. CCGs are incentivising mental health Trusts to implement the NHSE Universal Capabilities through contract mechanisms (Summary Care Record SC24, Electronic Referrals SC6, Clinical Correspondence SC11, Child Protection SC32, End of Life Care Planning SC34) and to enhance those capabilities via the 2016/17 Digital CQUINs. Sharing mental health records and care plans with other care settings is critical to the new models of care identified in the STP as part of the Like Minded programme, and in particular the objective to reduce the gap in life expectancy between adults with serious and long-term mental health needs and the rest of the population. The main problem with current systems (both Jade and RiO) is that patient records are narrative based and lack coding or structure, which makes them very difficult to extract and share with other care settings, preventing them from being used to support integrated care. Addressing this issue will require changes in clinical processes and working practices and will take several years; the Trusts aim to start by piloting with a small number of critical services, driven by 2016/17 Digital CQUINs from the CCGs. At the same time, they will build up their use of some of the Universal Capabilities such as SCR, access to GP records and e-discharges; and local capabilities such as the NWL Diagnostic Cloud. In the longer term and once structured data is available, the Trusts will look to make more progress towards the strategic goals of the STP: Both Trusts are participating during 2016/17 (under the Digital CQUIN programme) in clinically led co-design across all care settings (including social care and the third sector) to develop a standard approach, templates and message formats for integrated care plans. Once CNWL has migrated from Jade, in Central London and West London, it will implement integration with primary and community care using SystmOne to exchange tasks such as electronic referrals, alerts and appointments, and share patient records and plans. In Brent, Harrow and Hillingdon, currently integration between CNWL and primary care would be difficult because of a lack of open interfaces between SystmOne and EMIS Web. The open interfaces expected to be delivered by the IT suppliers during 2017 should address this issue. It is not yet clear whether electronic referrals will be in scope; if not, NHS e-referrals will be used, but work will be required on a service by service basis to enhance both EMIS and SystmOne to capture referral information in templates, send and receive referrals NHS NW London Local Digital Roadmap Page 21

22 appropriately. Integration with the diverse systems in community care and other care settings (including the sharing of care plans) will be considered once primary care integration has been achieved. For WLMHT in Hammersmith & Fulham, Ealing and Hounslow, integration is not currently possible between the RiO mental health system and primary care because of a lack of open interfaces between SystmOne and RiO. While SystmOne is expected to deliver open interfaces during 2016/17 at no additional cost (funded by the GPSoC and provider contracts), interfaces with RiO are only available at extra cost. In addition, WLMHT s objective of offering broader community services will require further investment in a dedicated community system/module which may, dependent upon the solution chosen, also require further open interfaces to be commissioned. WLMHT and local CCGs have already defined standard message formats for such an interface, but it has not proceeded to date, for lack of funding for the work required by Servelec (supplier of RiO) and to acquire an integration engine. NHS Digital are requested to commission an open RiO interface, to save having to fund all RiO user Trusts individually Mobile clinical working is a short term objective for WLMHT and a medium term (post Jade) objective for CNWL, subject to funding. A longer term objective for mental health care is the ability to share mental health crisis plans between care professionals and ultimately with patients, to fulfil the requirements of the national Mental Health Crisis Care Concordat, agreed by all care organisations in At the core of NWL s approach to Delivery Area 4, Improving Outcomes for Children and Adults with Mental Health Needs, is the Like Minded strategy, where Imperial College Health Partners is providing health economic support and exposing the sector to the latest innovations in mental health, making introductions to industry leaders in this area Social Care The digital enablement of clinical workflows and records in social care is not within the scope of the LDR, since it is primarily a matter for individual Councils which are not commissioned by the NHS. See below for a discussion of the approach to provide digital support for closer working between social care and healthcare Remote and Assistive Care Each acute Trust is considering the role of digital technology to support remote delivery of care, thus avoiding hospital visits. Technologies such as telemedicine and telehealth have existed for some time and have been trialled in many different specialties and disciplines, in particular to support patients with long term conditions, but despite numerous government and industry initiatives, there has been little or no successful deployment at scale to date; the business case for investment in the hardware, software and new services required has not been justified by reductions in the cost and time of care (notably the WSD project, ). Telehealth is one of the objectives mentioned in the STP, but more work is required between commissioners and providers to define the scope and intended benefits of what is required. For the moment, the focus is therefore on individual initiatives in specific provider clinical services where an emerging technology may help improve the quality or efficiency of care, for example: Imperial College Healthcare NHS Trust is the hub for the North West London Cancer Network, and has used Video conferencing for many years to support Multi- Disciplinary Team (MDT) conferences to discuss cases and agree treatment plans. The facilities available are under review to determine what upgrades and improvements across the network are required to support improved sharing of diagnostic data, images (e.g. histopathology slides and radiology) and to support better audio and video formats for more satisfactory conferences, enabling full participation from all locations. Also at Imperial, the liaison psychiatry team is piloting the use of web conferencing to enable remote consultations and support for patients using the service. This will be supported by the use of the Care Information Exchange to enable patient provided symptoms and observations to be captured and shared prior to or as part of the conference and to develop and share care plans between care professionals and patients. MDTs are a key component of integrated out-of-hospital care, and video and web conferencing is being considered to reduce travel time for the primary, community, acute, mental health and social care professionals. RBHT will be implementing a new managed service for enhanced MDT meetings which will incorporate sharing of images through the Agfa PACS portal. Further investment will be required to put in place a Vendor Neutral Archive which, once implemented, will make available images and reporting data to any external organisation providing the appropriate IG agreements are in place. Skype for business is now live at RBHT, ensuring teams from all sites can communicate effectively from desktops, sharing data and documents. This software is also being piloted for patient follow up appointments. NHS NW London Local Digital Roadmap Page 22

23 The Care Information Exchange offers the opportunity for patients to be able to record and upload data and observations of their own (weight, BP, heart rate, glucose, etc.) and allow remote tracking and monitoring for out of hospital care and supported/monitored early discharge. The new NHS Technology Tariff announced by Simon Stevens in June 2016 should make it easier to adopt telehealth technology for remote monitoring (wearables), subject to an appropriate clinical and business case. 2.2 Build a shared care record across all care settings New Models of Care Critical to NWL s STP vision for a sustainable care economy is the transition to new, less costly models of care, with more activity delivered out of hospital through multidisciplinary working that spans professions and organisations, overlapping with national NHS initiatives such as Right Care. Integrated care is expected to improve outcomes and patient satisfaction by preventing the onset of disease and reducing acute exacerbations, keeping people out of hospital for longer. It is particularly important for looking after the frail elderly and those with long term conditions, who represent as much as 70% of total health and care costs. Delivering integrated care consistently across the whole care community is expected to reduce health inequalities, evidenced by unwarranted variation in the management of long term conditions, and disparity in outcomes and patient experience. Digital Health potentially offers new channels of care with a reduction in face-to-face time in some settings. NWL is a national Pioneer of Whole Systems Integrated Care; integrated services already in place or being planned in NWL include the Community Independence Service (CIS) in the inner London Tri-boroughs, the Ealing Model of Care, the shadow Accountable Care Partnership being piloted by the Metrohealth network in Hillingdon, Hounslow ICRS and Whole System Hubs in West London CCG. Learnings from the structures, processes, IT systems and tools developed for the Pioneer programme will be extremely useful to support future implementation of Accountable Care Partnerships (ACPs). Experience in NWL with integrated care pilots shows that the channel shift to these new models cannot be delivered at scale, and realise the expected benefits, without integration of the care records that support them, at an appropriate level of granularity for the clinicians involved. The lack of interoperability between existing systems has constrained the efficiency of new care models to date, as information must be entered multiple times to different systems; and there are delays in alerting and notification across care settings. In particular, the inability of systems to share care plans electronically - between clinicians, and with patients and their carers - has limited their usefulness as a tool to manage integrated care. Addressing these issues is imperative, and because of the heterogeneity of providers and the NWL IT landscape, must be achieved through a number of methods: Exploit existing interoperability tools: NWL has made some progress towards a shared care record using national tools (e.g. SCR, e-referrals, EPS2) and through local initiatives (e.g. MIG in Hillingdon, CMC), but new models require a much greater level of integration across settings, with more clinical detail than these tools currently support. Common System: between primary and community care, in six of the eight CCGs there is or will be a common system (SystmOne in CWHHE and EMIS in Harrow); work is already under way on integrating templates, tasks and workflows in SystmOne. Interoperability: for sharing between other care settings (and between primary and community in Brent and Hillingdon) shared records are dependent on interoperability solutions, either on a bilateral basis between systems or through an intermediate system such as the NWL Care Information Exchange. Currently this capability is constrained by the lack of open interfaces to and from the main primary and community systems, SystmOne and EMIS Web, but these are now expected to be delivered in 2017; see discussion of Community Healthcare, above. The NWL Care Information exchange will progressively offer a platform for sharing records and communication care plans between professionals and creating plans and goals to share with patients and carers; and also be integrated into the new 111 platform, to support access to clinical information by clinical advisers. Shared integrated care plans are being piloted in the Hillingdon care community (including primary, community, acute, mental health, social care and the third sector), as an early adopter project of the Care Information Exchange, and will include sharing plans and messaging with service users (patients and carers), but currently because of the lack of open interfaces must rely on manual procedures which limits scalability. It is believed that the sharing of care plans is not included in the proposed interfaces from TPP and EMIS, this should be added by NHS Digital as a requirement. NHS NW London Local Digital Roadmap Page 23

24 Sharing between health and social care is more of an issue, since the two social care systems (Protocol and Framework-i/Mosaic) do not have open interfaces and the suppliers (Liquid Logic and Corelogic) wish to charge each council separately to develop them. NWL requests NHS Digital to define and fund such interfaces nationally to reduce the overall cost to the system. Experience in Hillingdon CCG and in other care economies (e.g. Hampshire Health Record) suggests that interoperability only really becomes effective when care professionals can use their own system to access information in other care settings, without having to log on separately to an online portal provided by the other care provider. Portals may offer a partial, short term solution, but interfaces delivered via open APIs are therefore essential. Population health is increasingly becoming a real priority, and to plan and deliver integrated care effectively, it is necessary to integrate business intelligence with patient care, multi-channel communication and predictive analytics. NWL has developed and is deploying analytical tools at both a population and personalised level (see Dynamic Data Analytics, below), but much work has been required to develop a suitable information governance framework, and to overcome the limitations of source clinical systems to provide the required data, and development of these tools is ongoing. The complexity of the clinical systems landscape in NWL, and the interfaces required to build a fully shared record, are illustrated below: NHS NW London Local Digital Roadmap Page 24

25 Shared care records will support all the key STP themes to address the Triple Aim: remove reliance on paper currently used to pass information between care settings (and duplicate data entry which is also highly inefficient and impacts clinical quality); integrated health and social care through shared data and whole systems intelligence; and providing the rich care records required by service users, to involve citizens in their own health through digital empowerment Exploit existing investments in NHS Digital Tools National digital tools include the Summary Care Record, e-referrals, EPS2 for community prescribing, and the Child Protection Information Service (CP-IS). Uptake of SCR and EPS2 has been good and these tools are useful in their own niche areas, but new models of care require a much greater level of integration across care settings. NWL CCGs intend to exploit SCR 2.1 (with additional information) by signing up patients in high risk cohorts (e.g. elderly people with one or more Long Term Conditions) since these are the people who place the greatest load on the care system, and local Trusts clinicians already have access to SCR data. However, for SCR 2.1 it is necessary for patients to opt in, therefore recruitment of a significant group of patients is likely to take some time. Pan-London digital tools include Co-ordinate My Care and the London Adapter to link to social care (see below). Local digital investments include the NWL Diagnostic Cloud which spans primary, community, mental health and acute care. Trusts are incentivised though contractual mechanisms and Digital CQUINs to focus on completing the implementation of these tools and realising the benefits. Projects will need to span implementation and organisational change in GPs as well as providers. Once these capabilities have been realised, they will be developed further as organisations move to greater digital maturity. Common use of SystmOne between primary and community care: more work is required by the CCGs and Trusts to ensure that shared records are effective standard workflows, configurations and coding templates to ensure that clinicians use SystmOne consistently in different care settings. Integration between EMIS and SystmOne via NHS Digital s GP Connect programme, expected to be delivered during After much effort on the part of providers, CCGs and NHS Digital, it is believed the IT suppliers (EMIS and TPP) will deliver such interfaces during 2017 under the GP Connect component of the NHS Digital GP Systems of Choice (GPSoC) contract, supported by the NHS Code4Health Interoperability community. Initially this is expected to be via HTML screen views, eventually via structured messaging, including tasks and appointments. By the end of 2017/18 it is expected that this approach will result in access to structured primary and community patient records across the care community NWL Care Information Exchange The next priority will be capabilities for information sharing that are not addressed by existing NHS systems. NWL has a programme under way to develop a Care Information Exchange (CIE), supported by Imperial College Healthcare s charity, to support further sharing of records across care settings and with patients, particularly acute care where common systems do not extend; to support this requirement, Imperial has procured a hosted solution from Patients Know Best (PKB). In some areas information will be shared via bilateral interfaces between clinical systems in different settings; in others they will interface directly to the CIE. Currently these projects are constrained by the lack of open interfaces provided by key suppliers such as EMIS and TPP, and integration capacity in Trusts and their current IT suppliers, which will require additional investment as each interface is likely to be bespoke dependent on the system used in the Trust. A particular concern is the current inability to share care plans for integrated care except where organisations use a common system. CIE interfaces will support national standards where they exist, in anticipation of pan-london and national integration. The CIE approach will be informed by the guidance on information sharing from the National Guardian (Caldicott 3) Support for Clinical Networks NWL is part of a number of clinical networks that span multiple footprints notably those for urgent and emergency care and cancer. The London Digital Programme of NHSE s Healthy London Partnership is driving these networks with standards for clinical data exchange (document content, format and delivery mechanism) that will allow patients information to be shared between different care organisations as they follow the pathway across footprints, and back to their GP. In some cases these pathways extend outside London, and the programme will seek to extend the standards to surrounding footprints. The aim is to do this work once for London so that individual footprints do not have to design their own standards. This work is complemented by the following local work streams in NWL: NHS NW London Local Digital Roadmap Page 25

26 Cancer care and treatment planning, MDT and pathway monitoring: Royal Marsden is playing a leading role, working with NHSE and vanguard care communities to design and create a standard cancer treatment care plan, including details for pain management and urgent care; this plan will be made available through its Integrated Care Exchange (already in use to share end-of-life care plans held in CMC) and RM s own clinical and patient portals, and will bringing together information from primary care, RM, end of life and other care settings to provide a fully comprehensive patient record that is available where needed across the organisations involved in the cancer treatment pathway, whichever footprint they belong to, including Integrated Urgent Care. PKB has been chosen by Cancer Care UK to provide a national portal for patients with cancer; there will therefore be a further opportunity to support cancer networks via the NWL CIE. Critical Care: the NWL Critical Care Network (NWLCCN) is a collaboration of clinicians working in critical care in various care settings across NWL, facilitated by the NHS NWL CCG Collaboration. This mainly focuses on co-ordinating the delivery of care, ensuring quality and peer support, supporting commissioning and monitoring capacity, but it also promotes the sharing of skills and good practice through training and communication, and its scope includes innovation it has developed the Safer Transfer App (STrApp) to provide checklists in support of critical care transfers, and would benefit from IT integration in the Trusts to populate the bed state in its Critical Care Directory of Services automatically, rather than manually as at present. Trauma Care and Stroke Care: Imperial is taking a leading role in shared records for these local networks. Outside the above clinical networks, NWL will seek to support the pan-london work by developing standards for inter-acute transfers of care occurring for other reasons, for example transfers from secondary to tertiary care and vice versa, which make up a significant workload for local acute Trusts and are not currently supported digitally (see Acute Care, above). These standards may be helpful to support such transfers on a pan-london basis once developed Integration of Healthcare and Social Care Systems Fundamental to the NWL STP is closer working between health and social care. Integration of IT systems that support delivery of health and social care is required to support care decisions and transfers of care, and improve efficiency, and is one of NWL s local targets for the STP/LDR period; it will be necessary to develop new capabilities for sharing of records through the integration of healthcare and social care systems. Open interfaces on the healthcare side will help this; on the social care side, progress is constrained by the need for each council to fund interfaces, at a time when they face severe financial constraints. NHS Digital are requested to drive - and fund - social care IT suppliers Corelogic and LiquidLogic to provide common standards and open APIs. Integration will proceed through a number of steps: 1. The key to integration is a common identifier for the citizen who is receiving care (the NHS number, which is already used across all healthcare organisations in NWL). Councils are populating their records with NHS numbers through batch matching with the NHS Spine, with a variable success rate (75% to 95%). The next stage will be to implement online matching with the Spine from social care systems, which will require councils to implement links to the NHS N3 network and its Public Service Network successor (funding may be required). Councils are committed to this objective, subject to funding being available. To avoid having to fund software development by every council in England, it would be useful for NHS Digital to fund implementation of online matching by the social care IT suppliers 2. The first key workflow to be automated is referrals to social care for new or changed services. Generally, these come from acute Trusts (and the inpatient units of mental health and community Trusts) when the time comes to discharge patients back into the community, in the form of statutory Assessment, Discharge and Withdrawal notices (formerly known as Section 2 and 5 Notifications under the Care Act); most local Trusts now produce these digitally and transmit them to Social Services via secure NHSmail; the NHS Digital London Adapter provides a technical solution for this that can be implemented by social care IT suppliers, though this is chargeable to each council and is not currently funded. The next stage is to enhance social care systems to receive the notices and incorporate them into an automated workflow, but again funding is required. Social care also receives referrals from GPs, which will be automated in EMIS Web or SystmOne using templates. 3. In parallel to the work on statutory discharge notices, some of the NWL social care providers are working to design a single process for discharge planning across most of the boroughs, with more detail passed along with the referral, such as therapist reports and medication summaries; this will include a review of business processes and likely implementation of a common IT portal, with an automated interface to enable integration with health and social care systems, and into which statutory notices could be incorporated at a later date as part of an automated workflow, subject to approval and funding. In Hillingdon a local solution will achieve the same objectives. Ultimately the workflows around discharges should be completely integrated across care settings, enabling intermediate and community services to anticipate when a patient will be ready to leave hospital and swing into action, reducing the number of beds blocked by delayed discharges. NHS NW London Local Digital Roadmap Page 26

27 4. Patients are often treated at other hospitals than the local hosted Trust (18% of NWL inpatients are treated by out-of-borough NWL providers, and 17% by out-of-area providers). For example, 37% Central London CCG inpatients go to Imperial and 17% to Chelwest, but 14% go to UCLH, 7% to Guys and 3% to Royal Free. Trusts will therefore have to work with councils outside their hosting CCG, and indeed in other LDR footprints. 5. The next area for automation will be an integrated care pathway involving all care providers, with care plans (including a summary of care that has been delivered, together with goals and actions set for the patient or service user) developed and monitored at meetings of multi-disciplinary teams (MDTs) and supported by care coordinators. It may also be beneficial to share a summary of care delivered with other care settings. Integrated care plans should include medical care plans, social care support plans, and goals and actions set for the patient; mental health professionals may be involved, for example to support patients with dementia; the plans should be able to be shared electronically with care professionals, patients and carers. In Hillingdon the care community has agreed a common care plan format and is piloting electronic sharing as part of the Care Information Exchange project; in other boroughs, co-design is planned during 2016/17 to confirm the approach to integrated care, with Trusts incentivised to participate through the Digital CQUIN. 6. It would be highly desirable for NHS Digital to define common standards for the exchange of information between health and social care which could be applied across footprints for shared records and care plans as well as statutory notices. To avoid having to fund software development by every council in England, it would be useful for NHS Digital to fund implementation of these standards by the social care IT suppliers. 7. The final stage for automation is required where health and social care professionals are brought together in joint teams. To deliver care in an integrated way, they must share information using the same system; but to comply with professional and commissioner demands they must use different systems. An example is the Triborough Community Independence Service in Hammersmith & Fulham, where social care professionals must enter details to both SystmOne (health) and Framework-I (social care). Clearly this is inefficient and introduces a potential clinical risk (from erroneous input). To avoid this duplicate input, it would be desirable to have automated interfaces between the systems, using APIs that have yet to be developed. 8. The sharing of information between health and social care, and vice versa, is particularly sensitive, and the preferences of the citizen should always be taken into account. NWL has been working for some time on the Information Governance principles (confidentiality, nature of the legal relationships, consent to sharing and audit capabilities, fair processing notices) and the Information Sharing Agreements required to support this sharing. The guidance on information sharing recently given by the National Guardian (Caldicott 3) will be taken into account Interaction between Shared Care Records and Data Analytics Ultimately the objective of the NWL approach to using data and technology is to combine the analysis of patients conditions, their treatment and outcomes, with the clinical activities, workflows and plans that make up their care. Many current clinical systems, particularly in primary care, are already capable of doing this. For example: Analyse how patients respond to goals and actions that they have been set (currently buried in free text or a detailed care plan) and understand the barriers to change Identify patients at high risk of developing disease or complications once they already have a condition; measure the success of the system in keeping them healthy or away from further complications, linked to their level of activation and response to the pathway they have been set; detect any correlation between outcomes and specific interventions, whether digital or not Track someone s progress towards their target weight/hba1c/blood pressure and send them timely reminders if they re off track Identify cohorts who are off track in the management of their long term conditions, and initiate tasks to help them: communicate with them directly, set alerts for the GP or other clinicians, generate automatic referrals if needed, flag automatically if something doesn t happen as planned (e.g. patient did not attend an appointment) Identify people who have slipped through the net, i.e. were at risk but there was no intervention and have now developed symptoms; provide data-driven decision support to suggest appropriate steps, help clinicians to direct them to other services that can help them back on track End of Life Care Planning As part of integrated care, providers will need to meet their contractual requirement to use an Electronic Palliative Care Co-ordination System (EPaCCS) for end of life care planning. For NWL this is Co-ordinate My Care (CMC) provided by Royal Marsden NHS Foundation Trust. The current usage of CMC varies across NWL: from 5% of the expected end-of-life population in Hounslow to 30% in Hillingdon; effective end-of-life planning is now an STP objective, and CCGs can be expected to encourage their GPs NHS NW London Local Digital Roadmap Page 27

28 to adopt the system. The CCGs in turn will drive Trusts to implement CMC during 2016/17 by reference to the standard NHS contract (clause SC34). CCGs will take the lead in monitoring the End of Life Health and Wellbeing Indicator scores for their care communities, reporting to Health and Wellbeing Boards. CMC has recently been re-platformed on to InterSystems Health Share which offers interoperability capabilities. Interfaces have already been implemented with EMIS Web and Adastra, to generate an automatic flag in a patient s primary or urgent care record that the patient has an end of life plan in CMC, and provides a URL to access the detail of the actual record; for urgent care, this removes the need for independent Special Patient Notes to be created by local NHS 111 and OOH providers. It is also possible for Trusts to access Health Share directly; The Hillingdon Hospital has already built an interface, to flag patients who have a CMC record in their Hillingdon Care Record. Such automated links will drive much more comprehensive use of CMC across all care settings, making care professionals aware of a person s end of life preferences and increasing the proportion of people who die in their preferred location. There is as yet no commitment from TPP to build a similar link into SystmOne; until this exists, the uptake of CMC in the CWHHE CCGs will remain poor - NHS Digital are requested to mandate this as part of the GPSoC contract Integrated Urgent Care (IUC) NHS 111 and Out of Hours (OOH) services The current providers of the 111 IUC service are London Central & West Unscheduled Care Collaborative (LCW) in Central London, West London, and Hammersmith & Fulham, and Care UK in the other five boroughs. Both providers use Advanced s Adastra system to support the 111 service, which sends NHS ITK (Information Tool Kit) compliant electronic post-event messages to EMIS Web and SystmOne to inform GPs about episodes of care, driven by practices profiles in the Directory of Service. Some practices are not set up to receive ITK messages but receive messages via NHSmail. In Hillingdon, Care UK s 111 and OOH service is able to access EMIS Web GP records from within Adastra via the MIG, under a clinical protocol developed with the local CCG; in other CCGs, Care UK is looking at accessing GP records via Black Pear. Out of Hours services are commissioned not by CCGs but by GP practices; in CWHHE almost all practices use LCW, which uses SystmOne in Ealing and Hounslow and Adastra in the other three CCGs, to support this service, and is therefore able to integrate with local GPs and (subject to information governance) community providers; in THH most OOH services are delivered by Care UK using Adastra, which hosts Special Patient Notes and can receive ITK messages (e.g. appointments) from GPs; in Hillingdon, OOH clinicians have access to GP records via MIG. Brent CCG is investigating the option of using the enhanced Summary Care Record (2.1 with additional information) instead of Special Patient Notes to inform the OOH service. A new model of Integrated Urgent Care is fundamental to the channel shift envisaged in the NWL STP, interacting with the patient via remote communication and freeing up face-to-face clinician time. New commissioning standards for IUC were published in October 2014, based on an upgraded 111 service which is currently being procured: The key requirements are an automated Patient Relationship Manager (PRM) system to route, triage and manage calls, driven by the Directory of Services (DOS), and an Integrated Care Exchange to share patient information, referrals and appointments in real time to and from primary, community and mental health providers through interoperability. The PRM will fuse the patient to a telephone number and look up their clinical details, enabling the 111 service to direct them to the appropriate clinical service for their condition and removing the current need for a cumbersome full pathway assessment. The PRM provides an interface between Adastra s Special Patient Notes functionality (SPN) and Redwood Technologies Storm telephony platform which recognises the incoming CLI, looks up the patient s record and care plan in EMIS Web or SystmOne using interoperability software from Black Pear, establishes a delivery plan for that patient based on the presence and type of SPN, and then delivers the call to a care professional with the appropriate skill set within NHS 111. The result should be a shorter and more accurate patient journey, with improved clinical outcomes and reduced demand on other services. Patients will be also able to access the service via an online portal that is fully integrated with IUC systems. The IUC hub will be available to clinicians in urgent and emergency care settings (including London Ambulance Service); and linked to CMC, the NWL CIE and the Out of Hours service. It should thus be able to share records, care plans and crisis plans as the source clinical IT systems make them available for sharing (from both local NWL and other footprints via the pan-london Information Exchange). The 111 service will be enhanced via complementary digital services such as video-conferencing and access on mobile devices. NHS NWL and its providers will support the 111 service in achieving these aims and overcoming the current constraint of a lack of open interfaces from some clinical systems (e.g. SystmOne, EMIS Web and RiO) through the implementation of standards-based interfaces as they become available, including documents shared via the Clinical Document Architecture as well as transactional messages such as appointments and tasks. A key feature will be the ability for the 111 service to book NHS NW London Local Digital Roadmap Page 28

29 appointments directly into primary care systems (supported by facilitation from the CCGs to make such appointments available); and into mental health and community services via endpoints specified in the Directory of Services. There are currently no national interoperability standards specified for receiving services or components apart from the high level technical standards of NHS Digital s ITK; this hinders the development of integrated care models, as system vendors are required to develop and support multiple interfaces, which is inefficient, expensive and complex. Further work by NHS Digital and NHS England at a national and pan-london level on interoperability standards would be useful. The Directory of Services will be key to the IUC workflow and ensuring right place, first time patient referral; NWL is outsourcing this capability separately from the 111 service, so capabilities for the DOS must be defined very clearly, and include interoperability with local services and clinician access to service information. The DOS will feed information about services to the NHS My Health London portal. The new IUC service will have specific Information Governance requirements to support the sharing of patient information required, with an appropriate Information Sharing Agreement and new Fair Processing notices to be communicated to the public. In addition to the re-procured 111 service, a number of innovations are being explored in Integrated Urgent Care: The Digital Assessment Service (DAS), which is being piloted by LCW in conjunction with the London Digital Programme (Healthy London Partnership), to test the concept and functionality of on-line symptoms checkers with automatic referral functionality to GP OOH services. The system captures demographic information from the patient via a web interface ( ) that also incorporates a decision support template to assess the patient s needs. For common symptoms such as diarrhoea and vomiting (D&V) and flu/colds, an interface maps to the local GP OOH service and will make a referral that presents as a live case in Adastra; in this case there is no requirement for the patient to make a phone call to NHS 111 or their GP practice. The DAS provides the platform to expand the use of web based symptoms and smartphone apps, which could be multi-lingual and therefore provide access for a much wider range of patients. Electronic prescribing: urgent care services do a considerable amount of prescribing, which is predominantly delivered on FP10 forms (printed and handwritten). The ability to use EPS2 in urgent care would significantly improve efficiency and governance, but is currently not available in any of the systems used by local providers. SystmOne has the required functionality in the GP unit, but there is no current plan to make the functionality available to their Minor Injury, OOH and 111 modules. Adastra s use of EPS2 is governed by NHS Digital, but currently no timescales have been advised for making such functionality available. A potential workaround to support pharmacists within the 111 service could be to set them up as a GP unit within SystmOne (for LCW at least), transfer the message from NHS 111 using ITK to SystmOne, and then utilise EPS2. TPP are reluctant to support this solution for commercial reasons, but should be encouraged to do so, to make full use of EPS2 as per NHSE s target Universal Capabilities. NHS Digital are requested to drive the GPSoC IT suppliers to deliver the required interoperability; the 42m Pharmacy Integration Fund (PhIF) announced by NHSE on 20 October 2016, has the objective of improving integration with the 111 service and developing new clinical pharmacy services, working practices and digital platforms to meet the public s expectations for a modern NHS community pharmacy service. Telehealth capabilities: one difficulty with implementing telehealth services for the remote monitoring of patients with long term conditions is the cost of establishing clinical teams to perform triage in the event of alerts. The 111 service already employs suitably qualified clinicians on a 24x7 basis; and Adastra has the capability through interoperability to receive referrals directly into 111 from a telehealth device, in the event that a measurement exceeds a specified threshold or the patient misses a scheduled monitoring time. The interface populates Adastra with demographic information and details of the results, as a live case that is visible to a clinician to triage and manage. Using the PRM and concept of a Clinical Hub, 111 could then transfer the referral on to a specialist team or directly to an integral NHS 111 component. Such a model could help respond to acute exacerbations and reduce the prevalence of 999 calls and emergency admissions. This option should be evaluated by CCGs as they consider the implementation of telehealth services as part of new models of care Urgent Care Centres and Walk-in Centres in NWL There are several Urgent Care Centres and Walk-in Centres in NWL, operated by a number of providers: BHH: Greenbrook Healthcare operates the UCCs in Hillingdon and Northwick Park Hospitals, in partnership with LNWHT; it uses Adastra which links to local GPs via ITK capabilities to share special patient notes and post-event messages. This version of Adastra incorporates an interface to the Summary Care Record (though it has not yet been activated) and MIG for GP records (Hillingdon only: 1,150 accesses in last 6 months); a link to the Child Protection-Information Service (CP-IS) is NHS NW London Local Digital Roadmap Page 29

30 being tested and is expected to be implemented in the next upgrade (November 2016, TBC); a link to CMC is under development but no timescale is yet available from the supplier (Advanced) for implementation. These UCCs do not currently link to the Diagnostic Cloud - diagnostics tests are requested manually; the local CCGs should encourage Greenbrook to implement ICE. A link to the Hillingdon A&E system is about to go live. With respect to the new Integrated Urgent Care model, the 111 procurement team needs to engage with Greenbrook. BHH: in Brent, the Harness GP federation runs the Wembley WIC, running EMIS so able to integrate with local Brent GPs; the Brent UCC at Central Middlesex Hospital is run by Care UK, using an older version of Adastra which sends post-event messages to local GPs via NHSmail, DTS or fax; an upgrade is planned during 2016/17 to the next release of Adastra which will support ITK-compliant messaging, remote appointment booking and access to GP records via GP Connect. BHH: in Harrow, Harrow Health Ltd runs the Walk-in Centre in Pinner, and the Alexandra Medical Centre operates a Walk-in Centre, both running EMIS so able to integrate with local Harrow GPs. BHH: in addition to the UCC at THH, there is a Minor Injuries Unit at Mount Vernon Hospital, operated by THH and able to access GP records via HCR. CWHHE: CLCH and LCW run UCCs at Charing Cross and Hammersmith Hospitals (hosted by Imperial) which use Adastra with access to SCR and linkage to GPs via ITK, and Walk-in Centres at St Charles Hospital, Soho Square and Parsons Green, which use SystmOne so can integrate with local GPs. CWHHE: Vocare Ltd has recently been awarded the contract to operate the UCC at St Mary s Hospital and are expected to implement SystmOne. CWHHE: LCW runs the UCC at Chelsea and Westminster Hospital, in partnership with the local Trust; Adastra is used as the patient management system, that incorporates SCR and also has a direct interface with the wider GP OOH service which also uses Adastra CWHHE: Greenbrook Healthcare operates the UCC in Ealing Hospital, in partnership with LNWHT and LCW, having recently taken over from Care UK; it uses SystmOne so has access to local GP records, SCR and the NWL Diagnostic Cloud. Links to CP-IS and CMC are being planned but no timescale is yet available from the supplier. Links to local A&E are manual. CWHHE: Greenbrook Healthcare operates the UCC at West Middlesex Hospital, in conjunction with Hounslow & Richmond Community Healthcare (HRCH), running SystmOne so able to integrate with almost all Hounslow GP practices and (in theory) to the Diagnostic Cloud. Links to CP-IS and CMC are being planned but no timescale is yet available from the supplier. A link to the local A&E s Symphony system is being investigated NWL Diagnostic Cloud NWL has made a considerable investment in recent years in a Diagnostic Cloud, spanning first Pathology and then Radiology providers, and all CCGs. All GP practices are able to transmit diagnostic orders and receive results electronically, using the Sunquest ICE system integrated with SystmOne and EMIS Web. GPs can view results of tests they have requested and using ICE OpenNet, can see tests done by acute providers that are members of the Cloud. Utilisation by GP practices for pathology requesting across most CCGs is very high; the system is already delivering significant clinical benefits by reducing unnecessary tests and saving GP time following up results. Projects are under way, supported by 2016/17 Digital CQUINs, as part of NWL s strategy to exploit the Diagnostic Cloud further: Support those GP practices that do not yet fully use the Diagnostic Cloud to change their processes and protocols accordingly Expand Radiology deployment to all GP requested Radiology tests in all Trusts (already completed in Hillingdon) Complete GP deployment by switching off paper ordering and duplicate paper reporting as the normal mode of operation (already completed in Hillingdon) Extend electronic order communication and reporting to Acute areas where not already implemented (e.g. Outpatients in some Trusts) Refine the formulary and rules for pathology ordering Extend Diagnostic Cloud to remaining community and mental health providers that do not already use it. All the NHS providers that deliver diagnostic services in NWL are participants in the Diagnostic Cloud, including The Doctors Laboratory (TDL) which conducts tests on behalf of LWHT at Northwick Park. However, the following organisations are not currently included, and unless further action is taken will be omitted from shared care records: NHS NW London Local Digital Roadmap Page 30

31 InHealth Ltd provides a proportion of the radiology diagnostics in the CWHHE CCGs. When these services were commissioned, there was no provision for tests to be requested or reported digitally and therefore they remain on paper; adding InHealth tests to the Diagnostic Cloud will require the contract to be renegotiated and there will undoubtedly be a cost. This is currently being discussed between CCGs and provider. Healthshare Ltd provides Musculo-Skeletal (MSK) services in Central and West London, and it would be useful to give its clinicians access to the Diagnostic Cloud to view radiology reports. The CCGs intend to discuss this capability with the provider. Digital retinopathy screening tests conducted by Health Intelligence Ltd in NWL since NWL has a high number of patients with diabetes and the volume of tests is considerable. It would be highly desirable to have a digital feed of results, suitably coded for inclusion in the GP record; currently GPs have to download the data from a portal and code it manually. It may be adequate to supply reports in the form of electronic documents, in the same way as discharge letters and other acute correspondence, to be transmitted to practices (potentially via MESH) and uploaded into GP systems (i.e. not via ICE). Discussions are in progress with the provider. Royal Brompton is technically ready to join the Diagnostic Cloud, but a business case for the required software licences has not yet been approved. Routine monthly blood testing at point-of-care for patients of mental health Trusts who are prescribed clozapine for schizophrenia or psychosis (a significant proportion). These are processed under a national contract by Magna Laboratories, and reported on by ZTAS (which maintains the national data base). Discussions with the supplier have taken place; Magna advises that unfortunately, under the terms of the national contract, these results are not available to other clinicians, for Information Governance reasons so until there is a change in the national arrangements, these results will not be included in the shared record, with the possibility that duplication of tests will take place. As part of the Seven Day Working Initiative highlighted in the STP, NWL is looking to further exploit the investment in the Diagnostic Cloud to improve quality of care: Review of the possibility of a pan-nwl or pan-london image exchange for radiology, to enable radiologists to support other Trusts out of hours Improving the decision support capabilities of the diagnostic ordering function for radiology, to ensure that the tests that are requested are appropriate for the patient and reduce unnecessary requests. Hillingdon and Hounslow CCGs have expressed interest in piloting this capability; discussions with a Clinical Decision Support software provider and Sunquest are in progress. The organisational background to the pathology component of the Diagnostic Cloud is due to change. The NHS pathology providers of NW London (i.e. all the Trusts, but not TDL) are coming together in partnership to develop a new model for delivering pathology services, to deliver a modern, innovative and sustainable service of high quality, delivering better value for money and implementing the recommendation of Lord Carter s 2015 report to reduce unwarranted variation in productivity and efficiency. The service will be provided through an arms-length organisation, North West London Pathology, owned by the partner Trusts. NWLP will be expected to continue to operate the Diagnostic Cloud and take advantage of its capabilities to further improve the quality and efficiency of pathology services Issues around Shared Care Records There is a potential overlap between different national, pan-london and local systems for the sharing of records. For example, should a care plan for a patient with long-term conditions be documented in Co-ordinate My Care (CMC), in the NWL Care Information Exchange (CIE), in a GP system, or even in the extended Summary Care Record 2.1? For now, our answer is that each system has its own purpose, and the most appropriate system should be used for the purpose; so, for example, end-of-life plans should be held in CMC, but shared integrated care plans should be created in GP systems and shared vie the CIE when feasible. Over time we expect these common systems to converge, so that data such as a care plan will exist once in the appropriate system - but potentially be shared via a number of channels, with clinicians using the most appropriate channel. Shared care records are also essential for cross-community safeguarding, for example the Child Protection Information System (CP-IS) currently being implemented across care settings, starting with local authorities and being extended to unscheduled healthcare settings such as A&E/ED departments and Urgent Care Centres. There is at present no national register or standards for sharing information about the safeguarding of vulnerable adults; this activity remains the responsibility of local authorities, and communication with health organisations is typically informal and paper-based, but digital tools are expected to emerge in due course. This will of course require national leadership and co-ordination by NHS Digital. NHS NW London Local Digital Roadmap Page 31

32 A key principle of information governance around record sharing is that the citizen s preferences should be taken into account, and people should not have to express their preferences multiple times because their records are held in different systems operated by different organisations. The first issue is that many clinical IT systems, particularly in acute care, do not incorporate the concept of consent to sharing; they were developed at a time when records did not need to be shared with other organisations, so the question of consent did not arise. The second is that even where systems do record consent (e.g. GP systems EMIS and SystmOne, using Read codes; social care systems) they do not currently have the capability to share this information with other organisations systems. Until interfaces are available to do this, people will have to express their consent preferences multiple times, or organisations will have to share the information manually, neither of which is satisfactory. NHSE Healthy London Partnership s London Digital Programme has recognised this, and will build consent into its planned pan-london citizen identity system. Pressure will need to be placed on clinical IT suppliers, particularly EMIS, TPP and Cerner, to add consent information to the APIs they are developing. NWL agrees that there is a need, and supports the programme. 2.3 Extend patient records to patients and carers Citizens are increasingly ready to make greater use of digital technology to take more control of their own health and wellbeing. The evidence (documented by NHSE in Personalisation and Self-Care: Case for Change, April 2016) suggests that people who manage their own health, wellbeing and care place less demand on high-intensity acute services (potentially 20% to 30% lower emergency admissions and secondary care costs, for patients with above average risk), and have a better experience of care (90% in a recent study saying they felt more in control and 50% saying they had seen an improvement in their wellbeing). There are likely to be particular benefits for patients with long-term conditions, who make up 70% of demand on the NHS, where they are confident in the use of digital technology. However, 40% of people have low levels of knowledge, skills and confidence to manage their health and wellbeing; and 44% say they would like to be more involved in making decisions about their care. Technology can support the health and care system to help people make better informed choices and to be more active in managing their own health, wellbeing and care; but must be supplemented by communication and education to help explain why and how they can do this. NWL supports the following objectives by 2020, as set out by NHSE: Patients are routinely and systematically involved as active partners with clinicians in clarifying acceptable care, treatment or support options and choosing a preferred course of action, supported by personal healthcare budgets which help them with decision-making. Patients and clinicians are supported by decision aids to help people think through the pros and cons of different care, treatment or support options. Meaningful care planning takes place for people with long-term conditions or ongoing care needs which guides the choices and actions of the patient and her/his professional team. This care plan is digital and can be shared between care settings and is owned by, and useful for, patients, their families or carers. People living with long-term health conditions or care needs are offered support to improve their confidence and their capacity to manage their own health and wellbeing, including: self-management education to give people the required knowledge, skills and confidence; peer support; health coaching; and group based activities that encourage healthier living and reduce social isolation. Social action beyond the NHS: working with local authorities to support the local population in building community capacity and resilience; social prescribing (helping people find the right care for their needs); strong partnerships between the NHS and voluntary groups to deliver health prevention and support for patients, carers and their families; and asset based approaches (community- based activities aiming to strengthen local skills, knowledge and resilience). NWL is committed to this strategy, but implementation is at an early stage. The first stages will be to complete the implementation of Patient Online, the national capability to share with patients the records held by GPs and care providers; and as a high priority, to develop the ability to record care plans digitally and share them with care professionals across integrated pathways, as well as with patients and their carers, which is one of the main objectives of the NWL Care Information Exchange. NWL has applied for licences for Patient Activation Measure (PAM) software to track people s level of engagement with their care; as set out above, there is strong evidence that those who are more highly active in managing their care will make less demand on the care system, and experience better outcomes. Some exciting new digital tools to communicate with people and support them in remaining well or managing their conditions are being trialled often tailored to specific long-term conditions or to address the holistic needs of people receiving integrated care though such trials remain at an early stage and it is not possible to confirm which tools will emerge and be adopted widely. NHS NW London Local Digital Roadmap Page 32

33 Over the longer term, the new models of care to be implemented will need to take advantage of these technologies and add the required services, content (tailored advice and guidance) organisation structures, people (e.g. coaches) and other resources to make them effective. These developments will respond to the STP targets: ensuring that patients get appropriate access to their record, enabling them to take an active role in their own health and providing them with tools for self-management, thus delivering digital empowerment and supporting the shift away from traditional care to new channels. Citizens are understandably cautious about the idea of sharing information (though many of them assume that clinicians already have access to their records for direct care, which is often not the case) and will require reassurance about the controls and safeguards around keeping their information confidential. NWL assumes that any concerted programme to get people more involved in their own care will need to be accompanied by a programme to explain how they can do so, what benefits they should expect, how it will work and security issues. The issues around consent are discussed under the Shared Care Record, above. There is also the issue of confusion between the multiple patient portals that may be available to access different parts of the record see below Sharing GP records with patients and carers: As part of the NHSE Patient Online programme, the GP contract obliges practices to make online access to GP systems available to patients: appointment booking and ordering of repeat prescriptions, and from the start of 2016/17, access to coded information on medication, allergies, illnesses, immunisations and test results - and ultimately the full GP record. In NWL all practices have enabled EMIS Patient Access or TPP s SystmOnline, though the take-up of online services from the public (in terms of percentage of patients who are registered) is variable. Currently the Patient Online interfaces do not permit the sharing of care plans; but we expect the GP system portals to develop rapidly, to provide more information to patients (e.g. care plans to support integrated care, interaction with secondary care through links to provider systems and/or links to local footprint Information Exchanges such as the NWL CIE) and additional services such as links to personal health data bases and third party apps. Many NW London GPs have concerns about the initial increase in workload involved in giving access to the detailed record. Those GPs that have already offered broad access to the detailed record have expressed concern about the increase in demand for consultations requested by patients to discuss issues arising from their records. GPs have also found that before sharing the full record, they need to go through it in detail to verify data quality and ensure there are no references to third parties that it would be inappropriate to disclose this process is time consuming. No research has yet been done on quantifying this additional work or the benefits that may be realised in patient outcomes; such research would help persuade GPs that increasing access to the detailed record is worthwhile. In the meantime, the NW London CCGs will support GPs in giving access to detailed records to patients who request it; and will encourage them to promote access to patients who would benefit the most (e.g. wish to actively manage their LTC and are digitally aware). There is as yet no national target for adoption of the detailed record, and no formal targets for access to the detailed GP record have currently been set by the CCGs. Sharing information with patients and carers is highly desirable, and there is no doubt that in the longer term it should increase patient engagement and ultimately reduce costs NHSE estimates a saving of 584m per annum by However, a recent report from the Health Informatics Unit of the Royal College of Physicians (Personal health record (PHR) landscape review, May 2016) concluded that the functionality currently available is limited, adoption has been restricted to small groups of patients, and there is little evidence of quantifiable benefits. NWL is committed to proceeding with the Patient Online agenda and contributing to the evidence base, but it is difficult to say which costs will be released or when NWL Care Information Exchange (CIE) NWL has been working towards integrated care models as a Pioneer for several years, and the difficulty of delivering integrated care without integrated patient records is well understood. At the heart of the NWL conception of integrated care is the concept of a care plan, which can be shared across care providers and with patients (and their carers) themselves. A care plan summarises the person s care to date (and therefore must be updated in real time, to reflect the most recent interactions with the care system) and sets out goals and actions which will help them stay well. Local STP objectives for integrated care therefore require more extensive patient portals than are currently available from GP systems, to enable patients to interact at a more detailed level with care professionals across a range of care settings (not just primary care), exchanging messages with them and not only viewing their records, but commenting and adding to them, e.g. responding to goals set in care plans with actions they have taken or vital sign measurements they have taken. The NWL strategy is NHS NW London Local Digital Roadmap Page 33

34 therefore centred on a Care Information Exchange (CIE) which will eventually be populated with data from all care settings primary, community, mental health, social care and the third sector and will contain the narrative of care plans as well as coded data. As well as records for specific patients, the CIE will provide tailored guidance (either embedded or as links to third party web sites) around local care options and services, developed by the CCGs and providers. The project is supported by the Imperial Healthcare Charity, which has funded the implementation project, and software licences and hosting from the selected supplier (Patients Know Best). Integrating clinical systems with the CIE is well under way, with most of the NWL acute Trusts already able to share information with the CIE to some degree (Imperial, Chelwest, Hillingdon), or currently developing links to it (LNWHT, and RBHT - which intends to pilot CIE with cardiothoracic transplant patients in late 2016). The CIE is currently constrained in other care settings by the lack of open interfaces with EMIS Web, SystmOne or RiO; for EMIS and SystmOne these are expected to be delivered in part during 2017, with more functionality added in 2017/18, and for RiO additional funding is required to develop the required interfaces, either by payments to individual Trusts or through open interfaces commissioned and funded at a national level by NHSE/NHS Digital. Interfaces to the systems of other care settings, including Integrated Urgent Care, social care and the third sector, are also being considered (again generally this will be subject to funding). Several patient applications are intended to be piloted with the CIE, though none of these early adopters has yet gone live. One such project, with both mental health Trusts, CNWL and WLMHT, is a portal to support the Early Intervention in Psychosis (EIP), which enables people to provide Patient Recorded Outcome Measures (PROMs) using the DIALOG protocol. Over time, this will be expanded to share people s records such as care plans with them, though a number of enabling steps are required within the Trusts (e.g. moving from unstructured progress notes to coded records) before this can be achieved. Another pilot, in the Hillingdon care community, is to share integrated care plans using CIE across all care settings (including healthcare providers, social care, and Hillingdon4All, a consortium of third sector providers), and with patients and carers who will be able to contribute their own input on the goals and actions set out in the care plans; currently the interfaces to populate the CIE with care plans in EMIS Web and social care support plans in Hillingdon Council s Protocol systems are both manual, but over time it is expected that automated interfaces will be developed (subject to funding) to support integrated care at scale. The ultimate objectives of the CIE are to: Enable people (service users and carers as required) to work more closely with their care professionals through shared information and better communication, enabling them to move towards joint decisions about their care. Give them the confidence and capacity to manage their own health and wellbeing through digital care plans and self-management support Help them understand and navigate through with the help of care navigators and care professionals - the options available from their local providers, and find the right care for their needs (social prescribing), whether healthcare, social care, or access to local non-medical support and self-help networks. Initially these capabilities will be targeted at the groups of patients that make the greatest demands on the health and care system (hence the selection for the pilots of high risk groups, such as elderly people with one or more Long Term Conditions) but ultimately it is intended that all people in NWL should be able to benefit from the capabilities of the CIE if they should so choose. The Information Governance arrangements for the CIE have been under development for some time, and the required NWL Whole Systems Integrated Care Information Sharing Agreement went live in June Patients using assistive technology for Personalisation and Self-Care Healthcare technology is evolving very rapidly; and many systems, applications and websites are emerging that may help people manage their health better, and/or stay well for longer. Digital health offers significant potential to deliver on the STP priorities, including remote monitoring, point of care and self-testing and mobile applications. Objectives that patients, especially those with Long Term Conditions, might have for technology to assist them with their care include: Be directed quickly and easily to appropriate educational (e-learning) and motivational information to help them manage their own care, driven by information in clinical systems about their specific condition they have and where they are in their care pathway; materials such as videos of local clinicians, patients and champions as well as national resources; access to peer groups such as supportive online communities Receive information at their appointment and between appointments that will help them keep on target with managing their LTC, personalised to their own cases but also taking into account demographic, ethnographic and lifestyle factors that will affect their response (including their Patient Activation measure score) NHS NW London Local Digital Roadmap Page 34

35 Upload personal measurements of vital signs (weight, blood pressure, HbA1c, oximeter measurements, insulin pump data, etc.) and receive feedback from clinicians; receive alerts if they are veering off course; though the body of research on such telehealth applications, for example from the Department of Health s Whole Systems Demonstrator, has not shown any evidence that telehealth is a cost effective addition to standard support and treatment (e.g. BMJ, 22 May 2013 et al.) and mass adoption of wearable technology may have to wait until there is a step change in the affordability of the technology, or breakthroughs in how it is used Access to support services when they have difficulties in changing their lifestyle or behaviour to respond to clinical recommendations, or lose motivation (e.g. telephone coaching, voluntary groups, online communities) Support services (e.g. care navigators) to track where they are in the pathway, and be alerted if they re not making progress Rewards and messages of reinforcement for making progress against goals and actions, driven by activity and clinical measurements, to help with motivation; encouragement from clinicians or peer groups if required. NWL s current approach is to consider and pilot suitable technologies, initially with small groups of patients, with a view to learning what may work at larger scale and what does not; and to keep an eye on similar trials in other footprints. It will work closely with Imperial College Health Partners and digitalhealth.london, with its network of technology partners, to identify a set of digital tools that can support the STP objectives across the NWL footprint, and to encourage clinical system suppliers to open up interfaces to link the patient s existing record to such apps. NHS Digital intends to provide leadership in this area but its programme to assess and recommend health apps and wearables is still in the incubation stage (NHS Digital Board meeting minutes, September 2016). A directory of recommended apps and services could be integrated with CCG and provider websites, national resources such as NHS fschoices and portals such as Patient Online, local portals such as the CIE and EUC, and would help citizens and clinicians negotiate the confusing morass of digital resources intended to support them. Entry points to such a directory could be the online and wi-fi touch-down portals of NHS organisations such as Trusts, GP practices and CCGs. With this in mind, the NWL CCGs have recently asked for a Business Case to be developed for a broad Assistive Technology programme across the care community, which will consider applications such as the following: Healthy citizens: preventative care through provision of online self-help health information and integration of self-care devices (e.g. Fitbits, Apple Health) with population analytics for individual predictive modelling; predictive analytics to identify citizen cohorts at future risk and advise accordingly. Patients with long-term conditions: online access to care plans, including integration of an individual s data with their existing care records (e.g. Vitrucare, currently being deployed to cohorts of patients with Diabetes in H&F CCG; and the Care Information Exchange pilot in Hillingdon care community, spanning social care and the third sector as well as healthcare providers); eventually using the Internet of Things telehealth connectivity (e.g. blood pressure devices, weighing scales in the home) to improve care; also access to social media for peer-to-peer support and health coaching. Elderly patients and those with life-limiting conditions: in addition to the above, access to social media for peer-to-peer and clinical support to reduce social isolation; access to end-of-life care tools for planning and recording preferences. An example of how transformation can be achieved through innovation and application of best practice in assistive care is our work being led by Imperial College Health Partners with primary and acute care services, industry and patients across NW London to improve the early diagnosis and treatment of patients with Atrial Fibrillation (AF), with a view to preventing hundreds of strokes. A series of pop-up workshops are exposing all these stakeholders to the latest innovations in diagnosis and treatment, including AliveCor, a digital device which uses smartphones to detect AF in patients (part of the NHS Innovation Accelerator). The device is now being rolled out across GP practices in Hounslow. ICHP is also running a series of targeted AF education sessions for GPs, introducing them to the latest innovations in diagnosis and drug treatments Issues around Sharing Records with Patients and Carers A key issue for patient access arises from the potential overlap between the different portals; it is not desirable that citizens should have to sign it to a number of different systems and have to remember different user IDs and passwords, but to start with, this will be inevitable since the portals are not yet linked. Over time we expect these portals to converge, so that patients will need to use only a single portal, or (if they have specific needs) to access the most appropriate one for their purpose which enables them to pass through to the data held in other portals. Secondly, there is the possibility that their care may be delivered across different footprints, and their records may be NHS NW London Local Digital Roadmap Page 35

36 held in multiple portals; again we would expect that over time the portals will become linked. A third issue is to do with patients preferences about who should be allowed to look at their records; currently with multiple portals it will be necessary to express consent preferences to multiple organisations, which clearly is potentially confusing and onerous. The London Digital Programme s planned supporting mechanisms (citizen identity and consent management, patient locator service, inter-footprint exchange) are required to address these issues. Another issue is the Accessible Information Standard, which NHS providers are obliged to implement under Service Condition 12 of the standard NHS contract. This directs and defines a specific, consistent approach to identifying, recording, flagging, sharing and meeting the information and communication support needs of patients, service users, carers and parents, where those needs relate to a disability, impairment or sensory loss. NWL s STP and LDR will take on board the guiding principle from Martha Lane Fox s review, Accelerating Digital for the NHS (June 2016): to use digital technology to reach the furthest first. From 2017/18 Trusts will be required to report back on their plans in this area under their contractual information schedules New channels for citizens to engage with Care Providers Under the Primary Care Transformation programme, new ways of interacting with patients, such as videoconferencing and e-consultations, will be trialled and implemented; this will be particularly useful for regular consultations currently requiring GPs to travel, for example to patients who are homebound or live in care homes. Video, and web consultations give the opportunity to move to a virtual GP model which will not be suitable for all clinician-patient interaction, but is likely to yield some efficiency savings. However, initial experience by NWL GPs suggests that sometimes it can actually increase work, as it makes it easier for the worried well to take up clinician time; so it needs to be implemented cautiously and targeted at those patients who will benefit the most. 2.4 Dynamic Data Analytics NWL is a Pioneer of Whole Systems Integrated Care, and is developing new models of care to keep people healthy and out of hospital for as long as possible. Analytical tools have been developed at both a population and personalised level to inform the development and delivery of these new models, and linking back to the STP, to inform care decisions and support integrated health and social care through whole systems intelligence. The analytical tools consist of an Integrated Care data warehouse which is used to extract standard and custom reports, and a series of dashboards that are tailored to support care delivery and to support Multi-Disciplinary Team (MDT) working across care professionals for patients, in particular those with long term conditions and complex needs. Much work has already been done to develop a suitable information governance framework, and to overcome the limitations of source clinical systems to provide the required data. The vision for NWL data analytics is to meet the following requirements: Timely sourcing of high quality Business Intelligence (BI) applications and analytics, supporting the CCGs ability to consult upon, plan, communicate, contract for, monitor and evaluate the impact of its key commissioning decisions, year-on-year. Easy and timely availability of a comprehensive suite of relevant (health and well-being) commissioning decision-support data-sets and associated analytical tools; Development and delivery of applications which support integrated care, new models of care, some elements of direct care and movement towards accountable care partnerships (ACPs), with the capability for per-patient costing based on outcomes and benefits, as well as population level reporting. Provide timely and responsive support for BI applications, and on-going training and development of relevant users from the CCGs or local GP practices. Non-disruptive maintenance and replacement of BI applications, so that the applications available to the CCGs are comprehensive and at, or close to, leading edge. Delivering on this vision will ensure that throughout the commissioning cycle, the CCGs are: at all times supported by high quality BI and associated analytic capacity, enabling them to consult upon, plan, communicate, contract for, monitor and evaluate the impact of the commissioning decisions they take; and accurately and timeously informed about clinical activity and contractual and financial performance of themselves, their GP Practices and their clinical providers. The current Business Intelligence tools available to external users (there are in addition internal NWL performance measurement and contract monitoring tools) are as follows: WHYSE BI solution - a SharePoint portal that hosts the reports based on the data that is available in WHYSE data warehouse. NHS NW London Local Digital Roadmap Page 36

37 SUS Reports - has BI/Management reports on secondary care SUS data. GPRS dashboard which provides access to a range of aggregated reports to support commissioning, at both CCG and practice population level. Urgent Care Clinical Dashboard (UCCD) provides clinicians with integrated, up-to-date information regarding urgent care activity for their patients. 111 Dashboard provides clinicians with up-to-date information regarding NHS 111 activity via a single reporting interface with the Patient Relationship Manager. GP Reporting Portal the GP Portal hold report for yearly activity, benchmarking reports and Finance & Activity Budget reports at practice level BIRT2 Portal this predictive model uses three years of secondary activity data for risk stratification purposes, calibrated to reflect local patient historic utilisation patterns and health needs. This is designed to help GPs understand which of their patients are most likely to need some form of hospital care in the future. Risk stratification is also provided by reporting tools built into the GP systems EMIS Web and SystmOne; and by some local tools to support specific initiatives, such as MSDi in Hillingdon, being trialled for granular analysis of multi-morbidity which the NWL tools do not address Out of hospital (OOH) Portal accessed by CCGs and Federation to manage performance and validate for the out of hospital services. The main focus for future development is the Data Warehouse and associated dashboards. The data warehouse already holds two years of acute (SUS/SLAM), community and mental health (local CDS) data. For primary care data, there have been challenges extracting data in line with the GP data specification directly from GP clinical systems; NWL has therefore appointed Apollo Medical to prepare bespoke extracts from EMIS and SystmOne GP practice data. The data extracted is for all adults, or just for people over 65, dependent on the local integrated care models deployed in each CCG. A successful proof of concept has been completed with 8 GP practices in NWL, and data extraction will be set up with all GP practices who have signed the requisite Information Sharing Agreements by the end of 2016 calendar year (currently 260 out of 389 practices). Incremental extractions will take place on a weekly basis. Currently primary care systems do not have the capability to provide real-time information, which limits the capability of the Data Warehouse and dashboards to inform direct care, but real-time feeds will be implemented when practicable (i.e. when the clinical systems have implemented open interfaces). An example of how data analytics are starting to influence care is the dashboards being designed to improve care for patients with LTCs in Hammersmith & Fulham through a population health approach: tracking actual/estimated prevalence; improving achievement of key targets in diabetes, hypertension, COPD, AF; holistic assessment and lifestyle intervention; proactive case management; enabling virtual MDTs involving specialists (including mental health); and sharing the results with professionals across the care community (mentors, champions, care navigators). Some of the dashboard screens are illustrated below: NHS NW London Local Digital Roadmap Page 37

38 A key part of the vision for data analytics is that the dashboards should include social care data as well as healthcare data. To date, adult social care data has been loaded from the London Borough of Brent and the Tri-Borough (Hammersmith & Fulham, City of Westminster and the Royal Borough of Kensington & Chelsea), and feeds the dashboards for these localities. Further work is required to establish regular automated data feeds from all the other NWL local authorities. Current and planned work to exploit this data resource during 2016/17 is as follows: NWL has been invited by the Department of Health to work with the National Clinical Lead for Diabetes and NHS Digital on per-patient analysis and reporting, with the aim of using the integrated care data set to improve the care pathways for this long term condition. Add PAM (Patient Activation Measure) scores to the dashboards and be able to report correlation between scores and outcomes. Develop an asthma-specific watch list, and other treatment-specific dashboards to be defined. Complete cost analysis of mental health and community data sets. Develop Accountable Care Partnership dashboards. Add data feeds from further secondary care providers as well as remaining social care providers. Pilot access to the dashboards for social care professionals. Extend Information Sharing Agreement to out of area providers NWL CCGs have funded project costs for delivery of the WSIC dashboards in 2016/17. As the requirement for new dashboards and data sets emerges there will be a requirement for additional funding to continue to evolve and extend the use of the dashboards to be relevant to different care settings, treatments and uses; and the platform is due to be re-procured. Planning for re-procurement of the analytical tools will start during 2016/17. The following objectives have been set for 2017/18: Establish direct secondary care provider feeds (to replace current SUS data feeds) Prepare initial capitated budgets using WSIC data warehouse Extend access to integrated care dashboards to out of area providers ISAs signed by third sector provider partners Extend data sets to include third sector Provide access to third sector provider partners. As longer term objectives, NWL will seek to incorporate national comparative data sets alongside the existing local data sets; and will plan to develop a capability for personalised analytics which can be shared with patients (integrated with information about their care from the Care Information Exchange), providing information to citizens about the level and cost of the care they have been receiving, and setting this in the context of the rest of the local and national population. There is some evidence that making people aware of care costs (especially when combined with personal care budgets) can have an impact on their usage of the system, support the desired channel shift and so reduce the overall level of demand. Ultimately the ambition is for analytical tools to be integrated in the care of individual patients: Understand the cost for an individual patient across the whole care pathway Ability to identify cohorts who are off track for good control, or are at high risk, or have slipped through the net (i.e. high risk but poor outcomes) where in the system are they? What is their geographical distribution? What public health measures do I need to put in place to address wider determinants of health? What-if simulations: if I change average population blood pressure by 5mmHg, what does this translate into in terms of healthcare costs and outcomes? 2.5 Information and Communication Technology (ICT) Infrastructure Digital transformation must be underpinned by a robust ICT infrastructure which will require ongoing investment. In particular, New Models of Care impose new requirements, such as mobile data and wireless networking, overcoming the capacity limitations of the NHS N3 network used in primary care, and extending the reach of clinical systems to new locations such as care homes. Advanced technologies such as unified communications (videoconferencing and e-consultations between clinicians and with patients; integration of calls with clinical ICT systems to apply Customer Relationship Management tools) will be implemented as part of the Primary Care Transformation programme. NHS NW London Local Digital Roadmap Page 38

39 Half of the local NWL Trusts assessed their maturity in this area as 53% or lower. The clinical systems programme set out in the LDR must therefore be accompanied by a parallel investment programme in IT infrastructure which needs to cover: End-user and central hardware and software, i.e. PCs and printers, servers and storage, including regular refresh of technology Network connectivity, including wi-fi provision as well as wired bandwidth to end-user sites and between sites Data centre hosting and resilience Disaster recovery and business continuity capabilities, including regular audits and testing Cyber security, including regular audits and testing Operational management and infrastructure support. Of particular importance to support the move to new models of care is the Mobile Working strategy of each organisation: Which users require mobile capabilities and why Which devices they will use (laptops, tablets, smartphones) and which operating systems they support (Windows, ios, Android) Network connectivity, including wi-fi, mobile data and how to connect when in the office Cyber security is of even greater concern for mobile working, with the need to disable a device if lost via Mobile Device Management (MDM) End user support while mobile, including replacement of lost or damaged mobile devices. Providers are each responsible for ensuring that their own infrastructures meet these requirements. For the NWL Collaboration of CCGs, the vision is that throughout the primary care estate and shared sites, the ICT infrastructure will enable all Healthcare providers to have access to information systems from anywhere at any time: Currently, multi-tenanted sites have each organisation bringing in their own network links, installing their own data, and often telephony systems, and then have to provide the recurring resources to manage these. There are also critical time-frames for these providers to source and install their own networks, leading to an inability to quickly deploy clinical services to new sites; ICT then becomes the critical path for clinical service provision, which should not be the case. Each time, directly or indirectly, these duplicated one-off and recurring costs are picked up by the NHS. These diverse infrastructures and telephony systems can also have a negative impact on the patients' experience. The planned approach is to agree that for each site there will be one organisation in charge of the ICT infrastructure; and to work with partners in the NWL care community to develop a model design for these sites. An understanding of the information systems that each organisation uses, their data flows and interoperability is key to the successful use of information to deliver excellent patient care. The key to enable staff from different organisations to have access to these systems, is having a flexible and resilient infrastructure. It is expected that the simplest approach to meet user requirements will be via secure Wireless (Wi-Fi) that gives care professionals access to the Internet and N3 (PSN) networks, and therefore a route to whichever clinical or business system they need. Such Wi-Fi networks can also facilitate guest access that can be opened up for controlled patient and non-nhs access thus creating a channel for communication to patients and visitors through the log-in portal, with identity management so they can, for example, log into their Patient Online record or receive personalised health advice. Mobile technology such as 4G will also be considered, especially for professionals who need access remotely. Providers will need to either use the ICT equipment provided at the site, or bring their own laptop/tablets and use the available Wi-Fi; and to ensure that they have robust remote access and mobile device management systems. It will be desirable to agree simple financial arrangements for sharing the associated costs across different providers. 2.6 Information Governance Completion of the Information Governance mechanisms required to underpin shared care records, building on the existing NWL Information Sharing Protocol and associated Information Sharing Agreements, including the Whole Systems Integrated Care ISA developed during 2015/16 - which support direct care, enable new care models and govern patient access as well as pioneering around the secondary use of data. NHS NW London Local Digital Roadmap Page 39

40 The supporting Information Governance requirements to enable the LDR objectives will be driven by the NWL Digital Governance Group which includes membership from all of NWL's partnership organisations and patients. The group as a part of the NWL Digital Programme governance are the custodians of the umbrella North West London Information Sharing Protocol (NWL ISP) under which there are several Information Sharing Agreements to support the sharing of health and social care records between professionals. The next steps of the journey for 2016/17 are to complete the Information Governance mechanisms to support system-wide sharing with patients and citizens through the North West London Care Information Exchange, and to work very closely with the London Digital Programme on their federated architecture and citizen account for future alignment and/or transition. NWL also hopes to be one of the first adopters of the Information Governance tools that are being developed by the London Programme. The sharing of information with citizens will look to actively support and honour citizens sharing preferences. The group will also continue to pioneer on the indirect uses of data to support dynamic analytics and population health. Over the last two years the group has worked with and will continue to engage with national bodies (LGA, IGA, Centre for Excellence for Information Sharing and the NHS Digital) and also important local stakeholders (HealthWatch and London-wide Local Medical Committee). The Digital Governance Group will also continue to support and oversee the Fair Processing strategies that form a part of the NWL ISP with the support of patient members on the group. 2.7 Digital Care Community Building a Digital Care Community across NWL under the leadership of the Digital Programme Steering Group, via a digital hub (a website for sharing good practice and a resource for local organisations and professionals) and continued engagement of lay partners, clinicians, other care professionals, IT professionals and managers. Health and Social care organisations in NWL share a vision of digital empowerment for its 2+ million citizens, harnessing the power of technology to empower and support people to maintain independence and lead full and active lives in their homes and communities, keeping them well for longer. In the context of shrinking budgets and an increasingly aging population, care providers will need to find new ways of engaging with their citizens in a more efficient and cost effective way. The achievement of this vision will be based on a collaborative approach, rather than a centrally driven plan or strategy. Transformation and transition to digital services requires a fundamental business change and cultural shift, that needs to be fully understood by everyone throughout organisations and across communities, therefore a priority is to reach out to those that are less digitally engaged and to enable them to become Digital Citizens, a term we will attribute to care professionals, patients and organisations. For citizens themselves, increased digital engagement is a tool to help change the social culture of overreliance on medical services, particularly emergency services, as they take ownership of their care, rather than care being something that they have done to them. Understanding the nature and costs of their own care, and learning about what they can do to avoid having to go to hospital, are key to this. Harnessing the power of the technological revolution is key in transforming the quality of care and also reducing the cost of health and care services by bridging the gap between efficiency and effective treatment or intervention. The next step is to support care professionals to actively and effectively harness the digital revolution and create Digital Citizens, reshaping the workforce by enhancing skills and capabilities, leading to a step-change in productivity which in turn will improve data quality, information flows across care settings and increase participation and access to present and future systems. Digital integration of services will also mean that care professionals will be able to change the way they work. Care professionals will need to be able to use the technology available to them and to develop new ways of working; it is of vital importance that we invest (supported by external funding) in increasing digital literacy to improve the knowledge, skills and behaviours of the workforce. Encouraging a digitally literate workforce to acquire a range of digital skills will enable staff with confidence to share information, participate in online communications and transactions to support healthcare delivery and participate in online communities and networks. The digital workforce will also be able to pass on and share their skills, to enable citizens to optimise the use of technology to support their health and well-being. Enabling this broader system-change, on the basis that every citizen has potential to participate in digital technology, could provide lasting social and economic change. Overall, improving digital skills and literacy of professionals and patients can maximise the potential offered by the rapidly developing applications of digital technologies. The proposed plan and approach to encouraging a digital community is in three phases: 1. Understand the needs and skills of the workforce 2. Collectively, with partner organisations, establish the shape, form and delivery of training 3. Concurrently, develop a NWL digital Hub and communications to provide online tutorials, material on best practices, signposting of training, information about support and technical developments across NWL. NHS NW London Local Digital Roadmap Page 40

41 Increased digital engagement from staff will: Reduce inefficiencies between providers of care through use of digital processes and tools (NWL Diagnostic Cloud, ereferrals, GP2GP, EPS2, Shared Primary and Community Systems SystmOne, EMIS and Docman) Providers of health and social care services working and sharing information as one seamless team (Summary Care Record and Care Information Exchange) Encourage the use of digital tools to improve independence and better quality of life for individuals (PatientOnline, EPS2); and reduce number of unnecessary visits and/or appointments (PatientOnline) Promote the awareness and use by citizens of self-care and self-management digital tools and information, keeping people well and healthy in a more cost-effective way (PAM, PatientOnline). NHS NW London Local Digital Roadmap Page 41

42 3 NWL Local Digital Roadmap: Delivery Programme 3.1Funding Requirements Projects set out in this LDR are those identified by the organisations of the NW London care community as required to meet the strategic objectives set out in the STP and LDR, and the objectives and timescales of the NHS Digital Strategy as set out by the National Information Board. The projects have been ranked based on what is required to deliver the Universal Capabilities and meet the most urgent priorities of the STP (shared care records for integrated out-of-hospital care). The programme will be reviewed and revised as required in the light of the final STP and NHSE decisions about funding. It is anticipated that Imperial College Healthcare will be nominated as a Global Digital Exemplar by NHSE; when this occurs, Imperial will start to play a leading role as the focus for acute IT in NW London, and NWL will take the opportunity to review arrangements for implementation and hosting of acute clinical systems in a similar way to the collaboration recently announced between Imperial and Chelsea & Westminster. It is expected that this will present opportunities to reduce some of the costs set out in this document, particularly at London North West Healthcare. Funding for the programme is still under discussion within NHSE, and full details of programme costs and the associated funding will be published in due course. NHS NW London Local Digital Roadmap Page 42

43 3.2Delivery Timescales The schedule for delivering the 10 NHSE Universal Capabilities, seven STP Local Digital Capabilities and the London Digital Programme Capabilities is illustrated below: NHS NW London Local Digital Roadmap Page 43

44 3.3Delivery, Leadership and Resources In NW London there has been considerable investment in local clinical and business leadership, change management and technical capability across the health and care community. Within primary care, a CIO/Director of Informatics has been appointed (Bill Sturman), with CCIO resource to be funded by the Primary Care Transformation bid to the ETTF, to complement the eight Clinical IT GP Leads who provide overall direction as members of each CCG Governing Body. The team spans a Programme Management Office, Primary Care Support team, a shared IT Service and technical support, running development and support for Primary Care Systems and infrastructure, and providing a co-ordinating role for the NWL care community via the Digital CQUIN programme and NWL Digital Programme. Each provider has a CIO or IT Lead, and Caldicott Guardian or IG Lead. Most Trusts have also identified Chief Clinical Information Officers. One of the major challenges for implementation of the Local Digital Roadmap will be to ensure a coherent strategic approach across all NWL organisations to deliver the STP objectives. Collaborative working is already under way during the planning and design stage to work together to mitigate this risk: All NWL health and care organisations have been collaborating for several years on a joint approach to Informatics and Information Governance with a shared Design Authority, via the structure described in the section that follows. In primary care, a shared Informatics service supporting GP IT systems (SystmOne/ EMIS Web in seven CCGs); a Digital Programme which spans all eight CCGs In community and mental health care, the NW London providers are working together to put common pressure on TPP to deliver interoperability with EMIS Web In social care, seven of the eight local authorities are working together under the umbrella of the West London Alliance In acute care, Imperial and Chelsea & Westminster both have a strong track record with digital clinical systems and have recently announced that they are working together on a common Electronic Patient Record system using Imperial s Cerner instance. Kevin Jarrold (CIO at Imperial) has taken responsibility for Information Management and Technology at Chelsea & Westminster. Imperial as a Global Digital Exemplar is taking the lead with other providers within the footprint. An expected challenge for the future will occur during the implementation phase of the LDR; once funding is awarded, projects will need to start simultaneously across all NHS England footprints. There is likely to be a scarcity of skilled resources with the experience and knowledge required to implement new clinical systems and shared records. NWL will mitigate this by collaborating to share expertise, resources and infrastructure, potentially even building common teams, especially in the acute sector. 3.4 STP/LDR Programme Structure and Governance, Patient & Public Engagement Development and implementation of the NWL Sustainability & Transformation Plan is being led by the NWL Health and Care Transformation Group (NWL HCTG), chaired jointly by Dr Mohini Parmar (Chair, Ealing CCG) and Councillor Shah, on which CCGs, Trusts, Local Authorities and Lay Partners (patients) are represented. The constituent organisations of the NWL Strategic Planning Group have delegated authority to the Chief Officers of BHH (Rob Larkman) and CWHHE (Clare Parker), who are both members of the JHCTC to sign-off the STP and LDR submission to NHSE on the 21 st October During December 2016 signed-off through the STP governance process (including, by reference the LDR) by the eight CCGs, ten Trusts, eight Local Authorities and eight Health and Well-Being Boards. Reporting to the HCTG is the Digital Programme Board, chaired by Dr Ian Goodman (Chair, Hillingdon CCG) and Ronke Akerele (Imperial College Healthcare Partners - ICHP), also with clinical and business representation from CCGs, Trusts, Local Authorities, Academic Health Science Network (ICHP) and Lay Partners/patients, and advised by the NWL Design Authority, to which all stakeholder organisations are invited. After the completion of the LDR this group will provide leadership across the care community for the ongoing delivery and further development of the programme set out in the LDR. Reporting into this group are the following: NWL Design Authority (which itself has reporting into it the NWL Digital Information Governance Governing Group, NWL Data Quality & Standards Group and Digital Co-Design Groups) Care Information Exchange Project Steering Group (managed by Imperial) Digital Analytics Steering Group (Whole Systems Integrated Care) NHS NW London Local Digital Roadmap Page 44

45 NWL Digital Diagnostics Steering Group Digital Innovation & New Technology Steering Group Digital CQUIN Steering Groups (one per Trust contract). The governance structure is illustrated below: Digital Programme, To-Be Governance Committees Function NW London Provider Population & Partnership Revise existing NWL Data Quality & Standards Group New NWL Design Authority Digital Co-Design Groups Enabling Functions Local Provider Internal Steering Groups Digital Programme Level, v2 NWL Digital IG Governing Groups Digital Programme Board (Formerly the Interoperability Board) Sub-Committee Care Information Exchange (Project Board) Digital Analytics Steering Group (WSIC) NWL Health and Care Transformation Group (NWL HCTG) NWL Digital Diagnostics Steering Group Partner Projects Digital Innovation & New Tech Steering Group Digital CQUIN (Trust Steering Groups) NWL Digital Roadmap Strategy & Roadmap Enterprise Architecture for NWL STP/LDR Funding NWL Digital Programme Digital Empowerment (Patient and Partners) Digital Sharing (Partner Collaboration) NWL Digital Diagnostics (CCG led) Care Information Exchange (Partner led) Advanced Analytics (CCG led) Trusts Digital CQUINS (CCG led) Innovation (Partner Collaboration) London Digital Programme New Organisation Forms (ACPs, Hubs) Internal Governance groups Patient and Public Engagement: NWL governance bodies for LDR (Digital Programme Steering Group, Design Authority, Digital IG Governing Group and CIE Project Steering Group incorporate Lay Partner/patient representation. Local CCG governing groups, including Health & Well-Being Boards, incorporate patient representation, and are generally open to the public. A public consultation programme regarding the STP is in progress. NHS NW London Local Digital Roadmap Page 45

46 3.5Development Process for Local Digital Roadmap The NWL LDR was developed between December 2015 and October 2016 by a small team of clinical and business representatives hosted by the NWL CCGs, led by Mike Davies, reporting into the NWL Interoperability Board (forerunner of the Digital Programme Board), the NWL CCGs BI & IT Collaboration Board and the STP Management Group. The development followed the following methodology: A Local Digital Roadmap Working Group (task and finish group) was set up to provide subject-matter expertise and advice to the LDR development process from CIOs and CCIOs, which met monthly between November 2015 and June The Working Group contained representatives of CCGs, Trusts, Local Authorities and Lay Partners/patients. Strong links were established with CCGs and primary care via GP IT Leads (CCG Governing Body members) and commissioners priorities identified. Strong links were established to all local hosted Trusts acute, mental health and community through CCIOs, CIOs and their deputies; first year targets for the LDR defined through Digital CQUIN. Royal Brompton & Harefield NHS Foundation Trust and Royal Marsden NHS Foundation Trust (specialised commissioning but located in NWL) agreed to join NWL footprint. Initial discussion with London Ambulance Service NHS Trust on 22 April 2016 to be managed at pan-london level. Initial discussions were held with all 8 local authorities. Discussions were held with main private providers in NWL - Greenbrook, Care UK and LCW: Urgent Care Centres, 111 service and Out of Hours services; Health Intelligence (digital retinopathy service). Other private sector providers are to be engaged at a later date during delivery of LDR: BMI (acute care), Inhealth and Alliance (radiology diagnostics). The LDR development team has worked closely with the NWL STP development teams and management group members; regular attendance by LDR Lead at STP Programme Management meetings, to ensure that the STP and LDR are very closely aligned. The LDR was presented to NW London-wide governing groups including the NWL Design Authority, IT Sub Committees and Governing Body Seminars of the eight CCGs (and in some cases also Executive Committees), and several provider organisations. Local Digital Roadmap Working Group The Working Group was set up to provide as a task and finish group, to provide subject-matter expertise and advice to the LDR development process from CIOs and CCIOs. Meetings were attended by: Mike Davies, Sonia Patel, Bill Sturman, Framon Rego, Chris Lambourne, Charlotte Stone (NHS NWL), Steve Buck (NHSE Healthy London Partnership), Michael Morton, Sonia Richardson (Lay Partners), John Kelly (Imperial Healthcare), Charles Yeomanson (Hillingdon Hospital), Richard Collins, Ian Bryant, Bill Gordon, Dr Gary Hartnoll (Chelsea & Westminster Hospital), Kevin Connolly, Gerard Traynor (London North West Healthcare), Nigel Tazzyman, Thea Grogan (CNWL), Andrew Chronias, Zakaria Ahmed (CLCH), Trevor Nelms, Andrew McEwan (WLMHT), Vic Wynn, Joe Wright (LAS), Rob Osborne (Hounslow Council), Avril Duncan, Peter Wakely, Greg Payne (HRCH), (CLCH), Dr Arjun Dhillon (Ealing CCG), Dr Kuldhir Johal (Hillingdon CCG), Heather O Brien (RBHT). Meetings were held on: 30 November 2015, 29 February 2016, 31 March 2016, 25 April 2016, 1 June 2016 and 27 June NHS NW London Local Digital Roadmap Page 46

47 4 NWL Digital Roadmap: Implementation Minimising the Risks arising from Technology 4.1 Change Management The Nuffield Trust report, Delivering the benefits of digital health care, identifies Seven Lessons for Success gleaned from the most digitally advanced and successful health and care systems in the world. These lessons are being applied in NWL: 1. Transformation first: Transformation comes from new ways of working, not the technology itself. A transformation programme supported by technology is needed, not the other way round. This is the fundamental lesson that underpins everything else. The NWL LDR will highlight the transformational projects that must follow the achievement of new digital capabilities. 2. Culture change is crucial: The majority of the issues faced along the journey of transformation are people problems, not technology problems. This means that organisations need to invest at least as much into the programmes of organisational change and transformation as they do in the technology itself. Clinical and organisational leaders will need a deep knowledge of clinical and technological systems. The NWL LDR will identify the costs and resource requirements of implementing change, including training. 3. User-centred design: Systems need to solve the problems and needs of the people who are going to use them, be they patients or professionals. This requires a deep understanding of the work as well as the needs of the user. Clinical organisations have historically procured cheaper off the shelf package solutions that are difficult to tailor for their own specific requirements. The most successful organisations will invest in tools such as integration engines and retain their own resources and capabilities to develop their own solutions in critical areas. 4. Invest in analytics: Improving productivity requires extensive redesign of work processes, the use of predictive models to reduce variation, allocate resources, anticipate demand and intervene earlier, and the ability to learn and adapt. None of this is achievable without analytical tools available to clinicians and managers in real time and sophisticated support for planning, management and improvement. NWL has already made a considerable investment in digital tools to support both community-wide and personalised care analysis. 5. Multiple iterations and continuous learning: Implementing technology is an ongoing programme of transformational change. Even with careful design there may need to be a number of iterations in the design of systems. This is a continuous process and there may be several cycles some quite painful before systems reach a tipping point where all of this investment starts to pay off. The NWL LDR delivery plan will recognise this. 6. Support interoperability: The inability to share and combine data between different systems is a major rate-limiting step to realising the full benefit of technology in health care. Typically, high-performing digital hospitals are integrating all their systems, to as low a number as possible, across their organisation. Where possible, systems should be interoperable across different organisations to improve patient and citizen journeys and outcomes. In general, it will be important to procure and use systems that comply with national data and interoperability standards. NWL is constrained by the lack of interoperability currently available in some of its clinical systems; interoperability will be built in as a key requirement in future procurement. 7. Strong information governance: Data sharing requires strong data governance and security, particularly in the face of a growing threat from cyber-attacks. Action is required at national and local levels to help organisations hold and share data safely, and also to enable citizens to own and share information if they choose to. NWL is pioneering in its work to date to develop the IG framework to support integrated care. Transformation at the scale set out by the STP requires investment in organisational innovation eco-systems to ensure that innovation is deployed systematically. NW London is working with Imperial College Health Partners on a number of programmes to achieve this: The Intrapreneur programme, in partnership with WhatIf? training both managers and frontline clinicians to scout for and implement innovation as part of their everyday roles; so far more than 100 clinicians across NWL have been trained. Royal Brompton and Harefield NHS Foundation Trust has used this methodology to improve the lung transplant referral process for patients with cystic fibrosis, reducing the assessment time from a two-day overnight stay to a day case. ICHP has also just launched the Outcomes-based Healthcare Commissioning Programme, in partnership with the NWL CCGs Collaboration Change Academy, Optimedis AG, COBIC and the International Foundation for Integrated Care (IFIC). The programme supports all NWL organisations currently transitioning to become NHS NW London Local Digital Roadmap Page 47

48 Accountable Care Organisations and covers evaluating population health, defining outcomes, designing contracts and implementing a values-based approach to commissioning. Each organisation in NWL will be required to adopt a formal approach to change management, to ensure that the above lessons are applied: change planning (including impact assessment); communications to end-users and patients; identification of change networks and champions; methodology for implementing change; measurement of progress of the change. Specific approaches in each Trust are as follows: Chelsea and Westminster: is in the process of adopting a quality improvement methodology to identify and manage change. The trust has established a dedicated transformation team led by the CEO with a focus on safe integration, implementation of new models of care and implementation of the EPR. There is already a well stablished Clinical Innovation Council as part of the clinical design authority, which reviews and champions digital innovation within the organisation. Imperial College Healthcare: has adopted a Quality Improvement Methodology to identify and manage change. The Model for Improvement asks three questions to ensure improvement work is on the right track: (i) what are we trying to accomplish? (ii) how will we know that a change is an improvement? (iii) what changes can we make that will result in an improvement? Then the change team will (a) Plan - make a plan to do something; (b) Do - try it out; (c) Study - see what happens using measurement; and (d) Act use the results to tweak things the next time round. The trick is to keep it rolling to build up lots of small changes that add together to make a big difference. London North West Healthcare: has a mature and well proven approach to change management and transformation, which is embedded in its overall Trust governance structure through the Trust Strategy Committee which oversees the Strategy, Transformation and IM&T groups, and through which all IM&T and change management projects report. Each IM&T project also has a dedicated transformation and change management work stream that works with the key stakeholders to ensure that processes are fully understood and mapped, and that change is agreed and delivered. Royal Brompton and Harefield: has a Transformation team led by Jan McGuinness, Director of Patient Experience and Transformation. The Hillingdon Hospital: has a Transformation Team who are heavily involved in process and culture change across the Trust, led by James Ross, Director of Transformation. ICT has three qualified Organisational Change Management Practitioners delivery the ICT Capital investment. Hounslow and Richmond Community Healthcare: HRCH will adopt a formal change management programme to align with the NWL change process. Change programmes need to be seen as legitimate and worthwhile at all levels and therefore it is important that the senior leadership at HRCH are engaged from the outset. At an informal level, the staff and patients who shall be influenced will also be involved in the process. To achieve this, HRCH intend to appoint a change team that shall include clinical leadership to ensure other clinicians and staff members embrace change instead of react against it. West London Mental Health Trust: WLMHT Business Technology Directorate has created a dedicated Transformation Through Technology Team under the leadership of the Trust s CCIO and made up of clinical, change and technical staff. The team have embarked on a change management programme to rationalise core clinical processes and then align them with the clinical system so that the RiO product becomes more intuitive to use, the training overhead is reduced, data quality is improved and clinical/admin efficiencies are generated. The core Transformation Team are advised in this task by the Clinical Design Group made up of authorised service line representatives from across the Trust who design and agree the rationalised processes and system changes before roll out. Central and North West London: CNWL has invested in an ICT organisation design that places significant focus on the need for a business engagement and change capability. The Trust informatics committee approved funding for five business change staff, and the trust has invested significantly in this capability to support its ICT strategy and associated strategic programmes in recent years. The team is currently working across clinical systems and infrastructure programmes, supporting 7,000 staff through substantial changes to systems, and working with clinicians and business managers to realise the efficiencies and benefits of new enabling technologies. A Business Change Framework and Strategy was developed to support programmes, all of which require formal business change approaches and plans to support the implementation of new systems. Digital adoption leads are embedded in clinical services to support clinical systems design, which is undertaken in consultation with transformation leads, clinicians, and business staff. More than 400 staff have been consulted throughout the programmes to date and CNWL have funded the secondment of 20 clinical and business staff to our clinical systems programme. NHS NW London Local Digital Roadmap Page 48

49 4.2 Benefits Measurement and Realisation The programme of work set out in this LDR is expected to realise a number of benefits, as follows: Care and Quality: improvements in the quality of care by sharing appropriate information about a person s care between professionals involved in delivering that care, within the required timescales, resulting in better decisions and eventually improved outcomes. Enablement of new models of integrated care (via shared care records, including care plans, and automated transfers of care) which will better meet the needs of patients, particularly those with complex conditions, with a view to keeping them out of hospital for as long as possible. Automated clinical workflows, to replace unreliable and potentially unsafe processes based on paper and fax. Reduction of health inequalities through the use of digital tools, and the ability to measure and compare care delivery and outcomes through dynamic data analytics. Finance and Efficiency: replacement of paper-based records with electronic records, reducing the costs of printing, postage, scanning and coding and eliminating duplicated parallel paper and electronic processes. Reduction of unproductive clinician time spent chasing information about patients because records from other care settings will be available online within their own clinical systems. Optimisation of clinical workforce productivity through shared records and dynamic data analytics. Reduction of IT implementation and operational costs by sharing assets, resources and expertise between organisations (e.g. common use of Cerner EPR by Imperial and Chelwest). More efficient estates usage through digital consultations, requiring less face-to-face care. Health and Wellbeing: getting people more involved in managing their own conditions, by sharing information with them about their care, and enabling innovative new applications to measure and monitor their symptoms and encourage them to take appropriate actions to stay well. Individual projects will each identify and quantify specific benefits justifying the associated investment. As part of these projects, each organisation in NWL will be required to adopt a formal approach to benefits realisation that covers the four key steps of benefits identification (including identification of baseline, qualification and quantification of benefits potential), mobilisation (including production of benefits map and development of benefits strategy), delivery planning (including definition of benefits profiles and realisation plans) and realisation and tracking (including review, analysis and reporting, followed by handover to Business as Usual). Such an approach should enable them to: 1. Identify, refine and categorise benefits for the programme together with a quantification of each where appropriate 2. Profile each benefit, identifying owners with responsibility for delivery. 3. Produce a realisation plan which forms part of the overall programme plan 4. We will combine these benefits into a benefits map to link identified benefits to programme outcomes and strategic objectives of the organisation Specific approaches in each Trust are as follows: Chelsea and Westminster: As part of the integration with West Middlesex Hospital, the Trust has clearly identified the benefits of implementing its digital strategy. Imperial College Healthcare will develop a business case for each investment resulting from the Local Digital Roadmap. To develop each business case, benefits will be identified and baselined with a schedule produced outlining how they will be realised over the investment period. Benefits tracking is managed through the Trust s ICT Programme Management Office. London North West Healthcare has a proven track record in benefits realisation from IM&T investment programmes. These start with clear quantification of benefits during the business case stage including financial (Cash and Non Cash Releasing) and non-financial qualitative benefits. These are documented in detail and profiled across the life of the proposed investment with detailed benefits realisation plans overseen by the appropriate Project Board and the IM&T Strategy Group. The benefits methodology includes clearly defined benefits owners who sign off the benefits and have responsibility for providing the evidence for the delivery and achievement of benefits. Royal Brompton has an established Programme Management Office which maintains a strong governance process to capture and report on benefits realisation: agreeing a baseline is in place, named owners identified for each benefit, and quarterly reports showing progress produced for the Information and Technology Committee. NHS NW London Local Digital Roadmap Page 49

50 The Hillingdon Hospital has recently been audited on Benefits realisation processes and action plans are being implemented this year. Hounslow and Richmond Community Healthcare: will adopt a formal benefits management and realisation programme to align with the NWL benefits process. Benefits identified shall be managed within the Change programme. HRCH shall ensure that the four key steps of benefits realisation are followed and reported as required. West London Mental HealthTrust: WLMHT will adopt a formal benefits management and realisation plan to align with the NWL benefits process. Benefits identified will be owned and managed within the Trust s Clinical Design Authority. WLMHT s Transformation Through Technology Programme is expected to deliver clinical and administrative efficiencies through rationalising clinical processes and then redesigning the clinical system to support this standard operating approach. The resultant system will be more intuitive to use and so reduce training, improve efficiency of access to/input of critical data, and transform largely unstructured textual information into structured forms. This approach of making the system more engaging and useful for clinicians at the front end also has benefits for administrative and reporting services as the improved timeliness, data quality and structured nature of the data supports reporting of business and clinical information, the automation of standard administrative processes such as letter production, and the direct system to system exchange of data through structured interfaces. Central and North West London: has developed a Benefits Management Framework to support the realisation of benefits across its strategic ICT programmes. The framework s objective is to: o Provide a set of processes, tools and templates to enable programmes and projects to deliver the benefits that were originally anticipated and that warranted the investment in the initiative. o Ensure benefits are identified and defined clearly at the outset, and are linked to strategic outcomes in line with the Trust s strategic drivers. o Ensure that benefits are defined and measurable so that the success of each programme or project can be effectively determined. o Ensure that progress against target benefits can be measured and reported to governance bodies. o Provide a focus for delivering change by ensuring business areas are committed to realising the defined benefits impacting those areas. Key principles specified by the framework are that: o The approach to benefits management should be consistent across all programmes and projects. o There will be effective reporting of benefits within the business. o All benefits will be centrally tracked and reported through to realisation. o Every benefit will have a clear owner within the business, who will be responsible for realising and maintaining the benefits in the longer term. o Benefits will be quantified and measurable so that achievement can be accurately and objectively tracked and reported. High level benefits identified for CNWL s clinical systems programme include: o Improved access to clinical information where and when it is needed o Reduced duplication of effort o Improved data quality o Facilitated patient journeys o Better sharing of information o A foundation to enable an active role for services users and their carers o Improved management information o Consistent evidence based care o More efficient management of resources o More time for patient care and reduced travel time. NHS NW London Local Digital Roadmap Page 50

51 4.3 Principles and Standards for Digital Health and Care A number of principles for the development of integrated informatics were agreed in March 2014 as part of NHS NWL s Informatics Strategy for Whole Systems Integrated Care, illustrated below: 1. Primacy of primary care data: almost every citizen in the care community is likely to be registered with a GP and have a primary care record; those cared for by other services are likely to be a subset of this whole. The primary care data base is therefore the fundamental starting point for shared care records. 2. Integrated and Interoperable: the NWL informatics strategy addresses the integrated whole system of primary, secondary and social care; it must therefore span multiple clinical IT systems and therefore be based on interoperability rather than a single system. This should involve reinforcing common standards for data, and an open architecture that can connect the key main systems. 3. Built around users, both patients and professional: patient care is at the heart of everything the NHS does, and the informatics vision should include co-production with patients and service users, including carers. At the same time, getting buy-in for the effective use of Informatics from the clinical community is key; the main outcomes for patients will not be achieved without addressing clinical users and making their lives easier. 4. Respecting local priorities: there is a mix of informatics capability across the NWL organisations. Any informatics strategy must cater for differing levels of maturity, capability and existing infrastructure. In addition, at the heart of any shared vision will be a trade-off around local priorities for different organisations. These priorities should be respected, whilst not undermining the objective of improved integrated care. 5. Open and collaborative: integrated care requires open and collaborative sharing of data about citizens. In NWL we have already made great progress towards getting all stakeholders involved in the development of a comprehensive Information Governance framework. The working relationships and understanding developed during this process are helping break down the barriers between organisations which may historically have stood in the way of information sharing. 6. Re-using existing investment: there have been substantial investments over the years in informatics and information systems across NWL by the current CCGs, providers and their predecessor organisations, including infrastructure, systems and data warehouses. There has also been investment in universal capabilities by the NHS as a whole. It is important to ensure that these high quality components are retained, and exploited fully. NHS NW London Local Digital Roadmap Page 51

52 Without standards for clinical records and the technical means for storing and transferring them, it will be impossible to realise the vision of integrated informatics set out in this document. Standards need to be defined, agreed, adopted by organisations and their IT suppliers, and developed on a continuous basis. NHS NWL supports the Newcastle Declaration drawn up by the NHS CIO Council in 2015: We declare that, in order to provide safe and effective health and care for all citizens, health and care professionals require unimpeded access to all relevant information available on those they care for. Too often, health and care professionals today lack key information available on those they care for, and have to make treatment decisions without access to all of the currently available knowledge, such as previous care and test results. Citizens and patients deserve better. We therefore urge all involved in planning and delivery of health and social care, not least policy makers and system suppliers, to urgently to adopt five general interoperability principles and, to support them, five key technical interoperability principles. The five general interoperability principles: 1. Complete, accurate and timely information fundamentally underpins safe and effective health and social care. 2. Clinicians and social care providers require information to be routinely shared if they are to provide optimal care to patients and citizens. 3. Patients and citizens have a right to expect that their information will be shared with their health and care teams along their journey, and that their consent to share or not share will be respected. 4. Within the health and social care system it is the legally defined data controllers who must determine information sharing. 5. Suppliers and healthcare providers must ensure the flow of data. It is unacceptable for any supplier or healthcare provider to impede the flow of citizens health and care data for narrow organisational, commercial, or other reasons. To achieve ubiquitous interoperability, we further urge all those involved in specifying, purchasing or implementing systems across health and social care to adopt five key technical principles. The five technical interoperability principles: 1. All clinically relevant data held within supplier systems must be made available for use by any care setting, wherever and whenever required, subject to relevant security, information governance and consent requirements. 2. It is the right and responsibility of the relevant data controllers to determine if clinically relevant data is transmitted between systems for viewing only or for storage and reuse. In support of principle 2 (above) suppliers must openly publish details of interfaces and provide these interfaces inclusively and without license fee. 3. Wherever interface or message standards exist, and those standards are fit for purpose, suppliers must adopt those standards. 4. Where standards do not exist, suppliers must collaborate with stakeholders to produce a consensus set of interfaces and messages. 5. Wherever interfaces exist, suppliers must support and maintain system availability and performance them within the levels of service expected to support safe clinical care, in terms of system availability and performance. At a national level, NWL endorses the efforts of the Code4Health Interoperability Community and the Endeavour Health Charitable Trust, together of course with NHS Digital (HSCIC) and NHS England, to address the issues raised in the Newcastle Declaration. It seems that these efforts are finally starting to break down the resistance of some IT suppliers such as TPP and EMIS to the interoperability principles required to realise the vision of integrated digital health and care; though it is still not clear exactly when such open APIs will be delivered and will be able to be exploited. Other key suppliers in NWL such as Servelec (RiO), Liquid Logic and Corelogic now also need to be encouraged to develop open interfaces. All procurements of clinical IT systems in NWL will specify the requirement for open interoperability standards, as set out in the HSCIC Interoperability Handbook and Healthy London Partnership s 2016 Commissioning Intentions document: Any new information systems must demonstrably comply with existing national (and potentially locally defined) standards (where these are appropriate), including clinical messaging standards and broader IT standards such as GS1 for barcoding. Any new information systems must be capable of exposing a comprehensive set of APIs (Application Programming interfaces) to enable the sharing of patient records. Providers must be capable of exposing data based on a common set of standards (eg IHE XDS, CDA, FHIR) NHS NW London Local Digital Roadmap Page 52

53 CCGs should be signalling to provider organisations an expectation that new and legacy systems/applications across London should be (directly or indirectly) capable of registering with a central orchestration service to send and receive a range of standards based messages, such as IHE XDS and CDA, to support defined use cases (e.g. for Urgent and Emergency Care and Cancer Care) across the capital. New and legacy systems must demonstrate continuing compliance with published and emergent standards such as those relating to transfers of care from hospital. Providers must support the use of electronic solutions for key cross-organisation transactions (e.g. referral, electronic ordering and results reporting). NWL supports the work of the Healthy London Partnership to develop common content definitions for the messages referred to above, and will contribute to that work wherever possible, for example in developing (through a co-design process between CCGs and health and social care providers) standards for shared integrated care plans. At a local level, NWL already has a Data Quality Group of CCGs and providers, which has the objective of highlighting and responding to data compatibility issues arising from the sharing of records across different care settings. This group will be tasked (via a new sub-group to be set up) with reviewing the potential issues around migration to SNOMED CT in the longer term (including in particular the readiness of clinical IT suppliers) and overseeing and co-ordinating organisations emerging plans in this area. Finally, NWL acknowledges the obligation of its component organisations to implement the Accessible Information Standard (SCCI1605), which directs and defines a specific, consistent approach to identifying, recording, flagging, sharing and meeting the information and communication support needs of patients, service users, carers and parents, where those needs relate to a disability, impairment or sensory loss. The Standard applies to service providers across the NHS and adult social care system, and effective implementation will require such organisations to make changes to policy, procedure, human behaviour and, where applicable, electronic systems. Commissioners of NHS and publicly-funded adult social care must also have regard to this standard, in so much as they must ensure that contracts, frameworks and performance-management arrangements with provider bodies enable and promote the Standard s requirements. Successful implementation will lead to improved outcomes and experiences, and the provision of safer and more personalised care and services to those individuals who come within the Standard s scope. The scope of the Standard is significant and so is its intended impact. It is unashamedly ambitious in seeking to set the framework and provide clear direction for a dramatic improvement in the ability of the NHS and adult social care system to meet the information and communication support needs of disabled people. Applicable organisations have a legal duty to follow this standard; however, the moral and ethical imperative in this case is also compelling. NHS NW London Local Digital Roadmap Page 53

54 Appendix A Acute Patient Flows within and outside NWL Footprint Patient flows are illustrated in the diagram below: Appendix B Providers of Community, Mental Health and Adult Social Care with IT systems PRIMARY CARE COMMUNITY HEALTHCARE MENTAL HEALTHCARE ADULT SOCIAL CARE System Provider System Provider System Provider System BRENT CCG EMIS LNWHT SystmOne CNWL Jade > S1 LB Brent Liq Logic Mosaic colours show common systems HARROW CCG EMIS CLCH EMIS CNWL Jade > S1 LB Harrow Liq Logic Mosaic HILLINGDON CCG EMIS CNWL SystmOne CNWL Jade > S1 LB Hillingdon Corelogic Protocol EALING CCG SystmOne LNWHT SystmOne WLMHT RiO LB Ealing Liq Logic Mosaic HOUNSLOW CCG SystmOne HRCH SystmOne WLMHT RiO LB Hounslow Corelogic Protocol H&F CCG SystmOne CLCH SystmOne WLMHT RiO Tri Borough Liq Logic FWi WEST LONDON CCG SystmOne CLCH SystmOne CNWL Jade > S1 Tri Borough Liq Logic FWi CENTRAL LONDON CCG SystmOne CLCH SystmOne CNWL Jade > S1 Tri Borough Liq Logic FWi NHS NW London Local Digital Roadmap Page 54

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