- Successful digital transformation delivers multiple benefits, from improved clinical outcomes and patient/service user experience, through to financial savings.
- The benefits of digital can be realised at an individual trust and whole system level.
- Substantial medium to long-term benefits can only be achieved and sustained with organisational change that goes beyond quick fixes and technology upgrades.
In the immediate response to COVID-19, few trust boards had time to consider the reasons for prioritising new ways of working or digital tools. They just got on with it. As the immediate crisis settles, leaders will need to step back and consider where digital transformation sits in their list of priorities in light of what has changed. If delivered successfully, digital transformation can lead to a range of benefits.
Clinical outcomes and patient safety
The ways in which digital can improve clinical outcomes and patient safety are well documented. Like all other industries, there are trends in healthcare technologies and a constant flow of new opportunities on the horizon. Almost all seek to improve clinical outcomes, patient safety and the quality of care.
New digital ways of working can build consistency across services. Most importantly, this leads to a reduction in clinical variation and fewer clinical errors. It can improve communication and documentation within an organisation and across a system. In the NHS, perhaps the most obvious example is the Scan4Safety campaign, which encourages trusts to use barcode scanning and radio frequency identification software to identify the most appropriate use of equipment, medicines and resources. Trusts are using other decision support tools to improve clinical consistency, such as electronic prescribing. Artificial intelligence will increasingly have a role to play too, as highlighted by the trusts using AI to help improve detection of acute kidney injury.
Digital underpins better and faster coordination of care, which means patients and service users receive the most appropriate care in the most appropriate settings. Perhaps the most obvious example here is telehealth, which allows clinical care to be delivered remotely when appropriate. Beyond telehealth, eObservations and virtual multidisciplinary teams are also giving patients and service users access to the most specialist and interdisciplinary expertise. Meanwhile in the ambulance sector, new triaging software is improving response times and ensuring patients are seen in the most appropriate care setting.
Perhaps the most significant digital transformation for the long term relates to prevention. Digital can play a big role in keeping more people healthier for longer. At the simplest level, this could mean giving patients and service users more control over their own healthcare, such as through remote monitoring and wearable devices. More sophisticated use of data will enable earlier interventions and upstream prevention of avoidable illness. This has already started with the development of predictive analytics and risk stratification, but the continued expansion of the local health care records exemplars (LHCRE) is enabling system partners to focus on population level health outcomes as never before.
There have been lengthy debates about the appropriate term to attach to experience when discussing digital. Whether it is user, citizen, patient, customer or stakeholder, the essential point is that successful digital transformation can dramatically improve everyone's experience of healthcare.
'User' is a helpful shorthand, because it captures the full range of actors for whom digital should enhance the experience - patients, service users, clinicians, visitors, support staff, managers, and so on - and the fact that the same individual can be a different type of user on the same afternoon. The word experience itself also has a different quality in healthcare to what you might see in other industries. Simplicity and efficiency are all valued just as much, but so are kindness, empathy and compassion.
Good digital services, underpinned by reliable data, can support a healthcare system that is more proactive and of higher quality, but just starting with the basics can make a huge difference to user experience and adoption. 47% of users will give up on a website if it takes more than 3 seconds to load. In 2018, Google tracked over 900,000 landing pages on mobile websites in an effort to understand their overall mobile performance and found that 70% of web pages needed significant improvements to enhance usability. ‘Light’ pages, clear language and mobile responsiveness are all relatively straightforward to deliver.
In healthcare this will often mean direct patient involvement in the development of new digital services. This is particularly relevant when designing services to enable patients and service users to actively monitor and manage their long-term conditions. Patient engagement in service design is also essential given the continued challenge of digital exclusion.
The central importance of user experience cannot be underestimated. The UK government digital service’s (GDS) mantra was 'start with user needs'. GDS' experience showed that by focusing on experience, the savings would come - the UK government saved over £3.5 billion on digital and technology between 2011-15. However, the GDS was never set a savings target - deliberately. Such targets were recognised as warping incentives when delivering services, leading people to make the wrong design, technology, policy and procurement choices, which leads to bad services, which are then not used, and therefore do not make savings. Focusing on user experience makes it more likely an organisation will find itself in a virtuous circle, rather than a vicious one.
Without staff in every part of an organisation playing some role in digital transformation at the right point and time, it generally fails. If digital transformation is delivered (or perceived) as a top-down, management consultant-led exercise where staff are ‘managed’ through the process, it is almost guaranteed to not work as intended.
Successful digital transformation recognises that frontline staff are very likely to offer many of the keenest insights on user needs that need to be addressed - both of patients and service users, and from themselves. These are usually uncovered and addressed by making frontline staff an essential ingredient of a multidisciplinary delivery team, rather than through occasional consultation. Digital transformation is best thought of as a combination of a mandate (from the top of an organisation) and a movement (from within the organisation, at all levels).
Many trusts will have a group of staff very willing to get involved, provided they're given a team to be part of, the time to commit to it, and a level of empowerment to get on with it without distraction. In government, GDS had a mantra: 'find the angry people' - shorthand for those who were passionate and committed to the organisation, and desperate to fix the broken things they could see.
More generally, the response to coronavirus has seen a change in clinical attitudes towards digital. In recognition of the urgency and challenging nature of crisis response, more are willing to tolerate imperfections in new services and ways of working, provided they are continuously improved upon. This tolerance, and a greater appreciation for starting with a 'minimum viable product' quickly rather than waiting for a perfect solution to arrive much later, is a behavioural shift that is essential to making digital change stick.
Like quality improvement methodologies, the point of digital should be to get the best from all staff, improving not just quality of care, but also reducing the day-to-day frustrations that impact job satisfaction. It should make it easier for staff to perform the tasks they are best at and automate or eliminate those that are drudgery. It could mean clinical staff operate at the top of their license. Returning to the carer's allowance example, the DWP reduced headcount in the carer's allowance unit by 11% due to the efficiencies brought about by the digital service, yet a staff survey showed that 91% of staff preferred working with digital claims as opposed to paper submissions.
Cambridge University Hospitals NHS Foundation Trust
Inspiring the workforce to embrace digital
Cambridge University Hospitals NHS Foundation Trust (CUH) is a university teaching hospital providing acute and specialist care across the east of England.
In 2014 the trust deployed Epic: a new electronic patient record (EPR) system. This 'big bang' implementation presented a number of challenges for the organisation, and a major incident was declared one week after go-live. Since then, CUH has worked hard to ensure it has the right culture, workforce strategy, transformation capacity and training plans in place to align its digital vision with the wider trust strategy. The board has made clear that future investment into its digital programme is linked to continuous improvement, safety, transformation and connectivity, rather than simply technology.
One of the lessons learned from the Epic launch was about clinical engagement. Clinicians had expressed concerns during the EPR deployment that they felt were not taken on board by the trust leadership. While Epic had lots of technical capabilities one senior leader described the situation as "owning a sports car but driving it in gridlocked traffic". The CUH board has worked hard since then to regain the confidence of the clinical community. Emphasis is now on building change management capacity and encouraging more integrated working between clinicians, operational and digital teams.
At the leadership level, the trust's chief clinical information officer as well as the director of improvement and transformation have strong links into the clinical workforce and feedback any frustrations or concerns to the board. There has been a greater recognition of the need to invest in staff training to ensure the benefits of new technologies can be realised over the long term.
The trust has built a narrative for staff on its digital journey, focusing on getting the building blocks in place to enable wider innovation, and highlighting the progress made to date: "we are better and more efficient as a result of implementing Epic, and we are getting better all of the time." The board believes establishing this narrative will support its digital strategy in the long term, regardless of any personnel changes at board level. The narrative has also been important in retaining and recruiting staff, not just to IT teams but also across the organisation: people want to work at CUH because of the progress it has made on the digital agenda. The trust’s brand is intrinsically linked with its digital maturity.
Like many trusts, implementing an EPR system is important in laying the foundations for more advanced digital transformation. As part of the trust's response to COVID-19, order sets (a form of dynamic protocol used in EPR systems) have been developed that are guiding clinical-decision making on testing. This allows expertise about infectious diseases to be shared more effectively and leads to better consistency in the application of evolving trust guidance.
Junior staff members continue to come forward with ideas for new digital solutions and apps, reinforcing the trust's digitally innovative narrative. CUH is already beginning to think about the use of machine learning and artificial intelligence in radiology and cancer multi-disciplinary teams with the use of natural language processing.
The board has to have the vision to make that leap into a digital future.Director of Improvement and Transformation
While business case methodology can lead to false certainty and excessive focus on quantification, successful digital transformation can unquestionably yield cashable, economic savings. These are usually achieved in one of 5 ways: eliminating duplication, automating or eliminating processes, making effective use of Moore’s Law (i.e. the cost of the same amount of computing power halving roughly every 2 years) when buying technology, shifting offline transactions to cheaper online channels, and eliminating ‘failure demand’.
The last of these is often missed. 'Failure demand' is the cost created by poorly designed services creating pressures elsewhere in a system. For example, an unclear appointment letter can lead to extra phone calls from patients for clarification, or appointments being missed altogether. When the Department of Work and Pensions (DWP) redesigned the online carer's allowance in 2015, rewriting and reducing the number of applicant questions reduced ineligible claims by 41%. As more people preferred to use the new online service, the number of expensive paper claims fell, saving the department more than £1m a year.
For most industries - and the public sector in particular - in practice, many of the economic savings that digital transformation yields do not make it to the bottom line but are instead reinvested within the organisation. Digital transformation delivers efficiency gains in their true sense, rather than the euphemistic sense of 'cuts': by successfully implementing new services underpinning by digital ways of working, trusts can reprioritise their resources to extract greater value from the same inputs. This way the efficiencies made from the use of digital are also heavily linked to quality improvements within services. For example, a virtual fracture clinic set up by one trust has allowed new patients to be assessed ahead of their appointments. This led to three quarters of new patient appointments being cancelled by people who instead opted for GP-led self-management. This in turn freed up consultant time for urgent referrals from elsewhere in the trust.
As well as improving the experience of discrete services within the healthcare system, harnessing the benefits of interoperability through digital opens up more opportunities to integrate different parts of the system more effectively, and give people more control over their own care.
This is a journey already underway, but there is great future potential. Better use of data will underpin the development of mature integrated care systems (ICSs). Local 'longitudinal' health and care records, such as The Leeds Care Record, will support the flow of patient data across organisations and drive improvements across the system. NHSX, in its tech vision, has made clear that open standards and sharing data are key to enabling digital technology to support the core ambitions of the long term plan.
Moving straight into sophisticated, centralised solutions without the right foundations in place is likely to lead to disappointment. However, with the right structure and capability in place digital can play a role in moving care out of hospitals and integrating primary, community and social care, ensuring a seamless user-centred approach in which services are planned, coordinated and delivered around people's needs. Trusts are already beginning to agree system-wide investment priorities to ensure they have a pipeline of local digital programmes in place over the next few years.
Successful digital transformation of an organisation requires an open, honest, transparent examination of where an organisation is carrying risk.
Some trusts have observed what initially seems to be an increased risk appetite in response to coronavirus. However, as a general rule, the real change caused by the pandemic - and indeed most crises - is not necessarily an increased tolerance for risk, but a huge increase in the visible cost of retaining the status quo. Suddenly, the risk of doing nothing on digital, and how that might impact patient safety and quality, is drawn into much sharper relief.
All trusts will have built up risk in their legacy culture, processes, operating models and technologies. Old technology systems will generally be more vulnerable to cyberattack, and may be out of support. The Wannacry ransomware attack in 2017 was especially damaging to organisations that had not applied security patches, or were using older Windows systems that were past their end-of-life. Some public sector organisations have found their reliance on very old IT has even created a demographic problem - many of those with the specific coding skills required to run essential mainframes built in the 1970s and 1980s are retiring.
There are also less visible ‘status quo’ risks, related to processes that may have been unvisited for some time, accreting greater complexity over many years. For example, paper-based medication orders have led to tragic mistakes, errors in back-office systems have led to under- or over-payment of staff. Failure demand, as mentioned earlier, is often symptomatic of these risks accumulating - not least because it exerts further pressure on a resource constrained organisation.
Digital transformation will not wave a magic wand to make all these risks disappear - and indeed, will create some new risks of its own. However, the principles of this way of working, especially in terms of openness and incremental, iterative delivery, should make the 'unknowns' far more visible to the whole organisation, and put leaders and teams in a stronger position to manage and mitigate them.
Analysis and learning
While discussion of digital transformation tends to be focused on the 'front end' - the services that users can see - organisations only see the full benefits of these by building them on strong foundations. One of the most important building blocks is data.
While a huge amount is written about big data, machine learning, artificial intelligence, and the like, the truth is that very few organisations have the quality or quantity of data to do anything but relatively piecemeal, straightforward analysis. Many more do not even get this far. Much as improving the user experience of online healthcare should start with small, simple but powerful changes, the same principle applies to data architecture and analysis.
Digital transformation - and specifically, the creation and curation of secure and reliable data sources that fit within a well-defined architecture - opens up a wealth of further opportunities for trusts to use a combination of analytics and improvement science to underpin a learning culture and organisational development.
Balancing short-term wins with long-term views
The benefits realised from digital transformation will be different according to the time horizon. The pandemic response has already shown many things that are possible in the short term, such as maintaining services through the use of video conferencing tools, or removing costs associated with paper based systems.
The potential benefits in the medium to long term require staff to embrace sustained and ongoing changes in their ways of working. Only then can trusts look forward to realising the profound long-term changes that digital transformation can deliver: more integrated care across local systems, population-level interventions that target support where it is most needed and manage demand, decision making informed by sophisticated data analysis. Boards must keep an eye on this long view, and developments in areas like machine learning which have the potential to fundamentally change the future of healthcare, without being seduced into thinking their organisations can skip the hard work needed before being able to derive value from them.