making it work
TRANSCRIPT
Robert M. Wachter, MDProfessor and Interim Chairman, Dept. of Medicine
University of California, San FranciscoChair, Health IT Advisory Group for NHS England
@Bob_Wachter
The Wachter Review of Health IT:Final Report
Context of our ReviewNPfIT mostly failed to meet goalsGP sector digitisation has gone wellFive Year Forward View demands another effort
aimed at digitisation and interoperabilityPreparatory work (NIB, digital maturity
assessment), £4.2 B allocation by TreasuryUS had recent experience with digitisation
Office of the National Coordinator for Health IT
~75%
EHRs in US Hospitals, 2008-2015
$30 billion in federal incentives under HITECH
$$
Things Now Getting Really Interesting
Traditional Enterprise EHRs (Epic, Cerner, etc)
Consumer-facing IT (patient portals, apps, sensors, etc)
A 7-year-old Girl’s Depiction of her MD Visit
Toll E. The cost of technology.
JAMA 2012
Residents’ Room Vs. The Ward
2014 Advertisement For AZ ER JobArizona General Hospital will be coming to The Grand Canyon State later this year!! Located in a Phoenix suburb, it’s a 40,000 sq-foot boutique general hospital. Services offered include:• Emergency Room• Radiology Suite inc. CT, X-Ray, Fluoroscopy• Two State-Of-The-Art Operating Rooms• Outpatient Surgery• 16 Inpatient Rooms• NO ELECTRONIC MEDICAL RECORD
Pressure to deliver high-value
care
The digitisation of the healthcare
system
The Big Picture: Two Transformational Trends
The Dominant Issue Today
Prediction: The Dominant Issue in 2026
Health IT: The Mother of All Adaptive Problems
“… problems that require people themselves to change. In adaptive problems, the people are the problem and the people are the solution. And leadership then is about mobilizing and engaging the people with the problem rather than trying to anesthetize them so that you can just go off and solve it on your own.”
– Ronald Heifetz, Kennedy School of Government
“You can see the computer age everywhere except in the productivity statistics.”
-- Nobel Prize winning economist Robert Solow, 1986
The Two Keys to Unlocking the Productivity Paradox
Improvements in the technology
Reimagining the work
itself
SoS for Health, NHS wanted to learn from past experiences (including US & UK) to increase chances of success in England
Members, National Advisory Group on Health ITUS Members
Julia Adler-Milstein, PhD David Brailer, MD, PhD Dave deBronkart Terry Fairbanks, MD, MS John Halamka, MD, MS Christine Sinsky, MD Robert Wachter, MD (chair)
Denmark: Christian Nohr, MSc, PhD
UK Members Mary Dixon-Woods, MSc, DPhil Crispin Hebron Tim Kelsey (now Australia) Richard Lilford, PhD, MB Aziz Sheikh, MD, MSc Ann Slee, MSc, MRPharmS Lynda Thomas Wai Keong Wong, MD, PhD
Harpreet Sood, MD, MPH (Staff)
Advisory Group’s Process~Ten 2-hour phone meetingsTwo-day in-person meeting in EnglandSite visits to four trustsMeetings with multiple stakeholder groupsI met with ~100 individuals
– Clinicians, patients, hospital leaders, researchers, suppliers, social care, charities, policymakers …
Ten Insights Relevant to Our Review1. Purpose of digitisation is not to digitise, it’s to improve
quality/safety/efficiency/patient experience2. Clinician buy-in & engagement are absolutely essential3. In U.S., a national programme that offered $s to subsidize
local purchases of IT systems meeting national standards led to high level of implementation (10%90% in 5 years)
4. That said, advantages of UK national system (Spine, single ID) should be leveraged
– Don’t overlearn the lessons of NPfIT5. Govt’s tendency to overregulate IT should be resisted
Ten Insights (cont.)6. Interoperability is crucial for many reasons, so bake it in
early (harder to do later)7. User-centered design must be a core value8. IT systems need to evolve/mature… need workforce (incl.
CCIOs) to do that, and some tolerance for messy early days9. The IT system is just the backbone–must have culture,
people, flexibility to innovate/reimagine people/processes on that backbone (adaptive change)
10. Be careful about overpromising: remember the Productivity Paradox
Our Main Concerns at Start
Some preliminary work on digital maturity, but no clarity on who would get money, how much, and when
Biggest worry: too little money, spent too fast, trying to wire all trusts to meet “paperless 2020” could fail
Need to balance equity with excellence: value of having advanced trusts as shining stars and national/int’l leaders
“If you think about the things that would get a CEO fired, not digitising is not on the list”
Implementation Plan
Our Approach and Recommendations
Divide implementation into 2 phases: now-2019, 2020-23Divide trusts into 3 groups:
– A (already digitally strong, with potential to be world class)– B (digitally fair now and ready to advance to next level)– C (not yet ready for major digitisation effort)
Support implementation (in A & B now, C later) with central resources to match local resources– Local decision which system to buy (vs. NPfIT’s centralisation)
Implementation Plan
Recommended Phases of Digitisation
2016
2018
2017
2020
2019
2021
2022
2023
Phase 1: Now-2019 Phase 2: 2020-2023
Sort trusts into
Groups A, B, C
Recommended Phases of Digitisation
• Approved plan• £ (shared central/local)• Work on own progress• Partner w/ int’l leaders• Help others in region• Anchor regional
interoperability• World class by 2019
2016
2018
2017
2020
2019
2021
2022
2023
Phase 1: Now-2019 Phase 2: 2020-2023
Group A: Centres of
Global Digital Excellence
(~12)
Recommended Phases of Digitisation
• Approved plan• £ (shared central/local)• Work on own progress• Partner w/ Group A to
build local network• Support regional
interoperability• By 2019, be digitally
mature
2016
2018
2017
2020
2019
2021
2022
2023
Phase 1: Now-2019 Phase 2: 2020-2023
Group B: Ready to
Digitise Now (~1/3 of NHS
trusts)
Recommended Phases of Digitisation
• Approved plan• £ (shared central/local)• Be part of local network• Work on own progress• Partner w/ Group A & B• Support regional
interoperability• By 2023, be digitally
mature
2016
2018
2017
2020
2019
2021
2022
2023
Phase 1: Now-2019 Phase 2: 2020-2023
Group C: Not Yet Ready to Digitise
(remainder of NHS trusts)
2023: End of national subsidies;Difficult to meet quality standardsif still on paper; CQC deems non-digital trusts out of compliance
Our Main Concerns at Start
Combo of adaptive change/productivity paradox-> vital to engage clinical staff, reimagine the work
Key: individuals who can bridge worlds of IT and clinical care (MD-, nurse-, pharmacist-informaticists)
Problems of both supply and demand– Few people in CCIO pipeline, no training programs, not
professionalised (interested folks changed plans after NPfIT)– In trusts, small numbers, not enough time, budget, authority
Thinness of Clinician-Informatics Workforce
‘My authority comes from my clinical and technical expertise rather than directly as a consequence of the title and position in trust hierarchy. Not holding any budget or having anyone report to me leaves me somewhat as an advisor rather than leader.’
‘Yes – [need] some training to bring all CCIOs up to a level. Yes, needs national recognition that this is really important for an NHS to be fit for 21st Century. My organisation feels a CCIO is a 'nice to have', not a mandatory role that requires time, resource and investment.’
CCIO Network survey commissioned for Wachter Report, 2016
UCSF Health System• $3 billion/year; 900 beds; 1.2M
outpatient visits/year• Clinical IT workforce: 15 named MDs,
6.5 full-time equivalents (nursing/pharmacy informatics on top of this)
• CCIO=80% time, reports to CEO
Typical Large NHS Trust• Similar size (albeit lower expenses)• CCIO workforce: ~1-4 clinicians, <1
FTE total • CCIO with ~2-3 sessions per week,
reports to middle manager• Even adjusting for different resources,
markedly lower degree of support
Our Approach and Recommendations
Insist on robust clinician-informatics workforce as condition of funding– Appropriate authority, funding, time
Promote workforce training, professionalisation, certification– Allocate 1% of £4.2 B for workforce
Need national CCIO to lead NHS digitisation effort
Workforce: Push and Pull
Prof Keith McNeil
Our Ten Major Recommendations1. Carry Out a Thoughtful Long-Term National Engagement
Strategy2. Appoint and Give Appropriate Authority to a National CCIO3. Develop a Workforce of Trained Clinician-Informaticists at
the Trusts, and Give Them Appropriate Resources and Authority
4. Strengthen and Grow the CCIO Field, Others Trained in Clinical Care and Informatics, and Health IT Professionals More Generally
Our Ten Major Recommendations5. Allocate the New National Funding to Help Trusts Go
Digital and Achieve Maximum Benefit from Digitisation
6. While Some Trusts May Need Time to Prepare to Go Digital, All Trusts Should be Largely Digitised by 2023
7. Link National Funding to a Viable Local Implementation/Improvement Plan
Our Ten Major Recommendations
8. Organise Local/Regional Learning Networks to Support Implementation and Improvement
9. Ensure Interoperability as a Core Characteristic of the NHS Digital Ecosystem – to Promote Clinical Care, Innovation, and Research
10. A Robust Independent Evaluation of the Programme Should be Supported and Acted Upon
“The experience of industry after industry has demonstrated that just installing computers without altering the work does not allow the system and its people to reach their potential; in fact, technology can sometimes get in the way. Getting it right requires a new approach, one that may appear paradoxical yet is ultimately obvious: digitising effectively is not simply about the technology, it is mostly about the people….”
From Wachter Report, 2016
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/550866/Wachter_Review_Accessible.pdf