Digital transformation projects are as complex as the health care systems they are being implemented within. There is plenty that can go wrong, and as clinicians we are often too ready to oppose change, rather than play our role in making it work.
I recently led the implementation of a major digital change in outpatients at Homerton University Hospital NHS Foundation Trust. Rather than documenting into paper notes and dictating on tape, letters are now created in real time using voice recognition software within a redesigned electronic patient record (EPR) flow. As a result, GPs and patients receive much more timely and accurate information.
As a future report from The King’s Fund will discuss, engaging clinicians in projects like this is crucial for success. There can be obstacles to change; for example, the way in which we take notes and document clinical decisions can be as much about our own habits as it is about the content itself. Understanding this and building in flexibility to accommodate personal styles was fundamental in our experience. In clinical areas such as outpatients, digital change disproportionately affects more senior doctors, many of whom may be sceptical of change or find it challenging, so another key factor of our project was proactively discussing and addressing these concerns.
The impact on ‘end users’ – in this case, clinicians – needs to be taken into account when introducing any new workflow. Typing on a computer screen is never going to feel the same as writing with pen and paper, and using voice recognition will always be different to talking onto a tape. This awareness informed our project’s design as much as possible, but importantly, it also informed the implementation. Instead of a ‘big bang’, we built in time for colleagues to get used to the processes over a number of weeks.
We brought together an engaged group of clinicians and other stakeholders to start a broader conversation about the benefits and pitfalls of technology in medicine and address pre-existing concerns well ahead of implementing any new changes. Spending longer in front of computers has been repeatedly linked with physician burnout, so it was important not to add more ‘busy work’ to a group already working under great pressure.
Ultimately, a small core team of engaged clinicians, developers and operational managers formed what was effectively a disruptive start-up in the heart of the hospital. We were able to map not only the patient journey but, crucially, the role of every stakeholder including clinic nurses, administrative staff, doctors and schedulers. This meant that we knew what the system should be aiming to achieve from the beginning.
No single off-the-shelf solution can work in an environment as complex as health care. The established EPR providers have powerful but often inflexible and expensive solutions. Smaller, but rapidly evolving, technology companies are keen to prove their concepts in our clinical environment but are often inexperienced and tend to be focused on single problem areas. Bringing these worlds together requires great effort from internal IT and development teams (who are also frequently under resourced). However, it is vital not to allow the ‘tail to wag the dog’ by implementing solutions that work better for the technical members of the team than they do for clinicians or the patients they see.
Without doubt we have had to make compromises and work within the limitation of our existing systems. It is impossible to design the perfect solution first time around; so further refinements will dovetail with improvements in the EPR and internal development capability. With a focus on safety, we piloted heavily and iterated the design several times. We continue to build the failsafe mechanisms that reduce the chance of human error in the process; each new service that switches to the paperless flow is given ample opportunity to ask questions and to customise the solution to their particular needs.
We’re now seeing the fruits of our labour at Homerton. The new technology has been broadly adopted and letters can be produced (often handed to the patients) instantly, reducing the chance of clinical error when referrers or patients are unaware of plans. Communications are more accessible within the electronic patient record, and clinicians are spending less time out of the clinic checking and finalising details.
This is one small part of a larger digital change programme that includes transition to electronic GP referrals and the introduction of self-service kiosks for check-in. Clinical images and reports will be directly accessible from the patient record via a new image archive, while a new mobile phone app will securely transfer these images directly into the record.
With all these changes the principles – engaging clinicians early; building in flexibility; communication; ensuring solutions work for the clinical teams as well as the technology teams and continuing to test and refine the service – are the same. This system would have been impossible without clinicians, managers and developers working together and understanding that what’s best for the organisation can be entirely aligned with what’s best for the doctor and, most importantly, for the patients we treat.
Our report, Digital change in health and social care, will be published later in June.
Our Digital health and care congress in July will bring together experts and colleagues to learn from successful adoptions and practical implementations of digital health and care.