For our digital ICS feature series, we spoke to Michael Shenouda on the importance of transcending geographical barriers within an ICS. Michael is the Commercial and Medical Director at Open Medical as well as an orthopaedic surgeon.
On his background
My background is as an orthopaedic surgeon; I have worked predominantly in London but also at various hospitals in Hertfordshire and Surrey.
My interest in digital comes from the need to identify opportunities to meaningfully impact healthcare provision, by understanding the way that clinicians use digital tools and providing solutions that cater to that. That’s why I got involved with Open Medical. I’ve been here since 2018, building up our market offering and helping refine how we can position our offering to provide the greatest value proposition to our clients. That is both through consultancy around digital transformation, being able to piece together client problems and provide a configured, bespoke solution, but also through delivery of the actual digital solution offerings that we bring to the market.
Transcending geographical barriers
Everyone is aware of the formation of ICSs and the shift towards more integrated care models. Transcending geographical barriers comes at multiple levels – between organisations, between clinicians and between clinicians and patients.
At the organisational level, you have organisations which are geographically dispersed and you also get barriers between different sectors of care. If I see a patient in my clinical work, for example, I’ll receive some basic information from their GP, but there’s a lot I don’t know about that patient, especially if they have been seen at other hospitals or in an emergency department recently. It’s very fragmented, which means that the consultation is not as efficient as it could be.
Even within the same ICS, two hospitals a few miles apart are often networked differently and utilise completely independent, siloed systems and data sets.
The first step in transcending geographical barriers is to overcome this issue, and that’s where cloud technology comes in. With cloud tech, you’re not restricted to a certain network, server or data warehouse – you’re allowing the flow of data across organisational boundaries. That in itself has multiple considerations. It’s not just about the technology, there’s the importance of ensuring appropriate information governance too. The reason each organisation tends to want to silo its own information is for the protection of patient health data, which is paramount in maintaining public confidence on use of their data, and being required by law.
You have to find ways to allow respective organisations and the clinicians within those organisations to access and share the data that they need safely, without being able to access other aspects of patient data that may not be required for a certain care episode. Traditionally, that is through specific referral letters, that are typed for a specific patient, and shared across organisations. Well-designed technology can allow this data to flow through between organisations, ensuring only the required data is shared, with visibility and access only by the relevant healthcare professionals.
The next step is breaking down the geographical barriers between healthcare professionals. The point here is around shared learning, multidisciplinary team working, and clinical staff being able to contribute in the area that they have the most expertise. You don’t need every hospital to have a specialist who performs a very rare, specific or really complex operation; you want to centralise expertise in a hub, but also allow sharing of knowledge and resources across a region to ensure patients get an efficient service. Following on from the first point, at present, the flow of information from the peripheries into the hub is very fragmented – data doesn’t flow smoothly, so often healthcare staff have no visibility of what is happening in units outside their perimeter walls. They cannot contribute their expertise to support clinicians in other organisations – or if they do, it often happens informally, through text messages or WhatsApp conversations between colleagues and friends working in different organisations. Breaking down this barrier – by providing regional technology that shares knowledge, expertise, learning, and facilitates multidisciplinary expert care to be coordinated in a governed manner – allows clinicians to intervene and contribute to the areas that are most relevant to their expertise.
Once you’ve achieved these two, the third part becomes easier. That’s around breaking down the barriers between clinicians and patients geographically. In London, we’re quite fortunate and the travel is reasonably easy, but elsewhere in the country, you often have to travel a long distance to reach your local specialist centre. You want to avoid unnecessary patient travel for multiple reasons; convenience, NHS sustainability targets, and more effective use of clinician time. Effective use of estate is a factor too, when you think about having a full clinic waiting room which people only visit for a five-minute consultation before leaving again – many of whom could have been consulted virtually without any negative impact on clinical outcomes.
You can only really break down this third aspect of the geographical barriers once patient data flows freely at the first two levels. You need the patient to be able to receive the same level of care remotely as if they were physically present.
One of the main reasons to bring in a patient in person is because you simply don’t have everything that you need, and it’s just easier to have the individual there in front of you to answer your questions. But if their data flows across all of the other respective organisations to get to the person who needs to see them, it doesn’t matter if that person is 60 miles away; the healthcare professionals have all the information they need to undertake that consultation.
It’s worth pointing out that all of this absolutely doesn’t detract from the importance of face-to-face consultations, and the doctor-patient relationship. That still remains critical, but even in the most sensitive of areas, such as cancer care, you can still break down those barriers and deliver as much of the care workflow as possible virtually, reserving the precious clinician-to-patient time to focus on what you specifically need. Indeed, this is often actually the most efficient way to ensure patients get the best care faster, by optimising the workflow, virtualising the aspects amenable to remote care, and ensuring governed flow of data to the right care provider at the right time.
An example of this in some of the work that we are doing at Open Medical is in the skin cancer pathway. A lot of patients are being referred to secondary care as possible skin cancers, but once a dermatologist looks at their lesion, they are often deemed benign lesions that need no further treatment. Historically, every one of those patients would have to go through that laborious pathway of waiting for a dermatologist review in person. But by breaking down that cross-organisation technological barrier, a large percentage of patients who don’t have cancer can receive completely virtual care.
An example of a care model that we use in this pathway is where the patients go see their GP, the GP refers them through the usual channels, but instead of seeing a dermatologist, the referral itself automatically generates a skin-cancer specific questionnaire for them to fill in, and then they get a high-resolution photograph taken of the lesion – either at their GP or local community diagnostic centre. That whole package is presented to the dermatologist – referral, questionnaire, and image of lesion. The dermatologist can discharge the patient if they deem that the lesion is benign, with automation of their letters to patient and GP. If the patient receives the letter and still wants to see a dermatologist, they can, but I think for most people, receiving the discharge letter is reassuring and they move on from there. It means that the clinician’s time is reserved for the percentage of people who do have skin cancer or a high probability of cancer, or something else that needs to be seen and discussed in person with the dermatologist.
Essentially, transcending geographical barriers is about piecing all of this together. It’s about allowing the removal of barriers to deliver more holistic, integrated and efficient patient care, and about reserving clinician resources for those who need it the most, while also sharing precious expertise and resources across organisations.
On tackling ICS challenges
Alongside information governance and the difficulty of having data sitting in siloes, there are a few other challenges that ICSs in particular can face.
ICSs have only been incorporated in the last year, so they are still relatively immature organisations. They are still working out their agendas, priorities and strategies in some cases. Often, there are multiple organisations within an ICS with competing agendas. For some ICSs they will have very different demographics from within their constituent organisations, which means that they require different models of care within each hospital. They can have different legacy systems, different processes, and they aren’t likely to have a shared digital infrastructure yet. Interoperability between healthcare systems, historically, hasn’t been great; that adds a further layer to the challenges that they face.
There is often variation in the delivery of healthcare models and pathways across different parts of the ICS too, not necessarily because those variations are wanted or warranted, but through ingrained ways of working. This can exacerbate potential health inequalities too.
In terms of tackling the challenges, again, having the digital infrastructure in place to support data flow through organisations is key.
Something that I would definitely emphasise is the importance of keeping any transformation work within an ICS very focused on specific goals. Sometimes, there is a tendency to want to do too much, too soon, especially for a new organisation. You have all these great ideas and want to deliver the benefits immediately. Unless you keep things focused on a specific goal, you risk fragmenting a project so much that it never comes to life. By the time it does come to life, there’s a chance that everyone will be so fatigued by it that it never delivers the benefits it was supposed to. Within an individual hospital organisation, you can perhaps try to tackle the challenges of streamlining or transforming the majority of that organisation in a certain way. But when you’re looking at ICS-level transformation, in our experience, the best bet is to focus on something specific, like a particular speciality.
One of the projects we have worked on at Open Medical has been around streamlining a musculoskeletal pathway at ICS level. That is a very disease-specific focus where pathways can be standardised. The focus is narrow enough for you to be able to increase chances of success by reducing the broad groups of stakeholders with competing interests. What the clinicians in the musculoskeletal pathway need is very different from what the clinicians in the dermatology pathway need, for example. So keeping a specific focus, in this case a specialty focus, reduces competing requirements and interests.
Another aspect is that you cannot force a model of care that is not suited to a particular ICS. This is something that we see sometimes when people go for off-the-shelf solutions that are not really suitable for the needs of that specific ICS. It may not suit the geography, or the clinician behaviours, or the patient demographics. It is still absolutely essential to have a framework that you’ve used before, something you can use to leverage experience and examples. You also want to be able to learn from shared best practice, leveraging the consultancy of other organisations. However, you must ensure that any care pathways and supporting technology are designed with the specific needs of that particular ICS pathway in mind. When it comes to delivering technology, you have to think: what is the ICS trying to do? What are the goals of this project? What are you trying to streamline? How can you empower the ICS to develop a model of care that is suited to their patients and caregivers? Then you need to adapt the technology model to suit delivery.
ICSs sometimes limit their options with this; they go out to search for a certain solution that does a certain thing, e.g., digital preoperative assessment. In argument against this, I would suggest that you are much better off focusing on service redesign first. Once you’ve got your service to work well, then you need to think about what technology, or combined technological solutions, can be implemented to support that model of care.
There are ways in which you can achieve this at scale; there’s a lot of work around automation, particularly for process optimisation. You have to have high-level standardisation and streamlining at ICS level, but allow local configuration for workflows so that each organisation can still deliver care to their specific population cohort in the way that they need, whilst not deviating from high-level strategic project aims.
Looking at data silos and how to tackle that challenge, we are seeing a trend where there is increased information sharing. And while, as before, this is absolutely critical in breaking down geographical boundaries, it’s important to keep the balance in mind; the value to be gained from information sharing versus the risk of information governance breaches and loss of valuable health data. Building secure-by-design technological solutions is key here to tackle cyber security risks.
We also need to focus heavily on interoperability and what that actually means. We need all the new technology brought onto the market to be genuinely interoperable, and to conform to NHS digital – and indeed healthcare industry – interoperability standards.
How you gather and distribute the data is key, too. It is essential to integrate data capture into any platform that you work with. Users should be collecting and inputting data as they go, as part of their every day practice. On that note, it’s also important to make sure that you don’t miss the chance to capture meaningful data through lack of structure – you have to create methods for users to capture as they go. Retrospectively sifting through unstructured data to try to create granularity and structure – to identify patterns, address service improvements, or research interesting topics – is time consuming, expensive, and often inaccurate.
Looking at Open Medical’s work in the skin cancer pathway again as an example, a referral might come from a GP to a dermatologist. That referral comes in the form of a bulk PDF containing some clinical information. At the point that it comes through, the meaningful, structured data within it is quite minimal from the dermatologist’s perspective. You need to transform that into useful data which you can capture granularly.
As part of my everyday clinical work, I have to give my impression of what the diagnosis might be, whether I think it is malignant or not, and suggest next steps. If I capture all of those things in a structured, clinically coded format, I am transforming an unstructured referral into very useful structured assessment data that can then be analysed with significantly greater ease later. All I’m doing is undertaking my everyday activity, yet I am creating a huge pool of valuable structured data. If technology can take this a step further again, and use this data in real-time to streamline what letter is sent to the patient based on the coded information I have provided, that means I don’t have to complete a dictation letter, and that has freed up even more time for me.
Cross-team and cross-discipline visibility
Often, we work with organisations to integrate a number of disparate systems into a central repository to facilitate the workflow. The dermatology work is an example of this – we get information from one source and feed it into multiple different outputs, such as local EPRs or GP practices.
A key focus of this work is to allow cross-team and cross-discipline functionality and visibility within organisations.
With cross-team functionality, you’ve effectively got three organisations with three dermatology departments, each with different expertise and different demographics within their patient cohort. They will have areas of particular interests and nuanced experiences. Being able to connect all of those teams on a single platform means that you can share your experience and learning, you can get second opinions with ease and speed. Role-based access is key in order to ensure we adhere with information governance, which includes governing the teams and even governing the IP address of the access. It’s about allowing connected care whilst protecting data.
Another project we are working on is the management of referrals from across the whole country for the Royal National Orthopaedic Hospital NHS Trust. Wherever you are in the country, you can log in and make a referral, but you can only see the outcomes of patients that you have referred, or who have been referred from your organisation. Thus protecting the data of patients referred from elsewhere from unauthorised access.
When it comes to cross-discipline visibility, the work focuses on interdisciplinary and multidisciplinary processes and pathways. An example of this could be a patient requiring a multi-disciplinary team (MDT) assessment, where you’re bringing together surgeons, radiologists, physiotherapists, and other healthcare professionals together to make a holistic management plan. You need to connect the data that these health professionals can see in order to start an MDT, and also facilitate processing of information outside the actual MDT itself, such as being able to review cases and give their sub-speciality input prior to the MDT. This means that when they attend the MDT meeting, they have a much more structured agenda and approach where all the concerns raised by each member of that team can be addressed. Technology has a huge role in supporting this in a streamlined and governed manner.
With regards to connecting the patient into their care journey, at Open Medical, we tend to do this through various forms of patient communication technology. This means using secure portals and encrypted functionality to allow patients to access their data, as well as allowing clinicians to share data with patients throughout various points of their respective pathways where deemed appropriate. We’re currently taking this a step further in terms of patient-reported outcomes and patient empowerment in their care journey. We want to be able to measure patient-reported outcomes over the entire care journey so that on an individual patient level, the clinician can see progress or deterioration of a particular condition and remotely monitor it, flagging anything which may trigger a need to bring the patient back or initiate another treatment, and the patient can also initiate their own follow-up where they find they are deteriorating.
Hopes for the future
We need really high-level, streamlined care pathways within each ICS that allows more efficient care delivery across an entire region.
Perhaps, due to the nature of the NHS and healthcare traditionally being a more conservative industry, change can be difficult. When an organisation is experiencing challenges, I think the solution most often explored is increasing investment to tackle it. Investment in infrastructure, real estate and technology is critical, but I think there is a lot that we can do to improve efficiency by streamlining care pathways within current budgets and expenditure. This will allow us to do the most with the resources that we have, and will allow patients to benefit from receiving more integrated, holistic care earlier in their journey, which will improve outcomes accordingly.
That absolutely doesn’t negate the need for more resources; without doubt there is a need for more investment in health and social care. But there is more that we can do to increase our efficiency through streamlining, and technology has a big part to play in that.
Many thanks to Michael for sharing his thoughts.