Last week we were joined at HTN Festival by Digital Health Care Consultant David Kwo. With experience from working as a Chief Information Officer for various NHS trusts, David considered population health and patient engagement channels in an ICS digital ecosystem, with topics including the importance of case management in managing patient pathways within and across ICSs, and how patients will navigate remote services from their own homes.
David began by sharing the purpose of integrated care systems (ICSs) for context: they aim to improve outcomes in population health and healthcare; to tackle inequalities in outcomes, experiences and access; to enhance productivity and value for money; and to help the NHS support broader social and economic development.
“It’s all about coverage, capability and convergence,” David said, showing the key targets for ICSs: that 90 percent of providers will have a EPR in place by December 2023, with the remaining providers in implementation, with March 2025 as the final completion date. March 2025 is also the deadline for as many providers as possible to meet the minimum capability standard for digitisation, and the key target for convergence states that all ICSs will have developed a convergence strategy appropriate to local context in their digital investment plans.
ICS digital design principles
Moving onto ICS digital design principles, David shared some of his own experience from recent work with the Bath and North East Somerset, Swindon and Wiltshire (BSW) ICS, on their acute hospital alliance programme. David provided some background: the ICS has three acute trusts which are geographically dispersed, and have agreed to use a single instance EPR system.
“What I want to point out is that they have a high degree of clinical collaboration across their three trusts,” David said, “exemplary in my opinion. An example of that is that they have engaged a design authority to work across the three trusts, and they have published ten design principles which they’ve allowed me to share here.”
The ten design principles are:
- Our services and pathways should be designed around the person/patient/citizen journey.
- The EPR should facilitate excellent patient care and experience, reflecting and supporting the diversity and inclusion values of the trusts.
- The EPR should aid improvements in patient safety.
- The EPR must enable citizen self-care, giving them ownership of their medical record and allowing them to contribute to it,
- The EPR should enable population health management and vertical integration.
- The EPR must facilitate continuous improvement and audit.
- Equal weight should be placed on design decisions for each trust, with process designs created from scratch.
- There is a shared EPR with no variation between the three acute trusts, unless warranted and ratified through the Clinical Design Authority
- Information should go into the EPR once and in a user-friendly manner, ensuring efficiency/usability.
- The EPR should be future-proofed and able to interface with new technology and innovations such as AI and remote monitoring
David commented on a couple of the principles to provide more insight. On creating process designs from scratch, he said: “This is really a culture issue… up and down the country, acute trusts are being encouraged to share EPRs. But then the question is, which trust dominates in terms of EPR design and build? This principle states that they want to create process designs from scratch with equal weight on design decisions from each trust… it’s not assumed that the trust running the [chosen] EPR system has the best practice built into it.” It is a worthwhile design principle to consider for other organisations, David recommended, taking into account local contexts.
When it comes to the shared EPR, David highlighted that BSW ICS “are very clear that they want one shared EPR and one shared EPR instance”, but acknowledged that they benefit from having only three acute trusts. Larger ICSs, he acknowledged, will find this more challenging.
ICS digital strategy: framework
Next David showed a graph representing a high-level framework for ICS digital strategy.
The graph presents the patient or citizen at the centre of the ICS, with different factors branching out. Patient portals link the patient to other services such as the ICS shared care record, GP systems, mental health systems, and other providers. From there, other factors are linked in such as community diagnostic hub, virtual ward systems and the NHS App. The full graph is available to view at 11:30 on the video below.
The graph is intended to “give you an idea of the type of entities that one can expect to find in an ICS,” David explained. “But from a patient’s point of view, there are potentially several patient portals associated with these various digital systems, which can be very confusing to the patient if they are meant to interact with various portals.”
Building on that, David highlighted three key points to consider to consider when developing ICS digital strategy.
“The first point is around population health management,” he said. Population health management is “about improving the health of defined populations, in this case within an ICS, at various levels and at various stratifications. So it might be disease orientated or it could focus on long-term conditions. It’s about improving outcomes for those populations and their wellbeing, introducing preventative care and targeted interventions.”
David continued: “In my mind, all of the various systems that you would typically find within an ICS should in theory be connected or interfaced to a population health management system. It can sit at ICS level, on top of a shared care record system, on the back of a trust system… but theoretically, it should link to all of the systems or future systems from the provider organisations.
“The second component is that of case management,” David said. “Case management is about assigned accountability of an individual or team for each patient. Somebody within the ICS would be accountable for the overall coordination of care for a patient – they would coordinate the patient journey from GP to hospital to community to home to social care, and all the other providers, as needed.” They provide a single point of access across the ICS pathways and promote continuity of care.
Linking case management to population health, David commented: “Case management can be seen as the mechanism for taking identified populations of interest for intervention or segmentation from a population health management system, and case managing them on a proactive basis to coordinate patient journeys along pathways.”
The third key point to be brought up was patient conversation management. “How will ICS digital strategies in the future manage the touch points or patient portals of all the various systems in that ICS?” David asked. “We probably don’t want to ask the patient to interact with multiple patient portals in the future. Is the NHS App intended to be the single point of access for a patient in the ICS?”
Here, David posted a question to think about with these three topics in mind. “Who plays the case manager role in the ICS of the future?”
In summary, David emphasised his advice for people working to form digital ICS strategies: “I invite you to consider how your population health management system of the future is going to interact with a case management process or mechanism, to enable an accountable agent to coordinate the whole patient journey. Additionally, who is managing the conversation of all the digital interactions between the patient and the surrounding providers and their systems?”
Many thanks to David for taking the time to join us at HTN Festival.