For our latest edition of HTN Now focusing on digital integrated care systems, we held a webinar with Imprivata to explore the role of a digital identity framework to support transformation across health and care systems.
The session was led by Andy Kinnear, Consultant and former CIO, and Andy Wilcox, Senior Solutions and Enablement Manager.
Andy K began by setting some context for the current NHS landscape.
“The last decade has created probably the most challenging NHS environment any of us have ever been involved in,” Andy said, listing factors such as the 2011 National Programme for IT, the COVID-19 pandemic and yearly funding cuts as contributors to this. Funding is a particular issue; Andy shared statistics showing how NHS budgets rose on average just 1.4 percent per year between 2009 and 2019, compared to 3.7 percent average rises since the NHS was established. This is despite demand for services rising approximately 4 percent per year.
In the face of these challenges, Andy suggested that it helps to “focus on the people who, regardless of system structure or funding, are the most important – the patients and anybody who is in direct contact with them, delivering care to them. I’ve been lucky to be involved in a really good piece of work over the last year or so and I want to share some of its results, because I think it leads us onto the whole point of why digital impact is more complicated perhaps than people necessarily believe.”
The Arch Collaborative programme was created by US company KLAS Research, who specialise in researching the impact of digital systems in a healthcare environment, particularly the way in which they are received by users. The Arch Collaborative is a global programme spanning 275 provider organisations across 12 countries (with the entirety of the NHS counted as one organisation within that). Participating clinicians answer a short survey on the degree to which they are satisfied with the digital systems they are using, and use the data to create resources such as case studies of high-performing organisations, best practice reports, webinars, yearly summits and training quality benchmarking.
Results from the research show that clinician satisfaction with digital systems varies widely, including among clinicians who are using the same system. “What this is starting to tell us is that the determinant of clinical satisfaction is not necessarily determined by the product that you buy,” Andy said. “It’s undoubtedly a factor, but it’s not the primary determinant of success.”
Other determinants of success, Andy continued, include the organisation itself and the degree to which it is committed to improving its systems through investment, infrastructure and so on; and “the degree to which the individual user is competent and capable within the system – and of course, the degree to which they are supported and developed through training.
“The point that I really want to stress is that organisations have far greater control to improve user experiences than people like to think,” said Andy. “The conclusion that we have drawn from this work is that there are four key efforts that need to be made.”
The first area is infrastructure and integration: viewing infrastructure as the foundation of EPR usability and satisfaction, and looking for opportunities to improve reliability, response times, and internal/external integration. The second is shared ownership, with the need to acknowledge clinicians’ desire to have a voice in prioritisation of enhancements and updates, and emphasis placed on the importance of clinicians feeling a partnership with their IT department and the EPR supplier. The third area, digital mastery, focuses on how “NHS-wide improvements to training resources are a dire need” and notes that “particular attention should be on training for personalisation available to each EPR in order to improve overall efficiency”. Suppliers are the fourth area requiring focus, with Andy noting that research indicates that EPRs do not meet basic expectations for clinical use for acute, mental health, learning disability, community and ambulance sectors.
Andy W took over at this point to discuss the opportunities that ICSs present.
“The bedding down of ICSs is going to take time, innovation and strong leadership,” he said. “I want to talk about the issues that Andy raised earlier and extrapolate it into the ICS environment.”
The first issue that Andy highlighted was around improving clinician experience.
“One thing that stuck out to me about the research into EPR usage was a comment from a clinician on the frustration of using the EPR, but when you actually read the comment, the frustration wasn’t with the EPR itself but with the computer,” he shared. “The underlying infrastructure was the problem – logging in, waiting for the computer to boot up, and so on. As Andy said, the difficulties can focus on elements outside the EPR. So what we really want to try and do is to improve that experience.”
Andy highlighted opportunities for ICSs to improve, covering improved clinician experience, collective buying power, relevant standardisation and appropriate convergence.
“ICSs have the chance to move staff around, to ease manpower pressures,” he said. “But it brings challenges. If you’ve got 20 or 30 different organisations within the ICS, of different categories, then a clinician needs many different identities to be able to move around them and deliver care. Organisations also have to manage the on-boarding of staff, the off-boarding, provisioning, getting people ready. There is a real opportunity, I think, for ICSs to standardise on certain levels of infrastructure. By doing this, they can create an expectation that a clinician can go to any organisation within the ICS and get the same baseline level of experience.
“Some of this centres around digital inclusion as well; it’s about making sure people have the right level of skills to use the systems. It needs to be considered – within the numerous organisations, there will be some that are very digitally mature with the latest tech and very efficient ways of working. Within that same ICS, you’ll have other organisations who are not digitally mature.
“Some of this goes hand-in-hand with the point about standardisation,” he said. “Decision-makers within ICSs need to take responsibility for identifying opportunities to bring everybody up to that same baseline level. Then they need to use that collective buying power to deliver that standardisation.”
Andy shared an example from Imprivata’s work: “About two years ago, we were working with a region to create a buying framework for all organisations within that region to invest in a single sign-on access management product, at a flat cost across the whole region. The individual organisations were able to buy into that. What that does particularly well is that it helps the smaller, less cash-rich components of the ICS to buy into some of those technologies that the bigger organisations within the ICS have already got. It creates a level playing field and it lessens competition about getting access to money.
“It comes back to standardisation – it’s about looking at what’s present and identifying a baseline standard of access to computers, to applications, to clinical systems, and most importantly, access to data. That’s really what these systems provide, access to the information about the patient to deliver higher quality care.”
On the topic of convergence, Andy said: “My view on this is that convergence can be the right thing to do in certain places, but we shouldn’t do it for the sake of it. It doesn’t necessarily make sense for everyone to be using one EPR across the whole ICS. A lot of different training and configuration has already gone on, so it’s important to think of it in terms of what makes sense to converge.”
“I’d agree,” said Andy K. “What it requires for a lot of people is a different way of thinking and in particular, a different way of behaving. I think one of the slightly more subtle challenges I see is that through the years of commissioning-focused versions of the health service, it has been a relatively competitive environment. Inside the NHS there have been levels of competition between organisations in the same city or across the same patch. I think that people who have been successful have often been those who have been motivated and driven by that competition. This future world requires a different sort of thinking. It requires much more collaborative leadership, it requires people to be much more interested in the holistic patient journey.
“I think some of the topics we’ve raised here could be healthy drivers to a more collaborative set,” Andy continued. “If we have clinicians across a patch collectively looking for the same support, then that’s a driver. ”
“It impacts the factor of collective buying power as well,” added Andy W. “When you move away from competitive bidding for pots of money and move wards looking at purchases from a collaborative perspective, you can work together to buy something that you need which will deliver benefits for end users and develop best practices so that it can be deployed across the whole ICS.”
Andy K brought up ICS digital governance. “Two topics always come up in conversations about this,” he said. “The first is needing some level of consistent design authority function. People want an ICS level set of processes for digital decision-making. The second topic revolves around finances: how do you carve up a budget so that it actually focuses on the right priorities?”
Moving onto why digital identity is important, Andy W said: “At Imprivata we’ve been talking to NHS Digital a lot recently about why digital identity is going to be critically important within ICSs. The core of what we are trying to achieve within an ICS is to deliver better quality care across all settings, from primary to community to child services. What we really need to do is make sure we facilitate the rapid access to patient information for clinicians across the whole ICS. That means that there needs to be some degree of consistency about the use of identity across the ICS.
“Some of that can be delivered through interoperability and shared care records,” Andy continued. “Some of it is going to mean provisioning user accounts across multiple different organisations, to allow access to that data. It’s hugely complex. A lot of these organisations have their own active directories, their own identity store. But we want to hide that complexity from clinicians so that they can just tap their badge into a computer wherever they are in the ICS and have that same consistency of experience in accessing the systems.”
Ultimately, Andy said, this reduces digital friction. “With all the pressure that clinicians are under, having to try and remember which password they use in this organisation or how to use the system in that organisation is just not conducive to good care. It can potentially impact clinicians’ focus on patients.
“The other element here is the adoption of digital technology. We see this quite often. I’ll give you an example of a mobile project we deployed in a trust in the north – there was resistance to rolling out mobile devices across the trust because of the challenge of identity as staff struggled with logging in. Nurses were very vocal about the fact that they didn’t want the hassle. How do you deliver an e-observation project via mobiles if the people who will be using the mobiles are saying that they aren’t good enough? By recognising that the identity component was the blocker to that adoption, we can address it a streamlined, integrated IM solution on the mobile device through Imprivata mobile device access.”
Identity is often a challenge when it comes to the adoption of digital technology, Andy said. “We all face it in our own lives – you’ve got passwords for all these websites and if you don’t have a password manager then you have to keep them all in your head. When if you forget one of the passwords, there’s the issue of resetting it, sometimes you can’t remember which email you used, and so on. All of those challenges become frustrating. We can’t throw that into the mix for a clinician who has been working for hours in a pressured environment.”
Security also plays a significant role in digital identity. “You hear stories of generic accounts for locum staff, for example,” Andy commented. “With that, you have no proper auditing of access to systems and you can’t really know who is using what. That ultimately leads to a degradation in the security of our systems and the data that is contained within them.
“The other opportunity presented by having a very streamlined digital identity within the ICS is the ability to explore new clinical workflows,” he said. “A well-implemented digital identity and IAM strategy can really provide that.”
“The identity space can be very complicated,” commented Andy K. “Having a level of expertise in the management of all of this is critical. I think it’s fair to say that not every NHS organisation can afford that skillset, so it’s another great argument for ICSs. With organisations working collaboratively, they ought to be able to afford more of the right skills.”
Looking at Imprivata’s digital identity framework for healthcare, available to view at 47:20 on the video below, Andy said: “When I started in the NHS I was a statistician, I’ve always been driven by data and measurement and understanding the reality of a situation. What I like about the framework is that if we were to take it and do a benchmark exercise across each of the ICSs at the moment, looking to understand the state of the nation and the local positions, I think we’ve got a great chance to begin to understand what needs to be done next and where the priorities are. The framework gives us the chance to create a level of measurement and maturity assessment about digital identity.”
Concluding the session, Andy W said, “From my perspective, what ICSs are trying to do and where digital identity fits into the ICS strategy, is fundamentally about improving life for clinicians and giving consistency of experience across organisations in the ICS is a major element of that. Ultimately, it will lead to better patient outcomes.”
When it comes to how that can happen, Andy K summarised: “There’s a teamwork element, including clinical skills and digital skills. We need to elevate the conversation to an ICS level to start operating as a true system. There are organisations in the UK and around the world who have delivered much of this already, and I would encourage people to look around for ideas. To get through that improvement cycle, you need to improve the baseline but then keep running a continuous cycle of improvement time and time again.”
At this point, Andy and Andy moved on to answer some questions; this section can be viewed below from 52:29.
