This September, we’re taking a focus on cloud here at HTN.
We spoke to Piyush Mahapatra, Director of Innovation at Open Medical, for a featured interview; Piyush discussed some of the cloud projects he has been involved in, how cloud technology can be used to support new clinical pathways and models of healthcare, his advice for integrated care systems when implementing cloud tech, and more.
To begin, Piyush shared some information about his background and current role
I’m an orthopaedic surgeon and I specialise in lower limb arthroplasty.
I’ve always been interested in technology, whether that be digital health or robotics, which eventually led me to taking on a role at Open Medical, a clinician-led digital transformation organisation; I initially started in a product-facing role and I have since moved into a leadership role as Director of Innovation, all while being supported by the NHS through the Clinical Entrepreneur programme.
My background and interest is in delivering novel solutions and transformation into the frontline, in particular, with regards to novel technologies and innovations., eventually taking me down a route of working with technology and cloud delivery.
The advantage of cloud tech
The number of cloud projects I’ve been involved in is fairly large – at Open Medical, we’ve now transformed over 35 NHS organisations, and we’ve always had a cloud-first approach.
At Surrey and Sussex Healthcare Trust, for example, we are running a virtual fracture clinic which is a model of treating patients with broken bones that attend a minor injuries unit or emergency department and are then referred to specialist orthopaedic surgeons. That model of care has numerous delivery mechanisms and structures. At Surrey and Sussex, we are fully integrated with their existing EPR and we are able to consolidate all their referrals and orthopaedic trauma activity within one platform, which was an issue before as they had referring sources from minor injuries units that were outside of their digital infrastructure. Cloud facilitated that connection and helped us provide a unifying clinical workflow solution, which essentially meant that patients could be referred from a minor injuries unit to the central specialist site on a readily-accessible, browser-based application. All of that data was then returned to the central EPR.
The significant advantage here is that we were suddenly able to capture a lot of data that was previously running in a workflow completely outside the primary EPR. Thus, helping to consolidate the regional pathways into a single platform and allowing the Trust to make better informed decisions. This really brings out the message around the separation of applications and data, and cloud enabling that to occur.
Cloud pathways within an ICS
My first example here is around community-based diagnostics. I’m sure a lot of people are familiar with Professor Sir Mike Richard’s report around improving cancer care, and specifically setting up community-based diagnostics and the efforts to bring cancer diagnosis forward to much earlier in the pathway.
One particular model that we are looking at, at Open Medical, is around community-based diagnostics for skin cancer. We’re undertaking a large project funded through NHS England, in partnership with the SBRI healthcare programme. The project is setting up specialist dermoscopic assessments within local GP practices, so that patients can be referred to dermatologists in secondary care.
We’re seeing that about 98 percent of patients do not require a face-to-face consultant dermatology assessment. A high quality image is taken and their medical history is submitted, and the dermatologist is then able to use this information to make a definitive diagnosis. So the dermatologist can discharge patients if they are not concerned, or if they are concerned, further investigation through a biopsy can be arranged directly. The aim is to reduce that diagnostic journey by a significant amount, by minimising the touchpoints that are needed until we arrive at that definitive diagnostic test.
There’s no reason why implementing that model for other conditions is not feasible, developing straight-to-test pathways. With the emergence of community-based diagnostics, having that information flow on a readily-accessible cloud system that can connect an otherwise fragmented digital landscape. It helps to unlock these new pathways and models of care delivery.
There’s a similar project around elective surgery, with the move towards high-volume, low-complexity surgery. That’s about being able to deliver care at a regional level; you need a combined surgical waiting list and you need to be able to allocate patients based on capacity and demand. Cloud is the only way to go for a lot of that regional coordination.
Connecting primary and secondary care
Primary and secondary care have traditionally been on completely different infrastructures. The challenge has always been making that communication between them seamless. When you’re looking at primary care, there are a lot of individual installations, with every practice or small unit potentially functioning as a standalone entity.
NHS Digital are doing some excellent work around here to bridge that gap a bit, in terms of allowing suppliers a fairly defined route towards integrating with national applications.
One thing that keeps coming up at the moment is around workforce, particularly the challenges that we have in finding staff. Therefore, I think we need to start thinking about smart ways of working and being more flexible in terms of how we can allow people to work in different ways; we need to allow them to access information based on need, rather than restricting on the basis of their physical location, allowing them to work collaboratively.
Going back to the skin cancer project that I mentioned: we are now utilising primary care staff to deliver what is effectively a secondary care service, hosted within a primary care location. So that means you have a member of staff who needs to log-in and access the secondary care system.
That’s the power of cloud – it has allowed us to deploy primary care staff very flexibly and allow the secondary care organisation to manage their user permissions and authentication remotely. Similarly, it’s good to have a workflow system where everyone is working off the same application, looking at the same thing, and there’s one version of that data. If people are working on different infrastructures then you potentially have issues with version control – is secondary care looking at the most up-to-date message that has been sent out of primary care and vice versa?
Considerations for implementing cloud tech
I think at the moment we have a golden opportunity to really utilise cloud and take advantage of it.
The NHS has had a cloud-first approach for a number of years now, and for various reasons there has been slightly slow adoption. I think things are certainly picking up, however, and if you look at NHS Digital’s new architectural principles they are very much promoting a public cloud-first approach that utilises modern web browsers.
I would suggest that ICSs look for suppliers that have deep technical knowledge. I would recommend that they talk to senior engineers or cloud architects within the supplier teams, to see whether the supplier really understands their technological capability. It can be challenging – there’s a lot of health tech out there, and sometimes the technology has been outsourced or the organisation itself can’t continue to adapt and evolve. The real advantage of cloud is that it allows for that ongoing continuous development, transformation and change. However, that development is really needed with an understanding of the clinical environment because by their very nature things move and change all the time.
I would also recommend that ICSs look out for suppliers with a good understanding of the security requirements. My personal opinion is that cloud, provided that sound security principles are being followed, is secure. There are obviously always concerns around being able to access machines from anywhere, but if you look back at the 2017 WannaCry attack, for example, that was an issue with legacy systems not being patched and kept up-to-date. With modern cloud’s sound engineering principles, security shouldn’t be an issue but it’s worth ICSs verifying that with suppliers.
The other thing they need to consider is how they want to implement cloud solutions. I think that the separation of data and applications is the best way to go. The ICSs can own the data and can create structures so that you can access the same data wherever you are within the ICS. Then you can have an application layer which can access the data and meet specific requirements for that particular use case. That will then allow the best of both worlds. You have the control and oversight that something like an EPR in its current guise gives you, but you also have the flexibility that the best-of-breed approach gives you, where you have specific applications for specific use cases that are highly optimised around user requirements.
Supporting new pathways and models
I’ve already touched upon the regionalisation of care, which was the whole reason for the implementation of ICSs, but the virtual fracture clinic is again a good example here.
That model has an integrated fragility fracture service. Essentially what that means is because the technology captures all fracture referrals through a unified system, we are able to automatically identify patients who are potentially fragility fractures. We can refer them to a fracture liaison service through our system, where they can receive treatment and secondary fracture prevention care such as bone protection treatments.
Having a unified cloud system in place here at a regional level means that we can capture all of those referrals and engage other allied specialties and multidisciplinary teams to deliver a preventative and holistic care approach. Cloud can really support the drive towards earlier intervention and more proactive, preventative care.
Another major example is around preoperative optimisation. By having that unified cloud system that can link everything together, we can move the point of assessment and optimisation for surgery to a point much earlier in that patient journey. Hopefully that can then have significant knock-on benefits to the whole system.
We’ve also worked with the Royal National Orthopaedic Hospital; they deal with complex referrals across a large part of the country. They’ve taken a cloud-first approach to their referrals and they are currently able to receive referrals from any healthcare provider, which was particularly useful during the pandemic when they had to rapidly evolve into a trauma setting. Being able to quickly take referrals that capture granular data from across the country really helped to decompress some units in terms of capacity. Also, the cloud-first approach has helped with team-based working and communications, so everyone can see the information and history of the patient rather than that information being siloed.
I think it’s worth emphasising how cloud helps with change – as we’ve seen over the past couple of years, transition and flux can happen very quickly. Having a cloud infrastructure and set-up allows for very rapid adoption of change.
What would success look like in three years for a digital ICS?
I think there are a few key things that would be really good to see.
First and foremost, from a technical perspective, I’d want to see a defined data model and a data warehouse with a suite of accessible and high performing APIs that allow applications to access that central data.
Secondly, we need a clinical workflow application suite or platform. Looking for platform-based suppliers is probably something that is going to yield the most long-term benefit because it will allow for modification and upgrades as we transition. This suite or platform needs to actually address clinical workflow problems and challenges, delivering real user benefits. This is particularly important as we don’t want to end up in the cycle that we are seeing in some other healthcare systems, with frustrations around the digital technology in place. I think the UK has a very vibrant and forward-looking health technology market and I think that is something to really look at closely and see if there’s real value in adoption.
The biggest thing is around establishing a culture of embracing innovation and evolution, particularly with a user-centred approach. There needs to be an understanding that digital transformation is not a hit-and-run type transformation. This is a continuous journey, you need to partner with suppliers and technologies that will continue to evolve and continue to be adaptable, because your clinical environment will keep evolving too. We need to make decisions now that future-proof ourselves going forward, and I think if we get this right, the rest should follow.
Many thanks to Piyush for taking the time to share his thoughts.