Our latest HTN webinar looked at the role of digital in supporting the primary and secondary care interface, with our experts sharing details about their own approaches and experiences in this area, including best practices and key learnings. We also explored interoperability, collaboration between care settings and how digital can ensure patients are directed to the right place at the right time.
Panellists included, Kath Potts, chief digital officer at University Hospitals Plymouth NHS Trust and Dr Sheikh Mateen Ellahi, GP and practice partner at Elm Tree Surgery and South Stockton Primary Care Network.
Wider introductions and latest projects
Kath started by explaining her role and the projects she and the team at the trust have been working on. “We’re a large acute trust in the South West providing both tertiary services and some community services. We’re currently embarking on a One Devon EPR programme, rolling out a connect model across the three acute trusts in the region, with two sites already live and two sites due to go live next year.”
Speaking more specifically on her own role, she said: “I’m a nurse practitioner by background but have moved over to a digital role within the EPR programme, while also leading our digital teams here at University Hospitals Plymouth.” She shared how the digital team is particularly prevalent in the primary and secondary care interface “as you’d imagine for an organisation with three acutes and multiple sites on a single EPR”.
Mateen then told us more about his role and organisation, stating: “I’ve been a doctor for about 11 years and have been a GP partner for six years at Elm Tree Medical Centre. I also have roles in digital health as a medical director of one of the new EHRs coming into the primary care sector.” On the medical centre’s digital and primary care progress, Mateen explained: “We like to think we’re quite an innovative practice in the North East of England and we’ve also done quite a lot of collaborative work in the community. I’m happy to talk about the interoperability between primary and secondary interface and mainly the challenges we face, but I do believe that over the last 10 years nothing has changed much, unfortunately, and I think the future remains uncertain.”
Challenges with interoperability in primary – secondary care
Our panellists next went on to discuss some of the challenges they’ve seen within their own organisations and projects, with Kath sharing some of the unique challenges she’s faced when trying to implement a single EPR system across all of the acute trusts. “Across the primary care space we’ve got multiple different providers in terms of systems that people are using. To add to this complexity, our colleagues across the peninsula are actually moving to a different EPR. So, we have to consider interoperability between two different EPR systems.”
Expanding further on this point, Kath explained: “Our ultimate goal is to make sure that everyone has real-time data available without having to go through multiple systems or logins. How we manage that between multiple primary care systems and multiple EPR records across a very broad population is the main challenge for us at the moment.” She shared how their focus is primarily on creating the best user experience when it comes to accessing data and finding workarounds to help tackle the problems with interoperability.
“There are also challenges with finding the right solution that works for everyone,” Kath said. “Because, as you can imagine, we need to think about our primary care colleagues as well as the wider service and other sectors, and one solution might not fit all. I don’t have an answer to that challenge at the moment, but it’s something that we’re working on.”
“For me, the biggest challenge with interoperability or having one system across multiple sites, is trust,” Mateen said. “It’s the soft skills, rather than the hard skills. The hard skills being the meetings and the resources, time, etc., and the soft skills being the trust itself.” Explaining more on this challenge, Mateen added: “Are we, as primary care services and community services, able to trust each other? And not just each other, but also the technology itself to be able to handle interoperability from one system to another. That’s the key in my opinion.”
When considering how to solve these issues, Mateen suggested further development in soft skills, including encouraging involvement from all the key stakeholders, however he recognised “how tricky this could be at a larger scale”. He also suggested: “It’s naive to think that the NHS will ever have one national clinical system. Partially because of procurement history and partially because hospitals and GPs just need different workflows. But if we can get interoperability to a stage where you can view one system from a different system and see the same clinical data, that’s where interoperability comes in.”
Feedback from key stakeholders, patients and primary care
When asked about the involvement and feedback received from key stakeholders on the One Devon EPR, Kath said: “We’re always working closely with stakeholders, as well as patients and primary care. Our approach began with mapping out the patient journey and looking at what people really need. For example, we started with the premise that everyone should be on the EPR, before realising from feedback that that’s not entirely necessary. For our community partners, read-only access is probably enough.”
Exploring this in further detail, Kath noted: “I think there’s a huge piece of work still to do to understand what’s driving the EPR in some areas and what the concerns are in other areas.” In terms of adoption and uptake, Kath added: “We were one of the early adopters of the NHS App and if you look at the data there, we’ve got some practices with great uptake, where we’re in the top quartile, and others where there’s limited-to-no uptake whatsoever. So, it might look like things are going really well, but you’ll have pockets where it’s either not being taken up or not being adopted.”
Kath added: “I think the key thing is going to be that education piece, showing this is what’s available, this is what you can do and then really trying to get some champions on board who can share some of the real case studies on the difference that it has made for the clinicians, the user and the patient.”
What good looks like for the primary – secondary care interface
To demonstrate what good looks like when it comes to the primary – secondary care interface, Mateen highlighted an example: “Let’s imagine an 86-year-old woman who has been seen at a hospital for acute kidney injury, was given IV fluids, maybe some antibiotics because she developed an infection in hospital and was then discharged after a week in care. Some of her blood pressure medications have been changed because she developed a kidney injury and she’s been discharged. She calls the GP practice after a week and tells the doctor she’s finished the medications the hospital gave her. Can she have some more? We as doctors go into our system and we have a look and we see no discharge letter. We ask the patient about the medication, but they’ve already put it in the bin because it’s finished and they don’t know the name of the medication.”
Mateen then outlined the same scenario where the discharge plan can be seen by the GP within the same second or same hour that it has been added to the system because of interoperability. “Any medication change can be accessed from the primary care provider itself,” he said. “And any medication changes can be made instantly by the GP and provided to the patient before the patient even contacts the GP.” He explained how this version of events is more beneficial because it “saves time for the patient, reduces frustration and anxiety, saves lots of resources from an NHS point of view and reduces hassle from our administration and a clinical point of view. So, everybody wins. But I guess that’s easier said than done.”
After highlighting both scenarios, Mateen concluded: “What good looks like is the patient telling their story once, the hospital doing their job once, a GP doing their job once and not having to repeat everything to get the same message across to several different teams. To work collaboratively rather than creating extra admin for each other.”
Moving forward and balancing priorities
On the topic of progression, Mateen emphasised the important of “having the guts to challenge the status quo and helping revert the issues we already face.” He added: “I don’t think we need to wait. Everyone’s talking about the 10-Year Plan, but I don’t think we need to wait for 10 years to pass by. We need to prioritise now.” However, Mateen also recognised that not everything can be done all in one go, stating: “I think it’s impossible to try and fix everything at once. But I think choosing simple, high-impact areas is always the best way forward. That might differ from ICB to ICB, but for me it would be looking at referral templates, shared care records and synchronised communication between GPs and consultants.”
For Kath and her team: “the focus is very much the EPR and that’s because we’ve been in implementation phase since March”, which is why it has been the main priority moving forward for the trust. “It’s taken priority over the majority of elements, but we’re also looking at how we can optimise and what our other priorities look like,” she explained. “We’ve set out our digital strategic intent over the next few years, and there are things that will have to come afterwards or things that the current EPR platform doesn’t provide that we’ll need to be looking towards in our future roadmap.”
As part of that roadmap, Kath touched on the importance of clinician participation and how it can help to direct those priorities: “I think if you spoke to our clinicians, what they’re wanting are the things that actually make their lives easier and make things far more productive and efficient. Ambient AI is certainly high up on that list. So we’re still working on that. We’ve got an AI group and a clinical taskforce and we’re looking at what comes post-EPR, so that we can get on with that as soon as we have capacity.”
Managing the digital front door
“From a front door point of view, we’ve had pretty good access over the last couple of years,” Mateen shared, as he discussed how digital tools have benefited patients and clinicians at Elm Tree. “Patients don’t have to worry about the 8am rush. They can call at 3pm, 2pm, 1pm or whenever they wake up and if they want an appointment that day, they get an appointment that day. Because of that, we’ve had success in the patient survey results and our Google reviews etc.”
He highlighted how the practice is currently adopting digital triage technology to be ready for October, outlining the importance of maintaining patient satisfaction as they go through this: “We’re being careful so that we don’t compromise the high level of patient care that we’ve already built because it only takes a few instances to ruin your reputation and we just need to be mindful of that.”
Local interoperability between primary and secondary care
When asked how the local interface has been set up in Plymouth, Kath said: “We’ve done a lot of work on our interoperability group, which is our local interface. Not just with primary and secondary care, but with other community services and mental health providers to see how we link up. I think the EPR has driven that, if I’m honest, not just for our local group, but for how we connect with our Cornwall colleagues and make that as seamless as possible. Prior to the EPR, that was limited.”
In terms of the benefits realised as part of this, Kath explained: “I think it’s been really good from a networking point of view and in helping to guide that future roadmap in terms of what the next few years look like. We’ve had some really good discussions, workshops and responses from people. But I would definitely say the EPR programme has been the conduit for making that happen.”
Kath then spoke about some of the lessons that have been learned from the One Devon EPR programme, highlighting how the main consideration should be on “making sure that you’ve got people involved from the very start of the journey and shaping what those best practices are”. Expanding on this, she explained: “You want to make sure it’s a user- and patient-centred system and a big part of that is communication and making sure that you get those messages out early or at the right time. We’re very focused on ensuring our staff know who to call or what happens when their password is not working, for example.” One of the ways the team has achieved this by implementing a help desk for both patients and staff, Kath shared.
Short-term changes for the future of the primary – secondary care interface
Finally, our panellists each gave a summary of short-term changes that could be made to impact the future of the primary – secondary care interface. For Mateen: “It would be to mandate interoperability standards and invest in making existing systems talk to one another. So, having all the information from one primary care or secondary care service be seen from the other side instantly. If that can be done, that would be a game changer for me.”
From Kath’s point of view: “It would be some form of platform that actually makes digital communication easier and more accessible. Something that’s much more responsive, so that we can get rid of some of those frustrations around not being able to contact your clinician, to help reduce delays and make the best use of people’s time. If we could solve that and make systems that much more user-friendly, giving people the right access at the right time, I think that would be the thing I want to put in place.”
We’d like to thank both Mateen and Kath for sharing their expert insights with us.
