For a recent HTN Now session exploring what good looks like for a digital patient journey, HTN was joined by a panel of experts from across the health sector. Panellists included Shanker Vijayadeva, GP lead – digital transformation in primary care, London Region, NHS England; Amanda Jackson, associate CCIO and digital inclusion lead, Leeds Community Healthcare NHS Trust; Tom Stocker, CHCIO and EPR adviser; Simon McNair, head of digital business development, Restore Information Management; and Tom Baldock, MD at Synertec, part of Restore Information Management.
Our panel each offered a brief introduction to their role and remit, with Amanda outlining her role as associate CCIO and digital inclusion lead for Leeds Community Healthcare, Tom Baldock explaining his position as MD at Synertec which has recently been acquired by Restore Information Management, and Shanker sharing his background as a GP and current digital transformation roles with NHSE and West and North London ICB. Simon told us how his role focuses on helping organisations to manage paper to digital transformation programmes; and Tom Stocker highlighted his current involvement supporting Norfolk and Norwich with their EPR programme and integrations, as well as his background supporting NHS trusts around the country.
What does good look like for a digital patient journey?
Tackling the subject of the webinar, our panellists considered what good might look like for a digital patient journey, with Shanker suggesting that it should be so seamless that the word “digital” doesn’t have to be mentioned, as it becomes part of business as usual. “If you strip away the digital, does it work for the patient?” he asked. “Is it intuitive, easy to understand, and does it flow sensibly? Where there are step-offs into non-digital, and is that part smooth? I think it’s really important to analyse the whole journey, not just the digital elements.”
Echoing the need for journeys to feel seamless, Tom Baldock noted the tendency to sometimes go too far with the digital piece, in terms of maybe those who don’t want that, or don’t want to interact in that way. “It’s not only getting those step-offs to fit seamlessly if an individual has alternative preferences or requirements; it’s linking them together so that digital works alongside everything else,” he added.
“From a patient perspective, it should be simple, with no repeating themselves, and it should work for staff as well,” Amanda noted. “Digital inclusion also matters, because if it isn’t easy and inclusive, patients and service users aren’t going to use it, so we need to ask them how they interact with digital and how we can support them with their digital journey. There are lots of reasons people don’t interact with digital health, whether that be fear or lack of digital literacy, or simply choosing not to, and it’s important we recognise that.”
At Leeds Community, a screening tool on digital literacy and ability is embedded into the EPR, Amanda told us, which allows information to be gathered about how patients interact with digital on a “really simplistic level”. It includes questions about access to devices and connectivity, and ability to complete simple digital tasks like following a link, she shared, “and it’s about user-centred design and having those conversations with our patients and service users”.
“There’s an opportunity for us to also take that further and for the NHS to ask people how they want to be communicated with,” Tom B agreed. “At the moment, we tend to try digital until effectively we don’t get the result we’re looking for, before we try something else. Maybe we could be more proactive and ask the question, or provide a service that offers choice in that process to make sure people are getting communication in the form they need.”
A good digital patient journey is centred around patient need, considered Simon, which is a key part of personalisation. “In our day-to-day lives, we communicate with businesses all the time, and we can set preferences for how we want to be contacted,” he explained. “It’s about personalisation both in terms of how you’re communicated with and the content of that message that drives the right outcomes, or the patient to be at the right place, at the right time, with the right information.” This becomes more complicated when considering the number of different providers patients might interact with on their journey, and the fragmentation between systems, he added.
Pointing to the lack of consistency across the NHS with this kind of work, Shanker said: “We get told to record communication preferences in our EPRs, but they don’t track any of this. From a patient’s perspective, they often see it all as one NHS, rather than every separate organisation, so my wish would be that we do that preference tracking and some of those digital inclusion bits, like distinguishing between smartphone users and non-smartphone users. Maybe we could use a default setting, and then as individual organisations we could choose to override it or update it – that would be more closely aligned with what we experience in our daily lives in retail and other industries.”
“What people have done in the last ten years is they’ve usually bought these digital solutions, plugged them together, so you’ve got an appointment reminder or an initial invitation coming through digitally, and then if they’re not accessed in the next 24 or 48 hours, there’s a failover to a physical letter, and that’s where it stops,” said Tom Stocker. “That’s what everyone has done, because there has been NHSE money and policy for it, but that’s not necessarily what I have heard patients asking for – I’ve been quite shocked by the lack of patient engagement in some trusts.” There’s a lot of scope for more patient engagement, he went on, as well as more user research work, and the potential to use things like AI.
“For the patients, what really matters is that they have to keep all these rheumatology appointments, which they could do from home and keep their job more easily, or look after their kids,” Tom Stocker continued. “The fundamental drivers are what makes their experience better, what improves outcomes, and we’ve got this low-hanging fruit in digital because we know about care journeys, we’re often in the same team as the BI team, and we can ask questions or bring value in a completely different way to our operational or clinical colleagues.” A good digital patient journey should not be a digital way of enabling an existing pathway; it should be digital as a genuine pathway partner, looking at doing things differently and working with the latest tech to make those improvements, he offered.
Shanker agreed with Tom Stocker’s point about not doing enough user experience work, or doing it purely as a tick-box exercise with a few patients who might not represent those at risk of digital exclusion. Not enough resources are allocated to helping people use things like the NHS App, he noted, or implementing patient feedback when it does come in. “It’s not only having the drive to go live with a product, but keeping that drive going once it’s live – it should be an ongoing process,” he suggested.
Tom Baldock discussed his experience of trying to work on getting feedback or engagement from patients, noting “take up of that in general is really low”. Key challenges for the NHS are budget and resource constraints, he considered, “but that’s where commercial businesses can help – find out about the issues, then get that information and make sensible decisions about what can happen going forwards”. Ultimately, it’s about communicating with people in a way that makes their journey better, he went on, “and it might be that they say they never want to receive another text message, but let’s stop and listen to that”.
Improving the digital patient journey
“Everyone in the NHS is well motivated to do what’s right for patients, but there’s something about how it gets stuck at the governance, leadership, or practicality layer,” Tom Stocker observed. “I’ve seen that get unblocked with a really good strategy and really good leadership around that strategy, but I wonder whether Amanda could offer some insight from her perspective about what it would really take to shift an NHS organisation into a more patient-centric model?”
Amanda shared how at Leeds Community, what has worked really well has been going out and having conversations with staff and patients. “We can’t expect our patients to turn up at our head offices and have conversations with our digital teams – we need to go out into our communities,” she said. “We’ve also got a really good community third sector organisation group within Leeds, we have 100% Digital Leeds that is run by the City Council and brings together partners interested in digital; I’m part of their group and I go out and have conversations with our patients and service users.”
The projects that are successful are the ones that have clinicians on the ground, Amanda acknowledged, “and when we look at user-centred design, we absolutely need to include patients, but we need to include staff, because they know what our patients want, as well”. The take-home message is “be curious”, she continued. “Talk to people outside of the digital world, help them understand what the aim is, and then help them drive that aim with you.” The team at Leeds Community has devised a design strategy around involving people right from the start, which has helped with the involvement and engagement piece, Amanda told us. “Then it’s keeping comms at a simplistic level, letting people know what is happening, because if they don’t know how it works, they won’t use it.”
“What always stuns me is the number of times I’ve seen things get rolled out when the people rolling them out haven’t actually tried it or tested it themselves,” Shanker reflected. “I’m not saying I watch a lot of Gordon Ramsay’s programmes, but he would scream at his chefs for sending stuff out of the kitchen without trying it – why do we do the same with digital for our patients?” Experiencing what the patient experiences is integral, he highlighted, “and we do really need a feedback loop, as well as a roadmap that clearly shows where feedback has been actioned”.
“We need to stop thinking about communication as a commodity – it’s historically been considered as the cheapest possible way you can get something to somebody, but in today’s world with the myriad of different communication methods on offer, it’s starting to become an expert industry,” said Tom Baldock. “We need to understand the positives and negatives of every format – if you get 164 characters for an SMS, it’s probably not a good way of sending out large amounts of information. There’s evidence to show emails are not as easy to read on screen as a physical piece of paper. The NHS needs to fall back on expert communications providers to get that understanding and help drive the digital piece going forwards.”
Shanker considered how in an ideal world, things would be so easy to use that no additional training or communications would be necessary, like with completing an online shop. “I also want to mention, outside of communication, the challenges that arise from using different systems,” he continued. “An example is the electronic prescription service, which is difficult to push through all the different EHRs, not all community providers have it, and a lot of our hospitals are struggling with the standalone platforms or just waiting for their EHRs to engage. The next problem about digital journeys is where patients are frustrated they can’t get the same experiences in different parts of the NHS.”
Tackling that means looking at the beginning of a procurement journey or strategy development, and planning ahead to promote uniformity, according to Shanker. “Now, with looking at things like prescription tracking on the NHS App, it’s considering that seamless journey of how we get all the EHRs on board with the vision, the strategy, and so on. Ideally, you want it not just to be contractual, but you want those suppliers to buy into the patient journey, seeing that it adds value to their products.”
“Innovating and structuring patient communications in EHRs the way you want to is possible, but it’s made difficult and expensive,” Tom Stocker commented. “The other thing to touch on is what framework to use to measure patient-centred outcomes following digital tech implementations? For that, you have to really know why you’re doing it, and then what matters.” Feedback or outcomes can be collected and analysed “very easily” now through targeted surveys, workshops, or direct engagement, he offered, “and the most productive conversations I have with patients are walking around inpatient or outpatient areas, where you can catch people who might not turn up to a workshop, or who are less confident”.
Simon emphasised the importance of getting patient records and data into a format that actually supports clinicians and administrative teams, but also empowers patients. “A lot of the work we have done at Restore has been in making that data and information accessible and usable, whether that’s through clinical EDMS systems into an EPR, or at GP level in ensuring records are accessible in the National Document Repository. Making that information available to clinicians and patients ultimately improves the data we have on patient journeys and care pathways and the decisions we can make to improve them.” Having a clear plan to change course or direction if something isn’t working is also key, he added.
Measuring success and overcoming challenges
“Sometimes we blame things like the NHS App when we get frustrated about there not being GP appointments to book, but often we need to look at the process, which is usually the EHR, the appointment systems, which were never designed for a patient to self-book or self-manage, and they’re not intuitive,” Shanker explained. “Sometimes we need to accept that we need to do a radical redesign of the system and the processes that then render the NHS App – it’s the obvious things, like letting patients choose what they want to book for. If a patient comes in to see me, I might be absolutely useless at dressing their wound, but the nurse they should have seen has now finished for the day.”
Shanker also pointed to other factors in the patient journey, such as patients having a last minute emergency, or not being able to find a car parking space, and frantically trying to get in touch with someone to let them know or change their appointment. “There’s no functionality to get that message to the clinician or care team,” he said. “If you’re lucky, you’ll be given a phone number to call at the hospital, which nobody will answer, which isn’t a great experience. You’ve really got to do that end-to-end journey mapping, but we also have to accept nothing is perfect, it’s just how we keep iterating and making improvements, moving those goalposts further and further ahead.”
Digital-first isn’t always the best approach, and understanding pathways and their pinchpoints is essential to be sure that you’re not just putting a digital process into a pathway that already isn’t working, Amanda suggested. Design should be a process done with patient choice in mind, understanding the need and how to address it. “It’s also being curious, and bringing staff along on the journey, getting to know what the hook is for people to get involved with these digital projects and processes.”
AI and automation
Tom Baldock tackled the risk of introducing AI and automation, citing misunderstandings that still happen about them being two separate things, and the promise of automation when used in removing mundane tasks and giving time back to clinicians to care. AI, on the other hand, has “an exceptional amount of benefit in a huge number of areas”, he shared, but requires a lot of caution in how it’s used. “As Tom Stocker highlighted earlier, you can use AI in getting data and information, getting feedback from patients and summarising it, and giving you an overview of that. But a great question in this environment is about where in their journey patients will be happy to be met with an AI bot?”
In primary care, AI is mostly in use at the front end, or in that first point of contact, with things like AI navigators, Shanker told us. “In London, we’re starting to do that online consultation and AI assistance in that first step off from the NHS App when someone’s seeking help, but if I put that aside, I would like to see it used more in assisting patients when they’re going through their health records, to help them understand those.” AI could be used in answering simple questions, like in letting patients know whether they have had a test for diabetes, and what those results meant, he considered.
For Simon, it’s about knowing where patients will be happy not to interact with a human, compared with when they will absolutely expect to speak to a person. “That comes down to effective use of technology, but also the use of personalisation, and a healthcare professional that you can speak to and access,” he noted. “The AI and automation piece is much more at system level, freeing up time for healthcare professionals to spend more time on the personal journey. The pace we’re seeing technology moving in the last six months means we’re reaching an inflection point, where we’re seeing AI pilots moving into operational AI at scale, and I think we will see massive benefits from that.”
Tom Stocker talked about AI in Europe and the UK lagging behind elsewhere in the world in the healthcare sphere. “If you go to an American provider, AI is used by the clinicians in treatment and diagnostic decisions, in drafting radiology reports, and just the regular off-the-shelf stuff. We don’t even have data centres, or enough data centre capacity. Clinicians are using AI without telling anyone, putting patient data in, because they feel it helps them deliver better care. We are cutting our nose off to spite our face, and forcing the system to use this stuff illegally.”
Tom Stocker also shared some of the work he’s been involved in around AI, including at the Clatterbridge Cancer Centre, where a chatbot is helping to collect and analyse patient symptoms to potentially catch cancer cases earlier. “It’s been incredibly quick working with an independent supplier to get to a chatbot that people are quite happy with,” he told us, “and I think that’s going to get easier and easier in the future.”
There are other possible use cases for chatbots, Amanda outlined. “When we look at the calls coming in to the 0-19 service, for example, a lot of those are fairly routine in asking about how to wean babies onto solid food, or how to support a baby with sleeping well. Those patients aren’t necessarily looking for individualised care, they just want a starting point, so it makes sense to deploy a chatbot that can direct to evidence-based sites, freeing up a phone call that could potentially take 30 minutes.” As long as the right governance structures are in place, “there’s definitely a place for AI and automation moving forward”, she added.
We’d like to thank our panellists for taking the time to share these insights with us.
