For our latest HTN Now panel discussion on advancing patient engagement with communication tech and patient portals, we were joined by experts including Jothi Vasan-O’Leary, medical information officer and outpatient clinical lead (GIRFT) at University Hospitals of Derby and Burton; Daniel Parkinson, digital IT project manager at Leeds Teaching Hospitals; Sally Mole, senior digital programme manager – digital portfolio delivery team at The Dudley Group; and Emma Stratful, chief operating officer at OX.DH.
Our panellists, discussed adoption, engagement, the use of AI and automation technologies, functionality and the future role of patient portals and communication tech in tackling NHS challenges.
“I’m the digital programme manager and head of the PMO for the digital portfolio team within the IT department at the Dudley Group,” said Sally, kicking off our introductions, “and I’m also a digital ambassador, which means I’ll go out and support at career events and promote the roles within my team and across the organisation.” After 24 years of working in pharmacy, she “sidestepped into digital” in 2017, Sally shared, “and I’m currently looking after 54 projects within our digital portfolio”.
Sally told us how a recent review of the PMO journey from the last three years revealed that a total of 84 projects had been delivered, including 11 constituting “first-of-its kind innovation”. This also included “multiple bespoke solutions that the team have built in-house,” she went on, “so having that in-house development has been a big advantage”. In terms of patient-facing engagement, “we have a patient portal, and we’ve also just signed a contract for the implementation of a risk stratification platform for the perioperative pathway,” she said.
Jothi talked about her role as a specialty doctor in oral and maxillofacial surgery, and as a medical information officer at University Hospitals of Derby and Burton. “At the moment, I’m involved in our process of implementing an EPR system,” she continued, “and as the outpatient clinical lead for the whole trust, my portfolio includes the Getting It Right First Time (GIRFT) programme in outpatients, along with other digital improvements.”
The trust has also recently set up a new task and finish group in its outpatient area, Jothi shared, “which is focusing on how we can effectively use digital technology, particularly patient portals, to improve patient care”. The remit of this group also extends to cover things like remote digital consenting and preoperative patient questionnaires, according to Jothi, “and I’m excited to be part of the massive EPR transformation journey we’re embarking on”.
Leeds Teaching Hospitals is “in a similar situation”, said Daniel. “We use a few different patient communication technologies, and we’re in an unusual situation where we have two main patient engagement portals instead of just one.” Along with those, the trust also has a regional patient engagement portal, and a number of other communication technologies “to be used on top”, he added, “and my focus has been on one of our two main portals, so I’ve been rolling that out over the last 15 months as my full time role”.
On her role as COO at OX.DH, “a health tech company providing SaaS solutions for primary and secondary care and the private sector”, Emma told us about the company’s beginnings in building an end-to-end solution for those undergoing fertility treatment, and the “huge amount of work” that had to go in to their patient portal, ensuring patient access to records, putting linkages in place between patients and partners, and “all the other things like paperwork and consenting that revolve around that”.
As a Microsoft partner and built on the Microsoft Azure platform, “we’re effectively a plug-in”, Emma considered, “and we’ve evolved that solution to pull out individual modules such as our waiting room functionality which includes online and video consultations”. That solution is deployed in the NHS, she said, “and we’re deployed on the national tenant, so anyone with an NHS.net account can log in and try our solution”. OX.DH has also been focused on onboarding onto the Tech Innovation Framework, “integrating across the whole of the NHS ecosystem to be able to pull data from other systems, but also develop our own and integrate with the patient-facing services app that the NHS have released, which will enable patients to communicate via the NHS app more effectively going forward.”
Approaches and challenges around introducing patient-facing technologies
Expanding on his earlier comments about Leeds Teaching Hospitals having two different patient portals, Daniel told us how this situation arose during COVID, when the second one was introduced “because something needed to be implemented very quickly to cover appointments and sending those out digitally”. That particular portal has been rolled out to the entire trust, which has been a “relatively smooth” process, he told us, “but the other portal that I’m currently focused on is a lot more involved – we’re looking to send out questionnaires for patients to fill in that go straight back into our EPR, and sending out educational materials, also linking those together in care pathways, so they unlock at certain points in time.”
Talking about some of the challenges encountered around scalability, Daniel said: “We need to look at digitising the entire process as it stands, and take it from paper and telephone calls to a digital approach. It’s not just figuring out how we can do that, but it’s how we can make sure everything stays safe on the back end, that all the appropriate follow-ups are in place, and that we can capture people when a digital approach isn’t appropriate for them.” In Leeds, “only 85 percent of the population is able to speak English”, he went on, “so we’ve got a huge demographic there that we’re very conscious that we’re not currently servicing as well as we’d like to, and that’s a challenge, too.”
“I think we’re slightly behind Daniel in our journey,” Jothi noted, “and currently we use our patient portal to send out appointment letters and to allow patients to access blood results, but we’re also exploring the option of having a two-way messaging system.” A big factor in overcoming challenges is having the right workforce in place, she said, “because even if you automate certain aspects of patient communication, you need human input at some point”. From a workforce perspective, “people are scared that they’re going to lose their job”, she highlighted, “so I think we need to instil some confidence, trust, and take those people along with us on our journey – I wouldn’t necessarily call that a challenge; I think it’s just something we need to plan for strategically.”
Referring to Daniel’s point about the potential to use patient portals for educational purposes, Jothi said: “If I talk to a patient about a particular condition, I can guarantee they’re going to go and do a Google search. So why can’t we provide those resources in our patient portal, and push those notifications based on their diagnosis?” Over the next year, her team are looking at how best to optimise their patient portal for patients, she continued, “because patients are the core part of our discussion, and we need to be mindful that as Daniel said, there are population groups who face digital skills, access, or language barriers.”
Talking us through some of the challenges faced at the Dudley Group, Sally said: “We went live with maternity in 2022, and since then we’ve done a lot of work with our supplier to try and build on its functionality, and we’ll be partnering with them on an enhanced portal to be released later this year.” In the meantime, she continued, “we’ve spent a lot of time within our services, asking them what it is that they need from a patient portal, which will inform our collaboration on this and help us get that to where it needs to be.”
The Dudley Group also has another comms platform, Sally told us, which was rolled out in 2023. “When we started that, I don’t think we really understood the impact and how many services it was going to include,” she said. “In our business case we’d said it would take months, but it’s actually taken us years to roll this out safely. From our analysis we worked out we would need 43 roll outs across 110 departments, and it was eye-opening how many different ways all the different services were sending communications to patients before.” Finding out how those services were currently working, and then communicating with them about how those processes needed to change, was a major part of the project, she shared.
Emma also reported on some of the challenges she’s seen working with different trusts and healthcare organisations, including access and “digital equity across patient groups”. Working with Microsoft makes things like translations “an easy fix”, she said, “but if people don’t have devices to start with, that becomes an issue”. She also picked up on Sally’s point around electronic consenting, saying: “It’s a consenting workflow – it’s not just signing a form, it’s assessing all of the risk, the Montgomery principles, how you get that information back into your existing EPR so there’s a digital trail. I think there’s a tendency to underestimate that workflow process, because you can’t just pick up a paper form and translate that to a digital form, because people often scribble their own notes, which are really valuable, and it’s how you structure technology to capture that in a meaningful way.”
Fear of change is another major challenge, Emma continued, “and it’s overcoming that to make digital a more consumer experience, because we do all our banking online, but for healthcare there seems to be an increased sensitivity, when actually, we’ve built our solutions in terms of their security to give patients and staff the confidence that electronic data is secure and accessible to those that need it.” Giving patients access to their own data helps reduce the resource strain on the NHS from things like subject access requests, she said, “and those staff, instead of fearing that their jobs are at risk, will be more likely to embrace it and see how they’re helping patients, as well as how they can use the time that’s freed up to deal with the more complex issues that patients face going forward. That mindset is really key.”
“It’s important to remember that it’s not just about digitisation of consent,” Jothi agreed, “because it’s not a replacement for those quality discussions between clinicians and patients – there is a two-step approach to consenting that I don’t think should be compromised.” Utilisation of the patient portal is “an extension of those discussions”, she went on, “and just because patients have signed, that doesn’t necessarily indicate that they’ve retained that information, so we need to reinforce it and repeat those discussions further down the line.”
“I totally agree,” said Emma, “and I think that’s exactly what we’ve done – we want clinicians to have those meaningful engagements with patients, so they fully understand any risks, and making sure they have the right information. Or recording those conversations so patients can listen back at home, share with their family and friends, and make an informed decision.”
Future directions, future opportunities, and the future state
Daniel shared that his team are currently undertaking prioritisation work to figure out the next steps for their patient portals. “In the longer term, we’re focusing on getting down to one patient engagement portal,” he said, “because we’ve realised that from a patient perspective, they also have to handle various other portals, with a separate one for their GP, the NHS app, and so on. Long term, I’d like to see everything going through the NHS app, including things like patient-initiated follow-ups and video calls.” The trust is also looking at what can be done in terms of proxy access, he said, “which is another major project”.
“At Dudley, we’re focusing on improving engagement with our preoperative platform and expanding that to other areas within surgery, looking at reasons for people not signing up like language barriers, because we’ve got a very diverse community,” Sally said. The trust is also looking at ways to repurpose its hardware, so devices which are no longer in service can be used to help improve access and make an impact in the local area, she reported. “There are a lot of process-driven things we can improve, and improvements to be made in our planning, to try and encompass a more rounded version of what our patients need.”
There’s also a need to consider wider patient access, and whether things like virtual consultations can help deliver services to patients who might not be able to attend clinics, or who might be put off by things like parking, Sally considered. “We’re looking at the actual patient pathways to see whether there are better ways of offering services to our patients, and we’ve just signed a contract for a perioperative support patient portal, which performs a risk stratification on patients. It’s been important for us that clinicians can still make changes to things like questionnaires filled in by patients, because they may not have always understood something correctly, or that might be subject to change, so it’d be really unsafe for us to just take what the patient says without talking it through.”
At an ICB-level, Sally said: “We’re considering how we can work at system-level, rationalising contracts and shared services, upscaling what we already have in place. We need to get to a point where we’re having cross-border referrals and cross-border services, and these patient portals that we’ve all got sporadically across different trusts just don’t really help for data sharing.” Placing the better integration of services into procurement processes, along with things like integration into Shared Care Records, and into the NHS app, has also been important, she continued, “because we need to be able to flow data through those platforms and into our EPR, because that is the one single source of truth for all of our clinicians.” The trust is also evaluating how things like AI and smart notifications can benefit staff and patients, according to Sally, “but realistically, we need to sort out the infrastructure and the accessibility for patients”.
From a supplier perspective, “there’s a backlog with NHSE to get that assurance done” around integration with the NHS app, Emma shared, “and we’ve been on that list for two-and-a-half years for one solution, and that’s still not happened – awarding those contracts might make that seem like more of a priority for NHSE”. Ongoing integration is good, she went on, “but we need to think about what we’re integrating for and what the priority is here”.
“I was having a discussion with one of our patient engagement advisors yesterday,” said Jothi, “and we were talking about ways to improve outpatient letters and how we design those in a patient-friendly way”. A priority for UHDB is implementing two-way messaging as part of a drive to reduce DNA rates, she went on, “but that’s a multifactorial problem – patients should be able to contact the organisation if they need to cancel, and we should be prepared to bring patients in at short notice.” Neighbouring organisations have a DNA prediction tool, according to Jothi, “and we’re exploring that possibility, but we need to have the processes in place to ensure that the information we’re providing to patients is actually accessible for them.”
As an outpatient lead, Jothi told us how there are clear metrics in place as part of the Getting It Right First Time FurtherFaster programme, “and one of the key things is reducing the number of weeks patients are waiting for their first outpatient appointment.” Reducing DNA rates would help create more slots for patients to be seen quicker, she considered. “We’re also focusing on what Daniel mentioned earlier about increasing the patient-initiated follow-up and how best to use remote consultations. But the main thing is around those accessible information standards, because I think it’s really important that we implement those in practice.”
Emma talked about how OX.DH tackles DNAs, saying: “We consume data from existing PAS systems to put appointments into our solutions. Then we can configure text messages, so SMS messages or emails that go out to the patients. And what we found working with a number of trusts is that if you send out that notification upon the confirmation of that booking with a number to contact if they can’t attend that’s specific to the department, and then send out regular reminders letting patients know that they will receive a link to click for their video appointment half an hour before, that works best.”
Those messages can be automatically triggered at set times, Emma continued, “which helps with those regular communications, which can help particularly when referring to secondary care, when there can be a big lull in that communication with patients and it could take weeks for that appointment to come through. A text message letting patients know if their referral has been delayed or where it is on the list would help reduce that burden of patients calling for updates.” It’s about working with trusts to understand their booking systems and PAS, she said, “and how we can integrate across those to make sure that patients are being seen appropriately and that they’re aware of what’s going on.”
Highlighting Emma’s point on referrals from primary to secondary care, Jothi shared how her team has set up a task and finish group looking at clinical pathways, “One of the key components of that is discussions around the primary-secondary care interface,” she said, “and I’ve invited, for example, Derbyshire and Staffordshire GP colleagues to be part of those discussions, and we go to their meetings as well.” Establishing those collaborative working practices is particularly important when it comes to advice and guidance on turnaround times, Jothi went on, “and if you have a good relationship with primary care colleagues, that makes things a lot easier, and we can challenge each other in terms of our practices and improve.”
Moving forward, what Jothi would like to see would be two-way messaging and how those responses could be automated within the PAS system. “That would be fantastic because it would improve oprtational efficiency,” she said, “and if you look at the statistics, 30 percent of operational processes can be automated. But having said that, one of the most recent publications from the Netherlands says that they are aspiring to have 50 percent automation, which is a huge target.” Putting regulatory things in place will be important to allow for this, she considered, “because when we talk about AI and automation, it evokes a sense of fear in people. But we’re not talking about clinical decision making tools. We’re talking about back office functionalities which can automate it.”
Sharing some of OX.DH’s current tools, Emma talked about having tools that “can read a PDF or clinic letter, identify the patient name, date of birth, and NHS number, and with a degree of certainty say that it belongs to patient X, and then it is automatically filed”. Where a digit may be wrong or there are inconsistencies, “those are flagged for manual checks”, she said, “and whilst that might not be high end AI, it’s really meaningful to those staff that are sifting through all of these letters – I think people are jumping ahead, but let’s start with the basics and see how we can improve efficiency and productivity.”
At Dudley, high-level scoping has been carried out to explore the potential of AI and automation across “multiple parts of our outpatient digitalisation”, Sally told us. Aspects the trust is particularly interested in automating include rescheduling of appointments, she said, “as well as documenting outcomes, clinical coding, and so on – once information is captured digitally, that can be extrapolated and that’s obviously going to be the efficiency saving.” From an AI perspective, there is a working group at ICB-level, she went on, “but there’s a lot of work to be done on regulation, and we’ve got lots of questions about how AI and machine learning work, as well as lots of clinical safety elements to consider, looking at who is monitoring that and how we know whether we’re getting the right outcomes.”
“We’re trying to figure something out around installing a working proxy through the portal,” Daniel said, “and whilst there is apparently something in the pipeline from NHSE, every time I try and track that down it seems to disappear. Eventually I’ll find someone in that area, but I haven’t found them just yet.”
“That’s enabled in our reproductive solutions,” said Emma, “and we’ve also implemented it into our GP solution where you can identify a proxy at your GP practice and that then can be recorded in your GP record, allowing them to see elements or your patient record. It’s a fine balance, but it’s making sure you’ve got those appropriate consents in place.”
We’d like to thank our panel for their time, and for sharing their insights with us on this topic.
