E-HEALTH/TELE-HEALTH UPDATE AS AT 31 MAY 2008

Report by Ian Bashford, Board Medical Director and Bill Reid, Interim Head of eHealth

The Board is asked to:

  • Note the issue of the Consultation Draft National eHealth Strategy and the importance of this in relation to an emerging integrated, pan-Highland eHealth Strategy.
  • Note the intention to amalgamate the NHS Highland Tele-Health Strategy within the overall eHealth Strategy.
  • Agreeto a separate but integrated Tele-care Strategy.
  • Noted the intended timescale of December 2008 for the production of the Final NHS Highland eHealth Strategy 2008–2011.

1. Background

The current NHS Highland eHealth Strategy (v1.4) was prepared and agreed in March 2005. The Strategy covers the period 2005-2007 and remains extant.

The Board Medical Director submitted an Update Report on Tele-Health to the September 2007 meeting of the Highland NHS Board.

The Interim Head of eHealth subsequently submitted an eHealth Strategy Progress Report to the December 2007 meeting of Highland NHS Board.

The National eHealth Strategy 2008-2011 has now been issued in several iterations, being periodically updated to reflect comments received from the Service. The Initial Draft was issued in February, the latest edition being the Consultation Draft issued in April 2008. It is expected that the Consultation Draft will lead to a Final Strategy Document to be signed-off by the National eHealth Programme Board.

The production of a revised NHS Highland eHealth Strategy will be based on the Final National Strategy. The National eHealth Strategy will be the main agenda item at the eHealth Steering Group to be held on 26 June 2008.

2.Telecare Strategy

The aspiration of older people and their carers are that support will enable them to live safely at home in their own communities for longer. Those people who have a disability or are vulnerable may also access the support to live at home and live as locally as possible.

The implementation of Smart Technology (or Telecare as it is now known) can help to meet the aspirations to give some users the confidence to live their lives independently in the knowledge that support and help are always available. The Highland Telecare Service Strategy has been developed by the Highland Community Care Partnership 2007-09, and has already been presented to the Health Board.

The Audit Commission definition of Telecare is:

“Telecare, Telehealth, Telemonitoring and Telemedicine are terms that are used interchangeably to describe the remote delivery of health and social care using information and communication technology. In simple terms Telecare can be defined as a service bringing health and social care directly to the service user.” It differs from Telemedicine and eHealth which involves ICT to support the exchange of information between healthcare professionals, generally for the diagnosis, referral or management of medical conditions.

It is now the opinion of the Telehealth/e-Health Strategy Group that Telecare is a separate entity from eHealth and Telemedicine. Telecare is essentially a multi-agency programme based around social care and independent living so that people may continue to reside in their local communities. While there is significant interaction between the Telecare and the eHealth strategies, the various agencies involved are separate in terms of funding, accountability and workforce. The NHS Highland e-Health Strategy should therefore be developed independently, but interact closely with the Telecare Strategy in a complimentary fashion.

3. National eHealth Strategy 2008 – 2011 – Final Consultation Draft April 2008

The Consultation Draft National eHealth Strategy is “deliberately high level” and fairly non-prescriptive in order that it accessible to all readers. The Scottish Government has undertaken to publish a range of more detailed supplementary papers in due course. These documents will include a Technical Plan, a Programme Plan and a further refined Financial Strategy. The Financial Strategy is of particular importance as the financial implications of strategy implementation at NHS Board level must be explicit.

It is important to note that NHS Highland, as with other NHS Boards, is not delaying implementation and development awaiting finalisation of the National Strategy. There has been no delay in project implementation pending the finalisation of the National Strategy. Key to the ethos of eHealth and the implementations already taking place is clinical involvement and direction and a focus on the patient-centred benefits and patient safety. This will lead to an element of service redesign in support of the implementation.

4.Key Strategic Principles

The Consultation Draft of the National eHealth Strategy 2008 – 2011 identifies six broad principles which will underpin the future National work programme and the implementation of a local eHealth Strategy for NHS Highland:

  • Confidentiality safeguards are an obligation;
  • Continuing an eHealth journey;
  • Focus on benefits, supported by technology and change;
  • Virtual, not a single large database, electronic patient records (EPRs) in direct care;
  • Technology development, standardisation and convergence; and
  • Collaborative approach to delivery, drawing on best expertise.

The above are over-arching strategic principles which will form a thread through subsequent direct action planning and implementation.

5.Action and Outcome Summary

The Consultation Draft of the National eHealth Strategy 2008 – 2011 contains a summary of actions and outcomes. This is where the document becomes more specific and prescriptive and sets out real activity and timescales to be complied with in order that the overall strategic aims can be met.

In common with other areas within the NHS in Scotland there is a sense that many of the achievements will be target driven and that monitoring of NHS Board actions will increase.

These actions and timescales are summarised and tabulated as Appendix 1 to this paper for the information of Highland NHS Board Members.

The main features of the actions are the exploitation and improvement of what already exists. Examples being standardisation, deployment of “change and benefit”methodologies and a programme to deliver enhanced eHealth support to community, social care, child health and mental health sectors.

The introduction of significant procurements or developments;the things which are completely new. This will involve procurement of a National Patient Management System, a transition from the GPASS System used by general practice to a nationally procured replacement, development of single sign-on for users and modernisation of the Community Health Index (CHI).

The content and context of future planning. This will include safeguarding confidentiality, eHealth in support of long term conditions and medications, support for 18 week waits and development of the professional skills of eHealth staff.

The above actions will further integrate the eHealth function with the clinical activities of the NHS in Scotland and ensure that it is used effectively to support the work of clinicians and therefore to enhance the quality of patient care.

6. eHealth within NHS Highland

The vision for eHealth Services, including Telehealth applications, in NHS Highland is to pursue excellence in terms of an IT Infrastructure to support:

  • Direct Patient Care
  • Education and Learning
  • Management Processes
  • Communication and Meetings

This vision is based upon the maxim that:

“The Right Information should be available in the Right Place at the Right Time using the Right Ways, Means and Safeguards.”

The expected issue of the National eHealth Strategy has not constrained eHealth activity within NHS Highland. There is at present an extensive workload of specific clinical project implementations, communications network enhancement and a major roll-out of video conferencing capability. In addition significant work is taking place throughout the GP sector, providing support and migrating a significant number of clinical systems.

The following are some examples of live projects:

  • Pathology System
  • Radiology Information System
  • PACS (digital imaging)
  • Content Management (Intranet Development)
  • Renal System
  • CHP Infrastructure (connecting community bases)
  • Universal Uptake of CHI
  • New Ways of Defining and Measuring Waiting Times
  • Video Conferencing/Telehealth
  • NHS Mail Migration
  • Docman (in general practice)
  • General Practice Infrastructure
  • Pharmacy Contract Implementation
  1. Tele-Health

An important element of the implementation of a local NHS eHealth Strategy is the development of Tele-health in a clinically focussed, planned and coherent manner across NHS Highland. Tele-health is defined as “information technologies used locally and at a distance combining health, tele-communication, information technology and health education to improve the efficiency and quality of healthcare” [NHS Highland Tele-health Strategy Group 2007]. This enables the provision of a significant amount of healthcare in many specialties to be delivered as locally as possible, by the appropriate person with the appropriate support and information within an appropriate setting. Tele-health should always be regarded as an integral component to service provision and re-design and the management of NHS Highland business, especially against the backdrop of our remote and rural setting.

The Scottish Centre for Telehealth was commissioned to undertake a number of consensus conferences on Telehealth within the NHS Highland Community Health Partnerships. The outcome only reinforced the potential applications that were detailed in Dr Bashford’s paper to the Board in September 2007. Most attendees accepted that the technology was available and should be used in service redesign. The most significant feedback was the need for a robust, quick and comprehensive infrastructure network, education and training, support, reliability and an adequate resource funding to facilitate and develop service redesign.

The development of Telehealth across NHS Highland has historically been determined by individual projects and champions. There are many projects being delivered utilising Tele-health throughout NHS Highland, but not within a structured and consistent framework and these are identified in Appendix 2. Implicit in the innovation, development and adoption of Telehealth applications throughout NHS Highland is the presence of an effective, comprehensive and reliable communication network and infrastructure. NHS Highland e-Health are currently finalising the programme, which will see all community locations, connected to the present network, which already includes all hospitals and general practice sites to support the e-Health function identified earlier. In parallel, e-Health are continuing to roll out a robust and increasing video-conference network throughout NHS Highland to ensure and provide this comprehensive connectivity. Appendix3 is a schematic which illustrates the current extensive video-conferencing network available in NHS Highland and identifies all sites. Therefore, at the present time there are many sites throughout NHS Highland that presently have the capacity for the implementation of Telehealth in its widest form.

There are currently seventy nine units deployed across NHS Highland, seventy five of these are centrally managed and supported. A further fifteen units are about to be deployed. Three of the units are on general practice sites reflecting the policy of inclusion. Clinical use of the video network is expanding.

Videoconferencing Usage Across NHS Highland:

Date / Number of Conferences / Hours
July 2007 – September 2007 / 1354 / 592
October 2007 – December 2007 / 1937 / 839
January 2008 – March 2008 / 2456 / 1090

A significant number of the above conferences have been “multi-site” when a number of geographically disparate locations come together in the one event, but the data to identify the number of multi-site conferences used or the number of people involved is unknown at the present time.

The increase in usage especially in clinical and management meetings has undoubtedly led to material reductions in travel and the far more effective general utilisation of staff resources. This has led to direct financial savings as well as the more effective utilisation of staff time. The implementation of an extensive video conferencing network across our geographically diverse area has been achieved in a short time. As would be expected initial technical challenges have been faced but the reliability and utility of the equipment has improved significantly since inception and continues to do so. The ability to remotely support the units has minimised the input required.

The objective is now to further engage clinical and managerial colleagues in developing the use of Tele-health in patient related areas and direct clinical care and to identify champions within the health workforce.

The implementation of Tele-health must be pragmatic and realistic but within a strategic environment if it is to succeed. There will be material financial and cost/benefit implications to be considered. The Scottish Centre for Telehealth has pioneered a Tele-medicine booth. This is a small facility located at a distance which can be accessed either by a patient separately or a patient and a healthcarer. Within this booth there is a fixed and mobile video camera, the ability to utilise an electronic stethoscope and ECG, the undertaking of clinical examination and monitoring of some vital signs. The piloting of this booth was seriously considered at the Invergordon site, but this was deferred on the basis of the prohibitive cost of a resilient connection.

The majority of NHS Highland hospital locations outwith Inverness are connected at a speed of 2Mb but thisis likely to be inadequate for future roll-out of critical clinical applications. The increasing utilisation of data communications between clinical locations means that a point will be reached where line speeds will require to be increased. There is continuing dialogue with our colleagues in the Scottish Government around this issue.

8. Financial Implications

Implementation of the eHealth Strategy will have financial implications both nationally and for NHS Boards. Although a discussion paper has been issued further guidance is awaited to provide further clarity.

The Scottish Government have issued a discussion paper around the eHealth Finance Strategy. The implementation of the eHealth strategy will have financial implications for the Scottish Government and NHS Boards. The simple fact of the matter is that technically anything is achievable, very often the constraint being the affordability of a mooted solution. The exact financial implications have yet to be determined as the strategy and associated procurements move towards implementation.

Finances have not therefore been considered in detail as part of this paper.

9. Contribution to Board Objectives

The development and implementation of an eHealth Strategy contributes to the delivery of improved services to patients through effective clinical systems and information provision. Tele-health will support Delivering for Health, the NHS Highland Clinical Framework, Better Health Better Care and the implementation of the remote and rural report as well as aiding the achievement of Performance Related Targets. A clear and effective strategy for Tele-health is fundamental to the emerging strategy for care in the Primary Care setting, the Remote and Rural setting and Out of Hours, the Emerging Strategy of Rural and Community Hospitals and Shifting the Balance of Care.

10.Governance Implications

Staff Governance: The provision of efficient and effective electronic communication systems (e.g. email) contributes to staff governance requirements. User involvement is an inherent component of eHealth led projects. This will support training communication on formal networking to support the Staff Governance Standards, in particular, Well Informed, Involved and Well Trained.

Patient Focus, Public Involvement: The eHealth Steering Group has a member representing the interests of the public and patients thus ensuring this involvement in the strategic process.

Clinical Governance: The implementation of the eHealth Strategy will be monitored by the normal Clinical Governance arrangements and the involvement of the Centre for Rural Health ensures the development of evidence based eHealth and Tele-health to support clinical services and will also provide evaluation of such activity.

Financial Governance: The majority of clinical system implementation projects are funded by capital. Business cases prepared reflect the on-going revenue implications of projects.

11. Impact Assessment

Impact assessments are carried out as an element of formal project management.

Dr Ian BashfordBill Reid

Medical DirectorInterim Head of eHealth

23 May 2008

1

The following is a summary of the actions associated with the emerging National Consultation Draft eHealth Strategy 2008 - 2011 (extracted from the Consultation Draft Document)

A.Exploit and Improve What Exists

WhatBy When

A1.
SCI Gateway and SCI Store will be further consolidated and standardised, with support being for the 18 week waiting time programme. / Targets and programme of work agreed by September 2008.
A2.
Deploy central “change and benefits” methods to help ensure that the potential of new and existing systems is fully reached. / Throughout the period of the strategy.
A3.
Emergency Care Summary service will be enhanced through additional items of patient information and a wider user base. / Subject to stakeholder and business case acceptance, progressively introduced over 2008-2011.
A4.
Programme to deliver eHealth support to community health and social care focussed on NMAHPs. / Progressive improvement targets agreed with each NHS Board, through to 2011.
A5.
Definition and delivery of a Child Health Summary will provide the focus for improved integration of nationally held child health information. / Specification and proving work completed by end 2008 and roll-out thereafter.
A6.
Mental Health: short term focus on eHealth support for the Mental Health Benchmarking Programme. In the longer term it is expected that the Patient Management System (PMS) will, provide upgraded facilities to further support mental health services. / Short term targets and programme of work agreed by September 2008.
A7.
For tele-health, priorities will be to support home based care support for managing long term conditions, delivery of care in remote and rural settings and improved ways of addressing Unscheduled Care. / Throughout the period of the strategy.

B.Significant Procurements or Developments

ActionBy When

B1.
Led by a consortium of NHS Boards, national procurement of a suite of products known as Patient Management System (PMS) / Contract in place spring 2009, roll-out thereafter; live in three NHS Boards by 2011.
B2.
Led by NHS Tayside, national procurement of products and services for user identity management and single sign-on. / Contract in place spring 2009, roll-out thereafter; live in three NHS Boards by 2011.
B3.
Plan a managed transition from GPASS to a nationally procured replacement. / Contract in place summer 2009, roll-out thereafter with projected date for migration of last GPASS practice end 2011.
B4.
Led by NHS NSS, the technology which delivers the national CHI index for patient identification will be modernised and the service improved. / Complete by end 2009.

C.Further Planning