COMMENT: STP success rests on whole-system interoperability

As sustainability and transformation plans (STPs) shape the future of care for millions, interoperability must extend to all care settings, says InterSystems’ David Hancock

The NHS is demanding and proving that true integration is finally about to happen. Big changes are happening as it strives to be more efficient and save billions of pounds. Sustainability and transformation plans (STPs) now shape the future of healthcare through 44 footprints across England, each covering populations of around 1.2 million people, where integrated services, shared budgets, collaborations and vertical integration will underpin the future.

The success of these STPs will in large part be down to how whole-system interoperability can be delivered. Interoperability is a well-used term in healthcare IT, but it is something that all clinical leaders and managers need to have an understanding of. At its simplest, interoperability is 'the ability for IT systems to exchange information and for the systems to be able to reason on the data that is exchanged'.

Therefore, when information from one system is interfaced into another, it is as if the data coming into the receiving system has been entered through the application's own user interface. Whole-system interoperability is connecting different care settings and across social care, the third sector, education, etc., knitting together currently disparate systems and organisations.

Integration and interoperability are long sought-after goals. Technologies like portals have played an important role in connecting information for now, but rising digital maturity and the increasing prevalence of electronic patient records (EPRs) beyond primary care, into Electronic Palliative Care Co-ordination Systems – EPACCS, and Social Care Case Management Systems, are creating the demand for more sophisticated interoperability, where health and care professionals really can see absolutely everything about a person from every care setting through their own primary system. The NHS will achieve whole-system interoperability to meet frontline demands. Here’s why and how.

Rising digital maturity means new demands from clinicians

The NHS is reaching a point where it doesn’t need new solutions to underpin the success of STPs. Instead it needs whole-system interoperability across STP footprints.

Interoperability projects of the past have failed to reach out to all care settings. New models of care, and the reconfiguration of health and social care, require that systems, organisations and care workflow be truly person-centric and not organisation- or service-line centric.

With rising levels of digital maturity, the NHS will soon have much of the technology it needs to match personalised care ambitions and to realise new interconnected models of care. Many parts of the NHS, including a growing number of acute trusts, already do.

The key challenge is joining up these technologies and this must happen quickly.

As digital maturity advances, people at the frontline of delivery need access to information in one place. But that does not mean logging into separate systems to access information, however available those logins may be. Once familiar with their EPRs, clinicians want to access information in that one system, even if that information is held outside the organisation. In a world where clinicians are accustomed to incomplete information, they will not spend their time searching for it in multiple systems.

Clinicians are now demanding a comprehensive approach to interoperability from within the NHS, so that they can make full use of EPRs – systems which have required major investment and which, from the user point of view, need to be able to talk to their counterparts across the entire care spectrum.

Responding to new demands

Interoperability must be achieved in the truest sense of the word to respond to this clinical demand, based on expectations. Information can no longer only be interfaced, but the receiving system must be able to process and understand that information.

Ultimately the NHS is moving to more digitally mature systems – where acute providers need to connect their EPRs with community, primary care, social care and others across a whole system.

One of the reasons why interoperability in healthcare has been so difficult is that healthcare standards have been insufficient. The HL7 v2 standard, for example, was incomplete. In fact, it was not a standard; it was a guide. Vendors could create their own version in their messages – they could put anything they wanted into it, and they did. There were different versions, making a standard very difficult.

Comprehensive, flexible and internationally agreed standards are needed to enable a new way of working focused on structured data. Healthcare standards must mature and are showing signs of doing so. The completeness of the standards is finally materialising.

The recently formed INTEROPen supplier action group is key in this regard for the NHS. With more than 50 IT suppliers working in various care settings already signed up, the market is now joining together to signal its commitment to establishing open standards that will allow the exchange of data across their systems.

An INTEROPen hackathon is planned for later this year, where suppliers will meet to join up systems for real, working through specific scenarios using the new HL7 FHIR standard.

HL7 FHIR shows great promise in moving towards a more complete standard for joining together systems: it is more developer-friendly, making it easier to develop mobile applications. But it should not be seen as the silver bullet, as it does not oblige the provision of a full clinical context that clinicians want if the information is available.

Other standards will therefore have a role. Work is taking place with clinical document architectures (CDAs) by Coordinate My Care, for example, with urgent care plans. Coordinate My Care (CMC) is an NHS clinical service, underpinned by the electronic sharing of information between healthcare providers across the 32 CCGs in London.

Originally it was used to store and manage End of Life Care Plans and by using mature standards, in this case HL7 v3 CDA, the development of an information exchange is possible that allows a GP to create or update a care plan and for it to be shown in the hospital’s EPR, an out-of-hours system, social care, 111, a hospice or to the ambulance crews - to all those who have a legitimate relationship with the patient. Within the year, these plans will be visible by patients on line on their own smartphones.

The new London Digital Programme will reflect this way of working – seamlessly transferring patient information across all care settings in London and beyond. It requires the partnership of 32 clinical commissioning groups, NHS England (London), the academic health science networks, 28 trusts, London CIO Council and representation from the capital’s local authorities.

Extending capabilities without building something new

Mature interoperability also means that existing capabilities can be extended and adapted to meet new requirements without having to build something new. It became clear to CMC that End of Life systems (Electronic Palliative Care Co-ordination Systems – EPaCCS) can provide valuable communication and co-ordination for wider cohorts of patients, i.e. other than those in the last year of their lives.

This includes adults and children who are vulnerable in other ways, as a result of long term conditions, physical frailty, homelessness and cognitive impairment - in other words, anyone who might benefit from a crisis care plan. Having an interoperable solution means that what you have can be extended and re-used, for example to deal with the concept of urgent care planning for those who need care at 3am, regardless of their prognosis. This is something that CMC has been able to do to expand its solution and offer interoperability with this data set using HL7 v3 CDA.

We need a set of tools in the box, not immediate perfection

Work in England is under way to make interoperability clinically driven. The Professional Records Standards Body has been central to the definition of the urgent care plan in London. It will also be engaged in the work being done by INTEROPen.

Despite these major recent steps, there will still be many systems out there that will not talk HL7 FHIR or CDA. There must therefore still be a capability to allow these systems to interoperate with those that do. Some problems are better solved by HL7 FHIR, others by CDA and perhaps other problems using other standards.

The NHS must not try and leap to perfection in a single attempt. It will need a set of tools in the toolbox to allow all systems to participate and exchange structured and coded data, even if they don’t conform to these latest standards.

By focusing on the most urgent clinical integration priorities first, the NHS can show others what 'good' looks like and then let them solve their problems using standards so these can be re-used across health and social care wherever possible.

STPs are driving the industry towards real whole-system interoperability, and initiatives like urgent care planning in the London Digital Programme and INTEROPen are now proving we are closer than ever to achieving this.

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