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Advances in Patient Flow Management Technology We Can’t Just ‘Go With The Flow!’ Time to Focus on Patient Flow How Digital Technology is Transforming Care Implementing and Commissioning Patient Flow Management Patient Flow Holds the Key to the Future

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Advances in Patient Flow Management Technology We Can’t Just ‘Go With The Flow!’ Time to Focus on Patient Flow How Digital Technology is Transforming Care


Implementing and Commissioning Patient Flow Management Patient Flow Holds the Key to the Future



Tom Cropper, Editor

We Can’t Just ‘Go With The Flow!’


Clint Schick, Managing Director and Chairman of European Council, Strata Health Ltd Sponsored by

Published by Global Business Media

Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom

Overview/Introduction Case Study – Bringing System-Wide Efficiency to Patient Flow Delayed Transfers of Care – Driving Down Delays Across the Whole Health and Care System

Time to Focus on Patient Flow


Tom Cropper, Editor

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Eliminating Complexity Matching Demand and Capacity Delivering Impact

Publisher Kevin Bell

How Digital Technology is Transforming Care

Business Development Director Marie-Anne Brooks Editor Tom Cropper Senior Project Manager Steve Banks Advertising Executives Michael McCarthy Abigail Coombes Production Manager Paul Davies For further information visit: www.globalbusinessmedia.org

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Jo Roth, Staff Writer

Meeting Targets Connecting Departments Rise of e-Referrals

Implementing and Commissioning Patient Flow Management


James Butler, Staff Writer

Problems with Paper Catching Up Data Security Changing Culture

Patient Flow Holds the Key to the Future


Tom Cropper, Editor

The Optimistic Future Big Data and Choice Obstacles Still Remain

References 16

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Foreword D

IFFICULT TIMES call for new thinking. With the NHS trying to cope with rising demand, higher expectations and a restrictive funding environment, patient flow management has become more important than ever before. In order to maximise efficiency, improve standards and reduce costs, the health service is working to build connections between hospitals, community care and mental health. They must ensure patients are seen, diagnosed, treated and discharged as quickly as possible, and that clinicians have access to comprehensive patient information. To do that, they are turning to a new generation of technologies which streamline processes and connect all stakeholders in a patient’s treatment. Our opening article comes from Strata Health. They provide cutting-edge IT systems to health care providers. They transfer labour intensive paper-based administration and convert it into fast, efficient digital systems which minimise administration, cut the risk of errors, reduce cost and improve real-time information flow. They talk about how technologies such as theirs are transforming the way patients receive care.

Jo Roth then looks at what this new technology can do. It’s easy to talk about the potential of digital solutions in the healthcare sector, but that does little good unless there are specific goals in mind. He’ll look at some of the ways technology has already been instrumental in driving change, and how it can evolve in the future. James Butler will then look at implementation. The market for patient flow management systems is growing; cloud-based systems offer faster online administration, enhanced data visibility and reduced error-rate. However, they also bring a host of issues such as compatibility with existing infrastructure, disruption to working practices and data security. Before implementing any system, commissioners must have answers to all of these issues. Finally, we’ll turn to the future. With the Government working hard to create a paperless NHS, patient flow management will take centre stage. It’s an exciting time, full of promising developments. The question is – just how much can technology help the NHS meet the challenges of the future?

We then look at why the time has come to focus on patient flow. Complex systems increase the number of steps in any treatment – each of which carries a small but significant risk. Technology can eliminate some of these steps, simplify processes and so reduce the risk of error.

Tom Cropper Editor

Tom Cropper has produced articles and reports on various aspects of global business over the past 15 years. He has also worked as a copywriter for some of the largest corporations in the world, including ING, KPMG and the Zurich.



We Can’t Just ‘Go With The Flow!’

Innovation delivered.

Clint Schick, Managing Director and Chairman of European Council, Strata Health Ltd Thousands of transfers of care take place in the NHS every day. Yet outdated processes mean patient flow is often not as smooth as it should be. Could better use of technology make a difference?

Continuing Healthcare: Overview/Introduction If the true test of character is what we do when no-one is watching, then perhaps the true test of healthcare is what happens when one professional passes watching duties to another. In our complex and fragmented care system – where support exists across primary, secondary and tertiary healthcare; in council-commissioned social care; and in the third sector – handovers are a common occurrence. Yet too often the process of transferring care to a colleague in another department, organisation or sector remains an unnecessarily complicated and unnecessarily dated one. In many areas, referrals continue to be managed on paper and via fax – not always a reliable method of communicating information. Small, inadvertent omissions can lead to the rejection of a form and further delays. Meanwhile, knowing where a patient can best get the support he or she needs often depends on the possession of an encyclopaedic knowledge of the services available in the local area. Managing and understanding the capacity of different services provides another key challenge. With no quick and accurate sight of referral patterns, it can be extremely difficult for commissioners to know where extra resource is genuinely needed. Some services remain consistently over capacity, while other provision which could provide a viable option remains constantly under-utilised. The consequences for the system and patients are serious. Financial inefficiencies are one key effect: something which can be ill afforded in an era of ballooning deficits and funding constraints. Inefficient referrals also contribute to less than optimum patient care and experience. Currently, too many patients are waiting too long for the care

they need; failing to flow through the system in the seamless manner they rightly expect. Even if individual episodes of care are high quality, the overall performance of a healthcare system can rapidly be dragged down by inefficient transfers. In February 2016, Lord Carter’s final report into hospital efficiency underscored the sheer scale of the issue with delayed transfers of care from an inpatient environment. His report estimated that, on any given day, as many as 8,500 acute beds are occupied by patients who are medically fit to be transferred but who cannot be moved for want of appropriate support elsewhere. The cost of these delays to providers? An estimated £900m per year. The situation over the past year has worsened. It is worth emphasising these figures only cover hospital discharges. They do not take into account referrals between, say, GPs and community services; or community services to hospitals; or primary care to third sector. Every day, thousands of patients experience a transfer of their care from one professional to another. And every day, many of these transfers will be unnecessarily inefficient. The potential to improve performance is clear, as is the scale of the benefits which could be realised. If every referral in our care system was rapidly made and received – and entirely appropriate – we could anticipate financial improvement alongside vastly improved patient experience. At Strata, we believe that there is a better way of managing that part of healthcare when one professional transfers the responsibility of watching and caring for a patient to another. Like so much in healthcare, it is a challenge: it involves multiple stakeholders, and changing processes. Yet the experience of those NHS organisations we work with suggests it is a journey worth

“The previous paper process was manual and difficult to manage; now the quality and consistency of data being received electronically is greatly improved.” Sharon Owen, Clinical Lead West Funded Care

“It’s brilliant(!) and will vastly improve the information we receive.” Clare Burdon Clinical Lead, South Funded Care

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There is a better way of managing that part of healthcare when one professional transfers the responsibility of watching and caring for a patient to another


undertaking. This special report shows how they have used technology to improve handovers, generating efficiencies as well as improvements in patient care. It also demonstrates the potential for others to do the same.

Case Study – Bringing SystemWide Efficiency to Patient Flow In select parts of England, the introduction of an electronic e-referral and resource matching system is making transfers smoother and more efficient – and closer to what would already be expected in other industries. Claire Read reports. Anyone who has ever listened to a conversation about the potential value of technology in the NHS will be familiar with the airline analogy. It typically focuses on the ease of making a booking. If it is possible for us to book our plane ticket online, the argument goes, why isn’t it possible to book our healthcare appointments online too? William Lumb is as familiar as anyone with this analogy. As chief clinical information officer at Cumbria CCG – and a practising GP – he spends his days focusing on improving healthcare through the use of technology. Yet while he believes the comparisons between aviation and healthcare are appropriate, he often feels they take the wrong angle. “I think the real analogy I’d like to draw with the aviation industry is the experience of arriving at an airport, of being processed in an effective manner, of transiting through buildings which are solely designed [to support smooth transitions],” Dr Lumb told delegates during a speech at the 2016 Health+Care show, held in London in June. It is a smooth experience which is in stark contrast to the flow of patients through the health and care system, he argued. Each day, thousands of people transfer from one 4 | WWW.PRIMARYCAREREPORTS.CO.UK

care professional or another – often between departments, organisations or sectors. Their experience is rarely like that of moving smoothly through an airport. Healthcare professionals typically have to make referrals on paper, with the occasional misplacing of information inherent in such a process. They do so with what tends to be a limited understanding of the possible referral options, and no picture of what capacity is available where. It is an ‘architecture’ which is simply not appropriate to efficient working and good patient experience, Dr Lumb argued. “We need a way of sending and managing referrals; whether that referral is episodic care, whether that is unscheduled care, whether that’s inbound, whether that’s discharge, whether that’s associated with a delayed transfer of care, it’s a referral of one kind or another – it’s one health and social care economy.” It is also a complicated economy, he emphasised. “Escalation of care from community setting into an acute or some form of escalated care setting is complex. Almost certainly it will be just as complex outbound. In addition, within each of those little nodes there will be a whole set of pathways internally that will look just as complex. And that complexity cannot be managed on paper. That complexity cannot be managed by trying to train thousands and thousands of people to do that on a daily basis without some support mechanism and without some structure. Yet the NHS expects, currently, to train people to operate systems. And I think we have to try and think of a different way.” Across the North West coast of England, that different way has been the introduction of new technology. For the past four years, local health and social care organisations have been using an e-referral software system. Provided by Strata,


Innovation delivered.


it launches from the electronic patient record (EPR), meaning much of the information is automatically filled in for the healthcare professional. Once any additional details are added to a referral form – which is standard across all local organisations – it can be sent with one click. Dr Lumb reported it takes about 30 seconds to make a district nurse referral. Even child safeguarding referrals, which are more complex, only take 15 minutes: down from two hours before the software was introduced. Reducing the burden of completing forms clearly frees up clinician time. But the Strata system is not simply about the streamlining of existing processes: it also helps clinicians find available services more easily than ever before. The value of this cannot be overestimated, Dr Lumb suggested. “What we should be doing as clinicians is identifying the clinical need of the individual

in front of us – that’s what we’re good at; it’s what we’re trained to do. We’re not necessarily trained, or should be expected, to navigate the myriad of services available, and those services change on a regular basis as new providers come along. As an individual trying to navigate a system, that creates an information overload, and I think takes time out of clinicians, away from looking after patients.” The electronic setup allows healthcare professionals to enter a keyword and then see a list of possible referral options, spanning the entirety of the local care economy – including University Hospitals of Morecambe Bay NHS Foundation Trust, the Better Care Together vanguard, North Cumbria University Hospitals NHS Trust, all six districts of Cumbria County Council, local nursing homes, hospices, mental health services, safeguarding, and the third sector. The e-referral software then not

Placement and Choice to Nursing Homes: “The Fraser Health Authority saves over 1400 acute bed days annually by combining Strata PathWays with the Strata IQ business intelligence module.”

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The electronic setup allows healthcare professionals to enter a keyword and then see a list of possible referral options, spanning the entirety of the local care economy


only makes it possible to instantly make the referral but also shows a real time picture of capacity. When multiple referral options exist, it is easy to match the patient to the service which has resources available. In Cumbria and the surrounding area, some 2000 plus referrals a month are now made using the Strata system. That includes all acute to social care referrals – the software is in place in every single nursing home and care home in the county, along with every single domiciliary care provider. New pathways are being regularly introduced to the system: two week waits for cancer, and referrals to the emergency eye clinic, have been added in recent weeks alone. The huge number of referrals now being made electronically also means huge quantities of easily-reviewable information. It is possible to run metrics on an hourly, daily or monthly basis as well as to have live dashboards. This data, says Dr Lumb, is crucial in helping commissioners know “where to look” when it comes to improving services. “The data tells us that community referrals are very good; our community team are very good at responding to referrals and getting people through the system. It tells us that adult inpatient social care referrals were slow at the start, picked up a bit, and have started to drift back. That makes sense, because we know our adult social care colleagues have lost staff and they’ve also got pressure on their budgets.” Added Dr Lumb: “The system gives the commissioners the ability to start targeting in real time information they need to know. Because as a GP and as a lead of a place-based provider team, I don’t want to know what happened yesterday, I don’t want to know what happened an hour ago, I don’t even want to know what happened a second ago. 6 | WWW.PRIMARYCAREREPORTS.CO.UK

“What I want to know is how to manage the patient here and now, today. Knowing what happened five or 10 minutes ago means you may be able to fine-tune a process. But with this approach, you’ve got the ability to fine-tune the process and you’ve also got the ability to manage the patient care in the first place. That’s the way I think we should be going, and we’re getting there [in our area)”

Delayed Transfers of Care – Driving Down Delays Across the Whole Health and Care System Delayed transfers of care cost the NHS significant money, and patients significant wellbeing. Claire Read explores how hospital discharges might be better managed. “A major problem”. That’s how Lord Carter described the issue of delayed transfers of care. In his review of hospital productivity, the Labour life peer suggested as many as 8,500 acute beds each day are occupied by patients who are medically well but who cannot be transferred. It was a figure which captured headlines – not that the issue colloquially known as ‘bed blocking’ ever really goes away. There are several reasons for delayed transfers of care, with the divisions between health and social care – as well as those within both sectors – adding to the complications. Amid talk of the need for integration, the reality is patients are often trapped in a hospital bed because of poor communication between organisations and a lack of shared understanding of capacity. In some instances, patients will not be able to move because non-acute NHS care has not yet been arranged. In others, they may be awaiting the arrangement of care in the community or at home. Often, the time consuming nature of referral processes is problematic.


Innovation delivered.

Reduction in declined referrals Delayed transfers of care rapidly become a vicious circle: patients trapped in beds they do not require, preventing access for those who really do need hospital care. Trusts waste money caring for those whose needs could be better met elsewhere, and when sufficient numbers of beds become ‘blocked’, elective procedures have to be cancelled. Across the commonwealth Strata Health has been able to deliver technology that supports and underpins localized best practice to ease these types of issues in patient flow and the transfer of care. In the North West of England, the University Hospitals of Morecambe Bay Vanguard is one example where , resource matching, access and placement across the care continuum can instantly make e-referrals to matching post-acute discharge support – across any downstream provider. The Strata system also makes it possible immediately to see which NHS step down care

is available, allowing staff to avoid referring to facilities which are already at capacity. What’s more, this innovative health and care system is now positioned at the front door of acute, at primary care and with an increasing number of emergencies services. Not only does this enable enhanced discharge from hospital but also helps to access better care options in advance of hospital admissions, thus helping to reduce avoidable hospital stays and embrace preventative care as a fundamental goal. This represents not only a significant financial efficiency in enhanced system capacity and throughput – it also considerably improves patient care, particularly for frail older people. Next, a patient access portal for transfers of care is being developed to further align citizens to their specific health and care outcomes and build accountability and knowledge into their everyday wellbeing.

In July 2016, declined referrals were at 16.7%. This has considerably decreased to just 4.3% in March 2017. Patients getting into the right care when they need to. Percentage 20

16.7% 15


In some instances, patients will not be able to move because non-acute NHS care has not yet been arranged. In others, they may be awaiting the arrangement of care in the community or at home




07/16 08/16 09/16 10/16 11/16 12/16 01/17 02/17 03/17


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Time to Focus on Patient Flow Tom Cropper, Editor Old fashioned, paper-based administration can be inefficient and dangerous. Transitioning to digital systems can be challenging, but doing so will save lives.

Any system which can streamline the process, reduce complexity and the number of steps will improve quality of care, reduce costs, increase patient wellbeing and, most importantly of all, save lives


HE NHS is coming under enormous pressure. It’s having to serve more people and, as our population ages, their problems are becoming more complex. Money is tight, and the demand to improve services extremely high. The search is on for solutions which can achieve the seemingly impossible: save money, but improve the quality of patient care. To do so, though, they may have to adjust their thinking. The focus in healthcare policy has moved towards integration of primary, secondary, acute and social care. As such, understanding how patients move through the system is more important than ever. However, although many Trusts openly acknowledge how important patient flow is, relatively few have made this a sustained focus of their strategy. The reasons are varied. Sometimes they simply do not see this as a priority; others don’t know how to adopt such a strategy. There is, then, a widespread recognition that things need to change; what’s lacking among some Trusts is a coherent strategy to make that change a reality.

Eliminating Complexity One of the most important goals must be to reduce complexity in the system, to ensure patients are assessed correctly and passed on to the right people. The more complex a system is, the more steps a patient must go through during their care journey. An analysis by the Health Foundation1 illustrates the potential impact of these inefficiencies. Every patient journey involves hundreds of clinical decisions and tasks. If it is assumed that an average journey consists of 100 different clinical tasks all of which are performed to a satisfactory standard for clinical trials (i.e error rate of 5% or less), fewer than six out of every 1,000 patients would expect to receive perfect care. In the majority of cases, those errors will result in care which is less than perfect or delays; 8 | WWW.PRIMARYCAREREPORTS.CO.UK

a minority of small administrative errors will combine to create a more substantial impact on care quality, resulting in an apology from the hospital – with all the reputational damage and poor publicity that could involve. However, a smaller, but still significant number of administrative mistakes could create a serious problem or even lead to unexpected death. Any system which can streamline the process, reduce complexity and the number of steps will improve quality of care, reduce costs, increase patient wellbeing and, most importantly of all, save lives. The analysis also discusses issues with the way the health service responds to problems. “Quality problems are often treated as if they are one-off events, rather than the inevitable consequence of random combinations of constantly occurring errors and delays in multitask processes,” it states. Instead, of addressing systematic issues, a Trust’s first instinct can be to add checks and monitoring to eliminate the problem. However, these serve to increase the number of steps taken during the care journey and also increase complexity in the system, which as we’ve already seen, increases the probability of administrative error.

Matching Demand and Capacity Another key area comes in matching demand and capacity. GP services are coming under increasing strain as demand outstrips their numbers. Surgeries are becoming busier, which, in turn, results in poor quality service. The traditional view has been to blame poor performance on high demand, but that only tells part of the story. Problems truly arise when demand and capacity are mismatched. It’s a mistake to design capacity based on average demand. At busy times, patients will be forced to queue and the service will suffer. At quiet times, excess capacity will reduce the impact of available staff.


Innovation delivered.

Assessment, Discharge, and Withdrawal The response of many managers is to optimise staff utilisation, but this may only create the appearance of efficiency. Staff may be busy but those tasks may not be the most productive. They may be managing waiting times, addressing problems and helping patients waiting to be discharged. All this leads to added cost both in staff time and infrastructure such as waiting rooms. The strain can tell on staff. They spend their time being run off their feet. Even in quieter periods, they are simply waiting to be overwhelmed again. It’s a stressful situation, impacts staff wellbeing, reduces retention rates and leads to mistakes. Instead, the report argues, Trusts could focus on patient flow to introduce slack into the system. This is not the same as inefficiency. Instead it creates spare capacity so that staff can cope with a surge in demand when it comes. They can spend the intervening time improving systems, assessing performance and improving care. Equally, they can use the respite to recharge their own batteries.

Delivering Impact Addressing patient flow, then, is something that can help Trusts achieve their elusive goal of saving money, reducing waiting times and improving patient care. The Health Foundation’s

Report highlights the example of two Trusts which took a systematic review of patient flow. Both reported reductions in mortality, sustained performance during times of financial restraints and, in some cases, removing some capacity. Quality of care improved and length of stay decreased. As with many things, technology is crucial. Automation and digitisation can be transformative in reducing error rate and administration time. By improving the link between primary and secondary care services, patients can be more quickly referred to the correct destination. It links into a key issue which we will focus on more elsewhere in this Report – the paperless NHS. Next generation systems have a huge amount to offer, if they can be used in the right way. It will require a change in technology as well as a shift in current thinking. Many practices have substantial inefficiencies programmed throughout their structure. Worse still, their instinctive measures to address such inefficiencies often serve to exacerbate rather than alleviate the problem. Switching focus from managing problems, to systematic reinvention and a new focus on patient flow management can eliminate many problems at source. The result is happier patients, happier staff, and a relieved finance department.

“Strata Health has helped deliver a new standard developed by the Social Care Informatics Programme (SCIP) at NHS Digital, on behalf of the Department of Health.” Delayed discharges cost the NHS upwards of £900m annually over the past year.

Waiting for Completion of Assessment Bed Days

Strata Health

500 400 300 200 100 0 Year

10 /11





Typical Process efficiencies: Strata PathWays™ patient centred Care Coordination

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How Digital Technology is Transforming Care Jo Roth, Staff Writer Digital patient flow management services help to save money, improve turnaround times, and deliver better quality care.

A key weakness of the existing system is the tendency for different aspects of care to be closed off within their own little universes


APER IS dead; long live digital. It’s the message we get in all walks of life. However, the NHS is still playing catchup. There are obstacles to digital take-up, especially in terms of security. However, these are outweighed by the immense benefits on offer. In this article, we’ll look at the ways in which outdated administrative systems are putting patient health at risk – as well as some of the key ways in which new technology is making gains. The worldwide market for patient flow systems is set for rapid and sustained growth. A report from Markets and Markets predicts the global market to grow by a CAGR of 22% between 2014 and 20192. Growth will be sustained by several factors including demand for improved quality care, a focus on patient satisfaction, incentives and pressure from governments and, most of all, the enormous return on investment these systems can deliver. When implemented correctly they can be one of those much sought-after solutions – something which can reduce costs, improve performance and help the service meet its core objectives.

Meeting Targets One of those core objectives will be meeting the many targets they have in place. High profile goals, such as becoming paperless by 2020 and having 95% of A&E patients being diagnosed, treated and discharged within four hours place enormous pressure on staff and systems. In many cases, they are missed. A report from the Nuffield Trust focused specifically on the 95% A&E target and compared those Trusts which had met it with those which had not to see what needs to change. They identified bed space as being a key issue and recommend a standard practice of having 5.5% of beds spare at any one time3. Adding more beds to a hospital is difficult given the unprecedented financial squeeze the 10 | WWW.PRIMARYCAREREPORTS.CO.UK

NHS faces. Instead, the report urges the NHS to adopt systems which would help to optimise existing infrastructure. It promotes the idea of using IT management systems which can track the availability of beds. Given the variation of demand throughout the day and the number of patients who will be leaving beds within a few hours, such systems enable managers to see where spare capacity exists and when capacity will be opening up.

Connecting Departments A key weakness of the existing system is the tendency for different aspects of care to be closed off within their own little universes. Clinicians are distracted from the core business of giving care to manage transitions by phone, email or fax. Communication is inefficient, administrative errors creep in and patient care suffers. Professionals work with an incomplete picture of treatment, which leads to diagnosis errors and wasted time as they get up to speed with the progress of a patient’s overall care. Technology can forge connections between departments, improve information flow, increase the amount of data available for all medical professionals and cut down on needless administration. One system doing this is Strata PathWays™ – an innovative cloud-based system designed to match the needs and preferences of patients with available resources. Clinicians receive up-to-the-minute reports on their patients, based on real-time information, available care options and waiting times. Patients can then be matched with the ideal professionals and care packages. Cumbria NHS Trust used the e-Referral Service to address some major patient flow challenges in referring patients to appropriate community, social care and mental health services. They needed a single electronic referral system which could integrate with existing systems, enable them to track referrals in real-time and ensure


a consistent approach to the sending and receiving of emails. It was initially used in 2013 for referrals between Morecambe Bay Hospitals and Cumbria County Council Adult Social Care, before being rolled out across other areas4. The new system was extremely successful. The trust saved money on paper-based administration and clinicians had better quality real-time information at their fingertips to make more effective treatment decisions. Patient turnaround times improved and there was less of a need for follow-ups over incomplete referrals. Dr William Lumb, Chief Clinical Information officer of NHS Cumbria CCG, explained how it worked. “The e-Referral Service provides a 24/7 service with interoperability through all our professionals’ systems,” he says. “We feed all data into Strata and have an even stronger hold on patient flow.” Nick McCarthy, Team Manager for Cumbria Social Care also praised the system. “Prior to the e-Referral Service we spent one morning a week going through errors and issues with referrals. Now issues are immediately highlighted, an audit trail ensures we can rectify these quickly and transparently,” he said. The system also made a huge difference in Rotherham. Here referrals had been made by fax, with little guarantee that extensive documents would be received. A five-month audit carried out in 2010 found that of 114 referrals made, 22 failed to reach teams within community services. Of those, 13 had to be refaxed while nine failed completely5.

Patient discharges were delayed, which led to patients spending an average of two additional days in hospital. By introducing an e-Referral scheme, the Trust was able to standardise referral forms, transmit them instantly electronically and give clinicians advice on appropriate services. An audit taken once the update had been completed revealed the scale of the improvements. Of 1,034 patients referred to community care teams between November 2010 and June 2011, none failed and the rate of rejected referrals fell to just 5% - all for good reasons. 392 acute beds were saved, with estimated economic saving of £1.5 million in acute beds.

Rise of e-Referrals The use of e-Referrals can produce quick and substantial results. They can take a Trust which is performing poorly and, as happened at Rotherham, place it in the top quartile of comparable councils. They do this by giving them all the characteristics of a successful practice – a service where diagnosis and discharge times are falling, while patient satisfaction rates are increasing. The technology is constantly improving. It’s gaining in functionality and becoming easier and more intuitive to use. As patient flow moves front and centre of NHS strategies, more and more companies are developing high quality systems. These continue to drive improvements and help the NHS deliver the joined-up, patient-centred service it’s looking for.



Implementing and Commissioning Patient Flow Management James Butler, Staff Writer Security, culture and infrastructure – all these present challenges to successfully commissioning and implementing new technology.

While the business world rushes headlong towards paperless operation and digital technologies – such as cloud-based accounting systems – much of the NHS lags behind


F THERE’S anything the press likes, it’s reporting potentially dangerous mistakes by the NHS. In 2012 they had a field day after a report from the General Medical Council found that one in 20 prescriptions had an error6. It was proof of two things – firstly GPs are only human and they make mistakes like the rest of us; and secondly persisting with paper-based administration processes was harming quality and, in turn, putting the lives of patients at risk. Small wonder the NHS is working hard to cut paper from its diet.

Problems with Paper The General Medical Council Report examined 6,000 prescriptions. In total, it identified an error in one out of every 20 prescriptions. Of these, 42% were judged to be minor, 54% were classed as moderate and 4% potentially severe. It was enough for the press to do what it does best – NHS bashing. “Millions of prescriptions contained dangerous errors”, spouted the Daily Telegraph7. It’s an exaggeration, perhaps, but a reliance on paper is harmful for everyone. It is becoming increasingly inefficient given the pressures on the modern healthcare service. As patient numbers increase and the pressure on staff intensifies, administrative errors are likely to increase. While the General Medical Council’s own figures suggest that the majority of errors are relatively minor, some can be dangerous. Reducing the error count and streamlining operations will inevitably save lives. In 2015, NHS England announced measures to help patients, commissioners and medical professionals reduce their reliance on paper. Tim Kelsey, NHS England’s National Director for Patients and Information said a transition away from paper was long overdue: “Every day, care is held up and patients are kept waiting


while an army of people transport and store huge quantities of paper round our healthcare system. This approach is past its sell by date,” he said. “We need to consign to the dustbin of history the industry in referral letters, the outdated use of fax machines and the trolleys groaning with patients’ notes. As well as saving precious resources, technology can dramatically reduce errors. Urgent action is a moral imperative where paper is the currency of clinical practice8.”

Catching Up While the business world rushes headlong towards paperless operation and digital technologies – such as cloud-based accounting systems – much of the NHS lags behind. Prescriptions are still filled out by hand and the fax machine – long since consigned to history by many businesses – remains alive and well. So why are they behind? In part, it’s down to the substantial investment involved in setting up a new system. Money is tight and every penny must be accounted for. It’s easy to argue that technology will reduce expenditure in the long run, but when funds are in short supply short term thinking comes to the fore.

Data Security Security is a major roadblock. The NHS must adhere to strict rules of patient confidentiality. While sharing and storing patient information digitally can produce many benefits it also puts data at risk. Cyber security is an enormous business and there are signs that criminals are specifically targeting the NHS. According to a study at the UK Health Show, 98% of healthcare professionals attending the show fear a cyberattack and 84% expect an increase in threats against their own organisation9. A recent freedom of information request discovered that approximately one


third of all NHS Trusts had suffered a ransomware attack10. The consequences for a Trust which finds itself locked out of its own systems are severe. In 2016, North Lincolnshire and Goole NHS Trust suffered an attack from the ransomware virus Globe 2 which took their system down for four days. Appointments were cancelled and staff had to resort to old fashioned paperbased administration11. The good news is that IT security is advancing rapidly. Measures are in place to deliver unparalleled levels of data protection. Such are the rewards technology offers that there is a drive to improve security provisions. Doing so is complicated. As patients and doctors access an increasing amount of data from mobile devices, securing the networks and ensuring each connected device is secure represents an enormous challenge. Equally, educating staff to ensure they are fully aware of the dangers they face should be a top priority. For all the advances in IT security, it is staff themselves who are often the weakest link. Setting firm processes in place, establishing which staff have access to which information and ensuring they stay up to date with the latest security trends becomes a top priority.

Changing Culture Operating culture can create obstacles. Digital technology is transformative and disruptive. Staff who are used to paper-based administration systems can push back when asked to process administration by computer. New technology will also need to be compatible with existing IT. For example, cloud-based e-Referral systems are increasingly common. However, they must be able to integrate with an existing EPR system. New systems will need to build upon – rather than necessarily replace – what already exists. Technology can be both transformative and disruptive. It can help the NHS make great strides, but there is a danger of focusing on technology itself and not on how it will be implemented. History is littered with examples of times when expensive innovations did more harm than good. The goal should be to introduce technology in a way which integrates smoothly with systems, accounts for risks such as data security and enhances, rather than impedes, the work of staff.



Patient Flow Holds the Key to the Future Tom Cropper, Editor To cope with an increasingly demanding future, the NHS will have to embrace digital technology.

Ensuring adequate security will become even more challenging in the future as mobile devices become more common


HE FUTURE of healthcare in the UK is far from certain. Will funding restraints collapse performance, and undermine the NHS; or will it be the optimist’s choice – a high tech, efficient and effective system which embraces change and technology? Whether the optimists or pessimists are proved right will depend in large part on how the NHS incorporates technology.

The Optimistic Future A report from NESTA into the future of the NHS takes the latter positive approach. It sets out four key axes of change: • Precision medicine. • A health knowledge commons stretching beyond traditional anchors. • A people powered health system. • A system which takes advantage of contemporary behavioural insights. Digital technology will be crucial in achieving this vision. NESTA argues for new digital platforms and widely agreed protocols for developing health knowledge. As it becomes more integral to operations, developers face a market full of potential12. A report from MedGadget said the market for patient flow management solutions was on track for strong growth up to and beyond 202113. Growth has been spearheaded by North America thanks to a rise in funding and training initiatives, but the rest of the world is catching up. The future is likely to see an increase in the adoption of solutions, as well as improvements in the sophistication of technologies. The rising usage of mobile devices and smartphones will facilitate the adoption of digital patient flow systems. They will also encourage mobile working and add more flexibility and speed into the system. Medical professionals will not have to be located in a specific place in order to make a referral – it could be processed from


where they are. For example, a doctor who visits a patient in the home might be able to schedule a referral there and then rather than return to the surgery. It speeds up the system, makes life easier for the doctor and also increases the well-being of the patient. They see action being taken and can take a greater role in the planning of their care.

Big Data and Choice Patient Flow has plenty of potential for growth particularly in the realm of big data. Technology enables the health service to capture a huge amount of information about patient journeys. If this can be collected and analysed it can be used to forecast future trends, predict spikes in demand and to further improve patient care. One example comes from the USA where The John Hopkins Hospital in Washington DC14 has taken all this data to create a central command centre. This displays real-time information about everything from bed availability to patient status and operating room efficiency. This saves staff time in making lengthy phone calls and sending faxes when processing patients through the hospital. As the technology becomes more refined, it can produce further information to show how each part of the process is performing, where inefficiencies lie and where improvements can be made. Managers will be able to read this data and use it to drive continuous improvements in the care process. Personal patient data is a delicate topic, but allowing more information to be seen by clinicians can improve diagnosis and help patients to have more personalised treatment. Giving patients access to this information can also help them to become more actively involved, to see the choices available to them and give them a say in the planning of their own care. Not only can this be effective, it is also a good way to improve patient wellbeing.


Innovation delivered.

Continuing Healthcare: The available technology will improve in the future. However, this creates its own set of problems. How does a health trust ensure it stays up to date with the latest trends? Widespread systemic change is slow, inefficient and expensive. Fortunately, the next generation of cloud-based solutions is quick and convenient to install, and can be easily updated.

Obstacles Still Remain However, there are obstacles. Medgadget’s report also highlighted a number of problems such as a lack of skilled professionals and providers, a need for huge investment and a lack of adequate infrastructure. While the technology is becoming available, injecting it into health care operations remains a major challenge. Adoption of new technology will require a shift in processes and the adaptation of existing systems to cope. Professionals may need to change their attitude, especially if they have been working in the healthcare profession for some time. The more technology takes a central stage in healthcare, the more important IT security becomes. There are signs that cyber criminals are specifically targeting the NHS. Not only does it handle vast quantities of highly sensitive patient data, but IT security lags behind large commercial institutions such as banks. The NHS will not be able to get the most out of digital technology until it learns to counter such threats. Ensuring adequate security will become even more challenging in the future as mobile devices

become more common. Every mobile device connected to a central system is a potential avenue of attack unless it is secured. IT managers will need to monitor closely what devices are connected. The adoption of technology, therefore, comes with the major caveat of security and not all managers have taken this into account. Staff need to be trained how to handle data, and how to minimise the threat of attack. They must be aware that opening an email or downloading a file can potentially open the door to attack. Security software must be kept up to date and constantly reviewed. Cyber attacks evolve quickly; hackers work hard to adapt to defences. Today’s state of the art cyber security package can easily be rendered obsolete tomorrow. Security suffers further complications when selecting an exterior provider for patient flow systems. Buyers will need to know everything about a provider’s security protocols – if these are weak they could compromise any security provisions they have already taken. Patient flow is set to become increasingly important over the next few years as the health service seeks new ways to improve its service delivery. Technology will be crucial as the NHS moves towards a more integrated high-tech future. Doing so will require substantial investment, and a culture change. It is a major undertaking, but those which have been swift to make the change, are already reaping the dividends.

“The previous paper process was manual and difficult to manage; now the quality and consistency of data being received electronically is greatly improved.” Sharon Owen, Clinical Lead West Funded Care

“It’s brilliant(!) and will vastly improve the information we receive.” Clare Burdon Clinical Lead, South Funded Care

+44 (0) 1322 30 30 35 sales@stratahealth.com stratahealth.co.uk



References: Improving Patient Flow: http://www.health.org.uk/sites/health/files/ImprovingPatientFlow_fullversion.pdf



Patient Flow Management Market: http://www.marketsandmarkets.com/PressReleases/patient-flow-management-solutions.asp


Understanding Patient Flow: https://www.nuffieldtrust.org.uk/resource/understanding-patient-flow-in-hospitals


Cumbria’s Use of Strata PathWays: http://stratahealth.co.uk/cumbrias-use-strata-pathways-enables-real-system-integration/


Using Strata Technology to Improve Referrals in Rotherham:



Prescriptions: 1 in 20 has an error: http://www.nhs.uk/news/2012/05may/Pages/gmc-medication-prescribing-errors-report.aspx


Millions of GP Prescriptions Contain Dangerous Errors:

http://www.telegraph.co.uk/news/health/news/9238524/Millions-of-GP-prescriptions-contain-dangerous-errors-research.html 8

Cutting Reliance on Paper Will Make Patients Safer: https://www.england.nhs.uk/2015/09/cutting-reliance-on-paper/


NHS to Face Rise in Cyber Attacks:

https://www.buildingbetterhealthcare.co.uk/news/article_page/NHS_to_face_rise_in_cyber_attacks_warn_experts/121204 10

Ransomware Brutes Smacked one in three NHS Trusts: https://www.theregister.co.uk/2017/01/17/nhs_ransomware/


Aggressive Ransomware Blamed for NHS Attack: https://www.digitalhealth.net/2016/12/aggressive-ransomware-blamed-for-nhs-cyber-attack/


The NHS in 2030: http://www.nesta.org.uk/publications/nhs-2030-people-powered-and-knowledge-powered-health-system


Global Patient Flow Management Market:

http://www.medgadget.com/2017/01/global-patient-flow-management-solution-market-estimated-to-grow-strongly-by-2021.html 14

John Hopkins Command Centre: http://www.hopkinsmedicine.org/news/articles/command-center-to-improve-patient-flow


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