Market Review

Paper by Bloor by Paper May 2017 May

Paul Bevan, Simon Holloway, David Norfolk, Richard Rose David Norfolk, Simon Holloway, Bevan, Paul

for NHS Technology Maturity Technology NHS for NHS Technologies Framework Bloor’s Publish date date Publish Market Review Market Authors Market Review 2 represents our best efforts at UK NHS healthcare. UK – healthcare is different Not US healthcare; US patient:in the USA is 1: doctor whereas in the 1, as patient moves is 1: patient:doctor UK many, inpatients care, and community acute between are based on a US systems – and outpatients data model. different and electronic voice Health IT many Not Legal; used in Clinical document technologies in Legal can also be used Correspondence business correspondence just Outpatient Client Correspondence Initially, later. the scope can expand we Systems; documenting a large and changing market as of it will beMarch reviewed 2017; at intervals as we information.get more This Market Review This Market Initial scope of the Bloor CCMI project CCMI the Bloor of Initial scope • • • •

This Report will be of interest to practitioners © 2017 Bloor managers. manual dictation and store correspondence in paper archives. trying to improve maturity the in NHS and to their maturity, it has to be used a mature in process, but it unlikely is that a high-maturity clinical use will process, for example, correspondence of technology can be an approximate indicator of process maturity. Although, of course, just buying the right technology doesn’t guarantee managing process. However, process automation automation process However, process. managing usuallyis key to achieving maturity and keeping it – making process maturity “sticky” – so the choice what process you have; institutionalising process process institutionalising have; you what process and sharing good practice across the organisation; of improvement metrics; continual process process based on key metrics; and, pro-actively Correspondence and Bloor’s Enhanced Clinical Maturity Maturity (CCMI). Correspondence Index a questionis of Process; the understanding of Market Update. It a survey is of available NHS technologies relevant to Bloor’s study of NHS ProcessMaturity the in context (initially) of Clinical Introduction This review document not is a conventional Bloor Bloor’s Framework for NHS Technology Maturity Technology NHS for Framework Bloor’s NHS Technologies NHS Market Review

3

). . https://www.gov.uk/government/ An overview of the strategy detail in and NHS strategy may be modified by theWachter Ultimately, these outcomes, particularly including these outcomes, particularly including Ultimately, cost management, must be the focus of any high- initiatives. improvement” maturity “continual how it changing is a KingsFund in is report at https://www.kingsfund.org.uk/sites/files/kf/field/ field_publication_file/A_digital_NHS_Kings_Fund_ Sep_2016.pdf review (see uploads/system/uploads/attachment_data/ file/550866/Wachter_Review_Accessible.pdf “It not is yet clear whether the government intends to accept however, this; it looks likely to take account of Wachter’s recommendations to give most acute hospitals more timeready to themselves for change” – Chris Rodwell, of Winscribe.

).

getting patients to clinics etc. where public where public clinics etc. getting patients to transport isn’t available and the patient doesn’t a car). to access have “artificial intelligence” or AI) via in internet chat chat via in internet AI) or intelligence” “artificial and integration conference), video session or with Uber transport address the issue of (to Innovative initiatives exploiting advanced advanced exploiting initiatives Innovative “virtual clinics” include examples – technology a medical even or possibly doctor, your (visiting The use of secure sharing of medical sharing of secure The use of outside and between inside, information on the organisations (this is predicated digital transformation). of achievement includes cyber security as an objective – – as an objective security includes cyber https://www.england.nhs.uk/digitaltechnology/ info-revolution/ The NHS “Digital Transformation by 2020” 2020” by Transformation “Digital The NHS 2018”; NHS by “Paperless be the (this used to and now pushed back but this has been A further issue that is the NHS as a whole © 2017 Bloor • • • and moving patients from expensive hospital care to cheap community and home care. This translates into: Issue 1: the NHS Strategic Direction Issue 1: the NHS Strategic NHS imperatives today stress reducing total cost analysis of the NHS using systems thinking will not be pursued further here – although readers should be aware of this possibility. by transitions between system states. However, Bloor believes that parts of this whole, such as clinical correspondence, can be adequately analysed terms in of process. For this reason, the probably behaves as a dynamic feedback- controlled system, exhibiting desired behaviours, associated with dynamic equilibria and changed much of the technology implemented in different the in technology of implemented much individual areas may be quite advanced. in this context. independent this many in There are Health Trusts, using different technologies, and standardisation a long is way off – although Two key marketTwo issues are the complexity of the NHS technology environment, strategy, and its development; and what “maturity” means Key market issues Key Market Review 4

replaced replaced .

here Y) SUS, VICES VICES N3 PSIS, SECURIT WEB SER (PDS, SPINE SER work closely with organisations closely work ntrols

Co

APPS TION TA ORKS AL/W RT PO ccess A s A Midlands and East of England regional team; vice – a South of England regional team. groups (CCGs) Clinical commissioning They April 1 2013. on care trusts (PCTs) primary (members include a GP by chaired are generally and others) and nurses and consultants GPs, the NHS bodies responsible for are statutory healthcare of planning and commissioning NHS England is the commissioner for primary primary for NHS England is the commissioner and pharmacists such as GPs, care services and health services including military dentists, this of An example services. some specialised is NHS England inviting clinical commissioning on an increased role in take to groups (CCGs) can read You services. GP of the commissioning and its benefits more about co-commissioning NHS England website. on NHS England’s the overall manages around £100 billion of NHS budget and ensures that organisations are funds effectively. spending the allocated teams Regional health and well- local authorities, such as CCGs, practices. as GP being boards as well there is: For example, – a North of England regional team; –  – a London regional team; TIONS table De A r Full esults • • Link to a list of commonly used NHS acronyms R Po TURE AREHOUSE MIS PMI OMMUNIC W C TA

Chemo ), ASTRUC DA Ordering orkstations W PRESCRIBING SYSTEMS ORDER / INFR PCs L CA

LO

GE HANDLING GE MESSA / ENGINE TION A INTEGR Wireless y “An alternative“An guide to from the Kings Fund at ology https://www.england.nhs. RIS ayroll Others P N Onc Maternit Document The UK Government LA . Management y t TION SYSTEMS CS HR A&E PA Suppor ardiology Business Pharmac C

INFORMA BUSINESS SYSTEMS e AL S

Data Storage

PA thology Year Forward View ( View Forward Year uk/wp-content/uploads/2014/10/5yfv-web.pdf the NHS. vision for which sets out the future to set the priorities and direction of the NHS of set the priorities and direction to for health and care outcomes improve and to Five NHS England’s See in England. people NHS England is an independent body, at arm’s at arm’s NHS England is an independent body, Its main role is the government. length to A YouTube animation, A YouTube Financ Theatre Systems https://www.gov.uk/government/organisations/ rocurement Pa LINIC P Child Health C

© 2017 Bloor department-of-health • The DH a ministerialis department, supported by agencies23 and public bodies; see the DH website at public health, the NHS and social care England. in It responsible is for the strategic leadership and funding for both health and social care England. in The UK Government. Secretary of State for Health has overall responsibility for the work of the Department of Health (DH). DH provides strategic leadership for At “business function” level, we have a have we level, function” “business At more or less: hierarchical NHS structure, probably gives a more approachable idea of the full picture, and of the complexity problem face. will readers the new in NHS England” https://www.youtube.com/watch?v=8CSp6HsQVtw Figure 1: NHS Information Management Systems. Figure 1: NHS Information showing the bigger picture, including hospital business systems, but at the level of this report, they are likely to add to the readers’ confusion. See, for example: Issue 2: NHS Structure Issue 2: NHS Only simplified a picture of the NHS structureis providedin this paper, there are charts Market Review

5 ); and ) for ) for https://www.cerner. ) and/or NHSMail ( ). Cerner http://uk.allscripts.com/ ( Electronic Patient Records (EPR) Records Patient Electronic (this where is the usedis CCMI www.hl7.org.uk Allscripts www.epic.com/ ); A&E Inpatients Outpatients today and where Winscribe mostly is). http://systems.digital.nhs.uk/nhsmail exclusively) using HL7 data communications data communications using HL7 exclusively) standards ( ( documents. Acute (urgent and emergency)Health Services These are divided into major areas: – – – – PAS (Patient Administration System) – Radiology Pathology – – Maternity Scheduling – – etc. (about 80 overall). health care is standardising around Acute cross-hospital uses and typically com/ ( Epic but not (usually data is distributed Again, • It worth is remembering that the NHS not is a simple “machine” with a single “product” many (as classic business systems are). It a complex, is dynamic system, facing constant change and with “behaviour” (possibly a poster child for future business systems). This means that attempts to understand it, and make it operate, as a “well- oiled machine” (like a Henry Ford production line) may be doomed to failure. • Acute Healthcare Services interact with A&E, Inpatients and Outpatient systems: • ) or https://

http:// (including ) for documents. ) – RiO ( – ) , to provide provide to , are commissioned are commissioned ) is important in mental and/or NHSMail ( private suppliers private local community hospitals local community https://www.emishealth.com/ https://www.tpp-uk.com/

www.hl7.org.uk) Community Health Care is standardising Health Care Community urgent and emergency care (including out-of- mental health services and learning disability around the primary care record and typically and typically care record around the primary uses EMIS ( ( TPP www.servelec-group.com/health-social-care/ healthcare/products/rio/ this. outside of health but is a poor cousin hours and NHS 111). services; some GP services (this supposed is to increase). Commissioning services Practices GP from Commissioning (which are private companies) strategic is but quite controversial, because GPs serve on CCGs and there might be a conflict interest.of Data is distributed (usually but not exclusively) but not exclusively) (usually Data is distributed data communicationsusing HL7 standards ( systems.digital.nhs.uk/nhsmail numbers are used (even more, if one wants to if one wants to more, numbers are used (even as in Manchester). care, health and social unify that the EMIS number will be It is likely TPP) and will for in future (even ubiquitous map 1:1 with NHS numbers. Tracking patients is an issue – many identifying many – patients is an issue Tracking

–  – – – Community Health Services Community –  –  services commissioned by CCGs include: CCGs by commissioned services – planned hospital care; – rehabilitative care; charities) and healthcare trusts) (community care The secondary health services. community NHS secondary care services NHS secondary example, for from, –  –  – most community health services; (CQC) data about service providers. data about service (CQC) account service quality, using both National using quality, service account (NICE) Excellence Health and Care for Institute Commission’s Quality guidelines and the Care services for their local area. A CCG has about CCG A their local area. for services into budget and must take the NHS 60% of © 2017 Bloor

• • pharmacies and high street optometrists. commission:CCGs In addition to GP practices, NHS primary care services cover dental practices, community Market Review 6 SNOMED SNOMED ) we would – see level 6 level see – . https://en.wikipedia.org/wiki/SNOMED_ of the coding (allocating spurious This important is to exploiting digital – “a systematically“a organized computer SNOMED CT codes. (Clinical Terms) . Winscribe has told us that analysis of Winscribe text allows checking against history (particularly hard to fake). Advanced cross-checkingmaturity thing. of a high ID is Validating a patient often is a matter of Note that recent ransomeware incidents (see checking more id numbers/fields:checking maternity numbers; NHS number; birthdate; name. Must handle lots ofnumbers and handle collisions. Must display at all points, not just at start of interaction. http://www.telegraph.co.uk/news/2017/01/13/ largest-nhs-trust-hit-cyber-attack/ class as a type of fraud. of the NHS (e.g. Transfer of Care). – ICD disease classificationcodes – see https://wikipedia/wiki/International_Statistical_ Classification_of _Diseases_and_Related_Health_ Problems – Coding intimately is involved with Billing (and Winscribe, for example, has automated check that coding correct, is e.g. operation a hip may have other codes for work done at the same time. Automatic coding ensures that you claim money for everything you can (but the total you can claim capped) is and minimises “gaming” codes to maximise revenue). Hospitals can sell coded data to the health industry – with a minimum of 5 anonymous patients a dataset, in so they can’t be identified. But there are real GDPR (EU General Data Protection Regulation) here. issues randomisation/anonymisation and Note the following coding topics: – CT is processable collection of medical terms providing codes, terms, synonyms and definitions used in clinical documentation and reporting. SNOMED CT considered is to be the most comprehensive, the in terminology healthcare clinical multilingual world” CT flow is done, but said that SNOMED was not currently exploited much; however, it seems to be critical to the future Digital Transformation Electronic Mail Electronic – NHSmail secure email management.Identity number ID and –  –  management Security Fraud and importance increasing of is – CCMI –  Coding. data the in NHS effectively and pro-actively, a high maturity activity. The system should • • • • ). ):

.

definition – £39.59. ). The ).

– Trust Integration – Trust . Springer 2012. Kindle – “an electronic record of periodic periodic of record electronic “an “Principles of Health Interoperability. Interoperability. Health of “Principles makes EPR definition somewhat makes Patient Administration System and Departmental Systems Clinical knowledge, decision support and integrated care pathways Integrated patient administration and departmental systems Advanced clinical documentation and integration Clinical activity support and noting    Full multi-media EPR on line   https://www.amazon.co.uk/Principles-

HL7 data communications standards. HL7 standard data interchange supported is by most serious electronic healthcare management systems. Client Correspondence Client CCMI/Winscribe fits here and links to the TIE Reference: Tim Benson’s (Grahame Grieve, SNOMED CT, HL7 andSNOMED FHIR” CT, edition: Health-Interoperability-Information-Technology/ dp/3319303686/ref=dp_ob_title_bk Contributor) Contributor)

http://healthcareinformatics3000feet.blogspot. http://healthcareinformatics3000feet.blogspot. https://www.theguardian.com/society/2013/

–  – etc. – A mature EPR management system will include: mature EPR management system A Appointments – – Client List Patient Administration System, PAS. PAS. System, Administration Patient EPR a subset of record, This uses a patient master 1). (EPR Level ( co.uk/2007/02/accurate-definitions-emreprehr.html EMR (Electronic Medical Record) is what the Medical Record) EMR (Electronic although it is not EPR is called in the USA, focused the same and more medically quite – Level 5: – Level 6: – Level 3: – Level 4: – Level 2: ( co.uk/2007/02/accurate-definitions-emreprehr.html – Level 1: health care of a single individual, provided mainly by by mainly provided individual, a single of health care one institution” EPR of 6 levels There are patient centric. ( sep/18/nhs-records-system-10bn NHS as EPR by of Electronic Patient Record (EPR) technology Record Patient Electronic the of instead in the UK, have This is what we failed Electronic Health Record (EHR) envisaged by thefailed NpfIT NHS IT modernisation project –  – Rhapsody;– – MIRTH open source; –  Engine, TIE Engine, Intersystems Ensemble; – Interoperability technology Interoperability © 2017 Bloor • • •

• • At the technology level, we have: we level, the technology At Market Review 7 . NHS https://www. “Principles Health of https://digital.nhs.uk/ ( ) depends (in part) on – £39.59. :-Beverley and reference: Tim Benson’s :-Beverley Benson’s and Tim reference: http://prestidigitatorial/features/45858/ Springer 2012. Kindle edition: amazon.co.uk/Principles-Health-Interoperability- Information-Technology/dp/3319303686/ref=dp_ ob_title_bk interview Contributor) Grieve, (Grahame Interoperability. HL7 and SNOMED FHIR” CT, Services now NHS Digital – possible contact Beverly Brand, Dr of Digital Transformation. See SNOMED coding and targeted is on an Oct 2018 implementation. – Contact: Health Care Statistical Information – No-one does full coding yet – but the Transfer of Care initiative transfer-of-care-initiative coding-based billing systems developed for US Healthcare). © 2017 Bloor Market Review 8 The trend for the proportion of documents Useful Metrics could also include cost per Maturity about is process, not technology; of secretaries; total number of documents; departmental reports naming doctors and associated doctors. What about considering the statistics for the purchase of typing/ photocopier paper? still on paper a good is indicator for the effectiveness continual of not) (or efforts.improvement letter; use of letter templates; total number but Bloor believes that technology can help to reduce the barriers to maturityand improvement.process Mapping this into Winscribe’s own CCMI The trend for secretaries employed over 5 maturity levels not is (yet) part of the present paper. years (this should go down) against the trend for the number documents produced (this should go interesting, is up) as an indicator of progress. A graph of the number of documents secretary employed per produced vs. technology purchased and installed an is indicator of whether technology adoption is effective. together with the proactive use of these to its and correspondence futuremanage resource needs. –  Maturity means, part, in having effective and practical (which means “just not enough”, “as many as possible”) Metrics, such as: –  –  –  A “High Maturity NHSTrust” needsto have capability all in the categories mentioned the in earlier parts of this paper, where appropriate; and effective usage of these capabilities (which metrics, procedures/process, policy, and implies initiatives). improvement proactive continual –  This paper largely restricts consideration of maturity just to theCCMI. In this context, “Maturity” translates having to metrics, procedures/process, policy, and clinical for initiatives improvement continual integration plus processes; correspondence with an effective TIE and Electronic Mail and the availability of an EPR for all patients. “High Maturity” translates into the availability of potential metrics for any aspect of clinical interest; of be that may correspondence • Specifically: • • http:// if it is being , can be an . In fact, it a is and how they are used. A typical generic is often is used as part of a sales pitch: When we talk about “technology maturity” this in In the specificcontext of a Clinical © 2017 Bloor Clinical Correspondence maturity if it still is using significant amounts of paperin a manualdictation/ typing process. indicator of organisational maturity, as a confirmatory check on other assessments. Conversely, it hard is to see how an organisation could defend claims of high will be needed by a high maturity process. Thus, the adoption of a high maturity technology, organisation the effectivelyused across technology will confer maturity on the organisation buying it. However, we recognise that different technologies have different capabilities and a “high maturity” technology will have the capabilities that if maturity not is uniform across the organisation). paper, we don’t mean to imply that buying a particular for all organisations, at least to Level the 3; absolute Maturity Level achieved at any time any in part of an organisation can be a bit of a distraction (especially, (in the generic scheme) to level 3 would bring major organisational and financial benefits. In Bloor’s opinion, increasing Maturity a worthwhile is journey focussed on organisational culture. 1 level from MaturityCorrespondence moving Index, successful organisations (for now) are at Level one, but threatened by better managed and governed competition that can operate at level levels 3; 4 and 5 are still mostly aspirational and very much improvement and organisational stability as a basis for agility and innovation the in face of change). Don’t worry too much about the definitions: many Managed (the organisation data-driven is and its goals are expressed quantitative in terms); 5, continual focuses on (the organisation Optimising identified andinstitutionalised across the whole organisation, which can now respond to change Quantitatively 4, rather reactively); than pro-actively and delayed delivery, and often with a dysfunctional Blame Culture); 2, Managed organisation (an knows what it has and manages its processes but only at a project level); 3, Defined (“Good Process”is Maturity Model has 5 levels: 1, General (things work, often surprisingly well if a Hero available is to make them work, but with a high risk of failure if you want to understand Maturity Models cmmiinstitute.com/capability-maturity-model- integration well understood way of evaluating process capability and the ability to execute without surprises. The CMMI Institute probably is a good place to start “our high maturityproduct has more functionality than everything else and will fix all of your problems without you needing to think much” Issue 3: Maturity – what is it? – Issue 3: Maturity “Maturity” Market Review 9 . “Put simply, “Put simply, ) is a rules-) is https://www. http://www.uhb. See “a leader in its field, ) is a highly) is mature US Bloor has heard that it http://www.intersystems.com/ . – see ) and outpatients not is its main focus. https://www.digitalhealth.net/2017/01/ http://www.epic.com/ is a leader in GP practice GP management in leader a is (Birmingham Systems Prescribing Information ( , from Servelec, an is EPR system mainly found RiO Mentalin Health, Community in Healthcare. It claims, on its website, to be [operating] across care settings for Mental Health, Community Health, Child Health and Social Care to support health and social care professionals in the deliveryof converged care for patients and service example, example, epic-improvements-pull-cambridge-out-of-special- measures-2/ Intersystems TrakCare. rather relies on typists, somewhat is document- centric, and that its EPR US model doesn’t really fit the EPRUK model perfectly (the UK has inpatients and outpatients, but the doesn’t). US Nevertheless, it claims its (on website) that making are countries 25 in organizations “Healthcare breakthroughs a patient in with care TrakCare, unified healthcare information system that enables coordinated care within a hospital or across care settings throughout region a — facilitating a seamless patient journey” our-products/trakcare/trakcare-overview-2/ PICS and Communications System; see nhs.uk/birmingham-systems-pics.htm support communications prescription based and system, with real-time checking for drug interactions, contra-indications, dose limits and allergies. It integrates with, e.g. Winscribe, order in to provide a full system CC (it doesn’t have voice etc.). recognition EMIS and Community Healthcare but not really a Winscribe competitor. It’s popular but there’s an issue with to – who EMIS lock-in owns the data/metadata? Perhaps maturity a issue for GPs, they simply didn’t realise the implications of the small-print.EMIS Sometimes used with Winscribe QSR – you can simply talk into an EMIS field. According to the EMIS website, thewe’re leader in connected healthcare software and services. provide We every health sector with innovative technologies, from market-leading clinical – tools analytics health to systems management support. And customer unrivalled with combined that’s Health. why now we’re EMIS brought We’ve together the divisions of EMIS, Ascribe, Digital Healthcare, Indigo4 and Rx Systems. Integrated care no is longer an aspiration.” emishealth.com/ Epic systems. wide hospital comprehensive of provider However, it has only a couple of UK sites (see, for

) is a suite) is of . . . /

“Docman the is leading supplier Lorenzowas the flagshipEPR system http://uk.allscripts.com/products- http://www.csc.com/health_services/ Management and distribution of ( is an important player in Acute Healthcare. anis important player Acute in Healthcare. http://www.docman.com https://www.cerner.com/ © 2017 Bloor track and manage their clinical and non-clinical documentation efficiently.” See track and transfer healthcare documents. There are now Trusts 5 NHS using our electronic document management solution functionality to workflow, of letters to primary care electronically. Over 6,000 GP Practices utilise Docman a centrally GP, funded solution to enable you to capture, organise, workflow, workflow and transfer software for Primary, Secondary and Social Healthcare organisations. Over Trusts NHS use Docman120 Hub to send millions trusts – and by GP practices. Winscribe will manage and use DOCMAN, if it there. is According its to website, Management, Document Electronic advanced of a hub-based solution similar to and EDI replaces NHSmail. Handles discharge letters, summaries, result reporting and used is by about a third of offerings/99982/103601-lorenzo DOCMAN. documents works (only at document level) and is for NPfITbut implementation was plagued by delays. It still is being used/implemented the in NHS. See: population one is person at a time”. See CSC Lorenzo. will shape the future of health care – one driven by accountability, transparency and value. Cerner believes the best way to manage the health of a data to engage individuals at all times, exchange information between providers and ultimately drive better outcomes. This shift in perspective maximize patient satisfaction and minimize resource complete, Getting requires there consumption. accurate patient data and meaningfully using that industry buzzword or the next big fad. It the is shift from solely automating health systems to managing a person’s health. A healthier overall population will Cerner Cerner According to its website, Cerner thinks that: an than more is Management Health “Population based Patient Administration System (PAS) developed specifically for the UK health sector. However, it doesn’t include voice recognition etc. Allscripts services/products/allscripts-pas products making upan Acute Healthcare EPR- (CC) Technology landscape Technology (CC) technologies CC “high maturity” Potentially in use in the NHS The Clinical Correspondence Correspondence Clinical The Market Review . 10

– );

. https://www. ]) for the transfer https://www.mirth.com/ https://digital.nhs.uk/ . It can be implemented in It can be implemented . ] by the British Medical Association http://www.theprsb.org/wp-content/ http://systems.digital.nhs.uk/nhsmail It worth is noting that email not is an option ConnectMate Software TC MIRTH Open source – – Open source MIRTH if implemented maturity high for good indicator Enterprise the Large e.g., with, properly Healthcare from NextGen version nextgen.com/Interoperability/Mirth-Solutions/ Connect-Overview the career safeguard to way, a low-maturity maturity popular low the supportof guy implementations. Engine— Integration Orion Health Rhapsody https://orionhealth.com/us/products/rhapsody/ in use in engine This is the main integration the NHS. Eclipsys eLink Suite Oracle SOA Cloverleaf Quovadx Siemens OPENLink Sun eGate Suite 5-ICAN Sun eGate in telcos – Impact Sybase e-Biz https://digital.nhs.uk/transfer-of-care-initiative see see under the NHS Transfer of Care initiative ( we are not sure if this precludes use of NHSmail. • NHSmail The use of NHSmail indicates high security but it isn’t really within the scope of the Bloor project.CCMI I would think that effective use of NHSmail equivalent) (or would be necessary for claiming High Maturity, but far from sufficient, overall. “NHSmailis a secure email ‘Government OFFICIAL to service accredited SENSITIVE’ status, approved by DH for sharing patient identifiable/sensitiveinformation. NHSmail endorsed is [ nhsmail (BMA), the Royal College of Nursing (RCN) and the Chartered Society of Physiotherapy (CSP) and the Professional Records Standards Body (PRSB [ uploads/2015/05/PRSB-Report-on-using-email- in-health-and-social-care.pdf of clinical information. security NHSmail’s credentials are also uniquely recognised by other specialist security organisations, including HeadquartersGovernment Communications (GCHQ), the Police and the Ministry of Defence.” – • • Other potential TIEs: • • • • • • • http:// . https://www. It includes includes It . See also See . https://www.tpp-uk. . https://www.servelec-group.com/ – . This a TPP is system much used in originates from New Zealand and is ) but a few stand out as commonin use:

www.intersystems.com/who-we-are/newsroom/ news-item/nhs-trusts-connect-with-intersystems- ensemble/ http://www.intersystems.com/our-products/ healthshare/healthshare-product-family/health- connect-a-healthshare-solution/ Intersystems Ensemble, delivered by CSC – see see – CSC by delivered Ensemble, Intersystems © 2017 Bloor quora.com/What-are-the-integration-platforms-used-in- the-NHS to a halt if it fails. There are many TIEs use in the in NHS (see Dave Waghorn, an NHS employee for well over a decade, writing on Jan 30, at 2015, not sufficient, overall, and I would hope that there a matureis NHS-wide standard evolving. A TIE a is critical resource for a hospital as it brings the hospital availability of a TIE, with HL7 support, an is indicator of High Maturity – we think that effective use of a TIE would be essential for claiming High Maturity but Trust Integration Engines (TIE) Integration Trust Winscribe, for instance, interfaces with all TIEs, and receiving), transcription (Outsource manager). Winscribe picks up all HL7 records and can work standalone, isolation in of EPR systems. Speech Recognition software with over 350,000 correspondence clinical users covers worldwide. It (Winscriberecognitionvoice Text), (Winscribe voice com/products/systmone Winscribe the global market leader Digital in Dictation and patient, one record’ model of healthcare.” SystmOnline, for self-service patient appointments, requestsprescription etc. See community healthcare (GP surgeries) but not Acutein Healthcare. According to its website, “SystmOne a pioneering is clinical system which fully supports a ground-breaking vision for a ‘one health-social-care/healthcare/products/rio/ SystmOne. makingour information systems more open and easier to integrate to enable the free-flow of patient information between products and hence across the continuum.” care primary care through integration with GP Systems and the use viewers. of RiO As signatory a of techUK’s Interoperability Charter, Servelec committed is to functionality. It delivers information securely in a browser, portal or on a mobile device. This data can be viewed across the care settings and shared with users. Long-term care at is the centre of RiO’s design principles in addition to providing patient centric • Market Review 11 ) is a ) is “allowing (according ) Talk & ) Talk http://www.g2speech. . ICE supports (proprietary) See http://www.sunquestinfo. See

http://www.imsmaxims.com/ ( . This GP is requesting & reporting, https://www.yorkhospitals.nhs.uk/ Provider of customised speech https://www.lexacom.co.uk/ ( . Half the of Winscribe,size mostly health, transcription using third-party vendors. It doesn’t support document nor change management (it mainly has SME customers and may not scale to very large rollouts), nor it is included the in SBS frameworks. sharing of patient information quickly and easily with other Trusts or ICE systems, with searching and validating on patient demographics easy transition between patient reports” website). the ICE to Maxims IMS supplier of clinically- oriented EPR-based business solutions for healthcare, which could be part of a full system CC (it doesn’t have voice recognition capabilities, workflow etc.). is alsoIt a pioneer thein use of Open Source Software (OSS) in the NHS, with the release of openMAXIMS. It is claimed that its open technology approach has increased clinical engagement the in development of the software. Lexacom digitalType dictation and workflow management software claims to be the market leader, but this the in is primary care (GP) market (where it integrates well with EMIS). Lexacom seems to target professionals general in now, not just health professionals, although it started in Healthcare. It has partial HL7 support at either end of the Transfer of care pathway (referrals and GP Letters) but not for full EPR content. It offers G2Speech. G2Speech. recognition and digital dictation systems for the medical and legal sectors. Has operations in Holland and the UK. See com/gb/ Netherlands bias. Competitor to Winscribe, but Winscribe would increase maturity because it supports change management and continual improvement. Also, offer G2Speech doesn’t transcription. Sunquest. from ICE com/products-solutions/integrated-clinical- environment for TPP SystmOne. It a wide is ranging solution but its use declining, is because it doesn’t handle HL7 well and slow is (it relies on polling and, anecdotally, response time measured is in “lunchtimes”). Old technology with poor usability. Supports (proprietary) Opennet. I have a User Guide from document.php?o=1980 OpenNet – designed to facilitate the viewing and “an . It partners with http://www.bluewire- . – see http://www.bighand.com/ http://www.tpp-uk.com/about- This looks like a potential – provides Digital Dictation, Voice http://www.crescendo.com/digital_ . – from seems to be an Accident and claims (at ) that it being is used to streamlineclinical http://www.bluespier.com/ © 2017 Bloor SystmOne ensuring the correct patient selected is every time” us/partners every dictation header which speeds up the dictation process and eliminates typing errors. Each time the dictation edited is or transcribed, the corresponding patient records are automatically loaded in “As an approved“As partner of TPP for over 4 years, our seamless integration with SystmOne ensures the correct labelling of patient demographics into dictation.html Recognition & Referral Management solutions to many NHS users, presumably Community in Care. reporting capabilities” technologies.com/epro/ Crescendo investigations paperlight (e.g. Echo / ECG), clinics, outcoming and many other modules, while also managing patient records and providing powerful EPR, configurablesupport to rapid deployment standards), latest the (to summaries discharge of handover lists, tasks/workflow, lab results/ EPR disruptor, to Bloor. Epro claims to be innovative and progressive software solution for hospitals... NHS It a web-based is modular see see Winscribe. Epro. Bluewire be the leading independent supplier of Theatre Management Systems the in UK, with customers across the NHS and private healthcare sector paper. Uses Dragon voice recognition. Bluespier Emergency (Acute Healthcare) EPR. It claims to Health organisations. It a similar is to G2 size in health but much bigger Legal in (it integrates well with RiO) – although legal out is of scope for this correspondence processes by 40,000 users in healthcare74 organisations including Primary Care Trusts, NHS Trusts, GP Practices and Mental implemented correctly, with appropriate metrics. with appropriate correctly, implemented Big Hand en-gb the technology used, is and on the processes implemented around it. All these technologies could be made part of highly mature systems if This category reflects the fundamental capabilities of various technologies. Whether maturity actually is achieved depends on how Potentially “good maturity” CC technologies technologies CC maturity” “good Potentially the NHS in use in Market Review 12 . /

) is an) is .

is similar is to G2 and a is http://voicepower.co.uk/about/ ( can offer high-capability solutions, http://www.voicetechnologies.co.uk/ Nuance conjunctionin with third-party products. See https://www.facebook.com/NuanceHealthcare VoicePower effective digital dictation solution, expertise-led, which only offers basic capabilities beyond that. It can be at the core of something like Winscribe, with voice recognition being partner-provided. Technology Voice Winscribe partner which offers Information Workflow; MobileWorkflow (using mobile device of choice, with uncompromising security); Digital Dictation; Speech Recognition. However, it doesn’t offer full integration of speech recognition thein way that Winscribe, say, does. See Good Good . (smartphone) – https://mmodal.com/ “Our cloud-based clinical documentation offers mainly cheap transcription and © 2017 Bloor US focused?US See the patient story, and by delivering information when it needed is most – at the point of care”. range of EHR systems supported. Might be a bit solutions connect workflows for efficient and speechaccurate recognition, medical transcription, CDI, and coding. facilitate We physician-patient relationships by making it easy for doctors to capture capabilities and real-time clinical intelligence services that may be interesting). Cloud-hosted; it says that N*Modal good speech recognition (although it has coding and management capabilities, including the capability for managing a “fleet of phones” for an organisation and for separating work and private use on the one phone. technologies will have a mobile app – to count as the “mature”, app will be available from a managed appstore, havefull security capabilities, mics. These increasingly have very sophisticated recording, noise cancelling and digitisation capabilities. All suppliers of mature EPR Mobile voice capture apps probably the coming thing, replacing speech Market Review 13 . ) provides )

. https://www. . Not really full

. Dictation microphone, Dictation microphone, Another dictation Just a powerful microphone The leading voice http://www.dictaphones.co.uk/ workflow software. From . http://www.dictaphones.co.uk/ “The Olympus DR-2300 is designed is “The Olympus to enable DR-2300 voice recognition engine, aka Cortana http://www.medisecsoftware.co.uk/ “Streamline your workflow with a tailor-made ( voice recognition engine – intelligent http://www.dictaphones.co.uk/?gclid=Cj0KEQiA39_ http://www.nuance.co.uk/index.htm workflow, it just supports 1 person. According to its website: digital dictation solution. Our solutions support every dictation scenario. This the is key to letting you work the way you want – and to providing individual solutions to the diverse requirements that are typical in enterprise- wide workflows”. products BigHand. as, for example, such Portable handset.Olympus see h813l9ASzHhKX9c BBRD0w-_rmOrc__8BEiQA-EtxXfM_ Al208P8HAQ AGlzOtEMWnMM2BrYNebh0L84a DirectRec. Wired Olympus for digital: easy integration in any work environment – no matter if in a doctor or lawyer practice. With four designated programmable buttons on the front, as well as the one on the back, the device can be fully customized, enabling complete systems integration. provide the To most secure and efficient dictation workflow, DR-2300 the offers a barcode scanner (available separately), which enables automatic allocation files of voice to client,case or patient records”. Olympus-DR-2300-with-Device-Configuration-Software-p/ v401140se000.htm Philips Portable handset. microphone, see Philips-Speechmikes-s/50.htm Speechexec Philips dictation.philips.com/gb/products/product/speechexec_ dictation_workflow_solution_lfh7330/ Google document capabilities (hover over field, speak to fill text)in but otherwise just voice recognition. Medisec integrated medical digital dictation software and clinical correspondence solutions, with electronic distribution and workflow, for the NHS. It doesn’t include voice recognition and only partial supportfor digital dictation, but it does support HL7 (which is unusual the in low-maturity group). Microsoft (with a neural processing model 2 years. in Just voice recognition. Nuance Dragon Dictate. recognition engine (Winscribe uses it) but under threat from the Microsoft, Google, Apple voice recognition (it also has a reputation for heavy server usage). Just voicerecognition, see However, Nuance can offer good or high maturity solutions conjunctionin with other third-party .

– that is It claims “No medical data “From a time and . http://dscribe.co.uk/ http://www.dict8.com/the-service/about/ This similar is to Dscribe but with This mainly a low is maturity vendor, it is voice recognition engine, aka Siri, oriented “the UK’s leading supplier of dictation solutions – see https://www.dictate.it/frontend/ © 2017 Bloor attractive and it has some prestigious NHS trusts as clients. See are made redundant or redeployed; there would be there would redeployed; or redundant made are significant organisational maturityimplications for success. It does supply training, its acquisition cost is Trust approximatelyTrust £85,000 per annum, making salary payments to that team £200,000 rather than £285,000”. However, whether such savings would be achieved practicein rather depends on whether the FTEs 52 on the findings above,7,000 totalledthis inefficient hours/annum which equates to £85,000 in cost. Typing in the accepted efficiency timeframe would save each Trust andTrust using statistics from our workflow, we noted an average number of dictations FTEs the handled 52 in (and hours 18,560 a year typing was 2313 Based time). Improvement Programme of Trusts”. NHS significant potentialcost savings: motion study secretaries of 52 in four departments in a delivering excellent patient DScribe care; manage CQUIN targets by delivering clinic letters hours, within 24 eliminating resource wastage. Our implementations have shown to make a major contribution to the Cost “Clinical Administration Services designed for the NHS. Proven to deliver major efficiency improvements and measurable cost savings. Hospitals concentrate on Dscribe. a free product but you pay for Indian transcription services. It doesn’t support It claims to offer: HL7. to the NHS. Dictate offers IT a one-stop solution for your medical transcription and digital dictation”. See Dictate IT. transcription services Eastern in Europe. It claims to be true, and may be helpful, butisn’t a substitute for customers having proper security policies. from experienced typists and that: leaves the UK in the DICT8 system and therefore is subject to UK data regulations and safeguards – these would be hard to enforce in, Asia” say, Recruits local UK transcription typists, often NHS typists working spare in time, which may raise some issues practice. in Claims high transcription quality towards speech commands but otherwise just voice recognition. Dict8 capabilities Apple transcription systems, with no, or limited, workflow capabilities. They might be part of “high maturity” solutions, with other products to flesh out their Low Maturity Technologies in use in the NHS in use Technologies Maturity Low These are digital recording or outsourced Market Review 14 . ) offers digital dictation This a speech is recognition https://emiswebexperiences.wordpress. www.tpro.ie/ ( Talk for EMISTalk Web solution for medical professionals (in Community Healthcare) using the clinical Web EMIS system. Included the in package are voice commands for fast navigation; a Clinical Lexicon Terms to enhance accuracy, a Philips SpeechMike microphone along with training andtechnical support. Seems to have a bad reputation (although seems EMIS to attempt support); see, e.g.: com/2011/12/22/emis-web-a-voyage-of-surprises- and-usually-nasty-ones/ T Pro and transcription services, together with voice recognition and workflow capabilities, but doesn’t offer support. HL7 document management or . But ) works This just is a (good) https://www.dictation.philips.com/ “best-in-class recording with Precision “best-in-class with Precision recording http://www.scribetech.co.uk/ ( © 2017 Bloor It relies on outsourced transcription services but does have voice recognition and workflow capabilities, without support for document HL7. management or with the NHS and Health sector companies to deliver digital dictation, speech recognition, clinical transcription and clinical coding services. results. The new touch sensor ensures easier navigation, saving you even more time.” Scribetech a built-in noise reductiona built-in antimicrobial filter, housing and a motion sensor for the clearest speech recordings and most accurate speech recognition Microphone. SpeechMike the is Premium Touch latest innovation from Philips. It comes with a premium decoupled studio quality microphone, gb/products/product/speechmike_premium_touch_ dictation_microphone_smp37003800_series/ it does offer Philips Wired Speechmike. Wired Philips microphone: Market Review 15 It will be of great interest to politicians; to great interest It will be of visible in the press; very will be An NHS project and there is thus an aversion Failure kills people impact innovation; which may risk to “demographic with the is incompatible Austerity are living the NHS—people by faced time bomb” age, maintain in old more to longer and cost are and costs volumes which means that NHS increasing naturally; with large egos skilled people The NHS is full of technology excellent implemented who have but may NHS, the of their little bit solutions for that on collaboration focussed not be entirely impact themselves. doesn’t immediately that those involved will live “interesting in times”. There are plenty of technologies available with the capabilities needed to support NHS modernisation. Its biggest issues are probably politically based. Any NHS technology implementation going is to be high risk because: • • • • • The bottom line that is NHS modernisation, using the latest technology; and the increasing of NHS process maturity, both is essential and a guarantee The NHS no is stranger to the very latest Goals are quite well defined at a strategic level, © 2017 Bloor a bureaucracy and the (in general) high quality of NHS health care itself. implemented and unnecessarily manual processes are still common. It important is to distinguish between the operation of the NHS as effective the in long term. technologies but they are not universally to be achieved. It possible is that a concentration on cost saving the in short term prevents investments that might make the NHS more cost Transfer of Care initiative) just is starting. but there rather is less guidance on how they are practices rapidly adopted across the NHS. Individual departments may have (different) effective but integration and processes automated communication of information across the NHS (the In Bloor’s opinion: the structure of the NHS is complex and not especially functional – there isn’t a simple hierarchical structure, with best Summary conclusions and

Not Not Not Not Not Not Not Not Not wide Many Many Acute Acute 107k+ world- known known known known known known known known known CC Users CC UK users UK 1 1 1 1 ment process process

manage- Change & 1 1

Market ReviewHL7

Support Mobile Solution Integrated Integrated 16 Patient Patient Support Pathway Pathway

ToC Data Data ToC Capability 10 Inte- gration NHS Mail

(NHS SBS) TIE Inte- gration 5 1 ment

manage- Document (or speech recognition) has (or speech recognition) ) is a is a joint venture between

2 3

2 Full EPR to NHS to Vendor Vendor

On SBS SR Lot 3 SR Lot Category

www.sbs.nhs.uk/ as compared to analogue tape based dictation as compared to analogue machines. Voice recognition advanced. It doesn’t intelligence, and is more and is both the need a specialist mic/recorder or program to receive and ability of a machine to understand and carry interpret dictation, and It includes automatic out spoken commands. coding of information input. NHS Shared Business Services ( the Department of Health and Sopra Steria. tables) Various SBS Frameworks/categories (see identify approved NHS technologies, although other technologies can be used. Lot 1 Lot DD/CC DD/CC On SBS Category • • 1-5) On SBS (Any Lots Lots (Any Framework Framework 9 Workflow

7 Tran-

scription

7 Voice Voice nition recog-

2 Digital

Dictation Lockin Vendor Vendor Minimal Clinical Correspondence 9 9 9 9 2 4 2 is a method of recording itself dence dence clinical

system in system Complete Complete correspon-

EPS EPR EPR EPR Main Acute Acute Acute Acute scope Mental of Care Care of System wide but Hospital- Npfit EPR Messages & Comms & Comms Acute and Acute Acute EPR Acute healthcare healthcare Healthcare

Prescribing Prescribing Health EPR Community Community Community Community Community for Transfer Transfer for Information Information largely in US largely eDistribution

longer battery life and are able to record for a longer battery life and are able to record lot longer utilizing the same media, and editing the spoken word in real-time. and editing the spoken word in real-time. The recording is done by the use of a digital a recorder. Digital recorders are lighter, have Digital dictation © 2017 Bloor Capability

Table 1: High-maturity Transfer of Care/Clinical Correspondence Technologies, Technologies, Correspondence Care/Clinical of Transfer 1: High-maturity Table solutions. and automation Transformation NHS Digital used in full-featured various technologies, and theirvarious technologies, key capabilities. Note: • is implemented effectively). The 3 colour-coded low maturity) summarisecharts below (high, good, the maturity associated withour subjective view of of Clinical Correspondance in a particularof Clinical Correspondance by assessing the maturityorganisation can be made use (always assuming that thisof the technology in Clinical Correspondence Capability Matrix Capability Correspondence Clinical estimate of the maturityA preliminary, subjective, Matrix: High-maturity – Transfer of Care – of – Care Transfer – High-maturity Winscribe SystmOne (TPP) System C C System (Medway) RIO PICS TrakCare Intersystems Intersystems Epic EMIS DOCMAN CSC Lorenzo Cerner Allscripts Technology

No 40k 40k Not Not Not Not Not Not 200k 200k users share Acute Acute About known known known known known known 40-50k 10 NHS CC Users CC Large UK UK Large estimated GP Market Market GP physicians worldwide worldwide Trust users Trust ment process process manage- Change & Market Review 1 HL7

Support Mobile Solution Integrated Integrated 17 Patient Patient Support Pathway Pathway of Care Care of Transfer Transfer Capability

NHS Mail Inte- gration TIE Inte- gration 1 1 ment

manage- Document

6

Full EPR to NHS to Vendor Vendor

On SBS SR Lot 3 SR Lot Category

Lot 1 Lot DD/CC DD/CC On SBS Category 1-5) On SBS (Any Lots Lots (Any Framework Framework Workflow Trans- cription 7 7 7 Voice Voice nition recog-

Digital Dictation Lockin Vendor Vendor Minimal Clinical Correspondence 1 1 1 itself dence dence

clinical system in system Complete Complete correspon-

ERP EPR EPR Care Core Core Main scope led SR SR led DD/CC DD/CC DD/CC DD/CC DD/CC SR Led Acute/GP Acute/GP Primary Primary General Medical Origins) to GPs and GPs to Modular Modular eDischarge Expertise Winscribe Outsource Outsource led DD/CC/ communications, communications, Transcription Transcription SR Winscribe SR Results reporting Results (Legal Market Market (Legal

© 2017 Bloor Capability Technologies, used in NHS Digital Transformation and automation solutions. and automation Transformation used in NHS Digital Technologies, Table 2: Good-maturity Transfer of Care/Clinical Correspondence Correspondence Care/Clinical of Transfer 2: Good-maturity Table Clinical Correspondence Capability Matrix Capability Correspondence Clinical Matrix:

Good-maturity – Transfer of Care – of – Care Transfer – Good-maturity Technology Voice Voice Voice Voice Power Nuance N*Modal Lexacom IMS Maxims Sunquest ICE from G2 Speech Crescendo Bluewire Epro Bluespier Hand Big Technology

45k 45k Lots users Some Acute Acute Quotes Quotes Quotes regular regular system system depart- General General 9k users 9k ments in CC Users CC 70 Trusts operating operating Worldwide Worldwide Worldwide worldwide usage with usage with

ment Change manage- Market Review & process HL7 Support Mobile Solution Integrated Integrated 18 Patient Patient Support Pathway Pathway

ToC Data Capability

nte- NHS Mail gration 1 TIE Inte- gration

ment manage- Document

Full EPR to NHS to Vendor Vendor On SBS SR Lot 3 SR Lot Category

8 Lot 1 Lot DD/CC DD/CC On SBS

Category 1-5) On SBS (Any Lots Lots (Any Framework Framework Workflow Tran- scription 1 Voice Voice nition recog-

1 Digital

Dictation Replaces Pathology and eDischarge links only and eDischarge links only Pathology SaaS product only EPR modules only Third party or Partner provided provided or Partner Third party Lockin Vendor Vendor Minimal 6 – 7 – 8 – 9 – 10 – Clinical Correspondence itself dence dence clinical system in system Complete Complete correspon-

SR SR SR led led led led led led Main in US scope led DD SR led. SR led. CC and CC General General General Hardware Hardware Outsource Outsource Outsource Outsource Outsource Outsource Outsource Outsource Outsourced Outsourced Transcription Transcription Transcription Transcription Transcription Transcription Transcription Transcription Transcription Transcription eDistribution

Outpatients only Partly only systems led/GP GP Mental Health only Winscribe integration

© 2017 Bloor Capability 5 – 1 – 2 – 3 – 4 – Key used in basic digital transformation of the NHS. of digital transformation used in basic Table 3: Low-maturity Transfer of Care/Clinical Correspondence Technologies, Technologies, Correspondence Care/Clinical of Transfer 3: Low-maturity Table Clinical Correspondence Capability Matrix Capability Correspondence Clinical Matrix: Low-maturity – Transfer of Care – of – Care Transfer – Low-maturity Technology TPro ScribeTech Philips Speechmikes Olympus microphones Nuance VR engine Microsoft Microsoft Medisec Google VR engine Dscribe Dictate IT Dictate Dict8 VR engine Apple Market Review 19 . . No part of this publication may be No part this publication may of . © 2017 Bloor © 2017 Whilst every care has been taken in the preparation of this document to ensure that ensure that this document to in the preparation of taken has been care Whilst every efforts represents our best documenting a large and changing at Review This Market For over years, 25 Bloor has assisted companies to intelligently evolve: by embracing We provideWe actionable strategic insight through our innovative independent We’ll show youWe’ll the future and help you deliver it. © 2017 Bloor market as of March 2017; it will be reviewed at intervals as we get more information. get more information. as we at intervals March 2017; it will be reviewed as of market the information is correct, the publishers cannot accept responsibility for any errors or errors any for responsibility the publishers cannot accept is correct, the information omissions. Research’s intent to claim these names or trademarks as our own. Likewise, company company Likewise, these names or trademarks claim to as our own. intent Research’s and the owner of with the consent reproduced been shots have graphics or screen logos, copyright. that owner’s to are subject Due to the nature of this material, numerous hardware and software products have been been products have numerous hardware and software this material, the nature of Due to these product names are the cases, of if not all, In the majority, name. mentioned by It is not Bloor the products. that manufacture the companies claimed as trademarks by Copyright and disclaimer Copyright This document is copyright Bloor Research of without the prior consent method whatsoever any by reproduced we will help you challenge assumptions to consistently improve and succeed. growth and profitability. technology to adjust their strategiesand achieve the best possible outcomes. At Bloor, technology research, advisory and consulting services. assist We companies throughout their transformation journeys to stay relevant, bringing fresh thinking to complex business situations and turning challenges into new opportunities for real Bloor brings fresh technological thinking to help you navigatecomplex business situations, converting challenges into new opportunities for real growth, profitability andimpact. but if you do not adapt then you will not survive. So the in age of Mutable business Evolution Essential is to your success. Bloor overviewBloor Technology enabling is rapid business evolution. The opportunities are immense Bloor Research International Ltd 20–22 Wenlock Road LONDON N1 7GU United Kingdom

Tel: +44 (0)20 7043 9750 Web: www.Bloor.eu Email: [email protected]