19 June 2013 11:35
Portals are once again a hot topic in the NHS, with a starring role in the Power of Information strategy.
Yet, as Dr Lloyd McCann, medical director of Harris Healthcare Solutions in Europe, the Middle East and Africa, acknowledges “portal means different things to different people.” Indeed, there are three main ideas about the role of this technology in the acute sector.
The first is that a portal is a credible alternative to a new electronic patient record system – one that is cheaper, that avoids the disruption of a new system, and that allows clinicians to stick with ‘best of breed’ solutions.
As the National Programme for IT in the NHS winds down, leaving many trusts without the systems they hoped for just as they feel the ongoing squeeze on public finances, this is a major driver for portal implementations.
But some experts are not convinced that portals can be EPR replacements. The second view is that they are, instead, a useful step towards an EPR – one that allows clinicians to get used to working in an electronic environment while using familiar systems in the short to medium term.
The third is that they are useful even where there is a new EPR - allowing clinicians to connect information and communicate across a health community or with a specific user group.
Starting with the basics
The defining characteristic of a portal is that it is a web browser that sits on top of not one but of many clinical systems, bringing the information they hold into one view.
“That might be for patients to view or professionals,” says Dr McCann. “At the moment most trusts are developing portals for professionals and the majority of them serve single organisations, bringing together information from a number of different source systems.”
Predominantly, these source systems are the patient administration system, picture archiving and communications, the laboratory information system and document management, he adds; although others are coming on board rapidly.
From viewing to doing
The next question is whether the portal simply holds information, or whether it allows clinicians to do something with it; update it, order tests, generate correspondence and so on. “View and do is where people are going in terms of portals,” Dr McCann says.
Phil Birchall, healthcare business development executive at InterSystems, agrees that there is a significant move to portal technology, but says clinicians want more than a view of aggregated information.
“[Interest in portal technology] is a natural reaction to the situation that the market is finding itself in as the national programme comes to an end,” he says. “But equally, there is a lot of anxiety in the purchasing community as to whether a single, robust clinical solution exists.”
Often, he says, the portal story starts with a trust’s chief information officer or IT director wanting to give clinicians something tangible. “Very often it is about the desirability of providing a common desk top for clinicians,” he says. “It is visual and tangible. But the question then comes: is it enough?
“Our observation is that very quickly it creates highly desirable clinician engagement and demand for things they find useful. Very quickly, you have to start looking at the robustness of operational systems because clinicians want to do ordering, scheduling and prescribing.”
Creating a view-only portal can go two ways: it can stimulate demand that leads to an operational portal or to disappointment. Birchall argues that the difference between success and failure is often down to whether trusts see the portal as a tactical investment or a strategic one.
“With a tactical investment there is a risk of giving a quick fix but no follow through,” he says. “Trusts need to have a view of where they want to go and a road map of what will satisfy clinicians.”
The strategy will need to take in not just the vision but also how it will be underpinned with robust integration and interoperability, how the analytics will not just capture the data but also aggregate it into something useful for clinicians, and how to deal with information governance, security and so on.
Mapping the way ahead
This notion of a road map is widely accepted in the supplier community and is supported as essential both by Orion Health and CSC.
“It’s what we call our maturity model,” says Colin Henderson, general manager for the UK and Ireland for Orion Health. “We have products that take people along the stack, from integrating workflow and transactions to ending up with patient access and telehealth.”
For Henderson, there are four key steps in developing a fully functional portal: systems integration, developing a viewing portal, getting people to use it, and then introducing functionalities they want. “It’s like The Field of Dreams. Build it and people will come,” he says.
But he warns that it needs to be built well. “Presenting information is not enough,” he says. “You need to consider how to index information and how to present it in time lines that are meaningful to clinicians.”
There are issues such as single sign-on, launching applications within the portal, and access to consider.
“We have spent many years tailoring a portal for use by clinicians in the NHS,” he says. “Now we are seeing lots of new technologies emerging and there are lots of different ways of doing this. But the devil is in the detail.”
While some trusts go so far as to call their portal an EPR, and argue that it will eventually take them paperless, others are skeptical.
Nick Harte, solutions director at CSC, which has been developing portal technology in New Zealand for 20 years, argues that portals can provide some quick wins - but that, ultimately, they will take trusts only so far and no further.
“There are a few trusts in the UK that will go down the road of a genuinely portal-based approach for their EPR.
“But they are very few and tend to be in places where the chief information officer and chief executive believe that by buying bits and pieces and using local capability they are able to do it more cost effectively,” he says.
In general, he argues: “There is no substitute for an integrated system and we all know that. Ultimately, you have to have full semantic integration with full clinical support and that requires an information repository and a move to an EPR.
“For most trusts, portals are a transitional phase that will allow trusts to leverage their existing investments in systems until they are ready for an EPR and all the organisational change that involves.”
He argues that there will still be a role for portals – but he sees them more as a way of communicating with the outside world than as an EPR.
Some healthcare communities in England are already collaborating on community-wide portals or building use-specific portals, such as those being developed to share information about child protection, while the Power of Information arguably focuses on portals as repositories of resources for managers, clinicians and patients.
David Davies, senior director of collaboration and innovation at Cerner, also takes this view, saying that even where there is a new system, trusts are using portal technology to provide an electronic health record that captures information from other settings.
“[Our clients] recognise that all clinicians involved in a patient’s care need accurate, up to date, appropriate access to the full longitudinal record wherever it is created or added to,” he says.
“[They] are developing solutions with us that enable full relevant sharing of patients records from everyone involved in their care from the patients home to the acute facility and back again.”
Similarly Civica, which provides the community and mental health system, Paris. Managing director for health and social care, David Roots, says: “If a portal is implemented where Paris is the only system then it is redundant.
“What is more interesting would be a mixed trust that is taking over responsibility for, say, mental health and clinicians need to see information from different systems.
“But our overriding comment is that you should be clear about what you are trying to do with a portal, or you will end up re-writing the system in the portal - and that is not going to get any further than the national programme. There is a danger of wanting it to do too much.”
Case study: Northumbria NHS Trust 
Northumbria NHS Trust covers 3,000 square miles in north east England, taking in urban centres in North Tyneside and rural areas in which there are fewer than two people per square mile. It is developing a portal provided by Orion.
“Key for us is how we can effectively transfer information across the area we cover and how we can integrate care,” says senior project manager Michael Mythen. “We looked at two options. Going for an integrated solution, such as Cerner, or going down the portal route.
“We decided on the portal based on the investments we had made in our systems and on the fact that we are not in a position to rip and replace. We needed to make the best use of our existing assets.”
The decision was taken in late 2009 and led to a project called Single View. Mythen says: “The concept was to present clinicians with a range of information from different solutions, and then evolve so that we could replace paper notes and use the portal instead.”
As of today, four elements have been deployed: the Rhapsody Integration Engine; Concerto portal software; the Next Gate master patient index; and the Sunquest ICE order communications system.
“The first three elements allow us to integrate the systems,” says Mythen. So far, 12 have been integrated and have consistent demographic data and a master file.
Clinicians can view patients by individual consultant, by group or ward and by clinic list. From this they can delve into the individual patient record.
They can see, for example, pathology results, radiology reports, PACS images and clinical correspondence. The addition of Sunquest ICE allows clinicians to order tests, making the system active.
The next step is to integrate Orion’s RAPA solution – repeat attendance patient alert – which will be used to support chronic disease management. Then the trust will be looking at single sign-on to all the applications a given clinicians is entitled to view.
“The system is very will liked by clinicians,” Mythen says. “It is helping them move away from a reliance on paper notes. It is improving patient safety and efficiency. Clinicians do not need to wait for paper notes, for example.
“The Master Patient Index is saving us significant amounts across the organisation as we now have to register a patient only once, not multiple times on multiple systems.”
A clinical reference group is advising on which systems to integrate into the portal and ultimately Mythen believes the model will take the trust to an effective EPR.
“This model allows clinicians to have their solution of choice and that’s as it should be,” he says. “We can build up the breadth and depth of an electronic record and reduce reliance on paper while having systems of choice.”
Case study: Northern Lincolnshire and Goole Hospitals NHS Foundation Trust
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust has developed a portal to cover all diagnostic disciplines, giving clinicians access to information and order communications in a web-based application.
Recently, it has expanded to take in ward administration, bed management, patients at risk of readmission (PARR) scores and patient observations, working closely with InterSystems but doing much of the development in house.
“We are making it the first point of contact for clinicians,” says diagnostics technical lead, Robin Howes. “Ultimately we see the portal moving us to a paperless hospital.”
So, for example, ward clinicians no longer use the old white board but instead refer to 46” touch screens where they can see who is in what bed, their PARR scores, whether they have had blood clot (venous thromboembolism) or dementia assessments, whether they are close to discharge or whether they have procedures scheduled.
They can manipulate the data view so that it shows only their patients.“For the first time, we know where patients are, we know how ill they are, we know what beds they are in and how many are close to discharge,” says Howes.
“It really helps with the bed management and will help when it comes to managing winter pressures.”
The project has a dedicated team led by manager Paul Jackson and with high-level clinical involvement in its project board. It reports at senior level to the director of diagnostics and therapeutics.
The feedback from clinicians has been extremely positive. “We are the stars at the moment,” says Howes.
There have been a number of challenges along the way. The interoperability work was well supported by the ITK standards while InterSystgems provided invaluable advice about security.
Clinicians have been well engaged in supporting the team to understand workflows and how these can be embedded in the portal.
“Within the organisation there has been a great deal of enthusiasm about making it work,” says Howes. “When people have come up with challenges, others have come up with solutions.”
Monitor wants trusts to move towards patient level costing, and PLICS is the only way to do it. Daloni Carlisle reports.
17 May 2013
