The concept of an online ‘metaverse’, whereby a new, interconnected virtual reality could be created to facilitate many aspects of human and social life, is one which has been excitedly welcomed by many across the tech sector and beyond.

The metaverse has been touted as a kind of ‘3D social network’, where users interact as avatars in a virtual world, exploring virtual environments and engaging in virtual activities together. Along with the social aspect of the metaverse, there has also been talk about the virtual economy, whereby users can create, buy and sell various types of digital goods, browsing virtual stores from their home.

The metaverse is expected to be accessed using a range of wearable devices, which could mean for easy switching between reality and virtual reality. As more and more technology companies and providers show an interest in the concept’s future, there could be a rapid expansion of possibilities which could take it in directions not yet even thought of.

Although not yet in existence, the concept has already begun to attract investments, with some estimates predicting that the value of the metaverse economy could reach $5 billion by 2030.

Unsurprisingly, questions have begun to be posed about the implications of the metaverse for a diverse range of industries and populations, and the field of healthcare arguably has significant potential. In this feature, we take a look at some of these implications, considering how the emergence of the metaverse could impact on work, communications and outcomes in health and care.

Building upon current uses of VR in healthcare

Virtual reality (VR) is already used for many different purposes in the field of healthcare, including in carrying out virtual consults, aiding in the teaching and training of medical students, and in supporting patients to engage with treatments or programmes such as physiotherapy.

The concept of the metaverse has incredible potential for further improving patient-clinician relationships which is only beginning to be explored. In an article entitled ‘‘Metaverse going beyond adoption: the next frontier for global healthcare’, Umer Zaman considers one of the biggest implications of the introduction of the metaverse to be its help in reaching underserved populations across the world, giving them access to specialists, healthcare consultations and treatment options, that they would not normally be able to engage with. There are limitations to this, of course, in terms of the cost of devices required to access the metaverse, and the chances of remote communities being able to afford them; but like with all technology, prices will eventually come down, and developers will most likely find a way to leverage users’ existing devices such as mobile phones.

VR has already begun to be used successfully in treatment and rehabilitation for patients, enabling them to be treated within their own homes, and having a positive impact on patient engagement. Although the initial outlay for VR devices remains relatively high, preliminary studies have shown that overall, there are cost benefits. In a study entitled ‘What do we know about the use of virtual reality in the rehabilitation field?’, the authors consider that VR’s contribution in reducing healthcare costs and improving rehabilitation outcomes means that investment in VR has worthwhile long-term benefits.

The metaverse in preventative healthcare and public health

In an article titled ‘Staying active while staying home: The use of physical activity technologies during life disruptions’, the authors explored the ways in which VR and other digital technologies played a sizeable role in reducing physical inactivity amongst populations under restricted conditions.

“Use of online tutorials/classes and fitness apps was significantly more prevalent during lockdown than before lockdown. Online classes and groups allowed people to both continue accessing knowledge from trainers and stay connected with their exercise communities. This is in line with previous research exploring the use of virtual training platforms and the importance of the social context of exercise.”

The metaverse has also been touted as having the power to encourage public engagement with health. An article entitled ‘Harnessing public health with “metaverse” technology’ considers the benefits of the metaverse for improving public health in the context of India, tackling what the authors refer to as the “three low areas” of low technological competence; low equipment coverage; and low patient satisfaction. The differences in resources between hospitals and regions, and the lack of modern medical equipment in rural India, result in problems with registration and administration as patients travel to major hospitals for better diagnosis and treatment.

“The large number of people from rural areas who go to hospitals in cities limits how much time each specialist can spend with each patient. This means that services in the “Four Limitation Areas” of preventive healthcare, disease management, and rehabilitation are limited. To carry out the Healthy India Plan, it is very important to change the way things are now…According to the current Medical Internet of Things (MIoT) theory, doctors in large hospitals (called “Cloud Experts”) and doctors in smaller hospitals (called “Terminal Doctors”) can work together to make graded diagnosis and treatment more accurate and effective.”

The metaverse will allow patients to be connected with doctors and specialists from around the world, and will also help to facilitate peer-to-peer education and training. Surgeons in remote India, for example, will be able to access education and training they would not normally be able to utilise, developing their own skills and improving outcomes for the patients they treat. This prospect of improved education and training links with the next section of this article, which will look at the ways the metaverse can enhance teaching and learning in health and care.

Virtual treatment and the metaverse

Interesting progress has already been made over the last couple of decades on the concept of virtual treatment, or treatment which is facilitated by digital technologies.

An article entitled ‘Virtual reality in the management of patients with low back and neck pain: a retrospective analysis of 82 people treated solely in the metaverse’ covered a study conducted by Orr, et al., exploring the possibility of completely virtual treatment. 82 participants with non-specific low back pain (NS-LBP) and/or neck pain disorders (NPD) received exercise therapy delivered using VR, with findings suggesting the feasibility of treatment delivered in this way for certain conditions.

“The study demonstrated that virtual reality treatment delivered via the metaverse appears to be safe (no adverse events or side effects). Data for more than 40 outcome measures was collected. Disability from NS-LBP was significantly reduced (Modified Oswestry Low Back Pain Disability Index) by 17.8% and from NPD (Neck Disability Index) by 23.2%.”

Other studies demonstrate different uses; for example, Zhou, et al.’s study, ‘The paradigm and future value of the metaverse for the intervention of cognitive decline, showed how the metaverse could be a preventive tool for phenomena including cognitive decline, collecting and using intelligent data to tailor treatment plans to individual patients. Zhang, et al., in their article ‘Gastroenterology in the Metaverse: The dawn of a new era?’ commented on the likelihood of the metaverse offering remote surgical treatment using wearable devices such as tactile gloves and remote operation robots.

“In the future, we will be able to enter the Metaverse through VR simulators and tactile gloves, complete various difficult endoscopic treatment operations, and accumulate massive endoscopic experience.”

In a world where growing pressures threaten to overwhelm even the most established of healthcare systems, this is perhaps the most exciting prospect for the metaverse. It will be enthralling to watch the development and expansion of current models of treatment as steps are taken toward making the metaverse a reality.

Education and training in health and care

In an article titled ‘Metaverse for education – virtual or real?’, the authors delve deeper into the seemingly endless possibilities of the metaverse for education and training, including the benefits for promoting accessibility and inclusion.

“A true realisation of the metaverse will make the geographical boundaries disappear making the education accessible to the least privileged communities. At the same time, the virtual worlds with immersive experiences of usually less accessible resources would provide at-scale resource sharing throughout the world. The metaverse would enable seamless access of Stanford labs, for instance, to someone in Africa to do collaborative experiments in the virtual worlds.”

The authors cite some important examples of the ways in which education in healthcare and beyond will be transformed by the metaverse, including the introduction of immersive 360⁰ content, virtual classrooms, AI personalised learning, easier skills transfer, and education without cultural barriers.

In the article ‘The metaverse: A new challenge for the healthcare system: A scoping review’, Luca Petrigna and Giuseppe Musumeci conducted a scoping review of current literature on the metaverse within aspects of healthcare including education and training. One of the key areas it identified was the possibility for the combination of VR and augmented reality (AR) in the metaverse to help enhance standardisation across the medical industry, replicating real-life scenarios and mapping important organ systems or organ functions in realistic 3D.

Specialists in certain fields will be able to share their knowledge directly with students, having the added benefit of walking them through procedures step-by-step, or engaging with them on a level which facilitates learning and information retention.

Medical students and professionals conducting research have begun to think about the introduction of virtual laboratories, or the possibility of replicating world-leading facilities, giving access for these to individuals anywhere in the world. Research will also benefit from the abilities of researchers to collaborate, as well as to reach, treat or report on participants across the globe. Where research is being conducted on rare conditions or in hard-to-reach populations, this will be significant in terms of the development of a global interconnected research community.

Mental health and psychiatry in the metaverse

When it comes to psychiatric treatment, VR has already been used in treatments such as exposure therapy for many years. The branching out of psychiatry into the metaverse is perhaps a natural progression of these kinds of developments. An article titled ‘Taking modern psychiatry into the metaverse: Integrating augmented, virtual, and mixed reality technologies into psychiatric care’ sees authors Ford, et al. cover ways in which the metaverse could transform different areas of psychiatry. Some of these ways include the ability to directly measure or observe social behaviours; increased cost-effectiveness of functional assessments; the possibility of exposing patients to stimuli or simulations; and in developing the concept of biofeedback.

Research in this domain remains in its infancy, although there are clearly some exciting prospects for developments here in the future.

The advancement of virtual reality (VR) technology has led to many exciting developments with vast applications to the field of healthcare and beyond. Currently, studies are ongoing into the potential uses for this technology, including in pain management, surgical training, mental health therapy, physical rehabilitation, and more. As the technology continues to develop, the possibilities for VR are only likely to continue to grow.

With this in mind, let’s take a look at some of the most innovative and exciting research on VR in healthcare to have emerged to date.

Surgical Training

Surgery and surgical training is one of the areas which has benefitted from the most scholarly research about the impact of VR, revealing some great successes and some exciting prospects for the future.

VR for jaw surgery

In the field of orthognathic surgical education, a study entitled ‘Validity of an immersive virtual reality training system for orthognathic surgical education‘ tested an immersive VR (iVR) training system for double jaw orthognathic surgery. Seven senior surgeons and seven fifth-year medical students were given the opportunity to complete a training mode and an assessment mode in bimaxillary orthognathic surgical procedure, before being asked to complete a questionnaire based on the Likert scale.

Immersed in a virtual operating room, and using virtual models of surgical instruments, participants worked on a patient model designed using computed tomography (CT) and dental casts of a real patient with skeletal class III malocclusion. The training mode included VR guidance on next steps and correct instrument positions, accompanied by voice prompts of the surgical procedure. In the assessment mode, participants needed to select the appropriate instruments from the virtual instrument table, before correctly initiating the next surgical step without guidance.

Results demonstrated that all participants strongly agreed that they hoped more surgical procedures could be simulated in the VR system; that the VR application could increase their interest in learning surgical methods; that it was very helpful in learning different types of surgery; and that they found the system interesting. All participants agreed that this application could be used as a supplementary method to traditional surgical training.

“iVR technology has the potential to revolutionize surgical training and education by providing standardized and cost-effective training, objective assessment, and multi-user capabilities. As the technology continues to develop and improve, it may become an increasingly valuable tool in surgical training and education.”

VR for clipping intracranial aneurysms 

In a study entitled ‘Immersive VR training system for clipping intracranial aneurysms‘, researchers attempted to use VR to overcome issues relating to ethics surrounding cadaver training and consumption of resources in 3D printed models, in the clipping of intracranial aneurysms.

The study states: “By proposing an immersive virtual reality training system, we make use of increased motivation, engagement and realism when using a virtual operating room.”

In the study, one senior and one novice neurosurgeon were tasked with performing the procedure using VR, before being asked a series of questions about their experience. Whilst the lack of haptic feedback and the absence of a stable surface (usually the physical skull of the patient being operated on) were drawbacks identified by the senior neurosurgeon, both participants were able to give feedback on how they felt the design of the system could be improved.

“Regarding clipping, both participants liked the deformation and rated it as realistic enough. They also emphasised that it is a crucial part of a training system. However, it would be good to have the possibility to modulate the speed of the clip application.”

“Regarding clip assessment, different possibilities were discussed. The first possibility would be to include visual exploration of the clipped aneurysm. Both rated this approach as very useful, as this would be similar to an angiography with which one can check whether the aneurysm is sealed off completely. Furthermore, they would appreciate an additional numeric output indicating how much (e.g. percentage) of the aneurysm ostium is closed.”

VR and learning

Another study worth noting explored ‘The Effectiveness of Learning to Use HMD-Based VR Technologies on Nursing Students: Chemoport Insertion Surgery‘. Using a head-mounted display VR nursing education programme, 30 nursing students were given paper handouts and tasked with self-learning for 30 minutes, whilst 30 nursing students were given training using the VR model. Results showed that the experimental group utilising the HMD-based VR showed “significantly improved post-intervention knowledge on operating nursing, learning attitude, and satisfaction compared to the control group.”

Patient education, preoperative anxiety reduction and pain management

Another exciting application of VR to have emerged is in the field of patient education and anxiety reduction.

VR for reducing pain and stress 

A feasibility study published last year entitled ‘The effect of Virtual Reality (VR) on anxiety and pain in patients undergoing port implantation‘, explored the effect of VR on pain, stress and anxiety in patients undergoing elective surgeries such as implantation of a central–venous port catheter. 

20 patients with an indication for port implantation were split into two equal groups of 10, before being assigned ‘VR’ or ‘no VR’ group status. As with standard practice, local anaesthesia was used for both. The primary endpoint for the study was the reduction of intraoperative pain sensation, as well as patient levels of anxiety and stress, measured using the Short Form McGill Pain Questionnaire. Secondary endpoints were identified as ‘the recording of preoperative pain and anxiety levels (baseline assessment) using the Pain Catastrophizing Scale (PCS) Questionnaire.’

Patients in the VR group selected from a range of relaxing scenarios including an underwater world, beach, winter landscape and forest walk; then selected jazz, lounge or classical background music.

Using the McGill Questionnaire, both total normative estimated pain intensity and present pain intensity were measured as being slightly lower in the VR group. Although not reaching significance levels, these findings support a growing body of evidence which suggests that VR may be beneficial to the reduction of pain and stress in patients undergoing minor surgeries under local anaesthesia.

VR as a component of patient education and preoperative anxiety reduction

A larger study conducted at the Department of Cardiac Surgery at LMU University Hospital, Munich, entitled ‘New perspectives in patient education for cardiac surgery using 3D-printing and virtual reality‘ found much more significant outcomes of VR on patient anxiety.

Using a sample of 99 participants who were scheduled to undergo coronary artery bypass graft surgery, surgical aortic valve replacement or thoracic aortic aneurysm repair, three study groups were created. One group was the control group, with participants educated using standardised paper-based models; one group was educated using 3D-printed models; and the final group was educated using VR models.

Three questionnaires were used at different time points in patient journeys: the first to gain insight into patient characteristics including age, gender, procedural understanding before patient education and basic anxiety using visual analog scale (VAS) and the state anxiety inventory. The second questionnaire was given to participants immediately following their patient education, again asking questions about procedural understanding, anxiety and patient satisfaction with the method of patient education in accordance with their group. Finally, the third questionnaire was given to patients at least one week following their surgery, or at discharge, and measured trait anxiety in each of the participants.

Results revealed a “significant decrease in VAS anxiety for patients educated using VR models”. As for understanding of surgical procedure, better results were found for both understanding and visualisation in the VR group than the control or 3D-printed groups.

Stroke Recovery, physical rehabilitation and physiotherapy

Physiotherapy in adults over 75

A study entitled ‘Physiotherapy Programmes Aided by VR Solutions Applied to the Seniors Affected by Functional Capacity Impairment: Randomised Controlled Trial‘ used 60 community-dwelling older adults aged 75 and over as participants in a trial of a virtual reality comprehensive rehabilitation rooms (VRCRR) software. The authors describe how the “physiotherapy programme introduces a comprehensively structured procedure aimed at maintaining or enhancing individual balance and cognitive abilities within a fully immersive VR environment”.

Participants were split randomly into four groups, including the classic programme group. The classic group completed traditional exercises; another group wore VR goggles to ‘relocate’ them to a VR environment; a third group completed dual tasks in combination with VR; and one group made use of VR ‘comprehensive rehabilitation rooms’ as an additional component to be integrated with the physiotherapy programme.

The groups had 30-minute physiotherapy sessions in their own homes three times per week, for three weeks. Their progress was tested with a preliminary assessment designed to allow researchers to measure improvements over the course of the study.

The participants were tested to establish their general health status, and then in the second the groups undertook a variety of activities to evaluate overall individual mobility and exposure to overall fall risk owing to stability issues when walking, with added complications such as timed assessments wherein they had to carry out the tasks whilst counting backwards and walking.

Results indicated that the group using the VR comprehensive rehabilitation rooms showed significantly higher score in balance when compared to the other groups, and also scored higher on the ‘timed up and go’ test which is designed to assess individual mobility and exposure to overall fall risk. However, the classic group scored higher in evaluation of gait.

The authors conclude: “Making use of VR environments in the physiotherapeutic management of community-dwelling older adults appreciably enhanced individual functional performance, especially in terms of static balance. Physiotherapy management aided by VR technology solutions offers a viable alternative to conventional physiotherapeutic regimens in enhancing individual functional performance.”

VR and chronic stroke patients

The study ‘Effects of a Brain-Computer Interface With Virtual Reality (VR) Neurofeedback: A Pilot Study in Chronic Stroke Patients‘, explores the potential effects of VR and brain-computer interfaces (BCI) in strengthening key motor pathways in stroke patients.

Using a platform combining both VR and BCI, four chronic stroke patients with different levels of motor impairment were assessed using EEG signals to detect attempts to move a virtual avatar arm. The platform could be tailored to meet the specific requirements and capabilities of stroke patients, offering differing degrees of freedom for patients. EEG was used in direct brain-to-VR interfacing in patients with no active movement; EMG in muscle-to-VR interfacing was used in those with weak muscle activation; and hand tracking was used for those who had substantial active movement.

During pre- and post-intervention assessment, motor impairment was measured in participants using a set of clinical tests, as well as through functional and structural scans with MRI, and with neurophysiological measurements with transcranial magnetic stimulation (TMS). The intervention itself consisted of eight training sessions of one-and-a-half hours, whereby participants were immersed in a virtual environment in which they had a virtual pair of hands that they could see from a first-person perspective. They were then tasked with performing a wrist and elbow extension toward a pre-defined target, with the virtual arm moving toward the target when an increase in sensorimotor brain activity was detected.

In terms of neurofeedback performance, only one of the participants demonstrated an increased score of 7.3 percent between the first and last training sessions, whilst all other participants demonstrated a significantly decreased score of 5.4 percent – 37.1 percent. During TMS sessions, the motor hotspot in the undamaged hemisphere around M1 was localised, and resting motor threshold (RMT) was acquired at the same intensity at this location in both pre- and post-intervention sessions. Only one patient had a reachable RMT during the first session (71 percent). A different participant demonstrated a reachable RMT by the final session.

The Fugl-Meyer Assessment for upper extremity scores increased in all participants from pre- to post-intervention, with one participant in particular demonstrating a six-point increase, meeting the minimal clinically important difference threshold. Self-reported scores on the Stroke Impact Scale (SIS) increased in three of the four participants. The patient with the most significant motor impairments was the only participant to have significant changes in cortical physiology, and also had large improvements in SIS.

“One potential hypothesis to explain this finding is that in individuals with worse motor impairment, there are fewer inputs to and outputs from the damaged motor cortex, hence poorer motor ability. Given this, these brain areas may be more flexible to neuromodulation and may be more easily trained because these regions are not being actively engaged for other tasks. On the other hand, in individuals with volitional movement, these brain regions may already be actively recruited through more naturalistic processes (e.g., trying to move one’s arm on a regular basis) and may be less flexible to learn new patterns imposed by the neurofeedback training.”

Future Directions

As VR technology develops, there are likely to be a host of unexplored applications of VR to the field of healthcare. Below are some of the most interesting proposals for research projects that we found, which could potentially have a positive impact in the future.

ADHD diagnosis

The study ‘A Four-Step Method for the Development of an ADHD-VR Digital Game Diagnostic Tool Prototype for Children Using a DL Model‘ proposes a four-step method for the development of an ADHD-VR digital game diagnostic tool for children.

It states: “ADHD is one of the prevalent neurodevelopmental disorders in a clinical setting. VR and machine learning, such as DL technologies, hold great promise for application in human health diagnostic tools in the near future, especially in areas with low health and mental health resources, such as general practitioners, child psychiatrists, general psychiatrists, psychologists, and behavior pediatricians. Therefore, by utilizing an ADHD-VR digital game diagnostic tool prototype for children with a DL model in standard health services or tele-psychiatry consultation, ADHD can be diagnosed and early management can be delivered, thereby reducing the impact of the illness.”

Exploring VR interventions following COVID

In the study ‘Effect of an intensive care unit-specific virtual reality (ICU-VR) to improve psychological well-being and quality of life in COVID-19 ICU survivors: a study protocol for a multi centre, randomized controlled trial‘, we hear about the protocol to test the possibility for an ICU-specific virtual reality intervention to have a positive impact on psychological well-being and quality of life after COVID-19 ICU treatment.

“The SARS-CoV-2 outbreak has resulted in a tremendous increase in hospital and intensive care unit (ICU) admissions all over the world. Patients with severe coronavirus disease 2019 (COVID-19) warranting ICU treatment usually have prolonged mechanical ventilation and are expected to be prone to develop psychological impairments, such as post-traumatic stress disorder (PTSD), anxiety and depression, which negatively impact quality of life. To date, no effective treatment strategy is available. In the current trial, we aim to assess the effect of an ICU-specific virtual reality (ICU-VR) intervention on psychological well-being and quality of life after COVID-19 ICU treatment.”

VR to reduce sedentary lifestyles 

‘Exploring the content of the STAND-VR intervention: A qualitative interview study‘ is an exploratory study of the perspectives of older adults on the STAND-VR intervention, intended to inform future work that are more accessible to retired and non-working adults, with the goal of reducing sedentary behaviour and improving associated health outcomes.

The study highlights how six or more hours spent sedentary each day has been associated with the development of a number of chronic conditions as well as mortality. “Immersive virtual reality, a relatively new digital technology, offers new ways to be less sedentary which retired and non-working adults can potentially ascribe more meaning to, such as taking part in physical activities they enjoy as well as facilitating social connection.”

It continues: “IVR is a computer technology that makes a person feel like they are somewhere else. The findings from this study describe how retired and non-working adults perceived IVR before and after use, how they would like to learn how to use IVR, the content and people they would like to interact with and finally, their beliefs about their sedentary activity and using IVR. These findings will inform the design of future virtual experiences that are tailored to retired and non-working adults’ needs and preferences.”

NHS England has shared a case study describing how Eastern Academic Health Science Network (AHSN) and Suffolk and North East Essex (SNEE) ICS have come together to fund a Head of Innovation role, as part of a shared vision to cultivate a culture of innovation across the health and care system.

The Head of Innovation role has emerged as part of a wider strategy to implement proven innovations across Suffolk and North East Essex ICS. The central aim is to create a culture where staff and clinicians understand how doing things differently can solve their challenges and give them the confidence to adopt and spread innovations.

Objectives 

With Eastern AHSN providing funding for the role, the objectives included:

• Create an innovation strategy for the ICS
• Develop a strong understanding of the positive impacts of proven innovation (including digital technologies, innovative care pathways and new medicines) to both patients and clinicians within the ICS
• Encourage and support the adoption and spread of evidence-based, innovative solutions that align with local health and care priorities
• Examine and work to deconstruct barriers to local innovation
• Cultivate a culture of innovation where health and care staff are empowered to innovate
• Build relationships with key stakeholders to facilitate the “pull” of innovation into the system as it aligns to local priorities.

Alongside the main objectives, there was a range of agreed key criteria:

• Experience working at a senior leadership level within the ICS
• Forming strong working relationships with directors, clinicians and staff within the ICS.
• Building knowledge (and access) of the AHSN’s specialist team and the stream of innovations relevant to local health and care priorities.

Patient and public involvement

Supporting the new initiative, the SNEE Patient and Public Involvement team placed patients’ voices at the centre of the development journey for the role, using patient co-production to identify, develop and test a variety of innovations to support the SNEE ICS strategic priorities. These priorities include developing virtual pathways for atrial fibrillation and innovations for early identifying cancer following horizon scanning.

Results

The health tech industry has rallied to support health and care over the past few weeks. As part of the HTN #HealthTechToShoutAbout feature series, supported by Highland Marketing, we spoke to 6 health tech suppliers to hear more about their recent work in response.

Please click on an image below to view or scroll to read on.

Care communities move to full Covid-19 tracking

Sharing information, and using that shared information to make complex decisions, has never been more important for the NHS as it copes with Covid-19.

Graphnet has been focused on supporting its customers by accelerating key shared record projects already underway, deploying new products and rolling out new releases of its software with new Covid-19 functionality.

New Covid-19 features released to CareCentric shared record customers include a Covid-19 summary page for each patient which displays any available information to professionals across a care community.  Information such as Covid-19 tested, suspected diagnosis, and confirmed diagnosis is displayed in chronological order. In addition, an alert ‘pop-up’ flags the most clinical useful/important Covid-19 information about a patient when that patient record is accessed, and the information displayed includes ‘shielded patients’ so key professionals are aware of their status.

Changes have also been made to display known advance care planning decisions, such as those concerning life sustaining treatments and the citizen’s wishes, and to make these very prominent in the shared record.

The company said to HTN “Some customers of Graphnet have deployed additional functionality. Frimley Health and Care ICS is in the process of incorporating information from the regional 111 service, for example, where a patient dialogue has resulted in highlighting the patient as a possible Covid-19 case, and then flagging this to clinicians who view the record.

“The use of analytics layered on top of the shared record has real transformative potential, even more so in the current crisis.  Graphnet’s population health team is currently rolling out the CareCentric Population Health Analytics Covid-19 dashboard.

“The dashboard analyses primary and secondary care data to identify citizens with a Covid-19 event. It also includes an ‘enhanced case finding’ function to allow searches which identify patients at risk and in need of intervention.  The dashboard is an operational tool and can also help predict demand.

“Elsewhere, shared records that would usually take six months or more to put in are being deployed in a matter of weeks.”

Brian Waters, chief executive of Graphnet, said “As well as focussing on new functionality, we are very aware that Covid-19 use cases for our products continue to emerge from our customers, where people have used or deployed products in innovative ways to help with the crisis.  We are documenting these and making them available to the entire user base.  Our focus is on working as flexibly as possible to best support our customers, prioritising clinical safety while reducing any cumbersome administrative barriers.”

“The coming weeks will be particularly challenging for everyone working in health and social care and we are committed to assist our customers in any way we can during the outbreak.”

How NHS hospitals are adapting their Allscripts systems to treat COVID-19 patients

Anna Bayes, UK medical director, Allscripts said to HTN “In these unprecedented times, I’m in awe at what healthcare organisations and professionals are dealing with daily. So, we were awe-struck when two of our UK clients chose to continue planned implementations of new functionality during the week of 23 March.

“At Bolton NHS Foundation Trust, the activation of new mobile functionality for community paediatric services went ahead as scheduled. Many of the staff who will benefit from this functionality – which includes offline working for home visits – have been redeployed to acute services; but once this crisis has passed, they will be able to start using this new software right away.

“At Gloucestershire Hospitals NHS Foundation Trust, the recent activation of Sunrise EPR nursing documentation at both Gloucester and Cheltenham hospitals has now been augmented with electronic observation recording, including National Early Warning Score2 (NEWS2) scoring. This will help staff monitor for signs of deterioration and intervene earlier, if required.”

Enabling change

“Other Allscripts clients in the UK have made significant, rapid changes that will help their staff manage those suspected of having COVID-19 and those who have been confirmed. At The Dudley Group NHS Foundation Trust, patients with suspected or confirmed COVID-19 are identified by an icon on the patient header in their electronic record.

“At Gloucestershire Hospitals and Wrightington, Wigan and Leigh NHS Foundation Trust, a specific icon has been added to the ward tracking board, so patients can be identified and managed at ward level and across the hospital. Specific patient lists can also be generated for managing patients requiring isolation.

“Salford Royal NHS Foundation Trust updated its Emergency Department clerking documentation to record salient COVID-19 features, enabling a streamlined clerking process and a direct link to a pre-defined battery of pathology and radiology investigations. Again, the ED tracking board provides staff with at-a-glance information about COVID-19 status, so they can put on the appropriate level of protective clothing – prior to entering the patient cubicle.”

Supporting reporting and analysis

“Salford Royal has also made changes to Sunrise critical care documents to ensure appropriate, structured data is recorded consistently. In parallel, its reporting team is providing reports that give an overview of current inpatients and use of high-acuity beds.

“Liverpool Heart and Chest Hospital NHS Foundation Trust also updated documentation templates. In particular, Liverpool has updated critical care documentation to record symptom onset as well as standard respiratory support requirements. Currently, the trust is looking to convey this data for automatic upload to the Public Health England COVID-19 Hospitalisation in England Surveillance System (CHESS) database to minimise reporting effort and reduce transcription errors.”

Looking to the future

“We are working with our clients to share their newly configured content, together with COVID-19-specific content and decision support rules built by Allscripts. We are also working with them to make sure their systems are ready for the complex protocols that will be required for anticipated COVID-19 drug trials.

“We want to make sure that data is collected as a by-product of normal clinical documentation, rather than requiring re-keying of clinical data to support this research. Not only will the COVID-19 drug trials be amongst the fastest mobilised, but the ability to review and report iterative, consistent outcome data from the EPR in near real-time will be a key benefit to the global fight to stem this pandemic.”

Remote monitoring to support high-risk patients

Remote patient monitoring can extend a vital lifeline to the 1.5m Britons told to stay at home because they are extremely vulnerable to the coronavirus, according to Inhealthcare.

The company has rolled out more than 100 digital services in partnership with NHS and care home organisations across the UK to support patients living with long-term health conditions.  It’s now seeing unprecedented demand for remote monitoring as NHS and care providers seek to create capacity in hospitals, deliver continuous care to people at home and protect staff from the risk of infection.

Last year, the NHS fulfilled more than 97m outpatient appointments, illustrating the scale of the challenge for the health service in maintaining “business as usual”. 

Bryn Sage, chief executive of Inhealthcare, said “Before coronavirus, our partnerships helped people lead healthier lives for longer and kept them out of hospital when they did not need to be there. After the onset, we are doing all that and working hard to help protect staff as well.”

The Government has advised people with underlying conditions including cancers, respiratory illnesses, organ transplants or pregnancies to stay at home and avoid any face-to-face contact for 12 weeks.

Ordinarily these patients would be seen regularly at outpatient appointments or community nurse visits for routine checks and treatments but the threat of coronavirus has made this difficult and dangerous.

The threat also appears to have deterred people with underlying conditions from seeking emergency treatment, as suggested by a dramatic fall in A&E attendances.

Mr Sage said “Our message to NHS and care home organisations is we can help you care for your high-risk patients. Remote monitoring is a mature and inclusive technology and is trusted by a growing number of NHS and care home providers across the UK.”

The company said “Inhealthcare, which is part of the financially strong Intechnology plc, owns and operates the UK’s only dedicated platform for remote patient monitoring and digital health.  

“The platform allows for the creation of new digital health services within 24 hours. For example, Inhealthcare last month rapidly developed and deployed a new Covid-19 symptom checker service for a major NHS provider to screen thousands of daily outpatient appointments.

“The Inhealthcare platform enables patients to communicate readings with health and care professionals through a choice of channels ranging from Amazon Alexa to the telephone landline.

“The fully inclusive approach, which includes video, SMS and apps, makes digital health services accessible to the vast majority of the population, regardless of age and ability.

“All alerts are automatically flagged up and shared with clinicians for review, allowing providers to focus their resources on those who need care the most.

“Patient information is fed into leading health and social care systems, overcoming any interoperability issues, and securely stored within the Government’s new Health and Social Care Network.”

Mr Sage said “We have been developing and delivering these services for a long time now and are proud to be stepping up at this time of great national need.”

Tracking COVID-19 Data with Lyniate Interoperability Platforms

As healthcare organisations throughout the world work to reduce the spread of COVID-19 and care for an overwhelming number of infected patients, the need for sharing patient data between systems, departments, organisations, and regions has never been greater.

Lyniate said to HTN “Globally, we are going through a healthcare crisis, and Lyniate is part of the solution to help the interoperability of the healthcare delivery system.

“Lyniate’s interoperability platform, Rhapsody, enables seamless data exchange among disparate organisations within healthcare, including health systems, telehealth platforms, Electronic Health Records and health IT vendors.”

The platforms support all health data formats and standards — including FHIR — allowing healthcare organisations to integrate quickly, easily, and securely either as an on-premise or cloud-hosted solution. Once in place, the platform ticks away in the background ensuring guaranteed message delivery so that healthcare staff can focus on patient care.

The company said “Our products enable a critical layer of interoperability to health IT infrastructure, allowing healthcare organisations to share, exchange, and report clinical data. For instance, which patients have been tested? How are patients’ outcomes being monitored and tracked? Which providers have access to that data to ensure continuity of patient care? How is that data being reported to public health agencies?

“Using data sharing to track information about symptoms, recovery times, and efficacy of treatments from disparate locations can help to identify further insights into the disease as health experts across the globe look to better understand the virus, care for patients who are exposed to it, and develop a vaccine for COVID-19.”

Here’s how the platform can help during the COVID-19 health crisis:

• Inspect every message or document flowing through the integration engine to identify those with COVID-19 codes, as well as site-specific codes where required. (Rhapsody has added similar flags for other results, such as MRSA and C.DIFF, which have won awards for our customers for innovation.)
• Supports multiple message formats, including Hl7v2, CDA, FHIR, CSV, JSON, XML
• Inspects all coded elements in your document or message
• Log and/or report each (matching) document or message
• A report can include all matches found in the document or message, identifying the matching codes and context
• Add metadata for patient ID and document ID
• Optionally send the results to a data store for extended reporting
• Easily scale up and cope with increased volumes of testing

“While the most important mission right now is saving lives, the COVID-19 pandemic will eventually force healthcare organisations to consider how well their systems enable data exchange — not only because it is the right thing to do for patients, but because we must be better prepared for the next public health crisis. As business models evolve, organisations that are best at enabling data portability and scalability — in a way that is efficient, accurate, secure, and shareable with any destination system — we can better address public health crises such as the coronavirus in new ways.

“During a time when so much is uncertain, it takes data that is easily shareable and actionable to help us make the right decisions and create a health system that is better equipped to care for patients in times of calm and in times of crisis.”

Real-time patient data

Liam King, Commercial Director, Healthcare Gateway said to HTN “The MIG shares data either as a HTML rendered view or in a structured format from a multitude of different health and care settings ranging through GP, community, mental health, acute, and social care.

“An example is Kent and Medway, where the population exceeds 1.8m. The MIG is utilised to connect all GP practices within the Sustainability and Transformation Partnership (STP), sharing GP data into 15 separate NHS organisations, in addition providing real-time feeds of data from acute, community and mental health back into those endpoints and also back into the GP surgeries. Going forward it will also be supporting real-time feeds into the Kent Care Record (Graphnet).

“We are committed to supporting the NHS during this critical time and as such made updates that include updating the MIG content model to include Covid-19 SNOMED CT concepts from all GP system providers. For EMIS, and Vision GP practices the SNOMED CT concepts will be added to the following sections; contra-indication, diagnosis, immunisation, microbiology and other investigations. TPP sections are to be confirmed.”

“The MIG GP Journal View displays all contacts and observations over the last 12 months and includes GP notes/annotations. Where a healthcare professional records multiple items within a consultation or template, the information is displayed as one encounter within the Journal View.”

“In some regions, EMIS GP datasets have been updated to include frailty indicators to support healthcare professionals in making informed decisions.”

“We have supported The Nightingale Hospital at ExCeL London. This is a fantastic feat and will be using the NHS Bart’s Health Trust instance of Cerner Millennium as its EHR. Healthcare Gateway provide GP data into this instance already and are proud to be supporting this project.

“The wider London estate is connected via the One London Central Hub; Healthcare Gateway have implemented additional MIG connectivity for the surrounding areas, including Hertfordshire STP, meaning that London and out of area patient data can be accessed right across health services.

“Across the North West we are supporting Covid-19 pathway management with the sharing of GP, care planning and community. We have begun to enhance our connectivity between health and care and the North West Ambulance Service (NWAS) into Orion and are in discussions to include all MIG connected CCGs. We see this as vital in supporting the pandemic for the North West.

“There is an expansion of Share2Care (North West England) and LPRES (Lancashire Person Record Exchange Service) to add an additional 12 CCGs (20 in total). This is configured to share GP and care planning information from EMIS and TPP into Philips Forcare and TianiSpirit respectfully.

“We have enabled new endpoints across the Midlands and have also connected Coventry, Rugby and North Warwickshire CCGs to our existing WMAS for 999 (Cleric) and 111 (Adastra).”

Driving the evolution of doctor-patient communication 

Paul Bensley, CEO of primary care communication specialists X-on said to HTN “Before the nightmare of COVID19 engulfed the nation’s healthcare system, doctor-patient communication within primary care was already embarked on an evolution.

“The centrally-driven goal, enshrined within the NHS Long Term Plan, was for “digital-first” primary care, with Primary Care Networks (PCNs) building on pilots to deliver roll-out of online consultations this year, and development of video consultations to follow.

“The current pandemic has simplified much of that debate, requiring a pragmatic assessment by PCNs, GPs and practices as to what the essentials are for effective, remote triage and consultation with patients.

“As strict national measures to manage COVID19 were imposed, GP practices were swamped with calls, putting a huge strain on surgery legacy systems. This and other issues including bandwidth and limited phone functionality when working remotely, a requirement for conference call capability, and a need at speed to set up patient contact centres, were all pinpointed by X-on at the outset as problem areas revealed as a result of the pandemic.

“To address such issues, different package options of X-on’s Surgery Connect phone system – currently used by 600 practices – have been introduced, supported by tailored advice and guidance for practice customers.

“In close collaboration with GPs, a GP@Home service has recently been developed which allows doctors to provide patients with the same level of phone and video care from their own home as from their surgery.

“It has received very positive feedback from senior medical figures who have been “really impressed” with how it can help them work more safely, and allow home workers to answer the phone as if they were in the surgery.

“Amongst features, it enables calls to be made on a personal mobile without call costs being incurred on the personal account, provides a softphone interface for use on a smartphone or laptop, enables a switch to video-on-demand for a consultation with one click, and also for calls to be recorded.

“Practices are being offered a free trial as they grapple with the pandemic.

“Surgery Connect’s Video Connect has been developed too, which also enables GPs to switch from phone to video consultation in a single click on the clinician’s handset, integrated with major clinical systems such as EMIS and TPP’s SystmOne, which are used to hold patient information.

“Unlike many other systems, the patient does not need to download an app, and the doctor does not have to schedule when a video consultation will take place.

“One senior GP and Clinical Commissioning Group Clinical Lead describes it as a “game changing” piece of software that has enabled his practice to perform normally through the current crisis. He says he has been able to assess the clinical condition of a patient confidently through high quality video, saving face to face appointments at the surgery and in turn increasing the access capacity of the surgery.

“To help local and regional co-ordination of the response, X-on is also offering free teleconferencing services to PCNs and CCGs.

“The pace and scale of the digital transformation of the local family doctor has significantly intensified due to the demands of managing COVID19.

“It has highlighted how in the move to digital-first primary care, integrated digital telephony can be the key to supporting effective, safe and modern patient care and should remain a focus in the future.”

As part of our continued coverage of the COVID-19 outbreak, in this part two feature we take a look at some of the innovative health tech companies that are supporting the NHS, patients and staff alike in the current crisis.

In this feature series supported by Highland Marketing, we hear from companies from across health and care to understand how the industry has rallied together over the last few weeks in adapting to an everchanging and demanding situation.

HTN spoke with leaders from across the industry to hear about new software, changing pathways, new features and initiatives to support the health and care system.

The System C & Graphnet Care Alliance steps up for round the clock continuity support and delivers deployments in days 

Markus Bolton, joint CEO said to HTN “For the past month we have been preparing our own organisation and 750 staff to provide round the clock business continuity cover.”

“Already we have doubled down on some of our deployments which were already underway.  North Bristol NHS Trust went live in just 5 days with our e-observations software over this last weekend, for example – e-observations being an essential digital tool for the identification of deterioration and giving whole hospital visibility of patient acuity.”

“Kettering General Hospital is now using CareFlow Connect for clinical messaging and care coordination for all doctors, nurses and AHPs. This provides key team-based clinical workflows that are designed to track cohorts of patients, ensure safe handovers of care and coordinate care.  It includes handover, photo sharing and task management and will provide the organisation with the ability to rapidly support new workflows.”

“At Graphnet, in the last few weeks, we have been supporting a number of ‘in-flight’ shared record projects which have accelerated their deployments in order to help the local health system cope.  Some customers are also accelerating the deployment of planning and analytics tools – these have already been used for the rapid identification of vulnerable patients.”

“On the social care side, we have been working with the 89 councils who use our Liquidlogic software, helping them record and report on Covid-19 cases. It means they can see the number of social care cases with coronavirus, track them, case manage them and report on them.”

Visionable supports doctor to doctor and doctor to patient consultations

Alan Lowe, co-founder and chief executive of Visionable, said to HTN “Visionable is a video collaboration platform designed for healthcare. It’s not one-to-one conferencing and it’s not a triage or consultation service delivered over third-party technology.”

“It’s a large-scale single platform created by NHS managers and with clinicians to respond to clinical needs. It enables multiple users to share real-time audio and video feeds – that could be anything from a CT scan to a camera in someone’s ear or throat – from any device.”

“When it comes to digital working, there is a need for careful service design and clinical engagement. That can’t be done right now, of course, but once the crisis abates, we will need to go back and do it. Barriers to remote working are coming down quickly, they are not going to go back up again.”

“The solutions that are being put in place at the moment may be going in quickly, and we may need to go back and do more strategic work, but digital healthcare is here to stay, and Visionable is investing to support it.”

Cerner sets up global response strategy

Deirdre Stewart, senior director and nursing executive at Cerner said to HTN “We have a great group of clients and employees spread across different regions, and some of the ideas they are coming up with are absolutely great and can be leveraged worldwide – so, we’re acting as a hub for clients and partners, pulling together all these ideas and helping them help each other.”

“On Tuesday, a new alert was implemented at West Suffolk Hospital and Milton Keynes University Hospitals. The alert prompts clinicians with relevant information of patients that have either tested positive for COVID-19 or are awaiting test results.”

Matt Pickett, senior director for global marketing and corporate affairs at Cerner said “Another example was the launch of access to primary care records from Milton Keynes University Hospital’s EHR, via Cerner’s Health Information Exchange (HIE) solution.”

“If we could highlight one thing from this whole situation, is that we’re seeing some initiatives progress much quicker and technology being adopted faster for the benefit of patients and clinicians – and that is really encouraging.”

“The ‘moral right to data’ is another interesting point being extensively discussed these days.”

“While we agree that flexibility around the sharing of data has a game-changing role to play in situations like this, we also need to be sure we do not breach any information sharing agreements or information governance processes in place. Understandably, the minds of healthcare clinical and operational leaders are elsewhere at the moment, but that’s not an excuse to bypass the legal rights around data control and protection.”

“Too much haste could have a negative impact in future sharing initiatives,” he said.

Cerner is also supporting the frontline with its clinical and nursing specialists.

“We have been asked if we would release some of these experts back to frontline care, and the answer is yes – but we also need to carefully consider where they can provide the most value, whether that is remaining at the centre and providing support through their clinical expertise on the technology frontline or actually going back to the healthcare frontline.”

EMIS Health rolls-out free video consultations and extends resources on Patients Access

EMIS is offering free video consultation software to its GP practices and is encouraging its customers to adopt existing tools such as to digitally triage coronavirus enquiries.

The resources on the Patient Access app and patient.info website have been extended to include a new clinically authored coronavirus symptom checker – aligned with NHS 111 guidance.

The organisation is also working with NHS Digital on new coronavirus insights, including a new, automated search tool that will give GPs a list of all patients potentially at high risk from COVID-19.

Suzy Foster, CEO of EMIS Health, said to HTN “Digital health services have a critical role to play in helping the NHS and patients to navigate through these unprecedented challenges.”

“We have acted swiftly to make new resources available so that clinicians and healthcare professionals can continue to support their patients. We’re also working hard to help reduce demand on frontline NHS services by signposting patients to trusted information and advice.”

Doctify has supported 500+ doctors and healthcare specialists with video consultation tools

Stephanie Eltz, Co-founder, Doctify said to HTN “In the past week, Doctify has provided 500+ doctors and healthcare specialists with video consultation tools and will continue to rollout the service to ensure continuation of care during these unprecedented times.”

“The service is available on the Doctify website and features hundreds of clinicians that can take video calls and initiate a consultation online taking all the risk of visiting a GP’s surgery.”

IMMJ Systems supports trusts run virtual outpatients

Jamie Hall Head of Sales at IMMJ Systems “We have seen a steep rise in trusts looking to expedite their MediViewer EDMS deployments to support their heavily impacted services during this COVID-19 crisis.”

“A number of trusts have contacted us that wanted to know how quickly we could deploy our solution to provide Virtual Clinics. By enabling Virtual Clinic activity this will provide clinicians with the ability to access patient medical records anywhere via any device and remove the need for patients to be physically present during the appointment.”

“We are working with two major London trusts that have been hit incredibly hard by the global pandemic, not only to get up and running quickly, but to also define at speed the proposed scanning strategy that supports an EDMS implementation. This has provided a mechanism to profile the clinics and services that can be operated remotely enabling trusts to consider which services can be run remotely and which patient activity needs to be assessed in person. The results include a reduction in case note movement which can in itself lessen the spread of the virus to other parts of a hospital.”

“A little-known fact outside of our specialist area is that a physical medical record is usually handled anywhere between 15-20 times before, during and after a consultation, so this is also about isolating the records library and reducing a route for infection within a Hospital.

“As this is not the “norm” we have also created a bespoke support and training programme so training needs can be delivered remotely.”

Allscripts supports quick e-obs deployment

Richard Strong, managing director, EMEA, told HTN “One NHS trust took the brave decision to continue their digital maturity journey last week and to go-live with e-observations functionality that automatically calculates the NEWS2 score that enables clinicians to escalate treatment for patients at risk of deterioration.”

“That was not an easy undertaking, but an important one all the same. This trust has also added icons to its patient tracking board to enable it to identify all the patients with COVID-19 and those waiting for the results of a test.”

“A second trust has enabled tagging for patients, using coded terms, so they can follow-up with positive patients. A third trust has created specific documentation and order sets for managing COVID-19 patients and a fourth trust has both rolled out new documentation and collated specific reports that it is planning to link directly to the Public Health England reporting portal.”

“We have created the Allscripts Go-Live Virtual office to enable trust staff members to get help whenever they need it during functionality activation, via voice and video capability, screen sharing, and other tools.”

“The office is connecting to floorwalkers using an app, so our team can be aware of issues in clinics and on wards before they have been logged through the help desk system.”

Alcidion launches new assessment tool

Lynette Ousby, general manager at Alcidion, said “An entirely new coronavirus assessment tool is already live in the NHS, built into our Patientrack early warning system. This is helping nurses carry out crucial assessments designed to allow hospitals to identify coronavirus patients sooner. The development is now available to any hospital using Patientrack, entirely free of charge.”

“It will mean that nurses on the ward can digitally record crucial information for all respiratory patients, that will be used to alert hospital professionals if a patient shows potential signs of coronavirus, and if they need to be tested.”

“In the UK and around the world we are also working quickly to adapt our full range of technologies to respond to the needs of frontline staff at this difficult time. This includes important work in patient flow, where we are working with hospitals to give them crucial insights into the status of coronavirus patients around the hospital.”

“Technology has helped the NHS to tackle many other issues, and it can play an important role to help to make life that bit easier for our remarkable NHS staff as they respond to the ongoing crisis.”

Now Healthcare sees increase in online medication ordering.

Patients have turned to the app as an alternative to heading out to their local pharmacy.

Lee Dentith, CEO and Founder of Now Healthcare Group said to HTN: “This is a very concerning time for so many people, especially those living with underlying health conditions and now is the time that people can start to understand the huge benefit of technology and put their trust first-hand in using app-based services like Now Patient. Many of our patients must go into a period of social-distancing so heading out to their local Pharmacy to collect the numerous medications is not an option – particularly when the Pharmacies can be a breeding ground for germs. We are proud to play a small role in helping to keep people safe and contain spread of the virus in the best way possible way”.

Celsium innovates temperature tech

Andy Mahoney, CEO of Celsium, said “Measuring people’s core temperature is key to helping to understand the spread of coronavirus, but the world is still reliant on a limited 300-year-old technology, with thermometers being the means to check your temperate occasionally. Since the onset of the coronavirus, Celsium has been having conversations that could change that. We are now ready to scale up production of an entirely new wearable that measures the wearer’s core temperature every four seconds – that’s 900 times an hour, delivering medical grade readings more times in one hour than most people have had in their lifetime.”

“If the temperature rises above a set level, for example 38.2 degrees C, Celsium can alert the wearer on their mobile phone. During the current coronavirus outbreak, this could help people take action to protect their families, and it could become an important part of personal protective equipment worn by hospital staff, to keep them safe. People can be alerted to their rise in temperature before they even feel it. And the alert is far more reliable than a digital thermometer that can be influenced by the ambient room temperature. With necessary consent, data can also be shared with healthcare planners and public health teams at this crucial time, informing them of potential geographical areas where there may be a spike in rising temperatures for the population. This could allow targeted decisions around allocation of resources and support.”

Better supports assessments and reporting – offering clinical data models for free

Tomaž Gornik. Owner and CEO of Better, and co-chair of the openEHR foundation, said to HTN “Open data models and standardised approaches to collecting data are already proving important in understanding COVID-19, as countries across the world respond to the coronavirus pandemic.”

“Three to four weeks ago the openEHR community from different countries got together and started to build clinical data models to support developers in the COVID-19 application space – supporting everything from assessments, to reporting on coronavirus tests, to reporting to the World Health Organisation registry of COVID-19 cases.”

“The models are free to use by any application developer, and throughout the world this is happening now.”

“Better has been using these models to help our customers, including the NHS, where we have been working free of charge to help solve problems relating to the ongoing outbreak.”

“One trust has used these models to build tools to help staff carry out COVID-19 critical care daily assessments for patients and reporting.”

“Slovenia has used the same openEHR platform to create a dashboard that shows the spread of coronavirus across the country. And this can apply to any country. It works directly off the data in the platform, which has been collected using internationally developed data models.”

“And we have made our offers to support the Cabinet Office as part of a UK wide offer of industry support.”

“In order for this to work, as coronavirus guidelines are changing daily, healthcare systems need to find ways to push updates into patient facing and clinician facing applications. It’s not only the data entry that is important, but the questions being asked and the rules of the assessments that are part of the screening process. This is a big benefit from having standard data models – so that rules can be enforced to allow data comparisons and an agile response to the challenges now being faced.”

CommonTime supports with compliant instant messaging

Matthew Gauler, CEO, CommonTime, said “Our conversations with NHS organisations to implement compliant messaging have quickly accelerated since the COVID-19 outbreak. Effective communication in emergency care throughout critical people, roles and teams is now more vital than ever. In response we have re-engineered our deployment approach to make sure we can get our technology in place as rapidly as the NHS needs it, with the ability to deploy quickly and remotely.’

“Most importantly, in these unprecedented times, we have done everything we can to shift any burdens away from the trusts. We can perform tasks such as loading rotas and authentication into our managed service in our secure cloud.  At a time of crisis, this is about alleviating pressure wherever possible on our NHS partners.”

“National decisions have also been made to allow staff to use WhatsApp to share patient identifiable data, however, evidence suggests this may not solve the problem for busy staff. In these times where teams will be redeployed, and when temporary and returning staff play an important role, everyone needs fast and reliable ways to communicate with each other. But consumer applications, such as WhatsApp, often require users to already have phone numbers for the people they need to reach.”

Katrina Percy, healthcare advisor, CommonTime, said “Communication must now be kept relevant and simple. Sending alerts to a critical role or team is much easier than trying to work out who should be contacted and whether they are available. So, we have been enabling our NHS partners to communicate efficiently – connecting entire organisations of thousands of people securely and safely.”

“A busy A&E nurse may need to quickly see which consultant is online and immediately send a secure message. And management teams need to be able quickly message their entire workforce when needed – for example if a ward needs to be quarantined.”

“Staff also need to take important downtime to rest during this crisis, without being messaged in the middle of the night when they are not on call. Enabling staff to keep their personal and professional communication separate is crucial at this time.”

InfoFlex supports data collection and reporting

Marc Warburton, Chief Executive “Since the outbreak of Covid-19, a number of our customers have approached us to see how InfoFlex can be used to support data collection and reporting to help with management of the Covid-19 outbreak. We are more than happy to support through the capabilities our solution offers and will be doing so at no extra cost.”

“The InfoFlex system can enable Trusts to configure data capture, gain access to in-depth reporting and enable an alerting tool as needed.”

Chronomics sets up free and simple online risk calculator

Dr. Tom Stubbs said to HTN “At Chronomics we have developed the world’s first epigenetic saliva test that reveals how the largest risk factors for chronic conditions are impacting our health and wellbeing at a DNA level. The insight from these results gives each of us the knowledge to take control of our health and prevent through action.”

“The importance of the information that Chronomics provides is highlighted by the current COVID-19 pandemic spreading across the globe. Age, heart disease, type-II diabetes and respiratory diseases are responsible for increasing our chances of becoming very sick from COVID-19 infection. These diseases are largely the result of long-term mismanagement of health and are preventable. Chronomics provides personalised insights that shine a light on the largest risk factors for these diseases and supports people to prevent through action – reducing the chances of becoming very sick from COVID-19 infection and avoiding heart disease, type-II diabetes and respiratory diseases in the process.“

“In direct response to the COVID-19 outbreak, the team has set up a free and simple online risk calculator (https://content.chronomics.com/covid-19) so people can understand their current risk and support loved ones in understanding their risk. We would encourage everyone to fill out this risk calculator.”

Servelec quickly supports with new solutions 

Steve Wightman, Managing Director of Healthcare, Servelec said to HTN “One of our customers, an acute hospital urgently needed its Tracking Lists redesigned to help prepare its Emergency Department, and we were able to create and implement a new solution within 48 hours to support the hospital in its moment of need. This prompted senior directors from the hospital to thank us for ‘the flexibility, dedication, understanding and responsiveness from Servelec which has been nothing short of outstanding.’

“There will be a spotlight on new technology at this point, but it’s important that we keep existing systems working as efficiently as possible and adapt them for the challenges ahead in the coming days, weeks and months.”

X-on delivers for primary care

Paul Bensley, Managing Director of cloud communications specialists X-on said “GP practices are being swamped with calls, and not all their phone systems can manage. The shift to delivering care remotely is also causing issues. We are working with hundreds of practices to ensure their telephony is a central part of their response to the coronavirus pandemic, as they switch to the ‘phone-first’ approach being advocated by central health policy makers, and look to address the issues that affect some legacy phone systems.”

“We have rapidly developed technology so GPs can work remotely and provide telephone triage and consultation services to patients from home. This is alongside providing video functionality, which enables doctors to switch from a phone call to a video call with a single click, which is helping them deal with greater volumes of patient enquiries.”

“X-on is also providing free teleconferencing to help teams at CCG and PCN level who are coordinating the local and regional response.”

In this feature supported by Highland Marketing, we hear from companies across health and care to understand how the industry has rallied together over the last few weeks in adapting to an everchanging and demanding situation. We interviewed leaders from across the industry to hear about new software, changing pathways, new features and initiatives to support the health and care system.

Part one of the feature includes: TPP, UKCloud, Inhealthcare, Lantum, Siilo, CliniSys, Healthcare Communications, Ingenica Solutions, Lexacom, Biodose, NextGate, AccuRx, Nurx & Carbon Health, EMIS, Draper & Dash, Hospify, Advise INC, iPlato, Healthcare Gateway, Concentric Health and PatientSource.

Hospify sees jump in teams using its messaging system, James Flint, CEO of Hospify, said to HTN “We are ramping up significantly to respond to the COVID-19 outbreak. We have seen an exponential growth in people signing up to Hospify since the coronavirus crisis has hit – to the extent that we are now helping more than 1,000 new NHS users a day.”

“Last week Hospify rolled out its instant messaging tool to all 10,000 staff at London North West University Healthcare Trust as a testbed project under the aegis of NHSX CIO Sonia Patel. Since the beginning of March nearly 30 NHS hospital trusts and several health boards have signed up to the trial version of Hospify Hub – a tool for managing instant messaging across the organisation. And GPs and clinical commissioning groups are engaging like never before.”

“Such huge interest says loud and clear that now more than ever NHS staff need a way to communicate with each other and patients quickly. But they also need to do this securely in a way that protects themselves.”

“NHSX and the Information Commissioner’s Office have relaxed information governance rules so clinicians can use tools like WhatsApp. But in many cases CIOs and CCIOs don’t see this as a long-term solution, and immediately this may not always be practical – especially for a doctor or a community nurse who wants to communicate with patients, without contact information becoming compromised. Particularly at a time like this, giving your phone number to hundreds of anxious patients could make it difficult or even impossible for health and care professionals to operate.”

“Our priority is to help as many people as possible as quickly as possible – other practicalities can wait until things have levelled out.  That’s why we have ramped up our support, and we have built a call centre in the last week, staffed in part by students at University College London who have had lectures cancelled and who we have trained to help people deal with technical questions.”

Last week Draper & Dash launched an Impact Assessment Tool to provide ICU and live demand data in real-time.

The team created the IAT tool to help trusts best manage their available resources during this crisis. A number of organisations adopted the tool last week combining national HES data with live global data sources, alongside each trust’s own local ED, pathology, radiology, and workforce data.

Organisations are able to instantly model the impact of increased volume and complexity caused by COVID-19 on their bed capacity and workforce, in addition to creating projections of how this may change based on the growth rates of sample countries and their own matched patient demographics. The IAT therefore provides a simple and effective tool to help ensure trusts are fully equipped to monitor and predict the upcoming needs of their health systems, allowing for improved preparation so that patients receive the best care possible.

EMIS last week announced it’s offering free video consultation tools to GPs.

EMIS said “The Video Consult service will be provided at no cost to practices for a temporary period (12 weeks) and online training and support materials will be given.”

TPP brought forward the launch of its new patient facing app Airmid.

The tool supports citizens take control of their own health record and engage with their own care team. It includes appointment booking to video consultations and wearable integrations.

Health Communications last week launched a chatbot for trusts to embed within their website or send to patients to answer common COVID-19 questions, reducing the burden on telephone lines.

The company has also automated SMS messaging to large cohorts of patients to convert complete face to face clinics to video and telephone appointments and keep patients updated on the changing situation. The company is also about to go live with two trusts to support virtual appointments and has introduced a digital symptom checker to triage and act as a pre-assessment – the information is instantly returned to the hospital for assessment.

Laboratory information specialists CliniSys has worked closely with Public Health England to streamline the reporting of crucial laboratory data to ensure as complete an analysis of the virus is captured nationally as possible.

Richard Craven, CliniSys UK CEO said to HTN “It is absolutely vital given the challenges from coping with COVID-19 that laboratory systems are as straightforward and effective as possible so the developing picture of the threat is captured centrally quickly and efficiently.”

“Working very closely with Public Health England, we have distributed free to all our laboratories new guidance on a simple configuration to our WinPath Enterprise information management system to enhance the presentation of test results for COVID-19.”

“We believe this is a significant enhancement, avoiding time-consuming manual processes and reducing further pressure on already over-stretched laboratory teams. Responses so far from laboratories have been very supportive and we continue to look out for further simple systems enhancements to save time.”

UKCloud has supported thousands with remote working at scale and the supplier community it supports.

Cleveland Henry, Director of Cloud at UKCloud Health, said “Like everybody else out there, we are trying to provide support where we can. The first, big challenge that trusts have asked us to respond to is enabling staff to work remotely, by making sure they can connect into their work machines from home and communicate with each other.”

“Working remotely is not new; but doing it at this scale is – and cloud lets you do it in days rather than months. Another thing in demand is Infrastructure, referred to as IaaS: Infrastructure as a Service. With people working remotely, there is an increased need for storage of files (video, images, voice) and messages. With the IT team unable to deliver this at pace through traditional methods, cloud can be a key enabler by providing on-demand ‘burst’ capacity.”

“Our cloud platforms are also connected to the Health & Social Care Network (HSCN), so we can enable secure connections to NHS standards. In addition, we have an extensive partner community delivering applications, so we have been supporting those suppliers with current initiatives, such as the rapid deployment for video consultations capability and health self-management apps such as Aseptika’s Activ8rlives App. So that’s all very positive.”

“The only thing that worries me is that there is a bit of a scattergun approach. We have seen panic buying in supermarkets, and we are seeing a bit of the same in health tech. There needs to be more consideration for what the strategy is going to look like on the other side. In normal times, we always say: go for the minimum viable product and build on it.”

While I completely understand that these are not normal times, the thinking should not be different. This is a huge opportunity to accelerate the digitisation we have all been talking about for a decade and to do things differently in the future – time now really is of the essence – but that will be much easier if people make the right considered decisions now.”

Lantum has supported trusts manage and allocate clinical resources across the system.

Melissa Morris, CEO, Lantum said to HTN “We have put every ounce of our focus and effort responding to this, because we have a moral obligation to. We are saddened as a team when we hear about the human cost of this disease, it is all consuming, and we feel the weight of responsibility to help do something about it.”

Siilo messenger is now providing its organisational crisis management tool to the NHS for free.

Lexacom is offering its mobile application for free.

 Andrew Whiteley, CEO, Lexacom said to HTN “last week we started to offer our mobile application to all our users free of charge whilst there is social distancing in action.”

“Our development team are also working hard to ensure that people can work from home but maintain the same very high levels of security and confidentiality that we are well known for.”

“We are used by over 60% of GPs on a daily basis and as an ex-GP myself, I am doing all I can to help them perform their increasingly difficult job.”

NextGate scales-up its identity management solution 

The company said to HTN“We have already taken the necessary business continuity and security measures to ensure our mission critical patient identification services are running at the highest level of performance to support our customers, protect our employees, and play our part in response to this global pandemic.”

“We know from customers that lab orders will go through the roof.  Our patient identity management solution is being scaled to meet demand.”

“Further, we are working around the clock with our state health information exchange (HIE) customers to expedite their onboarding timelines, knowing they will play a central role in disaster coordination.”

Inhealthcare is helping to minimise face-to-face contact.

The company is supporting remote patient monitoring for high-risk citizens – services include COPD, hypertension, heart failure, gestational diabetes and anticoagulation.

Its working with national agencies to provide an online symptom-checking tool to triage citizens based on the severity of symptoms and is supporting with an automated screening service for patients due to attend appointments.

The company is also supporting through its video consultation platform. The company said “Importantly all services are digitally inclusive. Citizens can access our services via SMS, online, automated telephone call or video.”

Advise Inc is supporting procurement teams with analysis.

Mat Oram, CEO & Co-founder, AdviseInc said to HTN “We’ve delayed developments in our analytics to free up analysts to support stretched procurement teams with analysis – for free for the next 3 months. Trust’s don’t need to be a customer of ours either.”

“Our business and data are setup to enable us to respond in minutes/hours not days/weeks like many teams will face.”

“As far as our staff are concerned it is business as usual. We’re used to dealing with rapid change and all have been homeworkers since inception, so our own use of technologies like Zoom, Monday.com, Slack, Google is just normal to us.”

“The services we provide are cloud based and our own infrastructure is cloud based.”

Accurx have, in one day, developed an online consultation service and is providing the tool for free.

Jacob, CEO and Co-Founder said to HTN “We are very privileged to work with an amazing team; they are very dedicated and very talented. When we decided on Friday to implement accuRx Fleming to our practices, the team worked through the weekend so we could test in a handful of practices on Monday morning and then release to all practices Monday afternoon.”

“I don’t know of any other healthcare company who has managed to go from concept to national rollout in one working day.”

Healthcare Gateway is supporting access to patient data at the point of care.

The company said to HTN “This ensures front line health and social care workers have access to patient data, when and where it is needed to support faster, more efficient care.”

“We can deploy real time connectivity at scale and pace, and if customers need support, they should not hesitate to contact us.”

Concentric Health digitises content for surgery.

The company said “During this pandemic, social distancing measures are projected to significantly impact on mortality.”

“For healthcare systems, a key element is managing the numbers attending healthcare facilities. Concentric digitally transforms the paper process of giving consent for surgery.”

“We are extending Concentric’s functionality to enable shared, remote interaction in response to this pandemic. This will allow patients and clinicians to have remote consent conversations, and documentation of that consent without unnecessary and worrisome outpatient appointments.”

Aire Logic is offering its online consultation platform for free to any and all healthcare organisations as well as supporting health and social care providers.

PatientSource has announced that it will be offering an adapted version of its Electronic Patient Record software free of charge with minimal cloud hosting costs.

The adapted version of the PatientSource software will feature a cloud-based electronic observation module complete with patient trackers and ward whiteboard tools.

Dr Michael Brooks, Chief Medical Officer and Co-Founder of PatientSource, said “Our PatientSource COVID-19 tracker will show you which affected patients are in your hospital or ward, what their latest vitals are, the plans for escalation, and who the expected incoming cases are in real-time.”

“This allows you to identify the patients who need oxygen bays and the patients who need critical care input, allowing you to allocate limited resources to those who need them quickly.”

iPlato has updated its remote consultation service. This will allow teams of clinicians to collaborate across GP practices.

Tobias Alpsten, CEO, iPlato said  “Using the myGP platform to manage everything from outbound patient engagement, appointment booking through to triage and video consultation primary care can continue to play its key role in managing the Covid-19 pandemic.”

“As our solution is web-based it means that a clinician can use the platform from his or her own device while working from home, triaging appointments and conducting them remotely while possibly being in isolation.”

Nurx & Carbon Health introduce COVID-19 home testing kits.

They deliver swab-based sample collection hardware for home use to collect a mucus sample, which they then ship back using protective packaging to be tested by one an FDA-approved commercial lab.

The test checks for the genetic presence of the COVID-19 virus and have a high degree of accuracy.

You can see more about their home testing kits here:

NURX Home Testing Kit

Carbon Health Home Testing Kit

Biodose is supporting medication management.

A spokesperson for the company said “We are supporting care homes, and those self-isolating, to control infection risk during the coronavirus pandemic.  This coating helps reduce the risk of infection and supports care homes to protect residents who are at significantly greater risk of contracting COVID-19.”

“For people over the age of 70 and those with certain health conditions encouraged to self-isolate in order to protect themselves from coronavirus, Biodose Connect support people managing their medication.”

Ingenica is supporting critical management and reordering of PPE.

The company said to HTN “Whilst we all face this crisis together, Ingenica Solutions, like so many other heath tech companies, would like to reassure the NHS that we are here to help and support all healthcare staff, who are working tirelessly and selflessly for us all in the face of adversity.”

“As demand for Personal Protective Equipment (PPE) soars during the outbreak of the coronavirus infection, and it is reported that there is a shortage of supplies to keep healthcare professionals safe from covid-19, Ingenica Solutions would like to offer our support.”

“We are able to assist in the critical management and reordering of PPE, which is currently a continuing growing concern for all.”

The draft standard outlines 10 components on what the NHS expects. It’s based on existing standards and will support a process for reviewing, assessing and evaluating digital health technologies that meet the standard. It is also intended to speed up and streamline how health technologies are reviewed and commissioned by the NHS and social care.

Dr Indra Joshi, Rhod Joyce and Dr Nina Wilson from NHSX in a blog post said “We have developed the draft Digital Health Technology Standard, based on existing industry and health standards, to bring them together in a consistent, transparent and accessible way. This standard intends to consolidate and replace existing standards, rather than add new ones. This is part of our wider programme of work to speed up how health technologies are reviewed, commissioned and scaled across the NHS and social care, and to provide clearer guidance to support digital health technology developers.

In this Industry View feature sponsored by CCube Solutions, HTN asked leaders in health tech for their views:

Data anonymisation and the risk of re-identification is an area which requires more detail. The ICO guidance on this is very clear – “it can be impossible to assess re-identification risk with absolute certainty”. A balance will need to be struck between suppliers revealing IP and ensuring data standards and ethical, unbiased approaches are maintained. How, where and by whom these decisions are made needs to be fleshed out.

There are clear opportunities here for collaborative partnerships between the NHS, its workforce and industry to produce robust solutions. A focus on long-term value, combined with fair commercial arrangements, will help get the right stakeholders working together towards common goals. Successful products, that adhere to the standards, are far more likely with this approach.

In summary, this is a welcome and timely draft document which sets a guidance framework to benefit the NHS, its workforce, citizens and suppliers.

NHS has tried different types of Digitalisation processes in last few years, without much success and at a huge cost. But, that should not deter us from re-visiting the area with more internal and global knowledge and learnings.

1. Technology itself – it should be safe, simple, user-friendly, portable and low resource-hungry. And most important they should answer correctly and effectively the questions they are expected to. They should also be upgradable in future.
2. People – with apology, I have to mention that not all clinicians are as tech-savvy as we will like them to be. In fact, there may be some resistance too. Hence, any new technology should be introduced after explaining all the advantages and the purpose, if necessary in stages. It should be ‘owned’ by clinicians, and not given to them.
3. Environment – it goes without saying that the systems should meet all safety standards, including Data protection and External interference. However, there should also be enough flexibility to expand its use and create interfaces without much changes.
4. Population Health – this paper does touch this important subject that though basically we will expect any Technology to deliver what it is supposed to in a specific clinical area, but it will be interesting to see how these changes and improvements can also link with the Social, Mental, Psychological and Economical improvement of the society. This will be a real test for any long-term success.

Gary Birks, General Manager, UK and Ireland, Orion Health

It is important that healthcare technology is developed to standards and that those standards continue to be assessed and developed in collaboration between the NHS and industry.  It is good to see NHSX recognising the importance of standards and the role they play.

As this draft recognises, most healthcare technology developed today must adhere to the many standards already in place, whether that be with respect to technology design, patient safety or security. The draft standard is useful in bringing these together in a consolidated view and is a helpful guide for the NHS and industry.

One consideration for NHSX and the industry is to work to ensure that standards do not prohibit or slow down innovation.  What the draft standard does reference but should make a priority is that innovation should focus on delivering benefits to patients and clinicians and that healthcare technology is not simply looking to align to technology standards, that technology is not for technology’s sake.  If the standard ensures that safe, effective technology gets in to the hands of clinicians and patients and delivers clear and defined benefits whether they are subjective or otherwise, that will be very welcome.

Orion Health works collaboratively with the NHS and the market to ensure that new standards are recognised, developed and done so with innovation in mind.  We are a founder member of INTEROPen and continue to support positive activities to ensure that standards work in practice through the regular INTEROPen hackathons.  These hackathons have created an environment of open collaboration, and it is collaboration in the development of standards that will ensure that they deliver benefit to the NHS.

The success of this standard should not be judged by whether companies comply, because reputable vendors will already be developing to the standards and approaches recognised.  It should be judged by whether it helps organisations to find, procure and adopt the technology they need to deliver clear and defined benefits for patients.

Martin Bell, Independent Consultant, The Martin Bell Partnership

There is much to be welcomed in the draft NHS Digital Health Technology Standard, and it’s certainly welcome that there is an element of consultation and discussion on this, from both within the NHS and the supplier community.

If one reads through the document, there is little one can disagree with, if anything. Helpfully, perhaps, all of the various elements one might want to see are brought together in one place, this is useful. It’s a good base from which to move forward. However, much or most has been discussed before.

Key to “moving forward”, versus previous NHS central technology strategies and approaches will be:

• Will the amount of funding for Digital Health/IT/NHS IT/Technology/Informatics – call it all what we will – increase to levels that allow deeper, faster penetration across all areas of the NHS and Social Care – Acute, Mental Health, Community, Primary Care, Social Care etc – and allow the scaling of technologies that we know work, but through lack of funds, have not got out there?
• Will NHS X / NHS Digital / Department of Health and Social Care “enforce” (can they enforce?) that any new contracts signed from a certain day forward must comply with the standard, or at least have a sensible period in which to comply with the standard, or that supplier/solution cannot service the NHS?
• Will the technology standard still allow swift innovation from small, agile start ups and SMEs, as well as support greater interoperability and greater innovation and partnership working from more established players, who may have dominant or even near monopoly/duopoly positions in certain areas of the markets?
• How will the transformational and human change support be embedded, to support the expansion of “tech” and crucially, will it be funded?
• Perhaps for the wider context, and given the “drop the AND” campaign around health AND social care that started at DH ReWired last week, perhaps it should include the words “Social Care” too in the title – at least to the extent that it can?
• How will citizens be genuinely involved in supporting the development of services, supported by technology, in the future – as it’s the delivery of services that is it important first, the underlying technology second?

Liz Ashall Payne, CEO, ORCHA

Regulation is essential to enable NHS professionals to trust digital health. One of the greatest challenges with regulations are that they need to strike the right balance between rigour and relevance.  When we look back, the NHS have been working on their approach to Digital Health Technology standards for around 5 years, the initial iteration had standards which were too low, exposing the NHS to risk, following which the bar was set too high, preventing all apps, even those actively used and built by NHS departments, to pass.

For the past 18 months we’ve seen the DAQ achieve significant improvements and greater proportionality – measuring the right things and setting the bar at an appropriate level for the specific digital health solution, however as with everything further improvements are always welcomed.

Looking at the new standard, the DAQ forms a part of the new standard alongside many additional sets of standards and requirements, some of which appear duplicative and do not show the proportionality which is critical in this work.  As such the new approach looks to be less streamlined and I do hope this doesn’t cause unnecessary cuts to the use of good apps for patients in the NHS.

As an assessor of DHTs across UK, Europe and Middle East, we await confirmation about what this final standard is and will work with the NHS to identify and turn any new elements in the standard into actionable and measurable processes that developers will be able to follow.  But first, it would be good to clarify what the current issues are with the DAQ, so that the modifications can directly address those in the first instance.

Louise Morpeth PhD, CEO, Brain in Hand

We welcome the standards and the intention to speed up and streamline the review of DHTs. We have three hopes. First that they will be applied proportionately – an app that motivates children to brush their teeth for two minutes can’t be expected to meet the same standard as one that manages diabetes. Second that they will encourage and not stifle innovation. There is no point in setting the bar so high that virtually all apps fail to make the grade. Third, that there will be a shift from a binary system of being ‘on or off the App library list’ to one where technologies are scored on the different dimensions (e.g. effectiveness, safety) akin to the Which? Magazine approach. By publishing the scores, the commissioner or purchaser can make an informed decision safe in the knowledge that the innovation had been independently scrutinised.

Sara Nelson, Programme Director DigitalHealth.London Accelerator programme

We warmly welcome this attempt by NHSX to standardise how health technologies are reviewed and commissioned by the NHS and social care. It is absolutely right that the NHS sets the highest standards for digital health technology to ensure patients and staff get the best possible care and services. Until now there has been no national standard of expectations of how to review, assess and evaluate digital technologies. This has meant time costly duplication, variations of processes and requirements and ultimately delays to digital innovations making a difference to people’s lives and work. NHSX have asked for feedback and input to these recently published standards and I would encourage our Accelerator companies, partners and NHS staff to contribute.

Chris Gibbons, Innovation Lead, UK health, Accenture

The Digital Health Technology Standard draft is a welcome starting point in providing greater clarity to developers in health and social care tech on the standards their products must meet. Having a common approach will speed up the review and commissioning of technologies; attracting more developers to contribute to providing people across health and social care with the tools they need.

We are pleased to see NHSX openly publishing early drafts of standards and co-developing the further detail and clarity required for the standard to be successful. Greater clarity will be needed on the linkages between existing standards and simplification of the steps developers must take; we look forward to discussing and contributing to NHSX’s continued development of the standard.

Rory Cameron, CEO, Gendius

Over 30,000 people have downloaded our diabetes app, currently over 1,000 a day, but we know we will help even more people by being part of a digital NHS system.  We agree that the NHS must set standards for apps, and we are currently undergoing the DAQ process, but as a technology start-up, it is frustrating to discover the process we are currently going through may be replaced not by a simpler process, but the same one with many more hurdles added.  To review and digest the proposed new standards will cost hundreds of thousands, budget we just don’t have – it will take about a month’s worth of manpower. In addition there is so much duplication with other standards we have achieved such as ISO27001.

David Kwo, Digital Health Specialist 

This document is a helpful collection of existing standards, guidance and regulations associated with digital health technologies (DHTs). It serves as a handy reference to know what relevant standards exist for DHTs in the UK.

It could be clearer about who is its intended audience. Is it the wider health and social service, to assure them that such DHT standards exist, or is to the DHT developers, or both?

As a compilation of DHT design principles, this document is useful. However, at times it also reads like a checklist for DHT developers to follow to demonstrate compliance. As a checklist though, it’s not clear precisely to which body (or bodies) the DHT developers need to prove their standards adherence (or how or when).

It could be clearer about the type of DHT products to which these standards are meant to apply. On page 3 it talks about “…health apps and tools.” But it then mentions “Digital Health Technologies” which is a wider concept. For instance, do shared care EPR systems and provider organisation EPRs come into this scope as they are different in nature and scale from “apps and tools”. It would be good to have examples of the range of DHTs for which this standard is intended.

Bias is mentioned in the first paragraph as something to be avoided in DHT design. It may be an idea to make more explicit reference to the need to avoid potential gender bias, as raised so well by Caroline Criado-Perez in her book “Invisible Women: Exposing Data Bias in a World Designed for Men” and in her excellent presentation at Rewired last week.

This document does add its own new standards for DHT developers to meet. For instance, there is now a need for DHT developers to “publish performance against KPIs openly and regularly alongside the assessment methodology” including “cost savings”. But it is not clear which standards body these standards must satisfy. Is it NHSD/E/X/or I?

I counted over 80 different standards, guidance articles and regulations being referenced in this document. Could a DHT developer company have to complu with them all in adhering this “standard”? Is that practical and facilitative of agile innovation? Will existing DHTs need to retrospectively demonstrate adherence?

– Thank you to the contributors –

Please click on an image below to view the case study or scroll to read on below.

Allscripts clinical wrap approach delivers for trusts

An eye on HIMSS EMRAM Stage 7 in Gloucestershire

Gloucestershire Hospitals NHS Foundation Trust contracted with Allscripts for Sunrise Acute Care as a wrap around its existing third-party PAS in March 2019 with an implementation that followed impressively quickly after in November 2019.

Beginning with a two-ward pilot project, more than 60 nursing documents were completed in the software the first morning. By early December 2019, just a few weeks later, Gloucestershire Hospitals NHS Foundation Trust went live with Sunrise in remaining wards.

Mark Hutchinson, the trust’s chief digital and information officer, explains aspirations to reach HIMSS EMRAM Stage 7 within five years. He also explains how the clinical wrap is a repeatable approach that other ambitious trusts can follow.

“If you buy a PAS and an EPR as one system, you always have to deploy the PAS first, and that can take two years. Instead of doing that, we are going to let our PAS do its thing and use clinical solutions to start helping our clinicians to improve care for patients as quickly as possible.”

“A PAS allows you to see where patients are in a hospital, to manage your waiting lists, and to send information to the central bodies that request it. All of that is important, but the clinicals are where you get the benefit.”

Richard Strong, vice president and managing director, EMEA, Allscripts, said to HTN “We have developed a clinical wrap approach that enables trusts to retain their patient administration and other systems and add clinical functionality at their own pace. It’s great to see many projects realising significant benefits like in Gloucestershire.”

View more Allscripts projects here.

Reducing outpatient appointments using digital information

Torbay and South Devon NHS Foundation Trust is the country’s leading organisation when setting the pace for integrated care.  It is also a leading trust for innovation, with many initiatives reaching across the hospital and the community it serves.

One area that has been particularly successful has been the use of digital information to transform pathways of care, resulting in reduced demand and costs.  This has been achieved through a partnership that was set up between the Trust and Rocklands Media Ltd. to form Health and Care Innovations LLP (HCI).

HCI has produced and implemented an online library of over 500 health information videos that support and educate patients across a range of care pathways. They are now a key partner in the Trust’s transformation programme with significant reductions being made in outpatient appointments, spanning multiple specialties including cardiology, maternity, physiotherapy, seeing savings of £350,000.

Angiogram pre-admission assessments is one particular pathway that has seen outstanding results through one video alone, ‘Having an Angiogram’.

Patients were provided with a link to the video and were given the option to watch it at home instead of coming in for a face to face appointment.  By offering patients a choice, this simple digital intervention achieved a 22% reduction in outpatient appointments.

For those that still opted to come in for an appointment, the cardiac centre at Torbay Hospital replaced one-to-ones with group clinics and played the video followed by Q&A.  This resulted in an 85% reduction in nurse time each week.

This is a cost saving of £20,676 in one year alone from just one video.

Similar results have been seen in podiatry, where 80% of follow-up appointments are now avoided after nail surgery. Likewise, in physiotherapy, providing patient information digitally has reduced Band 5 face to face follow-up appointments by 30%, as patients are now able to follow a virtual rehabilitation programme at home.

It is clear how the provision of digital information through the videos and online libraries has been key to reducing outpatient appointments, but the rheumatology department identified that being able to communicate with and manage their RA patients online would create more capacity and the patients themselves feel more supported. The ‘Rheumatology Connect’ app was commissioned and now neurology are following suit with MS Connect, and other ‘Connect’ apps are now in the pipeline for the management of long-term conditions.

Dr Matt Halkes, Clinical Director of Commercial Services, Innovation and Digital Transformation at the Trust says “Digital transformation is integral to our success as trust.  Like everyone, we’re struggling with increasing demand, especially in outpatients, but we are performing better than the national averages.  We want to make digital information standard practice within our health system so that we can deliver even more savings in the months to come.”

Director of HCI, Richard Wyatt-Haines, sees the impact that his team are having every day in pathways of care and says “The opportunity for trusts is enormous, and the question is not whether an impact can be made, but how much of a reduction in demand and costs should be targeted?”

HCI are keen to help trusts grasp these opportunities. Find out more about their work in transforming healthcare using digital information at www.hci.digital or start a conversation by emailing info@hci.digital

Chelsea and Westminster Hospital NHS Foundation Trust has utilised Lumeon’s Care Pathway Management platform to gain efficiencies in their busy postnatal maternity service and improve the experience for patients, their families and staff.

Dr Sunita Sharma, Consultant Obstetrician and Gynaecologist explains “Through studying women and staff surveys we identified that the stay and the care delivered on the postnatal ward can be enhanced with better systems in place. The ward has a hectic pace, which needed good communications and operational systems for all the people involved. This also needed to happen without increasing the workload on the team.”

Lumeon’s Care Pathway Management solution digitises the hospital postnatal operational pathway. All activities and tasks are orchestrated and automated in real time, with the ability to get a good overview of the care being delivered. Digital dashboards allow multi-disciplinary team members to quickly see the next steps required in the care of mums and their babies. Staff are able to communicate more effectively with new mums and the dashboard also provides a more holistic overview of steps remaining, which mums and their partners can also see because of the traffic light system on the ward TV screen.

Lumeon partnered with CW+, the charity of Chelsea and Westminster Hospital NHS Foundation Trust who funded this project, to co-create, test and embed the digital end-to-end care pathway. The project is one of over 70 innovation projects within the CW Innovation programme, a joint initiative run by the charity and the Trust to implement new high-impact innovation initiatives that improve patient care and experience.

Dr Sharma continues “We decided to digitise – and automate where possible – some of the steps in the postnatal process in order to improve the experience for women and staff on the ward.”

“The advantage that the tool has offered is improved communication between team members. There are times when there are up to 13 professionals coming onto the ward and a lot of time was previously spent trying to get information or give information to another team member.”

“The Lumeon system is very intuitive, it is very easy to use and we are also helped by the fact that we have a digital-savvy workforce, so in terms of implementing a new system it’s been great.”

The platform has automated and streamlined activities in the department, Elizabeth Stewart, Senior Midwife in Charge of Examination of Newborn (EON) service says, “I can get the history of the baby and mother instantly, do the baby check, upload to the system and make referrals with a click of the button, without having to leave the room.”

Solutions designed by staff

Dr Sharma said “This project has been helped by the fact that staff have been involved right from the start when we interviewed them and understood their pain points – a lot of the solutions have been proposed by the staff so it’s been a great implementation exercise.”

“It’s been an exciting opportunity for us to energise post-natal care and innovate to make experiences better for families and staff, and for them to see the difference. We are working to reduce delays once they are discharged by the clinical team, so the mums can take their babies home as soon as possible.”

To watch a video on the project or download the case study, please click here.

GP Federation uses RIVIAM’s Secure Video service with TPP SystmOne integration to deliver video consultations

RIVIAM Digital Care started working with a forward-thinking GP Federation in Hampshire in summer 2019 to add secure video consultations that allow integration with TPP SystmOne to their capabilities. RIVIAM uniquely delivers this.

The NHS Long Term Plan states that over the next 5 years ‘digital-first’ primary care in England will become a necessity and every patient will have a right to choose this from their own GP practice.  Mobile phones and apps have transformed every other industry; patients now expect the same experience from their GP practice.

The GP Federation wanted to deliver the clinical services themselves and were looking for a focused, proven technology platform and video service provider to host and manage the calls.

They chose RIVIAM’s Secure Video service firstly because of its high-definition innovative video conferencing expertise and secondly, RIVIAM’s direct interface with their clinical system, TPP’s SystmOne.

The GP Federation has in mind a number of different uses for RIVIAM’s service:

• Giving students virtual access to a GP video consultation using a mobile device, providing them with easier, accessible healthcare.
• Enabling nurses in care homes to consult clinicians remotely in real-time about patients.
• Supporting virtual multi-disciplinary team meetings.
• Providing remote consultations across geographies with highly skilled staff.

RIVIAM said to HTN, “The Secure Video service is available now to other primary and community care providers in the UK.”

“The technology service from RIVIAM provides a real-time secure video and audio-conferencing call for the Federation and is 100% part of RIVIAM, meaning it doesn’t store or process any video information outside England.”

“Customers can fully customise the patient experience including the digital waiting room that allows patients to see where they are in the queue as well as potentially answer pre-consultation questions. The waiting room is integrated into TPP SystmOne’s diary to provide the patient with a realistic waiting time.”

“The interface with  TPP’s SystmOne means a GP or clinician user can book appointments using their regular clinical rotas. Post-consultation, relevant information is written back into TPP SystmOne automatically.”

Paul Targett, Managing Director RIVIAM Digital Care said, “We’re delighted to see RIVIAM’s video service and NHS integration supporting the future of healthcare.”

“Our mission is to improve people’s lives by providing our customers with secure and interoperable digital technology to help them co-ordinate care better and give patients convenient access to advice and care. We will be developing the video service so it enables multiple users to have an audio or video conference call together. This will be ideal for virtual multi-disciplinary meetings, saving teams time.”

Booking a video consultation triggers an email invitation to the patient containing a URL link and pin code. The patient is able to access and launch the video with RIVIAM’s mobile app using any connected device.

During the call, the GP user or the patient can save the video and audio recording. Afterwards, RIVIAM keeps a secure copy of the video consultation in the patient record for later reference and access by the user.

For further details, please contact ptargett@riviam.com. Read more about the Secure Video service.

Connecting live health and social care data across Cumbria

Healthcare professionals across Cumbria are benefiting from bi-directional data flows using technology from Healthcare Gateway.

Since launching in the region in 2011, The Medical Interoperability Gateway has provided live information and datasets for health and social care, when they need it. Part of a regional record sharing project, live data is now being viewed by health and social care professionals over 90,000 times per month.

Dr William Lumb, GP Sedbergh and Clinical Lead East integrated Care Community, Clinical Director Integrated Services Care Group, Bay Health & Care Partners “To provide the best care possible for citizens we (health & social care) need to be able to share the right information in real time to our front line staff. Working with our Adult Social Care colleagues in Cumbria and utilising the MIG functionality has realised the vision of bi-directional real time record sharing and will clearly benefit service users and staff, helping to make us a great place to be cared for and a great place to work.”

“We now have bi-directional social care data, going from health to social care we provide a view of the core record such as demographics, allergies, medical problems, care plans and end of life datasets. We also have some special patient notes, such as notes for a vulnerable patient, child etc. and we share all that in real time. Social care datasets also come back towards health and we are currently in pilot for this.”

“The integration with Liquidlogic, the system used for social care services in our area means system data can be joined-up. The MIG provides HTML views from the Liquidlogic Adult content store system as a specified dataset. Real time feeds of social care data include patient demographics, allocated case worker, associated carer, disability, risk type and case details.”

Enabling feeds of social care data will help frontline staff to understand the full context of a patient’s care and will aid co-ordination between different teams, preventing escalating social care needs.

Liam King, Director of Commercial and Customer Experience “The programme of work in Cumbria demonstrates the value of social care data and how it is essential to join up care to provide better patient experience. We are proud to be the first offering this dataset in real time to provide integrated care between the NHS and Local Authorities. At Healthcare Gateway we strive to extend our offering of health and care datasets to support healthcare professionals working more closely and effectively together.”

The Liquidlogic Social Care dataset is designed to provide clinicians with a more comprehensive view of a patient’s medical history; offering the following benefits:

• Better co-ordination of a patient’s care
• Enables informed treatment decisions
• Improves patient safety
• Better management of challenging situations
• Provides more satisfying clinical encounters
• Improved data sharing between health and social care

To find out more please contact enquiries@healthcaregateway.co.uk

Luton & Dunstable University Hospital’s rheumatology department embraces innovative technology to improve patient care

The Rheumatology service at the Luton and Dunstable University Hospital (L&D) has evolved with medical advancements to offer local patients a high quality experience.

A few years ago it became apparent that demand was outstripping the capacity, especially with the need to respond to the challenge of delivering outcomes, the impetus to provide an EA pathway and to ensure annual and regular outpatient reviews within appropriate timescales. Capacity was poor at 42.8 % of national average. Mean wait for EA patients was 45 days. This led to 29% loss of referral activity from Bedford CCG and poor patient experience with 26% of patients not recommending the service.

In line with NICE RA guidelines and DOH BPT pathway for EA, an attempt was made to accommodate EA patients in general clinics. However, only 9% (14/157) patients achieved the desired time frames. Hence Early Arthritis Service (EAS) was established to reduce time to diagnosis, start of definitive therapy and accomplish good outcomes by introduction of dedicated Early Arthritis Clinics (EACs) to ensure achievement of BPT and facilitate medicines optimisation.

Treatment to Target (T2T) in inflammatory arthritis led to unprecedented improvements in not only the signs and symptoms of disease but also radiographic damage, functional outcomes and even improvement in mortality. It was only possible if every such patient could be monitored effectively. The Rheumatology team won capital bid for installation of an electronic database system and chose a tailored solution from InfoFlex.

InfoFlex is a leading digital healthcare management solution with a slightly different approach. Rather than imposing a rigid IT system, it models clinical patient pathways with clinician’s specific and individual needs which is why it worked well here.

InfoFlex helped achieve not only T2T for our patients but also acquire live quality data thereby fulfilling a number of the priorities as outlined by the King’s Fund:

• Secondary prevention – by identifying and inviting patients for annual review.
• Improving the management of patients with both mental and physical health needs – by monitoring patients regularly, escalating treatment accordingly, recognising poor treatment responders and adjusting their treatment efficiently.
• Care co-ordination and active support for self-management – by identifying patients who need to see the nurse specialist for education and case co-ordination.
• Medicines management – improved long term patient outcomes from the treat to target approach helped by this database will reduce the biologic use compared to routine care.
• Managing ambulatory conditions – by categorising patients with well controlled disease who do not need frequent monitoring thus allowing integrated approach to urgent and managed care. It will help avoid unnecessary clinic visits and admissions with disease flares.
• Improving referral quality – by providing feedback to commissioners and GPs generated from the database to help improve the quality and speed of referrals.

Implementation of InfoFlex in the department also helped with the delivery of an effective Early Arthritis Service. Nearly 80% of our cohort attained remission or low disease activity in less than six months. This was despite a significant delay in patients presenting to their GPs and moderately-high disease activity at presentation.  100% of our patients were treated to target facilitated by protocol driven escalation of therapy in these clinics. Patient experience also improved (94% would now recommend the service compared to 76% prior to the initiative).

Total savings for the year accounting for most generous cost estimates were £136,973. In addition, there was 42% reduction in biologic use in this group compared to the previous year.

Our care model attracted 48% growth in referrals confirming the confidence of subscribers to our service. Despite that, our waiting times remain the most competitive regionally and nationally. There has not been any 18-week or 3-week breach. Our patients F&F recommendation of service increased from 76 to 94% in the year. Compared to 495 overbookings prior to InfoFlex installation with poor feedback due to delays and hasty service in clinics, there were no overbooks. This also avoided premium rate initiative clinics to meet 18- week target costing £26,500 in the previous year.

Our EACs had 100% clinic utilisation leading to maximum productivity and efficiency. A new partial booking system was introduced which achieved reduction in cancelled appointments, less re-scheduling and lower DNA rate of 5.4% compared to 8.6% previously. This is one of the lowest DNA rate in the Trust. There are currently 5000 patients enrolled with regular reporting on disease indices, patient tracking and achievement of CQUIN by providing outcomes data to CIRCLE (Bedford MSK provider).

A partnership between Pennine Care NHS Foundation Trust and PCMIS has supported thousands of people that were affected by the Manchester Arena Attack on 22nd May 2017 where 22 people lost their lives.

The partnership between mental health and technology experts led to the formation of the Manchester resilience hub, hosted by Pennine Care NHS Foundation Trust. Its role is to reach out to children, young people and adults affected by the attack, to offer screening and co-ordinate any emotional wellbeing and mental health support they may need.

PCMIS is an easy to use web-based, patient information management platform from the University of York, with a strong link to the University’s world-leading Mental Health and Addiction research group (MHARG).

Nearly 3,500 people affected by the attack have received support from the hub. Many had travelled far from home to attend the Ariana Grande concert; some from other European countries and even further afield.

Due to the unprecedented number of people needing support, as close to their home as possible, it was essential to have the right technology in place to quickly, effectively and safely cope with a huge amount of complex patient information.

Understanding the need to work quickly and accurately, staff from PCMIS built on their existing online patient portal product.

Following discussions with the hub’s clinical staff, they included special questionnaires. These were designed to measure people’s personal reactions to a traumatic event and how their mood and anxiety was impacting on their everyday life.

With the portal set up and ready to go, after carefully considering data protection implications and sensitivities, people were reached through a co-ordinated awareness campaign designed to encourage them to self-refer online.

Referrals via the online portal flowed automatically into the PCMIS clinical system. People could complete an online screening tool that was scored and categorised by the system. This allowed hub staff to easily highlight those they were most concerned about and make sure they received the right care and support, close to where they live.

Dr Alan Barrett, consultant clinical psychologist and clinical lead for adults at the hub said “Having used this web-based clinical system for many years within another service, I was aware of the adaptability and reporting capabilities that it offered.”

“Following the attack we needed to act quickly to make sure the right clinical support was available to people. We worked with several partners across Greater Manchester to set up the hub and each had their own IT system.”

“We needed to choose one system that would best deliver what we needed. The familiar and effective PCMIS system seemed the obvious choice.”

Byron George, Director, PCMIS who oversaw the partnership with Pennine Care, said “PCMIS is proud to have been involved in supporting the important work being done by the Manchester resilience hub team.”

“We are committed to working alongside them to further explore how technology can help facilitate greater care and support for those affected by traumatic, major incidents.”

Nearly two years after the event, staff from Pennine Care’s hub and PCMIS continue to work together to provide ongoing support for those affected by the Manchester Arena Attack. Outreach work is planned for the upcoming second anniversary.

The rapid speed at which support was provided and the effective partnership working between lots of Greater Manchester partners has been commended worldwide and now informs major incident response planning by other health organisations.

Staff at the hub continue to share best practice and lessons learned from their experiences setting up and managing large scale support for those affected by major incidents.

For more information about the Manchester resilience hub please click here.

For further details about PCMIS please click here.

The Bedford Hospital NHS Trust (Bedford) serves a population of approximately 270,000 across Bedfordshire and surrounding areas (with a 900,000 catchment for vascular services). Its core local authority populations are Bedford Borough (160,000) and Central Bedfordshire (260,000). The Trust has over 2500 members of staff and is the largest local employer in Bedford. It has a current turnover of approximately £180m. Its main commissioner is Bedfordshire Clinical Commissioning Group. The hospital has a dedicated Cancer Centre, the Primrose unit. Bedford has approximately 360 beds and provides a full range of Acute services, with beds for Care of the Elderly, ENT, General Medicine, AAU, General Surgery, Gynaecology, Neonatal, Obstetrics, Oncology, Trauma and Orthopaedics, Paediatrics, Vascular Surgery, Breast Surgery and Urology.

In September 2017 the Bedford Hospital NHS Trust and the Luton and Dunstable University Hospital Trust announced their intention to merge their organisations; keeping their separate services and facilities, creating a combined workforce of approximately 8,000 members.

The Luton and Dunstable University Hospital Trust was awarded Exemplar status by NHS England in 2016 and under CCIO Sanjeev Taneja is focusing on digital transformation, and specifically on Interoperability. Bedford
has already started on this journey towards enhanced digital maturity with Viper360 from ReStart Consulting Ltd.

The problem

Like most NHS Acute trusts, Bedford has a wide range of clinical and administrative systems in use across the organisation which are not integrated. This meant hospital staff needed to re-enter the same information in multiple places, creating potential for error and omission. Patients and their carers also had the frustration of having to repeat the same information multiple times to different health professionals throughout their care journey.

John Bain, Associate Director IM&T said, “Bedford had endured the inefficiencies of multiple separate systems in operation for long enough. In a highly pressured care environment it is important to eliminate sources of patient and staff frustration and to reduce the potential for increased clinical risk.”

The ReStart Solution

The Viper360 Interoperability platform was selected following a tender process. It is a highly scalable solution which Bedford has requested be rolled out in several stages. Prompt access to new functionality is assured through a phased delivery approach with training taking place at each stage of the services expansion. Viper360 provides clinicians and administrative teams with access to realtime patient information. Single-Sign-On functionality eliminates the need for clinicians to log into and interrogate multiple systems to obtain an accurate and up-to-date view of their patients.

Viper360’s first phase roll-out at Bedford was to its clinical administrative team to give them access to Viper360 to view patient Radiology and Pathology reports and clinical documents through a user-friendly interface. The next phase of the project planned for delivery in November includes Single Sign on Functionality, Interoperability with PACS and Extramed systems, and visibility of Cancer data and Cardiology reports.

Luton and Dunstable CCIO Sanjeev Tajeda, in his Feb 2017 interview with Digital Health*, referred to the PACS system as the most under-rated digital innovation – eliminating the need for the logistical nightmare of hardcopy image transfer between departments. Viper360 will further extend the CCIO’s view through extended PACS across the organisation.

The Next Steps

In September 2017 Bedford Hospital NHS Trust confirmed the successful first phase deployment of the Viper360 Interoperability Platform. Viper360 is now in active use by clinicians and administrative staff. By the end of November 2017, 5 months after initial go live, it is anticipated over 100 users will be logging in and accessing multiple systems via the Single Sign-On viewing platform on a regular basis.

John Bain, Associate Director IM&T said, “With a relatively small investment we chose to adopt Viper360 as the platform to increase our quality of care, operational efficiency, AND improve patient experience at the same time.”

Mike Symers, Managing Director at ReStart said, “ReStart has developed Viper360 in response to NHS Trust requirements. It is an Interoperability Platform that can be deployed quickly. Viper360 is also scalable allowing further functionality to be built in as time, budgets and organisational capacity permit. And, very importantly, it is priced to enable even the most cash-strapped Trust to achieve their aspirations for organisational digital transformation.”