What is clinical engagement?
Clinical engagement is a loose term, the lack of which is often cited as a reason for IT systems not working in the NHS (the UK’s nationalised health service). However this is rarely accompanied by an explanation as to what it actually means. At CSC, clinical engagement plays a critical role in the development and deployment of any electronic system for the NHS. We define it as the process to engender ownership, to build on existing enthusiasm and to shape solutions so they are usable. Engagement means involving the people actually working in the service on a day-to-day basis. Clinicians are the subject matter experts and as such need to be engaged at every stage of the process, from design and build to test and deploy.
New systems of healthcare delivery almost always require clinicians to change the way they work, both at an individual level and collectively within their professional groups. It is therefore vital to engage them in the re-design process to ensure that new ways of working take into account their priorities. At the most basic level, clinical engagement is the willingness of individual clinicians to change the way they work and agree changes to the way their support systems operate.
Although not universally understood by IT companies, with clinicians often left out of the process, there is recognition within the medical sector that clinical engagement is a critical part of any system implementation. Connecting for Health, the agency responsible for implementing the national IT programme, identifies clinical engagement as a core focus and has a dedicated clinical division to help ensure that new systems are fit-for purpose and offer benefits both to the NHS and patients. In addition, arecent Public Accounts Committee report recommended that clinicians should be more involved in health IT projects.
How do you engage clinicians?
Step 1: Understand their needs and concerns
It is first important to understand what doctors and nurses want. Evidence from academic reports sets out that doctors want to know ‘what’s in it for me?’ – does the system make their life easier? Will it enable users to see more patients or spend more time with them?
Culturally there is a hesitancy amongst clinicians surrounding the adoption of any new systems: innovation will not be sought for innovation’s sake. They are concerned for the welfare of patients and have a strong vocational sense of trying to do the best for them. It is essential to understand this culture to achieve a ‘fit’ between strategic objectives and implementation, as this is where many previous, well-intentioned changes in the NHS have foundered.
Step 2: Speak their language
To engage fully with clinicians it is important to speak in a language that they not only understand, but which demonstrates that you have a working knowledge of the health sector. Homophily, the tendency of individuals to bond with similar others, is incredibly important for the success of any new project and without which clinical engagement is almost impossible.
Both the IT and medical professions are full of jargon which serves to divide people and can often lead to issues when IT projects are being implemented. CSC is often called in to resolve conflicts between medical staff and IT teams that have developed from a lack of clear communication and understanding. Its team members on the analysis side have clinical experience and working closely with the clinical team can deliver business insight. This additional expertise is necessary as it is not always clear to those on the frontline what solutions are needed.
Step 3: Appreciate the role of clinical lead
There is evidence to show that when clinicians change their practice, peer influence is a decisive influencing factor. The role of the Clinical Lead is therefore an important one that can aid clinical engagement at every level. A clinical lead is an identified person/s with a clearly defined role to activate, stimulate and nurture service improvement. Successful clinical leads have legitimacy with their clinician colleagues, at least with respect to service improvement and modernisation, so as to become opinion leaders. They work in partnership with managerial leaders at both strategic and operational level.
Clinical Leads are indispensable in ensuring that genuine concern for the welfare of patients is perceived by clinicians to be at the centre of any changes taking place, whether that is the introduction of IT, changes to working practices, or both.
E-health Insider has recently launched a campaign calling for every NHS provider organisation to appoint a Chief Clinical Information Officer (CCIO) to help the successful delivery of new IT projects. The medical director is not always the best choice to lead, as there is a specific skill set required to drive through new systems.
Role of electronic systems
As well as engagement from the early stages, it is important to understand fully the current challenges being faced by clinicians in order to answer the ‘what’s in it for me?’ question and demonstrate how electronic systems can provide a solution to their concerns.
Revalidation is one area that electronic systems can provide demonstrable benefits to clinicians. To ensure that doctors are competent, up to date and fit to practice, the Government has introduced a revalidation exercise to take place every five years. However, this requires data on individual practices, which is not always easy to obtain. An electronic system could provide a simple means to collect appraisal data on an annual basis, taking this burden away from doctors. Similarly, the Government has said that discharge summaries must be provided within 24 hours which simply cannot be done with a paper-based system.
Electronic systems can also relieve clinicians of the heavy administrative burden of clinical coding. Traditionally doctors have not been involved in coding hospital activity, necessary for reimbursement, but the Government has now requested that their notes are written in a way that can be coded. One clear solution is to build systems that automatically code notes, generate reports, etc as by-product of clinical activity.
At an organisational level there is increasing pressure on Trusts to demonstrate that they are driving cost efficiencies, with any new spend delivering return on investment within 12 – 18 months. Accurate tracking and reporting is essential to meet Government targets under the Quality, Innovation, Productivity and Prevention (QIPP) programme and cash-generating targets such Quality and Outcomes Frameworks (QOF).
Electronic systems also have inter-organisational benefits, as the focus turns to integrated care. Commissioning groups will need to contract services that are ‘joined up’. For example, the recent high profile reviews into child protection have revealed a lack of communication between agencies, such as social care, schools and hospitals. However, inter-organisational communications are not always simple owing to very different work processes and systems.
The solution is an integrated IT system to enable a number of different organisations to share information through a common interface. It doesn’t even have to be one system, but could be a portal linked to many systems but providing a seamless experience for the user.
Delivering ROI on IT spend
The challenges being faced by the NHS require changes to be made to the current systems in order to deliver an increase in efficiencies and drive productivity across the organisation. However, it is not about IT for the sake of innovation but how to enable change through the use of these new electronic systems. Good accurate information forms the basis of a trusted relationship between clinicians and patients and is a key driver in the implementation of any new system.
Clinicians need to be engaged from the outset to ensure that systems meet their needs, those of their patients and help the Trust to meet Government targets. This will enable widespread adoption so that the benefits can then be realised.
A lack of engagement may cause a ‘productivity paradox’, where the spend on IT does not correlate to productivity achieved. There needs to be more investment made in training, which forms an important part of clinical engagement, without which systems are doomed to fail. Equally, to attend the training whilst balancing busy schedules, clinicians need to be convinced of the system’s worth. Clinical acceptance and adoption can therefore help solve the productivity paradox: increasing performance and generating better value for revenue spend.