(The other) Hancock’s Interoperability Insights: If everyone is moving forward together, then success takes care of itself

Successful adoption of universal interoperability standards across the NHS requires collaboration and co-production – with all stakeholders including suppliers. David Hancock, Client Engagement Director at InterSystems urges the NHS not to mandate interoperability standards top-down, for risk of failure.

The digital vision for Health and Care was published in October 2018 and there was a definite, and commendable, inclusion around interoperability. Now that the NHS long-term plan has also been published, it’s evident that the vision – and interoperability – are vital to help the NHS achieve its plans.

At the plan’s centre is the drive towards integrated care and population health. In my previous blog, I acknowledged that visions for IT in the NHS, with various levels of ambition, have come and gone. How can we be successful this time and avoid failures of previous digital ‘inspirations’?

The definition of insanity is doing the same thing over and over and expecting different results

Many people will remember Einstein’s famous quote above and we should be mindful of previous strategies to implement visions that were mandated top-down and that have manifestly not worked. The  2015 Robert Wachter review “Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England” addressed this issue,   highlighting that Health IT requires both technical and adaptive change.

Implementing health IT today is one of the most complex adaptive changes in the history of healthcare, perhaps of any industry. And interoperability entails huge adaptive change, involving substantial and long-lasting engagement between the leaders implementing the change, individuals on the front lines tasked with making them work, and the other stakeholders, including suppliers.

All the individuals involved become a collective group that need to deliver on this long-term plan – collaboratively

Our ambition must be higher than ever because we need to integrate areas we have not done before including:

• Primary and community care including the voluntary and charity sector
• Primary care with specialist care (acute and tertiary in particular)
• Health and social care
• Physical and mental health

So, what does this really mean for us?

To implement adaptive change across multiple organisations, we need to deal with some key issues:

1. Organisation and agreement – how do we convince parties we have no direct control over to join?
2. Managing diverse interests and priorities – there has to be negotiation to get everyone we need on board.
3. Project management – How can we co-ordinate the activities, keep them on track and keep everyone bought in, especially as short term demands typically always take precedence?
4. Balancing costs and benefits – There is an unequal distribution of these. Some parties may incur great cost in doing something that provides benefit to other parties and not themselves; known as “Collective Action Dilemmas”. These are so prevalent in health and care, how do we overcome them?

If we don’t address the four issues above, successful digital transformation starts to look a lot less achievable. And for interoperability to be part of that success we also need to consider the wide variability of end points (systems) across health and care. We also know that there will be differing local priorities and organisations that are at different levels of maturity and capability to implement solutions.

In light of all the above, there’s no question as to why top-down approaches are not suited to solving these adaptive problems and why all previous attempts around interoperability have failed. One-size does not fit all.

Breaking the pattern of failure

Historically healthcare has been missing universal interoperability standards that inhibit clinicians’ ability to see comprehensive patient information. Now, with interoperability top of the political agenda, how do we successfully develop and implement interoperability standards?

As an adaptive problem the solution involves all parties. We need a demand-pull from the service, based on their local priorities and supply-push coming from a group responsible for the standards. This group should be made up of the service (end-user organisations, NHS Digital and NHS England), suppliers, standards groups and other professional bodies.

This level of collaboration would certainly change the repetition of failure, and by not working together could lead to predictable outcomes.

With demand-pull but no supply-push of relevant standards, a local health economy will have to implement something that is specific to them which is likely to be proprietary and typically not re-usable. This risks their ability to integrate if their systems don’t support it.

We could also face a situation where there is a supply-push, from say NHS Digital, and no demand-pull. This results in much effort being made defining and building standards into products but with no adoption – like we’ve had before.

Either way, if we do not address the supply-push and demand-pull, trust breaks down across all the parties and interoperability will never be achieved.

Solving the problem together

This is why INTEROPen was formed nearly 3 years ago – made up of people from NHS England/NHS Digital, Professional Records Standards Board, end-user organisations, suppliers, standards other professional bodies. We have a shared belief that co-production is the only way to succeed in solving the adaptive change needed to crack the interoperability problem.

Critically, INTEROPen is not only focussing on definition of standards but adoption too. Health and care services need to be able to use these standards to support their digital transformation and suppliers want to make sure the investment they make in supporting standards get used.

Along with shared belief in co-production, INTEROPen is founded, and proactively working, on shared principles:

• We work together in an honest, open and collaborative way.
• We constantly test and challenge each other in managing conflict, finding solutions and as a group we always come out stronger as a result.
• We have a governance structure and board and co-ordinate activity and a collaboration infrastructure to manage our work day to day.
• None of us just look at the problem from what it means for our individual organisation, or the group we represent.
• We are all part of the solution and we owe it to frontline staff, patients and tax payers to solve this.

Through collaboration of this type we have an excellent model for Matt Hancock to look at for implementing all of the adaptive change needed in his technology vision and the NHS long-term plan. techUK and the supplier community wants to work with the NHS to take up the gauntlet that has been thrown down. I am optimistic that the industry working collaboratively with all parties can solve these “wicked problems”.

In my next blog, I will look in more detail at how the technical challenge of interoperability is being solved, but before you go I encourage you to take 15 minutes to watch Dr Marguun Aanestad give an amazing presentation on what makes eHealth projects succeed (or fail) at the International eHealth Conference in Bologna in July 2016. (Hat Tip to Professor Joe MacDonald for sharing this).