Author

Michele

CCIO Handbook

CCIO Handbook Chapter 6

by Michele
written by Michele

How to deliver user-centred healthcare design

‘The cure for the pain is in the pain.’

Rumi

Key to any healthcare intervention is understanding and addressing personal experience. In clinical practice this is done by taking a history, observing, testing, and examining. We manage, assess, and reassess.

The factors forming personal experience are always complex. It’s only once the ‘pain points’ within that complexity are understood that effective interventions can take place.

In technology-enabled healthcare, design-led approaches can be used in a similar way to clinical methods to understand user experience and solve complex problems, as well as considering how best to deliver solutions.

These approaches have a long history in business. Management consultants McKinsey found, for example, that companies with strong design practices increased their revenues at nearly twice the rate of industry counterparts  (https://www.mckinsey.com/capabilities/mckinsey-design/our-insights/the-business-value-of-design, n.d.)

Today’s CCIO needs an understanding of these approaches to effect digital transformation.

What is User-Centred Design?

Human or user-centred design (UCD) is the creative philosophy and associated processes used to understand and address user needs, especially where problems are complex (Snowden, n.d.) (Norman, 2013).

In the ‘Design of Everyday Things’, Donald Norman describes how this complexity often manifests itself as difficulty defining the specification of a product or service.

UCD addresses this by deliberately avoiding specifying the problem at an early stage. Instead, UCD focuses on the iteration and rapid testing of ideas, allowing test results to quickly feed back into modifying the approach and the problem frame.

The design process allows us to ‘find the right problem to solve and to solve the problem the right way’. The result should be products and ‘services that achieve outcomes that solve problems for users’ (Vaananen, n.d.).

The double-diamond approach to innovation

‘Wherever there is decision there is design.’

(Grinyer, 2021)

Figure 1: Version of UK Design Council’s Double Diamond diagram (https://www.designcouncil.org.uk/our-work/skills-learning/tools-frameworks/framework-for-innovation-design-councils-evolved-double-diamond/, n.d.) (Vaananen, n.d.)

 

Figure 1 depicts a version of the UK Design Council’s double diamond process model for innovation (https://www.designcouncil.org.uk/our-work/skills-learning/tools-frameworks/framework-for-innovation-design-councils-evolved-double-diamond/, n.d.).

It’s divided into four stages, although the process is not linear and there will often be a need to return to a stage as more is learned. It’s often necessary to reframe the problem to get the best solution.

These stages are:

Discover – understand the problem as completely as possible. This might include desk and user research, such as surveys, interviews, empathy mapping and observation (Muratovski, 2016). Observation can be ‘participatory’.

The best design is usually done in the place where it’s needed. If good user research isn’t done, assumptions about the problem can generate solutions that don’t meet user need (Nuckley, 2023).

Define – take a closer look at the challenge by analysing material from the discovery stage. Specific tools can include service interaction mapping and service blueprints (Grinyer, 2021).

Develop – Once the problem is more clearly defined, brainstorming and other divergent thinking methods can be applied. This is likely to lead to creative solutions, especially if a non-hierarchical approach is encouraged to deprioritise the loudest voices in the room.

Deliver – flexible prototyping and testing are central to delivery (Agile and government services, n.d.).

Other frameworks, tools, and processes

Figure 2 Examples of tools used within the design process

There are many other frameworks, tools, and processes within the discipline of ‘design thinking’ that can help explore challenges and generate solutions. The key is to select what’s appropriate for the type of problem being worked on. (Muratovski, Research for Designers, 2016).

Continuous or quality improvement, for example, sits under the design umbrella within the field of ‘action research’. It’s well suited to systems where there is a requirement for existing practitioners to “investigate and evaluate their own work’ (Muratovski, 2016) and where there’s considerable ambiguity around how to make improvements.

Further examples of frameworks, tools and processes are shown in figure 2.

What does UCD mean for CCIOs?

“I wish people would stop trying to sell me solutions for problems that I don’t have”

NHS CCIO

UCD means being able to deliver effective digital transformation

UCD is vital to delivering digital strategy, building team capability, and encouraging a culture of innovation. The CCIO is usually at the heart of this, often acting as the interpreter for multidisciplinary teams. Adopting a UCD approach means that there’s a tried and tested philosophy alongside effective tools and processes that a CCIO can employ in pursuit of effective digital transformation; whether that’s through clinical leadership for EPR implementation or evaluating the latest artificial intelligence tool.

UCD gives CCIOs ways to deal with complexity

In healthcare, the relationship between cause and effect is often not linear, e.g. implementation of an EPR and the impact on patient safety. Key features of UCD, such as user research and iterative methods are geared towards dealing with complexity (Snowden, n.d.).

UCD means being able to deliver concurrently

Figure 3 Concurrent Development Browne, 2023

 

Well-functioning modern digital teams in any industry need to be able to develop their strategy, design, and delivery concurrently, rather than in sequence (fig 3 (Browne, 2023).

Adopting a UCD approach allows CCIOs to move away from continuous pilots towards working practices that are more likely to uncover bias and generate truly new ways of working (for example, see Royal Free London’s approach to intelligent automation – (Ali, n.d.)).

 

How can CCIOs implement UCD?

Bring the user in

Implementation of UCD can begin simply with a commitment to making steps to bring in the user. For example, by ensuring completeness of stakeholder mapping and conducting interviews with users early in the design process.

Increase design capability

Design capability can be increased internally through education and recruitment of professional designers, as well as exploring engagement with external design specialists.

In user-centred work we did in NHS England, for example, our discoveries informed an education programme aimed at building design capability in one team. Through surveys and interviews we established a curriculum that would increase the user-centredness of our work via individual practice and team culture (figure 4.)

By adopting similar practices, CCIOs can discover how best to implement UCD in their own healthcare organisations.

Figure 4 Design Capability in the Digital Care Models Team, NHS Transformation Directorate 2022

 

 

 

 

 

 

Credits for figure 2 & 4 to Helena Traill , Healthcare Designer

Thanks to Tero  Vaananen , Tony Browne and Pete Nuckley for their help with the preparation of this article

 

Works Cited

(n.d.). Retrieved from https://medium.com/wardleymaps .

(n.d.).

Agile and government services. (n.d.). Retrieved from https://www.gov.uk/service-manual/agile-delivery/agile-government-services-introduction

Ali, L. (n.d.). Retrieved from Innovation Collaborative Blog: https://gbr01.safelinks.protection.outlook.com/?url=https%3A%2F%2Ffuture.nhs.uk%2FInnovationCollaborative%2FmessageShowThread%3Fthreadid%3D10678606&data=05%7C01%7Clia.ali%40nhs.net%7C69c103ec10d34b6fd40c08db2a2e6deb%7C37c354b285b047f5b22207b48d774ee3%7C0%

Browne, T. (2023). Digital Transformation – personal communication.

Grinyer, C. (2021, October). Lecture on Service Design. MSc Healthcare and Design, Royal College of Art.

HBR. (n.d.). Close the gap between designing and delivering a strategy that works. Retrieved from https://hbr.org/sponsored/2017/10/close-the-gap-between-designing-and-delivering-a-strategy-that-works

Holmes, K. (2020). Mismatch: How Inclusion Shapes Design. Cambridge MA.

https://www.designcouncil.org.uk/our-work/skills-learning/tools-frameworks/framework-for-innovation-design-councils-evolved-double-diamond/. (n.d.).

https://www.mckinsey.com/capabilities/mckinsey-design/our-insights/the-business-value-of-design. (n.d.).

Loosemore, T. (2017). Retrieved from https://public.digital/definition-of-digital

Muratovski, G. (2016). Research for Designers. SAGE.

Muratovski, G. (2016). Research for Designers. Los Angeles: Sage.

Norman, D. (2013). The Design of Everyday Things. Cambridge, Massachusetts: MIT Press.

Orton, K. (2017). The Sweet Spot for Innovation. Retrieved from https://medium.com/innovation-sweet-spot/desirability-feasibility-viability-the-sweet-spot-for-innovation-d7946de2183c

Smith, R. (2021). Retrieved from Making content about skin symptoms more inclusive: https://digital.nhs.uk/people/nhs-digital/blog-authors/rhiannon-smith

Snowden, D. (n.d.). The Cynefin Framework. Retrieved from https://thecynefin.co/about-us/about-cynefin-framework/

Vaananen, T. (n.d.). Retrieved from https://digital.nhs.uk/blog/design-matters/2020/design-is-the-strategy

Vaananen, T. (n.d.). Retrieved from https://digital.nhs.uk/blog/design-matters/2022/products-deliver-outputs-services-deliver-outcomes

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CCIO Handbook

CCIO Handbook Chapter 4

by Michele
written by Michele

Everything a CCIO needs to know about Cyber Security

The risk of a cyber-attack in healthcare has grown dramatically over the past 20 years with many, such as WannaCry and Log4J, affecting the NHS directly. As a result, the question is now when, and not whether, a cyber-attack will ever happen to you!

Are cyber-attacks growing?

Since the introduction of Electronic Patient Records (EPR), the risk and severity of cyber-attacks has increased. Although EPRs improve transparency and patient care, they have the downside of increasing digital exposure and reliance on digital processes.

Cyber-attacks on healthcare organisations can come in a variety of guises. For example:

  • A direct cyber-attack on a specific NHS Trust, such as removing connectivity to a network or system. This may be done using malware, such as ransomware.
  • A cyber-attack that spreads across multiple organisations preventing access to devices that become infected with malware.
  • A cyber-attack on a product supplier, impacting multiple systems across multiple organisations that may include health, social care or both.
  • A cyber-attack against systems to steal data for the purpose of extorting funds.
  • Cyber-attacks that involve the hijacking of business processes to redirect funds from valid financial transactions to attacker’s accounts.

Cyber-attacks can have a huge impact

As cyber-attacks are a risk and not a certainty, it can be easy to deprioritise them in favour of higher-priority pressures. These might include an infection outbreak or needing spend money on a new medical device.

However, if you’re thinking that, you should consider the question, ‘what happens if all our Health IT suddenly becomes unavailable?’

Will:

  • You know which patients are due to attend for appointments?
  • You be able to admit or discharge patients and see their previous clinical records?
  • Reporting be available to show operational pressures?
  • There be visibility of your hospital beds and who is in them to manage patient flow?
  • You be able to access diagnostic tools for critical healthcare interventions?

If digital workflows become unavailable, this impacts every process – from clinical work to finance, with a major impact on patient safety. Being vigilant and aware of the threat posed by poor cyber security, and keeping systems safe, is everybody’s responsibility.

Why do attacks happen?

But why do people carry out cyber-attacks, and why attack your healthcare organisation? There are several possible reasons, with the most common being financial, or a desire to disrupt systems and core services.

The most common motivation for attackers is gaining wealth at your expense; by stealing your data, holding your systems to ransom, or hijacking your processes to divert funds. These attackers are often well-organised criminal groups with well-established ways of working, and they can act quickly.

Where funds are not the goal, the most likely motivation is disruption. Disruptive attacks can be undertaken by anyone interested in causing harm, and can include hacktivists, or anti-governmental organisations. Hacktivists tend to be less well-organised and impactful.

Cyber attacks – are you ready?

Someone will always press on a ‘dodgy link’ in an email, and we need to engage and train staff to prevent this. However, we also need to adequately fund and support robust infrastructure. It’s essential to consider clinical safety when implementing any process involving access to clinical information.

Key points that should be considered include:

  • Are staff adequately trained to reduce the chances of a cyber-attack? Ongoing awareness activities are needed to keep everyone alert to the risks they face.
  • Are staff ready to respond appropriately when a cyber-attack happens? The period where an incident is being managed is generally the worst time to try to devise new actions.
  • Are all your products up to date with patching to prevent an attack?
  • Is your desktop estate fit for purpose? There should always be a plan and a budget to replace devices. Machines can become extremely slow and along with causing frustration for staff, this potentially creates vulnerabilities.
  • Can your software update with new patches? Windows 7, for example, is no longer supported by Microsoft and can’t be patched if a vulnerability is found. This makes it easy for an attacker to get into your systems.
  • Do you have the appropriate technologies to defend your organisation, such as firewalls, anti-virus and anti-malware products?
  • Are Business Continuity Plans (BCP) in place and rigorously tested? Testing is vital to ensure your plans are functional and can support your organisation through periods of unavailability.
  • Have full timescales been considered from recovery to business as usual (BAU)? Do your plans cover up to six months of unavailability? It has happened before and will happen again.
  • Do your recovery plans account for data accumulation outside of your digital platform? If you have 6 months of data collated on paper for an entire EPR system, how long will that take to repatriate back into the system and what administrative resource would that require? The sheer volume of data created from one week of BCP means paper is not the solution. Options may include a failover data center, a simple eforms platform, or even the ability to revert to a backup.
  • Have you assessed how vulnerable your organisation is to phishing attacks? Tools are available to audit the likelihood of a staff member pressing a link by, for example, sending a deliberate phishing email.
  • Do you have your data backed up?

Taking things forward

As senior management, it’s never been more important to prevent cyber incidents and to know what actions to take if one occurs.

Whether you’re working to achieve CCIO status or an experienced CCIO already, you need to have the defence and resilience required to ensure the safety of data and – more importantly – the clinical safety of patients.

After all, in this ever-evolving digital world, patients still lie at the centre of  everything we do.

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CCIO Handbook

CCIO Handbook Chapter 2

by Michele
written by Michele

First 100 Days in the Life of a CCIO

Sarah Thompson and Ramandeep Kaur are amongst the first pharmacists in the country to become Chief Clinical Information Officers (CCIOs).

Sarah was recognised by the Pharmaceutical Journal in 2022 as a Woman to Watch, and Ramandeep was Highly Commended for the Dedication award for the NHS Year of the Digital Profession Awards 2022.

Both pharmacists have known each other for over eight years, having first become acquainted in 2014 after communicating about electronic prescribing and medicines administration. Their friendship has since grown and now they are determined to raise the profile of digital pharmacy, while embracing a concept of multidisciplinary working within digital teams.

They are passionate about inspiring the next generation of digital leaders and, after appointments to new roles during 2022, here they share their guide to the first 100 days of life as a CCIO through poetry and art.

“Sarah and I opted to do something a little bit different and fun,” explains Ramandeep. “I love writing poetry and Sarah has recently started sketchnoting, so this is a great opportunity to showcase our views through creative media.”

Poem 

First hundred days: the ingredients for the CCIO cake

F irst CCIO role or a seasoned pro, each adventure a rollercoaster

I n at the deep end, new Trust and role, battling the feeling of an imposter

R unning to never ending meetings, tip 1, diary management is key

S eek out time in first 3 months to determine where your attendance is truly a must- see

T ip 2, complete your mandatory, systems, and clinical training, it will pay off

 

H andover from a predecessor is vital, if possible, tip 3 will save you

U nder your frantic glaze or bewildered stare your digital handover will be your cue

N ew beginnings means rest and reflection is a must, tip 4 plan and book leave within first hundred days

D etermine your line management responsibilities and eroster access as tip 5 amongst the newbie haze

R olling to tip 6, book in your 1:1s, team meetings and your no-meetings time

E mbrace your inner child and plan a team bonding activity for tip 7, with a dash of soda and lime

D igital, clinical and operational team engagement for tip 8 is fundamental

 

D on’t pigeonhole yourself in the digital shell

A las tip 9, take time to listen to others and their stories

Y our time will come to fix the world but, right now, people will just want to share their worries

S eek out the positives for tip 10 in their tales so you can share their joyous moments too

T ip 11 don’t forget your own personal development, with everything else being so new

I nvest time in getting to know your seniors and peers, face to face meetings is up there at tip 12

P eople, positivity, priority and passion for me are essential ingredients to the initial CCIO role delve

S o take mine and Sarah’s tips, add your own flavour and icing and take a bite of the CCIO cake!

 

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CCIO Handbook

CCIO Handbook Chapter 1

by Michele
written by Michele

History of the CCIO – who, what, why, and where?

The rise of the Chief Clinical Information Officer (‘CCIO’) as a recognised role within the NHS has been the most influential change in how technology is applied to healthcare in the last 20 years.

As recently as the early 2010s, it was rare to find practising doctors who also pioneered digital healthcare. Developing and improving the use of technology was often seen as eccentric by NHS colleagues, who viewed the doctors pursuing it as harmless cranks.

However, such doctors were also often seen as “good with computers” and rapidly became familiar with colleagues asking them for advice.

The forerunners of CCIOs

There were formal opportunities in the NHS and some clinicians found it simpler than others. GPs, for example, found it relatively easy to trial new technology because their practices were small and they owned the business.

The major primary care systems, such as EMIS’ Electronic Patient Record (EPR), were all coded by pioneering GPs. Doctors working in secondary care with similar skills, however, didn’t have the same opportunities.

‘Computerisation’ in hospitals often consisted of putting large mainframe computers in the basement to process administrative data. Although some trusts succeeded in this wasn’t recognised at the regional or national level.

Nonetheless, these pioneering individuals were the forerunners of the modern ‘CCIO’.

The National Programme

The digital maturity gap between primary and secondary care worried the Blair Labour government who, in 2002, launched the National Programme for IT (NPfIT). This was, at the time, the largest public sector IT programme ever attempted in the UK, and had the aim to bring NHS information technology into the 21st century.

Much has been written about how local innovation largely halted in the face of such a large-scale national programme. A few heroic figures tried to avert disaster but, in retrospect, too much emphasis was placed on big technology companies, and the role of clinical experts was overlooked.

As the NPfIT drew to a close, most health care providers had made little progress, and the idea of digital transformation was largely discredited.

The CCIO role emerges

However, at grassroots level, change was brewing. People who disappointed by the National Programme nonetheless felt it was a missed opportunity, not a bad idea, and were keen to take the good ideas forward.

They latched onto a small, but vocal, website known as ‘e-Health Insider’ (now Digital Health), who had begun to socialise the US concept of a ‘Chief Medical Information Officer’ (CMIO). This was a senior doctor responsible for overseeing the design and operation of clinical technology.

The term ‘Chief Clinical Information Officer’ was soon coined and the EHI CCIO Campaign to lobby for “every NHS provider organisation to appoint a CCIO to provide clinical leadership on IM&T projects.” Unlike CMIOs, who were senior medical staff, the CCIO was intended as a role anyone with a clinical background could fulfil.

The rise of the CCIO

The campaign proved successful. People began to turn away from the NPfIT’s failures to look ahead. The promise of CCIOs was to bring clinical leadership to the fore and, through doing so, ensure every aspect of technology applied to clinical work was driven by those with a clear understanding of need.

Moreover, the CCIO could use their clinical understanding to engage staff at large. And, thus, improve engagement compared to the NPfIT.

While an interest in technical matters was clearly desirable to the new CCIO role, it wasn’t essential. The most important skills were in communication and managing change. Some described the CCIO as akin to a translator, responsible for explaining clinical requirements to IT staff, and articulating IT concepts back to clinicians.

The CCIO Network forms

This new group of CCIOs began to naturally join networks, which were nurtured by eHI. An active discussion group sprang up on Google Groups which, over time, matured into a mature web forum.

These communities were further bolstered by conferences and day events, with the first Summer Schools held in 2012. These have continued to the present day.

eHI also mounted a formal campaign for every NHS Trust to appoint a CCIO and, as part of this, the Secretary of State for Health formally launched the CCIO Network in March 2012. As interest grew, more NHS organisations launched large implementation projects and appointed clinical staff into leadership roles.

The Wachter Report

An important milestone was the 2016 publication of ‘Making IT Work’, popularly known as The Wachter Report. Bob Wachter, an American physician and internationally-recognised expert in digital healthcare, was invited by the Secretary of State to review NHS IT and make recommendations for further change.

Three of his recommendations relate directly to the workforce, recommending a national CCIO be appointed, as well as developing a workforce of clinician-informaticians, and investing in digital literacy among the broader workforce.

A national CCIO was appointed, and there followed a rapid series of reorganisations, including the brief existence of NHSX as a central organisation leading digital transformation. The national CCIO role continues to exist, but is currently vacant.

Education and Training

Wachter’s recommendation to develop a digital workforce has been pursued more unevenly, although the NHS Digital Academy was established and offers a few training places on a Digital Health Leadership programme.

Other schemes, such as the Topol Fellowship, also offer a training programme but, again, places are limited. The main requirement for working in digital health remains enthusiasm for the subject, with informal help and support available through the Digital Health networks for those at all stages of their careers.

The CCIO role today

The role of CCIO has become increasingly well established. While not every organisation has a formal CCIO position, it is now increasingly rare to find NHS Trusts without clinical leadership of systems and technology in some form.

For those with a passion for digital healthcare, now is a time of opportunity for developing a career, as the CCIO develops into one of the most important clinical leadership roles.

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Featured

A Networks debate on the Federated Data Platform

by Michele
written by Michele

Following the announcement that NHS England is to develop a national data platform to help transform and improve the way the health service operates, Digital Health hosted a Networks debate on the subject. Hannah Crouch reports.  

In April 2022 a notice was published which revealed that NHS England was looking to develop a Federated Data Platform to help create “an ecosystem of technologies and services implemented across the NHS in England”. 

Several months on and little information about the platform has been made publicly available, other than the £360million price tag attached to it.  

In August 2022, Digital Health hosted its first Networks debate on the Federated Data Platform and invited members of the Networks along with other key figures to take part.  

Issues surrounding data privacy and who gets access to what was spoken about at length. For Dr Jorge Cardoso, chief technology officer at London Medical Imaging and AI Centre for Value-based Healthcare, having a national health data platform will “allow more and better data to be used throughout the country”. 

“I think what is interesting about this [the Federated Data Platform] is that it is all about data and data privacy and how do we build the right infrastructure that gives people the confidence that the data is going to be used appropriately and that everything is being tracked and logged and audited so that we can make sure that this data is only used by the people that should be using it,” he added. 

Sticking with the theme of confidence in the platform, Dr Susheel Varma, who is head of artificial intelligence (AI) and data science at the Information Commissioner’s Office (ICO), stressed the importance of public engagement. 

“You need to be able to engage with the public and explain to them directly how the data is being collected, why it’s being collected, what is the purpose of its use and where is it being held,” he argued. 

“You need to explain the entire process end to end and understanding that takes time along with engagement and continuous engagement. 

“Building a platform is like asking people to raise their hands, maintain the trust and the platform is asking their hands raised.” 

Dr Varma also urged for transparency and openness during the process. 

“Every platform that you’re building, the procurement process needs to be transparent open to the public so we can bring them along for the journey,” he added. 

Questions on timing and PR 

For those on the panel who come from the provider side of things, there were questions raised about the timing and whether the platform could become a “PR issue”. 

Will Brailsford, who is an advanced intelligence analyst for Wales’ Collaborative Health Intelligence Service (CHIS), agreed “in principle” with the idea of a Federated Data Platform, adding that benefits can include population health management and helping to train AI. 

“I do question the timing of the FDP,” he added. 

“We’re in a difficult period coming out of the pandemic, with the cost-of-living crisis and I don’t necessarily see the development of centralised data sources and necessary investment when front-line services are struggling as much as they are. 

“There is a need, I really do think so, I just question the timing somewhat.” 

This issue was echoed by Shauna McMahon, CIO at Northern Lincolnshire and Goole NHS Foundation Trust and Hull University Teaching Hospital NHS Trust. 

“There is perhaps a PR issue around this and linking back to the timing, certainly people are very sensitive about data and privacy, there is still a public relations issue around it,” she said. 

“The other piece I reflected on was the financial burden, there are still trusts out that that can’t run yet and do not have a fully paperless environment. 

“We may be underestimating the huge task here. You can’t close your eyes to the amount of money that been put in the paper for this platform, we are looking at potential strikes on the front line and it doesn’t play well for them to be told there is no money, but we have all this money for something of this magnitude. 

“I am not discounting that the idea isn’t right, I am just not sure the timing is good.” 

In response to concerns raised about costs, NHS England and Improvement’s chief data and analytics officer, Ming Tang, stressed that the money for the platform has already been allocated.  

“From a timing perspective, we’ve just gone through the outline business case and it has been approved by the secretary of state,” she told the audience.  

“The money was allocated as part of the 2022 spending review, we – like everybody else – had big chunks of that cut off, so we’re not safe from cuts at all but we have profiled it differently and we ended up giving back about £16million this year. 

“We are now going through the treasury approval and so once we get the treasury approvals then we’ll go out to procurement.” 

Looking at timelines 

Tang also went on to explain the procurement process which included some draft timelines. This includes the contract notice going out for tender in early September which will then be followed by screening process where potential suppliers will be asked to take part in a proof-of-concept test. Final bids are expected in January with a contract award pencilled in for Spring next financial year.   

“People see the big number (£360million) – that’s a lot of spend but in the context of where we are in the NHS, each ICS [Integrated Care System] were going out to tender for anything between one and five million, times that by 42 and you can see that this is actually not an expensive thing,” Tang added. 

“The £360million is over five years, which is roughly £70 million per year, and has the potential to cover the whole of the NHS.” 

Return on investment 

For those working within the NHS, they want to know how the Federated Data Platform will benefit them and their organisations.  

“Where would be the return on investment and where do we get the value as a trust?” McMahon argued.  

“Where is the trade-off where we get to see that this is efficient, its helping us out – I’m struggling a little bit with that.” 

Responding to this, Tang set out the full uses of the platform, stressing that more than an analytics tool.  

“Don’t think about this [the Federated Data Platform] as one enormous data lake or one enormous data warehouse, that’s not the intention of the national data platform,” she said.  

“The data platform is really allowing data to be brought together for specific purposes or specific use cases.  

“We’ve developed five national uses cases which are broad enough to support the things that we already do within the data platform that we hold currently – that’s things like population health, supply chain and care coordination.   

“It is not about a data analytics tool, this is about creating applications and functionality to support the front line.” 

She continued: “Through the pandemic, we were able to make great strides in the way that the data was used, not just in the analytics world – which was great – but actually for the front-line to reduce the administrative burden.” 

Elephant in the room 

The debate chair, Dr Paul Jones, who is the vice-chair of the CIO advisory panel and chief digital information office at Leeds University Teaching Hospitals NHS Trust, did not shy away from the so called “elephant in the room”, Palantir.  

The US data analytics company has been heavily linked with the Federated Data Platform after it worked with the NHS on the NHS Covid-19 Data Store. However, Palantir’s involvement has raised some eyebrows across the NHS IT community. 

“Palantir is one of the providers that I am sure will be bidding for this work, we’re running an open procurement which means we are making provisions to enable other companies to participate as well,” NHS England and Improvement’s Tang explained.  

“Included in the contact is the fact that the platform is separated out from the privacy enhancing technology so that the platform supplier is separated from the people who hold the key for privacy. 

She continued: “If you don’t like Palantir, I guess there is a really strong feeling about Peter Thiel, he is no longer involved in the company, he has shares but he is not on the board anymore. 

“There is nothing I can say that will reinforce that but it is a really good technology, we used it during Covid, we are the data controllers. 

Tang also concluded the debate by stating “it is not a direct award”. 

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CNIO HandbookFeaturedNews

CNIO Handbook Chapter 6

by Michele
written by Michele

The CNIO role is often seen as a link between nurses working clinically and the IT department, but in my case it also involves being a link between two recently merged trusts covering acute and community services.

Differing approaches to informatics

The previous organisations had taken very different approaches to informatics. One had an electronic health record (EHR) used for all nursing documentation, with care planning having been completed electronically for around 20 years.

The other trust had a ‘best of breed’ style, using a number of smaller systems for specific tasks. Large parts of the nursing documentation, including care planning, had remained on paper.

The two organisations merged in April 2019, and a decision was made to implement the EHR across the entire trust. That implementation was relatively straightforward and on the whole was well received, but two large groups of nurses coming together to work on common documentation did highlight areas where work was required.

Care planning was the noticeable aspect where refinement was needed. The nurses who were new to electronic care planning spotted imperfections in the use of the system. Those who had used it for many years had often just learnt to work around those imperfections – but in so doing, it meant care planning wasn’t always as effective as it could be.

Simplifying documentation

For me, the care plan is the most important aspect of the nursing process. If we don’t have a plan our success is purely down to chance. If we don’t identify a goal or outcome how do we even know that we have succeeded? How can we compare the outcomes of our care with our peers, whether in the same organisation or beyond? Making sure the same care plans are used consistently helps reduce variation – everyone works to the same goals and the same outcomes, which improves patient care.

To make documentation and care planning work for nurses, and ultimately benefit patients, we need to make assessments and plans as easy to complete as possible. That includes using digital systems. As CNIO, I’m therefore currently undertaking a review of care planning across our trust.

The staff nurses who use the documentation on a regular basis are best placed to say what needs to be improved in the current system and to review and comment on suggested changes. On that basis I set up a project steering group with representatives from both hospital sites and a range of staff roles, including staff nurses in band 5 and 6 roles from a range of medical and surgical specialties, ward managers, matrons and IT.

The three key areas for improvement

The group met to debate experiences of using electronic care plans. It became clear there were three key areas for improvement:

  • How we use the electronic care planning system. Traditionally, we have used our care planning system to record and evaluate whether standards of care – support with hygiene, for instance – has been delivered. That’s meant nurses have had much less time to actually use the care plan functionality, and means we’ve never used the software’s ability to evaluate a patient’s care against a care plan.
  • The number of plans. We currently have 150 care plans. Some are automatically digitally activated for a patient but, if a nurse needs to add an additional plan, he or she has to search through the full list of plans. You either have to scroll through to try and find the one you need, but the names aren’t always as clear as they might be, or search. While nurses who have used the system for a while have got used to these imperfections, those who are new to the system pointed out that this was really challenging.
  • Training. It was felt specific training should be offered to nurses to make sure they were comfortable with how the digital care planning setup worked, as well with the general clinical practice around care planning.

I have also connected with fellow CNIOs and digital nurses to discuss the care planning. Via the Digital Health CNIO Network Discourse, I’ve understood that this planning is challenging for many nurses, regardless of whether a digital of a paper-based system is used. The issue is often one of time. I can therefore see that while digital working can help, there is also a practice issue – and that, as CNIO, I may need to look beyond the informatics element to truly transform care planning in the trust.

The organisation currently has around 150 separate care plans. Even though these can be completed digitally, there are so many that it is difficult for nurses to select between them and know the right one to use in the right situation. Our steering group has now identified around 30 subjects on which we think we need to focus plans, and we have ‘subject experts’ working on these.

We have also reviewed a different process for evaluating care plans within our EHR. This will place a greater emphasis on evaluating the care that has been given against the care that has been planned. There is the ability to do this within the care planning software, but we’ve nor previously used it. My plan is to pilot using it across a couple of wards to see if we might be introduce its use consistently.

What has been really important to my work so far on this project has been having the support and direction from the senior nursing, midwifery and allied health professional team. Around the time the trust merged, I was working as a nurse consultant in an operational role and giving what other time I had to the CNIO role. At that point, the CNIO reported into the IT team.

The benefits

The merger made the CNIO role more important still and so, with agreement, it moved to be part of the trust’s corporate senior nursing team reporting directly to the director of nursing. This meant I could support the team in understanding the importance of digital nursing, and the opportunities it provides, but also that I could understand the nursing priorities for the organisation. The team also offers me real support in implementing changes, like those to care planning.

The shared decision making approach with the steering group has also been very important. Feedback of clinical staff as the end users of the technology has led to some excellent and well received improvements in our electronic health record. I remember one particular example when we’d introduced an assessment for patients who were at risk of self-harm or falls and needed one to one nursing care, or to be in a bay where a nurse was always present. The idea was that, on a two-hourly basis, staff would record what support and interactions had been provided.

In conversations with teams, we heard that these assessments were typically completed by healthcare assistants – and clashed with the intentional care rounds they were completing. So we moved the document in the EHR so it sat within the care round checklists. By doing that, we moved from 20-30% completion of the assessment to around 90%.

We are fortunate that our EHR can be adapted to the way in which we work: we don’t just have to use a one-size-fits all, off the shelf setup. We can build and edit documents and assessments in a way that we find useful. The shared decision making process will help ensure that any changes we make to the digital care planning process enable nurses to provide good quality, safe care, in an efficient and secure way.

About the author: Melanie Robertson is chief nursing informatics officer and cancer lead clinician at South Tyneside and Sunderland NHS Foundation Trust. She initially took on CNIO responsibilities in 2018, reporting to the IT team. In February 2020, the role moved to report to the director of nursing. Melanie has been a registered nurse since 1994.

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CNIO HandbookNews

CNIO Handbook Chapter 5

by Michele
written by Michele

It’s fair to say I’ve had a varied nursing career. I qualified in 1994 and have held clinical roles and management ones. I started taking an interest in digitally-supported healthcare over 10 years ago when I discovered a love for data and how it can drive improvements for patients and staff.

I moved into my first chief nursing informatics officer post in 2019, when the trust I was working for at the time was procuring an electronic patient record. Since then, I have completed the Florence Nightingale Foundation’s Digital Leadership Scholars programme and started an MSc in data analytics and artificial intelligence. I tell you that to prove that as a new or potential CNIO you already have a set of skills to bring to the role – and those you don’t have you can learn!

One key area in which you will have pre-existing skills, though ones that may need developing further in the context of the CNIO role, is clinical safety.

Essentially this is risk management, and as clinicians we do this daily. The design of systems, how they are applied into practice and how data can be used to drive clinical safety are all components of the CNIO role. At times there will be a need to say no to an idea that has been deemed safe on a formal risk assessment but which would be a risk if applied to a certain department or patient group.

I experienced this when rolling out a task-based system. The functionality was sound but when it was used by the on-call team it posed a patient risk of duplicate tasks due to not having a scheduling function. It was however suitable for the hospital at night team. The understanding of how areas work and how certain systems impact on those areas is a critical skill to develop.

Top tip: Learning about general risk management is beneficial if this is a gap in your knowledge. (The aviation industry has some great examples – which is always good to hear!)

Digital clinical safety

So how do we define clinical safety in the context of digital? This is covered in the Digital Clinical Safety Strategy, published in September 2021. It is an essential and insightful read and aligns well with the The NHS Patient Safety Strategy.

I particularly like this simple definition:

“Digital clinical safety is about making sure the technologies used in health and care are safe, and then using those technologies to improve patient safety.”

Technology is changing patient safety by moving healthcare from a reporting culture to one of prevention. Personalised medicine, predictive medicine, and technology-supported diagnostics are just some of the domains working to prevent negative outcomes.

The relationship between digital innovation and clinical safety is well documented. Improving sepsis detection, alerting to patient deterioration, and improved access to specialist teams are a few I have personally seen improve patient outcomes.

Shared care records help to improve communication between healthcare communities and remote monitoring is helping keep more patients at home during the pandemic.

It is essential to understand technology alone is not responsible for these improvements. People, processes, and organisational culture are all equally important. The role of the CNIO in my opinion is to ensure the systems are fit for purpose, do not increase patient safety risks, and are successfully implemented so as to gain full benefits in practice.

Digitisation however can present some risks. Access to electronic data can lead to concerns about data breeches and confidentially. An essential part of the CNIO role is to support a culture of information safety through training, audit and learning lessons. Another area is data quality: does the information in different systems match up, can we trust it and how do we use this to improve patient outcomes?

Occasionally there need to be workarounds, the concept of deviating from the intended use, that may need a full risk assessment and logging on the risk register. It is important to understand clinical safety to ensure the impact and likelihood of potential harms. Workarounds can also lead to positive outcomes in the form of enhancement requests to the developers.

Top tip: I would recommend setting 30 minutes aside each week to read or learn a new digital skill (so that equates to 21 hours of learning per year). You will soon become an expert and understand the digital language.

Clinical safety standards and clinical safety officers

There are formal clinical safety standards that apply to digital systems. The one that applies to the use of health systems is DCB0160: Clinical Risk Management – its application in the deployment and use of health IT systems. (It is supported by the related standard for the application of clinical risk management in the manufacture of health IT systems, DCB0129.)

Evaluating the use of a system against DCB0160 is the job of the trust’s clinical safety officer (CSO). This is a named individual who is responsible for ensuring the safety of a Health IT System in that organisation through the application of clinical risk management.

The individual has to be a suitably qualified and experienced clinician who holds a current registration with a professional body; has to be knowledgeable in risk management; and is responsible for ensuring clinical risk management processes are followed.

Top tip: Arrange to spend some time with a clinical safety officer from your organisation or form elsewhere. It is always good to see the practical application.

To CSO or not to CSO?

So do you need to qualify as a clinical safety officer if you are a CNIO? There is no definitive answer to this currently. The Faculty of Clinical Informatics has produced recommendations for a CCIO which states this should be a desirable qualification.

There is not a CNIO standard at present. Some employers would like to combine the role and others have a separate CSO. I am not currently a qualified CSO – however, becoming one is on my personal development plan. Traditionally organisations have one or two CSOs but there can be more. Some organisations outsource the role to skilled professionals.

Being the CSO as the CNIO has a risk of becoming so time consuming the other elements of the role may be compromised. So it may be best that it is not seen as the duty of the CNIO, but that the skills of a CSO are useful for a CNIO to have.

Top tip: If you’re applying for a CNIO role, check whether the CSO aspect is also part of it. If it is, discuss the percentage of the role that will be allocated to safety sign off.

Becoming a CSO

There are currently two parts to becoming a CSO. The first is to complete the eight e-learning modules, which can be accessed for free by anyone with an NHS email address. Once someone has passed these modules, he or she can move onto what is called the foundation course. This involves direct teaching.

Once complete, you are a certified CSO. You also receive 14 continuing professional development (CPD) points.
You can find out more about the training on the course’s page on the NHS Digital website.

Top tip: Spaces on the course are limited so agree whether being a CSO is a part of your CNIO role and, if it is, include it in your personal development plan as an essential course. Then apply for funding and book a place in plenty of time. Remember too to book out time to complete the e-learning at a pace you are comfortable with.

About the author: Dione Rogers is chief nursing informatics officer at Kettering General Hospital NHS Foundation Trust (to March 2022) and at Barking, Havering and Redbridge University Hospitals NHS Trust from April 2022. She qualified as a nurse in 1994 and has held clinical roles in stroke, haematology, respiratory, rehabilitation and acute care as well as general, operational and project management roles.

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CNIO HandbookFeaturedNews

CNIO Handbook Chapter 3

by Michele
written by Michele

Back in 2015, Great Ormond Street Hospital for Children NHS Foundation Trust – a small but mighty specialist paediatrics trust – set a vision for its digital future. We were to introduce an electronic patient record (EPR): “An integrated system to be used by all staff, in all settings that will allow patients access in every interaction and hold the entire patient record.”

I’d worked at the trust since 1997 and, when this announcement was made, I was working operationally but also on a project to introduce electronic observations to the organisation. That led me to being approached to join the procurement team for the EPR, and into months of Excel spreadsheets, understanding system build, system testing, site visits and networking.

When implementation of the system began, it soon became clear a chief nursing information officer was going to be important to success. I was appointed to the role in January 2018, during the groundwork phase of implementation – the go live date was set for just over a year later. I remember feeling excited about the challenge ahead but petrified of how I would lead the nursing workforce through this transformational change in such a short timeframe.

Three core values

In working on the implementation, I always had three core values in mind. The first was patient welfare: we needed to make sure that the introduction of an EPR didn’t interfere with the safety of our care and, indeed, that it helped staff deliver the best possible care to our patients. The second was operational improvement. We needed to make sure that the EPR helped us deliver care more efficiently. The final was staff engagement, which as CNIO was and is a key part of my role.

I knew that clinical engagement was key to a successful implementation. Clinicians would be the ultimate users of the system and so they needed to be part of the journey, helping us build efficient workflows. The design of the system had to be intuitive to staff, to reduce not increase burden.

There are a few key steps I took which made the task of implementation feel more manageable, and which I’d recommend to any nursing colleague supporting a similar project.

  • Create a team: Creating a team of nursing informaticians was the single best thing I did. Members had diverse backgrounds, skills and experience. That meant we were able to build an EPR that was tailored to the range of people in the organisation and the range of work they do: the different pathways and workflows, and also different levels of expertise in digital systems. We appointed a huge number of subject matter experts, who advised us on how the specific workflows in which they and their colleagues were involved should be reflected in the EPR. This has been important in making the most of clinical decision support functionality within the system. We’ve ensured the EPR supports clinicians in applying best practice in specific areas of care, but also that it allows diversion from that when clinical judgement requires. It means we avoid clinicians becoming fatigued by alerts about deviations from best practice that are in fact entirely justified.
  • Learn from others: I spent time making friends with both national and international colleagues who had travelled the journey before. These relationships definitely played a part in the success not only of the EPR implementation but with my development as a CNIO. The CNIO Network was a particularly important part of building these relationships and sources of support.
  • Take the opportunity to review how care is provided: Before we implemented our EPR, we had several different ways of documenting the same information. I saw the implementation as an opportunity to rethink this, and create new ways to care – introducing an EPR shouldn’t just be about digitising existing ways of working. We, for instance, created some functionality we call Essence. This is a means of entering a brief description of what a clinical note is about: it only takes 30 seconds and is up to 156 characters, a bit like a tweet. It means that any clinician looking through a patient’s record can quickly understand which clinical notes are relevant to current care – rather than having to open all of them and read through they can judge the most relevant from the summary.
  • Take every opportunity to communicate with clinical colleagues about the implementation: I invited myself along to every clinical meeting that existed across the trust to talk about the journey, where we were to date, and what we needed from the teams. I wanted the EPR to be at the forefront of everyone’s minds and for everyone to understand that the system was theirs – to use and to shape. We weren’t introducing a system to people, but introducing a system with them.
  • Focus on change management: This project was the single biggest transformation the trust had been through. There are challenges to leading a huge programme of change. The logistics of bringing an entire organisation on this journey, at the same time as staff are facing the normal day-to-day challenges, were far from easy. We appointed change managers to help here. They were trained to support the system design but more importantly the adoption and longer-term optimisation. When working on an EPR project, the go live is of course the main focus but there is so much important work that happens afterwards, once people have actually started using it. Sometimes it’s only then that you see how a workflow or patient pathway can be best represented on the EPR. Having operational teams feel they had ownership of the EPR, and could shape it over time, was a key part of our success.
  • Get training right: We familiarised staff with the system by giving them basic sessions on how it worked and tip sheets. We didn’t train them to use the system fully, because we knew that you only really learn how to use an electronic patient record when you actually start using it in practice.

The system went live over the 2019 Easter weekend. We went with a big bang launch, so the EPR was live everywhere across the trust. It was one of the highlights of my career – seeing months of work come into fruition in front of your eyes was fantastic.

Running the implementation

It was such a big transformation that, as an organisation, we ran the implementation as though we were confronting a major incident. This enabled staff to bring any issues directly to the implementation team to either be actioned or support given.

As a nursing leadership team we created what we called SWAT teams – small groups of experts who were dispatched to help with some of the more complicated process in the new EPR. Blood administration was an example: when we knew that someone had ordered blood, a SWAT team was dispatched to go and help the staff through the process using the EPR.

With all that said, my advice is to make an EPR go live a celebration. It’s one of the few times the whole organisation will come together to support a transformational change. The success of an EPR implementation goes beyond just putting the system in. For some clinical teams, the true value was only seen later, in the form of opportunities to improve services and continually improve the care we deliver. It is at this point that patients, families and staff start to experience the deeper benefits that digital transformation can bring.

“With all that said, my advice is to make an EPR go live a celebration. It’s one of the few times the whole organisation will come together to support a transformational change.”

Benefits

One big area of benefit is the availability of data. With all information being held in the electronic patient record, and the knowledge that it is robust information, we’ve been able to create clinical dashboards. These give staff an understanding of where things are going well and where they are going less well. This in turn means that we can standardise and improve clinical workflows.

I’m always working to engage my clinical colleagues in making best use of the system, helping encourage a curiosity about it can be used to the maximum possible benefit. Once that seed is planted – and nurtured within individual clinical teams – staff can start to use data to drive change themselves.

It’s an example of how EPR-related work doesn’t stop with a go live. It’s a journey but one that it’s a privilege to be on.

About the author: Sarah Newcombe is chief nursing information officer at Great Ormond Street Hospital for Children NHS Foundation Trust. She joined the organisation in 1997 as a staff nurse. In 2012, she became the clinical lead for the implementation of electronic observations at the trust. She has been CNIO since January 2018.

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CNIO HandbookFeaturedNews

CNIO Handbook Chapter 2

by Michele
written by Michele

Introducing the CNIO role

The chief nursing information officer role is usually broad but, at its heart, it is about bridging the gap between technology and clinical practice. CNIOs should have a seat at the table when the clinical technology strategy is being set, and then through the procurement, planning and implementation stage of any new system. As CNIOs, we ensure the focus is on using technology to improve outcomes for patients and citizens.

What’s it like starting out in a CNIO role?

If you’re starting out in a CNIO role, you may be replacing an existing postholder or it may be an entirely new post for the organisation. You may also be a lone digital nurse, or you may be part of a team. It may be your first senior nursing role, which you’ve gained through previous digital experience, or you may already be a senior nurse and new to digital. These experiences are all slightly different.

When you’re the first

Being the first CNIO for an organisation can feel like a daunting prospect. It’s important to remember the positive aspects: that you have a fabulous opportunity to develop the role and to bring others along with you.

You will be able to set the agenda and direction, but it’s likely others will try and point you towards meeting existing agendas. Instead, give yourself some time to decide what you want the priorities to be – and agree with your senior colleagues that this is the approach you’ll be taking. You will have a more positive impact in the longer term, as well as getting personal satisfaction and a feeling that you are personally developing too.

If you’re going solo

If you’re the only digital clinical leader in your organisation, then the job can feel like a lonely one and really quite different to what most of us are used to as nurses.

The key thing to do in this situation is to form networks. In your own organisation, it’s helpful to connect to other senior nurses. A good way to do this is by joining existing nursing collaboration groups (these will have different formats in different organisations). Although these colleagues will have different specialisms and interests, they too will have a focus on nursing strategy and workforce development.

If you are not directly reporting to your chief nurse/director of nursing, make sure that you meet with him or her in the early weeks in post and continue updating on progress. The digital nursing agenda should now be a key part of every chief nurse/director of nursing’s portfolio, and he or she will be relying on you to help drive it forward.

Outside your organisation, there are plenty of opportunities to connect with fellow digital nurses. This includes via the Digital Health CNIO Network and via regional and sector-specific groups. There are also the likes of the Faculty of Clinical Informatics’ nursing professional interest group, the BCS (Chartered Institute for IT) nursing specialist group, and the Royal College of Nursing eHealth forum.

If you’re joining a pre-existing team

If you are lucky enough to be joining an existing team, this is likely to be multi-professional. That means it’s important to link with clinical and non-clinical colleagues to determine who will lead on which aspects of the digital strategy. You don’t want to step on each other’s toes, but it’s really important to make sure that all the clinical professions feel that their views are being heard. That means you may also be the identified lead for allied health professionals or other professional groups.

Who leads on what is likely to be based on individual interests and experience, but together the team will need to have input on areas such as research, clinical governance, digital clinical safety and patient/citizen involvement.

An important first step is to understand what has already been done – ask your colleagues to run you through progress over the past couple of years. Focus on what has gone well, but don’t forget to ask about the lessons learned so that you can make improvements in future. Quality improvement is a key aspect of the CNIO role, and it needs to start early and continue always. You will then be able to gain a clear idea of what needs to be done in future, and will increase your understanding around stakeholder relationships (including with system suppliers), transformation and change activity within digital and across the wider organisation, and how involved your nursing colleagues already are in the digital agenda.

Be careful with how much you take on

It’s hard to say no to things when you are new in post, but it’s important not to take on too much – the danger is you won’t be able to deliver, and that’s really demoralising.

Be especially cautious of taking on work which could or should be done by others. Although it’s tempting to ‘fix’ problems (especially for most nurses), you will get overloaded. The digital nursing agenda will be your key one, but it’s important to recognise that you will also want to get involved in things which improve your knowledge and/or pique your interest. It is important to leave time to be able to do those things too, and if you’ve taken on too much work you won’t have time to do so.

Remember there’s no one best way to be a CNIO

As you start out as a CNIO, remember there is not one best way to do the role. It will depend on your own background and how much leadership or digital experience you already have.

Remember too that while some of the digital aspects of what you are doing might be new for you, you have lots of existing and transferable skills from your previous experience – and that’s true whatever previous experience you have.

If you are coming into the role as an existing senior nurse with limited digital knowledge, make friends with colleagues in the IT/digital team. They will be keen to share their knowledge and experience with you, and it’s a really good way to learn the ‘language’ of digital healthcare.

If this is your first post at this level but you have previous digital experience, then the relationships you will likely need to work on are those with other senior nurses and clinicians. This can feel difficult if you haven’t done it before, but also because you are likely to be the one who has most digital knowledge. You’ll need to be prepared to teach, and to encourage others’ understanding and interest in digital, while developing these key peer relationships.

What skills do I need to flourish as a CNIO?

There are a number of key skills that I think you will need to succeed as a CNIO. Some you’ll have already, but all you’ll need to work on and develop.

  • Teamwork. You need to work as part of the team, to collaborate with and motivate others.
  • An authentic, credible style and a passion for improving clinical outcomes by using technology. This will often get you moving forwards even when times are most tough. It’s important to have resilience and tenacity, as well as a pragmatic but can-do attitude.
  • A knowledge of your own limits. You need to know the boundaries of your own abilities, and to be able to ask for help.
  • An ability to make decisions. You’ll need to be able to understand the issues facing colleagues and patients and be able to determine the best actions (sometimes without all the facts you would like).
  • Leadership. You need to be a good leader of others. Supporting and developing your colleagues is such an important part of the job of the CNIO. Some of my proudest moments as a CNIO have been seeing others develop into CNIOs (and other clinical leaders) themselves.

Don’t forget development

The CNIO community is a vibrant and very giving one; in my experience, people will be generous with their time to support you and teach you. The benefit for them is that they will also learn from you.

There are digital nurses in all kinds of roles and across sectors, so make your networks big; include non-nurses and don’t be afraid to link up with digital clinicians working in different sectors, including in industry and outside the NHS.

Know you’re part of a team that is continuing to grow

I was one of the first CNIOs in the UK and am very proud of that fact. What I’m more proud of though is that we have grown in number over the last 10 years and that we will continue to grow as a community of CNIOs and digital nurses. I’m proud too that we are now being recognised as an integral part of any healthcare team which is aiming to transform care through the use of technology. Good luck and keep in touch!

About the author: Jo Dickson is chief nurse at NHS Digital. She had a varied clinical background before moving into technology roles, and was previously chief nursing information officer at Leeds Teaching Hospitals NHS Trust and clinical informatics director at Nuffield Health. Jo is a past chair of the CNIO Network and a founding fellow of the Faculty of Clinical Informatics.

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Editorial BoardNews

Battling burnout

by Michele
written by Michele

Burnout is defined as the result of “chronic workplace stress that has not been successfully managed” – and, as such, is a clear risk for NHS staff.

In this piece developed with the Digital Health Networks Editorial Board, Claire Read explores why burnout might be a particular issue for digital staff, as well as how digitisation can both protect from and lead to burnout.

In the first half of 2020, when the general public were taking to their doorsteps weekly to applaud the efforts of NHS staff in the face of a novel and deadly virus, Ayesha Rahim and her colleagues were busy implementing an electronic patient record (EPR) in the most difficult of circumstances.

Rahim is chief clinical information officer at Lancashire and South Cumbria NHS Foundation Trust. She’s a doctor – a perinatal psychiatrist and also the trust’s deputy chief medical officer. She knows it’s a role which meant she was being thought of as hands were clapped and saucepans banged. But she fears those who were working alongside her to implement the EPR weren’t afforded the same consideration.

“When people clapped for the NHS, they were largely clapping for nurses and doctors – which is a proportion of the people that keep the NHS going, but in deploying an EPR during a pandemic my technical colleagues were working round the clock; ridiculously long hours. It doesn’t occur to people, including clinicians actually, that people are doing that and they’re working really hard.”

The value of recognition

Know that burnout is characterised by the World Health Organisation as “a syndrome resulting from chronic workplace stress that has not been successfully managed” (World Health Organization (2019) “Burn-out an ‘occupational phenomenon’: International Classification of Diseases) and it becomes clear why it’s an issue of general concern in the NHS workforce, particularly given the past two years. But add the lack of recognition of the efforts of digital staff and it perhaps becomes more of a worry still in this group.

It’s why Rahim puts acknowledging the contribution of such colleagues high up on her list of ways to reduce the risk of burnout. “Recognising the immense value of people in digital to supporting lifesaving care helps us to appreciate staff who have been working very hard through difficult times, just as clinical staff have.”

And while many clinicians have still been working on site, many of those who purely work on digital projects have been working from home – isolated to some extent, with contact with colleagues being through a Teams or Zoom box rather than an opportunistic in-person talk while making coffee in the kitchen.

Such digital working may have become the norm but, for Aasha Cowey – strategic transformation lead at Surrey and Borders Partnership NHS Foundation Trust – it has not yet been perfected. And that, she fears, has consequences for stress and burnout risk.

“I don’t think we’ve optimised the use of digital in the way we work,” she says. “Sometimes online collaboration makes sense – I can’t be the only person who has previously driven halfway across the country for a two hour meeting before. Yet I’m not sure we have found the optimal balance to maintain meaningful peer support and connectivity.

“There’s also some really practical stuff like what sort of devices our staff have, is their Wi-Fi and remote connection up to the job, and do they know how to get the most out of the digital tools they’re using on a daily basis,” she adds.

Time to optimise

The point is one echoed and reinforced by Sarah Newcombe, chief nursing information officer at Great Ormond Street for Children NHS Foundation Trust. Its EPR went live in April 2019, but Newcombe says the pandemic means opportunities to ensure it’s working optimally for staff have been more limited than they might have been otherwise.

“We missed out on that optimisation phase of the system, and I think Covid is a lot of the reason for that. I certainly worked clinically to support operational work during the early phases of Covid. That was the right thing to do, but it meant the ability to support clinical teams in the digital transformation was lost.

“So what’s happened is staff have kind of created workarounds on the EPR, because they’ve not had that influence or that support from the team leading on its implementation.

“I always look at workarounds as innovation in many ways, because that’s the clinicians finding their own way around something that doesn’t work that well for them,” she says. “So I want to get to is them sharing that innovation; them being able to feed back to me and say: ‘Sarah, look, we’ve found this way of doing it, we think it’s better, what do you think?’ And then we can set that as a standard across the whole organisation.”

And if we want digital to reduce burnout rather than add to it, then evidence suggests EPR optimisation should be a key priority. It has been reported (Gawande A, “Why doctors hate their computers” The New Yorker, 2018) that poorly designed IT systems are a key factor in clinician burnout, and Rahim is not surprised.

“I do one clinical day a week clinical, the rest of my time is doing digital work. Yesterday was my clinical day, and I worked from 8am to 9pm and two and a half of those hours were because my tech just wasn’t working as it should do. It added two and a half hours to my 13-hour day.

“I think we don’t place enough emphasis on user-centred design and design thinking in clinical systems,” she concludes. “Quite frankly, if I had that problem that I was having yesterday five days a week in my clinical job, it sucks the joy out of clinical work and would make me not want to do this.”

The fear of what’s next

As with so much else, that sort of feeling might be compounded by the pandemic and – particularly – the uncertainty of how it will progress. Newcombe sums this up powerfully, and highlights why the risk of burnout is going nowhere soon.

“Hospitals have not yet stepped away from Covid but the nation has started to step away,” she argues. “I honestly feel when I come into work it’s like travelling in two parallel worlds. You go on buses, trams, trains and people aren’t necessarily wearing masks; I choose to still wear a mask on public transport but if I chose to take it off one day it wouldn’t be considered a problem. And then I arrive at work and every other desk is empty to protect each other, and I wear a mask all day.

“For healthcare personnel, Covid is still very real. There’s the fear of what’s next.” And, therefore, an urgent need to find ways to avoid burnout among staff and ensure digital platforms aren’t further contributing to it.

Combatting digital fatigue and the back-to-back age

Back in March 2020, it was a revelation to be able to meet colleagues on Teams rather than having to find the miraculous meeting room which was free at a time mutually convenient to all (and to then have to turf out the team squatting in there at the point your booking began). Stress dropped away. Now, however, there’s concern we may have gone too far the other way.

“In some ways we’ve had a bit of digital overload, and we’ve all talked about Zoom fatigue, video fatigue, so we need to be mindful that technology isn’t always the panacea,” argues Ayesha Rahim, chief clinical information officer and deputy chef medical director at Lancashire and South Cumbria NHS Foundation Trust.

“Stepping away and learning to reconnect on an in-person basis might be something that is more valuable, although I’m sure digital does have a role in some domains. We just have to think a bit more broadly.”

She suggests managers could valuably schedule ‘chat time’ for employees now working remotely – trying to replicate the sort of conversations which would happen more opportunistically in person.

“It almost feels like a slightly naughty thing to do – ‘We’re having a meeting but we’re not actually getting any business done.’ Actually you can’t be constantly doing business, all 40 hours that you work in a week. It’s not healthy and actually reduces productivity if anything. So having some scheduled time to just chat about what you’ve been watching on Netflix or share pictures of your pets can really help.”

Similarly, she feels managers need to protect their staff from the back-to-back meeting culture that seems to have developed during the pandemic, perhaps due to the ease of setting up a Teams call.

“You need to have some time blocked off regularly, in your diary, where you don’t get assigned a specific piece of work and you use that in the way that you see fit,” she argues. “I think that would be a way that we could reduce that constant treadmill feeling.”

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